OTRAS ESTRATEGIAS EDUCATIVAS QUE PODEMOS UTILIZAR.

Social marketing

Firstly, we will look at how the concepts of social marketing can be connected to the way the government approached the vaccinations. In the first place, there is the price of the vaccinations. Since the vaccination is included in the state’s vaccination programme girls of the age of twelve can get the vaccination for free. Before it was included in the programme the vaccination was available to get at the doctor on request but the vaccination was really expensive. Therefore, not many got vaccinated. By including the vaccination in the state’s programme the government has already removed one big obstacle, which was the monetary cost. Price also includes other factors: time and effort. These are not factors that are discussed or mentioned in a positive or negative light in the media or the

research articles. When looking at the difference between 2009 and 2011 nothing changed here, the vaccination is still free and the amount effort and time have

also not changed. Secondly, there is place. The vaccinations

are done at convention or sport centers. These places are often well connected and easy to reach. Every municipality has a GGD so it is questionable that people had to travel a far distance to get the vaccination. With big scale vaccinations like this, the government, of course, makes sure that it is easy for people to reach. Here again, there is no mention of the place where the children are vaccination plays a big issue. Article 62 mentioned that in Belgium the vaccines are given at schools and that might be playing a role in why the vaccination rate is higher in Belgium compared to the Netherlands. The place of vaccination has not changed when comparing 2009 to 2011.

Thirdly, there is product. A lot of the critique is placed on the product. Where a vaccination is usually by parents seen as something desirable in the case of HPV by a lot it is viewed as a questionable product and not something to engage with. The vaccination has of course been researched a lot before it was approved by the European Union and the Dutch government to be included in the programme. Before the vaccination came to the Netherlands it was already used in the USA and in Australia so there was some precedent and in these countries, no signs of severe complications had appeared (yet). Moreover, the Health Council, of course, looked at the vaccination and deemed it appropriate for the vaccination programme. There was some critique but most health professionals deemed the vaccination safe. The Dutch government chose for Cervarix because it was the cheaper vaccination and had better results after the cost-benefit analysis compared the Gardasil. Between 2009 and 2011 a lot of stories have arisen about side-effects. All these complaints are researched and in the end not attributed to the vaccination. The European Union has also done another research to the vaccination which once again deemed it safe. For the Dutch government, there was no reason to change the vaccination so this is still the same. The only difference is that instead of three vaccination, girls now only need two.

The last concept is the promotion of the product. First of all, there has been a lot of promotion done to bring the dangers of HPV to the attention of people. The episode of Zembla showed how HPV was discussed in magazines, newspapers and TV’s shows. Often this attention was paid for by the pharmaceuticals companies. By the time the vaccination hit the market people

were already familiar with the dangers, HPV posed and it that more likely to buy the vaccine. The thing that the public resented, however, was how it was not clear that these articles were paid for by the pharmaceutical companies and that they played with the emotions of people and especially of parents. The discoveries done by Zembla made people distrust the message that was spread and it was now only seen as a way to make money. By the time the vaccination was included in the state’s programme, the government started to educate the public about HPV and the vaccination for it. Girls that were called for the vaccination got a package with information about the vaccination, answers to frequently asked questions and an invitation with the time and date where they could get the first round. So far the education and in a way the advertising of the vaccination had always been this way and there was no reason to assume that this would not work for the HPV vaccination. After 2009, when the vaccination rate was disappointing, the RIVM changed their strategy. They added the option for parents to chat with professionals and to ask questions. Schools were involved in the education about HPV and the vaccination. GP’s where better informed how to react to questions of parents. These changes were done to make the attention more personal. To promote face to face contact and to attend to the worries and concerns of a particular parent the RIVM hoped to get the vaccination rate to an acceptable number. In the information that the girls perceived the personal stories of parents, other girls, healthcare professionals, and HPV survivors were also meant to show that how other individuals thought about the vaccination and to emphasize the personal character of the vaccination and the choice to make. At the same time, the RIVM also explained in the media that it was not their job to persuade parents. It was always still the choice of the parent and the child. It was not deemed appropriate for a government organization to start a really big promotion campaign.

Risk perception and communication

When applying the risk perception of parents to the HPV vaccination the focus will be on four concepts: perceived severity, perceived susceptibility, perceived benefits and perceived costs or risks. Perceived severity is for each parent and child different. The overall theme that can be seen in the (news) articles is that it is the perceived severity of HPV is quite high. This mostly has to do with the fact that HPV can develop into cancer which is, of course, a very serious concern. On the other hand, there are also some more critical opinions voiced. Almost every

news articles about HPV also describe the percentages and numbers linked to HPV. One of the articles did an article about the frequently asked questions in which they answered the question: “If only 200 women annually die because of this cancer, isn’t this vaccination like shooting with a canon on a mosquito?” (Translated from Manschot, 2007). De Kok and colleagues (2008) agree with this sentiment. They argue that the vaccination does not fulfill one of the criteria that the vaccination has to fulfill. They question the priority of HPV. They mention other cancers that have a much higher death rate and wonder why the

Netherlands does not have an adequate screening programme for these yet while on the other hand, the government does offer the HPV vaccination. They do not argue that it has no urgency at all but they do think there are other with more

urgency like intestinal cancer. Perceived susceptibility

is the next concern. As mentioned before HPV is a different kind of virus for girls to be vaccinated against than the more classic vaccines. Since HPV can only be transmitted through sexual contact (with a few exceptions) an individual that is not sexually active, or does not have more than one bed partner in their life is not likely to get an HPV infection. Within religious communities, the susceptibility is not deemed as a problem. Another concern where susceptibility comes in to play is the fact that the girls are vaccinated at 12. Even though it might seem like teenagers start sexual relationships earlier than before, there is actually no evidence for this. The argument of the RIVM to start at 12 is because the vaccination only works if the girl is vaccinated before she becomes sexually active. Many parents find 12 too young of an age, certainly, because it concerns a vaccination against a sexually transmitted decease, article 46 for example. They find their daughter too young to make such an important decision or too young to start thinking about sexual behavior. Research in America has shown that girls who are vaccinated against HPV do not show (more) promiscuous behavior or become sexually active earlier (Marlow, Waller & Wardle, 2007 and Haber, Malow & Zimet, 2007). Parents do not assume that their 12-year-old daughter will need this vaccination in the near future, which why many parents wonder if the vaccination cannot be administered at a later point in time for their

daughter. The perceived benefits of this

vaccination are of course not getting HPV, not developing cervical cancer and not possible dying because of it. Being able to negate the negative effects of a

sexually transmitted disease that affects 80% of the sexually active women is incredible. More so because this disease can develop into cancer.

The perceived costs to project your child against cancer are huge according to some parents. Here all the side-effects, hoaxes and conspiracy theories come in full play. The vaccine not being safe, not being tested enough (on twelve-year-old girls), being a way to make money for big pharmaceutical companies and tax-payers money being spent on a

vaccination that might do more harm than good are all arguments that come back within this concept. Parents do not trust the vaccination and do not trust the information that the government has given. By doing their own research they discover the darker side of this vaccination, whether the information is true or not is not important. The media participates in the storm of negative stories and outraged parents. Even people who trust that the vaccination is save might have their questions. The vaccination only protects you for 60% of the types of HPV, it is unsure how long the protection will last and HPV does not seem like such a pressing matter that it deserves the priority treatment that it has gotten. In the anti-vaccination climate that starts to arise in the Netherlands, a seemingly hastily researched vaccination cannot find a lot of support. Parents go online and find the communities of critical vaccinators or anti-vaxxers where their concerns are heard, whereas the government seems to hide the real information behind the vaccinations. The trustworthiness of government agencies and healthcare professionals declines. This is also discussed in the article “Wetenschap is ook maar een mening” which translates to “Research is only an opinion” written by Keppel Hesselink and Bouter in 2016. Government agencies and experts do not have the authority that they used to have. Now they are just one of the many people who have an opinion about a certain topic. Intuition is more important than research. This articles also notes that is important for RIVM and healthcare specialists to take notice of this new attitude towards research and inform the patient or individual in a different way that suits the current climate.

So to focus more directly on answering the research question: How did the communication strategy of the Dutch government about HPV vaccination change between 2009 and 2011, and are these changes improvements in terms of the social marketing and risk communication theories? In 2009 the communication strategy did not match the themes and target

population. Especially when it comes to the target population the government and the RIVM could have employed very different methods to engage more with them and to reach them. Apart from religion, I think the government did answer some of the questions when it comes to safety and necessity but those answers

were not satisfying the public. Since the RIVM did not very specifically speak out about the uncertainties, like the long-term effects and the lack of research parents felt like they were being lied to. The RIVM was not trying to cover up these facts but it is part of the marketing strategy, of the promotion to not

emphasize these. By not mentioning them, however, it hard to calm and reassure people. In 2011 the government definitely made some changes. The target population was taken into account. The focus to really reaching people can be seen in the new information and in the option to chat as well. The chatting sessions are really a part of more personal attention and a more personal communication strategy. Whereas in 2009 the government focused on the technical rationality, they moved to a more cultural rationality (as Plough and Krimsky (1987)call it). You can see that they are trying to bridge the gap between their technical, numerical and scientific information and the feelings and

emotions that influence people’s decisions by adding anecdotes and giving people the option to seek more personal attention. I would argue that the

communication strategy matches the target communications better in 2011. As for the concerns, it will be more difficult to put these to rest, being more open, and more communicative help but the concerns about safety and necessity stay until there is some strong evidence that can show the effectiveness and safety of the vaccine. For that happen a lot of time needs to pass. That is also why in 2018 the arguments more or less stay the same. The focus is still on the lack of

evidence when it comes to safety and effectiveness. The HPV vaccine is also more doubted because of the lack of openness about these issues when the vaccination was first introduced. As mentioned before trust is a very important factor when it comes to making a decision. I do not think that the RIVM or the government are very trusted parties at the moment. However, I also think that this is not something that is going to change with a better communication

strategy or with more research. Trust is something that takes a long time to built and in this case a long time to regain. Trust in established organizations and parties is also much bigger than the RIVM and the vaccination crisis and this problem should not be taken lightly.