Developing Films to Support Vaccine-hesitant, Ethnically Diverse Parents' Decision-making about the Human Papillomavirus (HPV) Vaccine: A Codesign Study

"To address inequalities in vaccine hesitancy, community-led strategies are required that incorporate meaningful engagement to ensure diverse local voices are heard and codesign programmes that address local concerns to maximise vaccine uptake from the ground up..."

Uptake of vaccination programmes can be influenced by multiple interacting forces, which can be population specific and include vaccine hesitancy. Vaccine hesitancy is recognised as an important contributor to inequalities in uptake of vaccination programmes among minority ethnic groups. Evidence indicates that the engagement and knowledge needed to boost uptake can be facilitated by collaboration with trusted community representatives. This paper illustrates an evidence-, theory- and person-based approach to codesign  COMMUNICATE, a series of films designed to support parental decision-making about the human papillomavirus (HPV) vaccine for their teenagers in England.

Patient and public involvement was integrated throughout the study. The intervention planning phase involved carrying out a literature review and qualitative interviews with 29 ethnically diverse, vaccine-hesitant parents to understand barriers and facilitators to HPV vaccine uptake and to identify design features that should be incorporated within the COMMUNICATE films. For example, parents who were interviewed expressed worries concerning side effects (e.g., fertility issues) and safety of the HPV vaccine. Open, transparent, evidence-based information in relation to side effects - both minor and serious - is required to overcome distrust in the HPV vaccine. The COMMUNICATE films should also dispel misconceptions in relation to perceptions of serious side effects.

This phase involved identifying guiding principles for the COMMUNICATE films, mapping behaviour change techniques onto the behaviour change wheel, and codesigning the COMMUNICATE films. Guided by the primary and secondary evidence, the research team determined that the COMMUNICATE films should: Emphasise the benefits of the HPV vaccine, provide transparent information about the safety profile and side effects, and stress the universality and commonality of HPV infection. A series of scripts were used to guide 4 film shoots to create the content in multiple community languages with 16 participants, including vaccine-hesitant, ethnically diverse parents and professionals.

In brief, the COMMUNICATE films aim to: (i) increase parents' motivation for their teenager to be vaccinated; (ii) provide reassurance for parents to have their teenager vaccinated; (iii) overcome stigma of providing consent for a vaccine that protects against a sexually transmitted infection; (iv) engage parents in decision-making and consent process; and (v) be delivered flexibly to meet the needs of the intended population.

Feedback from users informed modifications to maximise acceptability and feasibility and to support behaviour change. Specifically, the researchers held online meetings to agree on adjustments to the COMMUNICATE films in line with a person-based approach and the guiding principles developed specifically for the COMMUNICATE films. This process involved considering whether they were likely to impact on behaviour change or be a precursor to behaviour change (e.g., acceptability, feasibility, persuasiveness, motivation and engagement).

Overall, parents were largely supportive of films to raise awareness of the HPV vaccine. Potential messengers and ways the films could be distributed include: (i) health promotion days; (ii) local social media networks; and (iii) text messages from physicians' offices. The need for information about the HPV vaccine to be shared by schools ahead of consent being sought was also raised. Representation of film participants (healthcare professionals and parents) from different ethnic groups was felt to be important to ensure relevance of the COMMUNICATE films and could help normalise vaccination within different communities. Indeed, the COMMUNICATE films (see one example, below) were made available in English, Arabic, Bengali, Polish, Somali, and Urdu to ensure that parents who do not speak English as their first language are not excluded from the decision-making process.

Overall, participants were positive about the films. Potential messengers and ways the films could be distributed, identified by parents, include local social media networks or text messages from general practices. The need for information about the HPV vaccine to be shared by schools ahead of consent being sought was also raised.

The researchers plan to undertake a future study working alongside key stakeholders and parents to refine the practicalities of how the films could be distributed, to support implementation activities, and to gather evidence in relation to changes to uptake of the HPV vaccination programme. Together with an educational resource they have coproduced with young people (available by clicking here), the COMMUNICATE films could contribute to a system-wide approach to improving communication about, and increasing uptake of, adolescent vaccination programmes.

In conclusion: "By using an integrated approach to intervention development, this study has begun to address the need for an intervention to support vaccine-hesitant, ethnically diverse parents' decision-making about the HPV vaccination programme."