Communication strategies about HPV vaccinations in the Netherlands

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Master: Crisis and Security Management Starting date: September 2017

Title: Communication strategies about HPV vaccination in the Netherlands Name: Leonie van Els

Student number: 2090856 Date: 05-08-2018

Word Count: 15.608

Crisis and Security Management

Communication

strategies about

HPV vaccinations in

the Netherlands

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In late June of 2018, the sirens started going off. The Dutch government reported that the vaccination rate of HPV of 12 years old girls was only 45,5% in 2017. Where the first few years the vaccination rate was around the 60%, the past few years interest for the vaccine has dropped with 15%. Moreover, not just the vaccination rate for HPV dropped(Noordhuis, 2018). The vaccination rate for many other diseases like measles, rubella, polio, and whooping-cough had dropped as well. The vaccination rate for these diseases all dropped under the WHO recommended 95% (RIVM, 2018). A new media storm started for HPV, just like it had when the vaccination was first introduced (and had a lower than expected vaccination-rate). Healthcare professionals, survivors of cervical cancer, mothers, daughters and governments officials got to share their opinions, stories, and experiences in newspapers, on television and, of course on the internet. And like 9 years ago, when the vaccination was introduced in the vaccination programme by the government, people were and are very divided when it comes to the HPV vaccine. On the one side mothers are urging other mothers to get their daughters vaccinated while on the other side the actions of the Dutch government to inform people are judged for being paternalistic (van den Biggelaar, 2018). Meanwhile, sisters and friends that lost their loved one to cervical cancer sharing their concerns while on the other side of the internet mothers shared their concerns about the long-term effect of the vaccination(Greer, 2018). Even though almost ten years have passed since its introduction, it does not seem like the Dutch government has got a grip on the situation surrounding the HPV vaccination. Ringing the alarm might not have been the best strategy to move the conversation in the right directions, as both sides are prepared and very much ready the fight for the good cause. Concerns about vaccinations are relatively new for the Dutch government and this time around it shows that they seem ill-equipped to fight it.

The point of departure for the thesis is the looming vaccination crisis that public health all over the world is facing. Vaccination crisis might seem like an exaggeration but anti-vaccination groups have become more and more vocal. Where not vaccinating in the Netherlands always seemed to be something that only concerned the deeply religious community, more and more parents have become critical. In 2016 it was reported that the vaccination rate of infants had reduced by 0.5% for the second year in a row. Even though this is a very low drop the fact that more parents stop vaccinating their children is alarming (Voormolen

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& Kouwenhoven, 2016). There are a lot of different reasons for parents to not vaccinate their children. One of the most persistent and false argument is that vaccinations cause autism (Petts & Niemeyer, 2004). Other reasons stem from other (wrong) assumptions: Vaccinations are toxic and unnatural, not vaccinating will give your child a stronger immune system or vaccines have very dangerous side-effects. Another reason mentioned often is that the current generation is not familiar with the devastating effect that the diseases children are now vaccinated for used to have on society. The necessity to prevent such a shocking event is not felt anymore (Wiegman, 2018). Even with the reduction the Netherlands still has on average and in comparison to some other countries a very high vaccination rate. Between the 90-99% for the infections and diseases. The ideal level of a vaccination rate is around the 95% because it ensures herd immunity. When most of the children are vaccinated and have become immune against the infection, the children that are not vaccinated are indirectly protected by the children that are. If most of the children in a population are immune it will make it harder for the disease to spread, slowing it down or stopping it entirely. This will make the probability that a not immune child will come into contact with the disease much smaller. So having a high vaccination rate for most diseases is very important since it will ensure herd immunization and this will help by the disappearance of the disease. In this way vaccinating is a private and a public good, the individual child is protected and it will also aid the maintenance of the herd immunity (Petts & Niemeyer, 2004). In the Netherlands for most vaccines, the vaccination rate is high enough to ensure herd immunity. Except for one: The vaccine for HPV.

HPV is an abbreviation for human papillomavirus. It is a sexually transmitted disease that can cause cervical cancer among other symptoms. It is one of the most common sexually transmitted infections (Palefsky, 2010). There are different types of HPV that can have different types of symptoms. In the 1980’s it was discovered that HPV can be the cause of cervical cancer in women. Type 16 and 18 are responsible for 74% of cervical cancer as well as other types of cancer, depending on the sex of the patient. Types 6 and 11 cause almost all cases of genital warts. Since this discovery effort has been put into developing a vaccine. It depends on the vaccination which of the types you are protected against (Marlow et al., 2012). In the Netherlands, vaccines are added to the National Vaccination Programme when they meet certain criteria regarding necessity,

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efficacy, safety, and costs. After it was established that these criteria are up to par it was decided to add the vaccination for HPV to the National vaccination programme. Based on price and effectiveness they have selected Cervarix as the vaccination to use. In 2009 they started with the vaccination and it was officially added to the vaccination programme. They also organized a catch-up campaign for girls between the ages 13-16. Since the vaccination is part of the national vaccination programme the vaccination is free and not mandatory (as with all the childhood vaccinations is the Netherlands). Families get an invitation for the vaccination when their child is in the right age group. So how is it that fewer children are vaccinated? And how come that the vaccinate rate for HPV is so low in comparison to the other vaccinations in the Netherlands? Where are the

shortcomings? For this thesis will

be looking at the communication strategy of the government when it comes to vaccination. Different governments provide the vaccination in different ways. Some provide the vaccination in a schoolwide fashion, others vaccinate via GP’s (general practitioners) or other health centers. In the Netherlands, the HPV vaccine is part of the national vaccination programme and therefore free and not mandatory, like all vaccinations in the programme. Once families receive an invitation for the vaccine they can go to their local health center (GGD) for the shot. For this thesis, the years that are focused on are 2009 and 2011. Since 2009 is the first year the vaccination was introduced it attracted a lot of media attention, making it easier to find a lot of sources about public opinion and government responses. Because it was the first year one can also see the most “pure” response to the vaccination and the risk perception of parents and healthcare professionals. The year 2011 was chosen as the second point because in this year the new campaign for the HPV vaccination had started. After the low vaccination rates in 2009, the RIVM decided to change their campaign in 2010 and 2011 is the year that the effects of this new approach can be seen. The research question is: 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?

The reason that the case study of HPV is chosen is that it has a significantly lower vaccination rate in the Netherlands. Moreover, looking at this issue can fill the gap of knowledge about the communication strategies of the Dutch government when it comes to vaccination and might reveal the right

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direction for communication about vaccination in the future. This thesis will start with an introduction to the theoretical framework. After this more explanation about the HPV vaccination will be offered. The methodology and the timeline will be established. To be able to get a grasp of the opinions about the HPV vaccination first the umbrella themes of the arguments against HPV vaccinations have to be defined. After this, the research will aim to explain the public opinion and discussion by using media sources. All the collected information, news, and data will be used to analyze these umbrella themes and in this way establishing target groups that the government should and have reached. Here the four P’s will also be assessed to see where the achievements and the shortcomings can be found. Theories about risk assessment will be used to analyze the public concerns. After this, the communication of the government will be described. Special attention will be paid to the group that the messages were directed to and on what themes of concerns the government focused. The next step will be to establish the discrepancy that can be seen between the concerns that the public has uttered and the concerns that the governments have focused on. The thesis will conclude with a conclusion in which the research question will be revisited and new ideas for research will be suggested.

2. Theoretical Framework

For this thesis, two different theories will be used to assess the two different sides of the issue. In the first, social marketing will be used to assess the strategy of the government when promoting this vaccination. Secondly, risk communicating and risk assessment will be used to look at the decision-making process of the parents and the girls. The low vaccination rate can indicate a few things. The reaction of the RIVM on the low vaccination rate indicates that the RIVM had difficulties in communicating the advantages of the vaccination to the parents and the girls. In the following sections, two theories are discussed that can help in explaining why the there was a gap in understanding the advantages and disadvantages of the vaccination between the parents and the RIVM. They will be used to analyze the vaccination campaign and the concerns of parents in 2009. After that, they will be used to analyze the new and (hopefully) improved campaign of the RIVM, the risk communication, and analysis in 2011. These will

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responses to the concerns of parents and girls. The aim is to close the gap between the professional risk assessment and the risk assessment that parents make by using risk communication.

Social marketing

The first theoretical framework in this thesis is based on the principles of marketing strategies. When applying marketing to a social issue, this type of promoting or selling is called social marketing. Looking at public health from a marketing perspective has begun around 1950 with wondering why one cannot sell people on a public cause in the way that one sells people on a product(Kotler & Zaltman, 1971). The selling of the social cause and how to handle that is called social marketing. It might seem like the commercial and the private world and the public and social world are non-compatible but there is a lot to learn from one another. The marketing principles start with the four P’s in order to sell something.

In the first place, there is the product itself. This includes the features and the characteristics and the benefits from using the product, or in the case of social marketing performing the behavior. Important here is how the product serves and fulfills the need of the people. Parents have the desire or need that their children live long and healthy lives thus they will vaccinate their children to obtain or to come closer to this goal. This is of course only if they see vaccination as something beneficial and not as something harmful.

The second P to consider is the price which includes money, time and the efforts that one has to put in to obtain it. If a vaccination is very expensive a big socio-economical dispersion will be created in a society where some parents can afford the vaccination and others not. It will also make parents think twice before purchasing it. Cost can also include psychological efforts of stopping or beginning a certain habit for example. Or the psychological problem that arises for some people associating vaccination with needles and pain. In some countries, free healthcare is a marketing problem because it involves a lot of psychological effort from the citizens to obtain this healthcare. The third P is for place. This encompasses access, distribution, and convenience. If one needs to travel far to get the vaccination there is a bigger chance of delay or of missing out on the vaccination entirely. The price and the place are usually very important when it comes to social marketing, especially since the government does not want to create a situation

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that fosters polarisation within the society and definitely not when it is about

public health. The last P is promotion. There

are the persuasive communication factors that highlight the benefits of the behavior offered by the government. This is where the communication strategies come in. This will also be the most important factor in this research. With promotion, the products become familiar, acceptable and even desirable. It includes advertising, personal selling, publicity, and sales promotion. The promotion efforts should also be consistent and persistent in order to work. One cannot expect that people change their behavior after some brief education and encouragement. Changing the way people think needs to be a longer process. These four factors together are called the marketing mix. This marketing mix will be used as a tool, as a lens to look at the way that the Dutch government has communicated about the HPV vaccination. Using the four P’s it might become more clear to see where the Dutch government has made mistakes and where they have had accomplishments. When it comes to social marketing usually two more factors are addressed, those of partnerships and participation. The first includes different stakeholders; GP’s, policymakers and journalists for example. Participation relates more to the already existing social norms and the social norm that the public health policy should establish. These two factors are seen as important when it comes to the accomplishment of public health(Nowak, Gellin, MacDonald & Butler, 2015). With the vaccination crisis, in general, it is important to remember that most of the Dutch population is already performing the desired behavior, hence the high vaccination rate for most infections. In this case, target groups become more important (Renn, 2006). How do you reach your target group and get the desired effect? The core idea of marketing lies in the exchange process. It involves two parties that are both able to communicate and distribute that both have something to exchange. Marketing management or strategies come in to play when the idea arises that something can be gained from this exchange. An important shift has come into play. Instead of a sales orientation, so selling a customer on a certain product, convincing him or her that he or she needs it, the new marketing strategy is a market approach. A lot of research has been put into finding out what the consumer wants. This way one will know for sure that the product will be picked up since there is a need for it. For governments, this is, of course, a whole different story. First of all the exchange is already a difficult concept. You could see it as the citizen paying taxes for which in exchange he gets certain benefits. With the new market

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approach that we can see in the marketing world, the citizen has more to say about how their taxes are spent since they are the costumer which have certain needs. The government has to respond to this, especially if they want to sure to be spending the national resources on the right social issue. Moreover, the government, in democratic countries at least, is supposed to be representing the

will of the people. Kolter and Zaltman

(1971) give the following definition of social marketing: “Social marketing is the design, implementation, and control of programs calculated to influence the acceptability of social ideas and involving considerations of product planning, pricing, communication, distribution, and marketing research.”(page 5). They also note that this technique of applying marketing approaches can be the bridge between the knowledge that is there and the way that this knowledge can be implemented into something that is socially useful. Here we can see how important knowledge and science are for government programmes, especially in the public health domain. Facilitating this bridge is in some issues of great significance. However, not everybody agrees with this definition since it is very broad. A more elaborated definition is offered by Roberto and Kotler in 1989: An organized effort conducted by one group (change agent) which intends to persuade others (target adopters) to accept, modify or abandon certain ideas, attitudes, practices, and behaviors.” (in Langford & Panter-Brick, 2013, p 134). Grier and Bryant(2004) name exchange theory, audience segmentation, competition, the marketing mix, consumer orientation and monitoring as important characteristics of social marketing. Social marketing has a bottom line to influence behavior. “Normal” marketing has as the bottom line increasing profit, and influencing behavior can be part of this process. In some cases products are designed with the social issue in mind. This in order to have something buyable to promote a certain social issue. The products’ selling should aide the social issue. However, when social marketing is employed, it should not aim to benefit the marketing organization itself. It should promote well-being on

an individual or societal level (Andreasen, 1994). However,

social marketing also has its shortcomings and limitations. Social marketing often has to deal with morals, values and core beliefs whereas business marketing more has to do with opinions and preferences, more superficial opposition. Another problem that might arise, also noted the beginning, is the fact that marketing and social issues do not seem to match. Often times a marketing campaign for social issues can be seen as wrong or as manipulating the public.

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Another way that social marketing might get in the way of its true purpose is the facts that it starts to look like all the other “promotional noise” that used in the media so often. For the public, the important social issues are hard to divide from the less important business opportunities. Even though social marketing should include programmes that promote social well-being that does not mean that all programmes of social marketing also promote such programmes. What a good social cause is to fight for of course depends on one's values and beliefs. Where some see anti-abortion as a righteous cause to employ social marketing for, the pro-choice side of this debate would probably not agree and see this as the promotion of unhealthy behavior (Andreasen, 1994). From this example, one can also see the interesting notion of competition that arrives with social marketing. To most social issues there is a pro and a con group, people who accept a certain behavior, people who do not. It depends on the social issue how clear this distinction is. In some social debates, both sides are very mobilized and vocal about the issue, wherein another discussion the opinions are more moderate and less extreme. An example of this is also bottle feeding versus breastfeeding (Grier & Bryant, 2004). Social marketers usually divide the audience they are trying to reach into different groups based on the current behavior. Social marketing creates an environment where free choice is at the center, same with vaccination in the Netherlands, it is voluntary. At the same time, it shows the different options the benefits that come with certain behaviors. Of course is the behavior that they are promoting more advantageous than the others. This creates the voluntary exchange. Policy and education do not create this environment where people voluntary make the choice for a certain behavior even though it is not necessarily within their self-interest by enhancing the benefits and minimizing the costs of the promoted behavior (Grier & Bryant, 2004).

Risk communication and assessment

When it comes to choices in public health risks emerge with every choice. So whether you participate in certain behavior or not, the risk is still there. These choices can align with people’s standards and beliefs. Risk communication is a means to an end. When it comes to the government communicating to the public about the risks that are attached to certain behavior it is very important to raise the awareness. Risk communication, like social marketing, does expect a change in behavior after communicating about the matter. When it comes to

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decision-making about the vaccines, parents will look at the perceived benefits and at the perceived costs and risks associated with the different alternatives. They will also assess the perceived severity of the disease and how likely their children will be to get it (perceived susceptibility). These assessments will all be factored into the decisions they will make in the end. Risk communication tries to build the bridge between the expert information and risk assessment and the “social and cultural” information that people rely on to make their own risk assessment. Individuals do not necessarily make rational decisions, how they feel about something and what their intuition says is often just as important as what the analytical side of the story-portraits (Petts & Niemeyer, 2004). Plough and Krimsky (1987) describe this as technical and cultural rationality. It is up to the regulators (government, GP’s, health center etc.) to reconcile these two rationalities and provide people with the correct information to make the right decisions. This also makes that different individuals perceive different situations as risky. Risk communication can be defined as “any public or private communication that informs individuals about the existence, nature, form, severity or acceptability of risks” (p.6, Plough & Krimsky, 1987). One of the disparities one can see in the different ways of communication between the government and the online action groups is that the online groups focus more on the value side of the decision. They focus how your parental values match or mismatch with the decision to vaccinate. How it relates to what matters to them. On the other hand, the government main focus lies on the numerical information communicating about risks and benefits (Witteman et al., 2015). Risk communication also focusses very specifically on the public that they are trying to reach and the message they need and can understand. It is a purposeful exchange of information. When looking at risk it might seem something that is easy to set into numbers, to quantify. This also means that risk can be calculated and in that sense evaluated rationally and choose the option with the least risk. However, this is usually not how it plays out. Risk assessment and risk communication are not just a rational process, there are many more factors in play(Alaszewski, 2005). As Peter Sandman (1978) puts it: “the risk that kills you are not necessarily the risk that anger and frighten you” (p.21). Sandman differentiates two functions of risk. There is hazard which is defined as the technical assessment of risk and there is outrage which is defined as the cultural view of risk. Communicating and acknowledging both of these function is important in risk communicating. The public outrage is usually something that is forgotten (Reynolds & Seeger, 2005). Risk managers see risk in a

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different way than the public does. Here again, bridging the gap between the numbers and the social construction is very important. Public concern needs to be increased in order to make people outraged about a certain issue enough to take action. It is upon the government to play and communicate it in such a way to point the nation’s attention towards the right hazard to be worried about. It is the more subjective part of the risk, the social construction of it and specific to circumstances and relationships where the risk perception begins. The numbers and statistics have some influence on this part of risk but there are many more factors that impact the risk perception (Alaszewski, 2005).

Both social marketing and risk communication social trust is crucial. Social trust is the willingness to rely on those who have the responsibility for making decisions and taking actions related to the management of technology, the environment, medicine or other realms of public health and safety (Chen, 2015). Without the trust of the public, the chances of the regulator to change the behavior are very slim. People often use personal experiences or contextual information to judge the trustworthiness of a doctor or government official. Information that is given by a source with a commercial interest is often viewed with a lot of suspicion. This is also why many do not trust pharmaceutical companies (Alaszewski, 2005). The public is also not a passive receiver of information. People often go looking for the information that justifies their distrust. This is found on online platforms with like-minded

people who share their concerns. So how are

these risk perceptions created? According to Alaszewski (2005), the response to the information provided by the government is based on social context, their own personal need for security and the extent to which they trust the source of the information. Risk perceptions are beliefs about potential harm. An important thing to take into account when it comes to immunization is the omission bias. People feel more guilty about the negative outcome from something that they chose to do than from something that they did not choose to do. So if they vaccinate and their child experiences serious side effects, they more likely feel more guilty about those then when their child is not vaccinated and ends up getting the measles (Witteman et al., 2015). Research done by Brewer and colleagues in 2007 shows that there is a substantial link between risk perception and behavior. In this research, they look at perceived likelihood, susceptibility and severity as factors that make-up the risk perception. Reyna (2012) also points out that the decision to vaccinate ultimately arrives at choosing between feeling okay

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without the vaccination versus taking a chance with the vaccination which can turn out in feeling okay or feeling not okay because of the side effects.

3. HPV vaccinations

Immunisation and child immunization in particular in central to any public modern public health system (Hobson-West, 2003). When looking at the history of vaccination the number of vaccines has rapidly increased after World War II. The ultimate aim of vaccination is of course to eradicate the disease, so vaccination is not necessary anymore. By most childhood vaccinations herd immunity plays a big role. When most of the children are vaccinated and have become immune against the infection, the children that are not vaccinated are indirectly protected by the children that are. If most of the children in a population are immune it will make it harder for the disease to spread, slowing it down or stopping it entirely. This will make the probability that a not-immune child will come into contact with the disease much smaller. So having a high vaccination rate for most diseases is

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very important since it will ensure herd immunization and this will help by the disappearance of the disease. The ideal level is around the 95%. In most Europe and the USA, the vaccination programme contains the following diseases: diphtheria, whooping cough, tetanus, haemophilus influenza type b, polio, measles, mumps, rubella, and tuberculosis. The timing when the child is vaccinated does differ from country to country. In the Netherland the vaccinations are divided into 4 categories, one for newborns, in which 6 vaccinations are provided, toddlers in which two are provided, school children in which two are provided and while and then girls in which one is provided, the HPV vaccine. Some of the shots are combination shots, dealing with the resistance for more than one disease, others only treat one. In the Netherlands, vaccination is not mandatory. This is a topic of discussion since France has made 11 vaccination mandatory in 2018. Italy also has mandatory vaccinations. There is a lot of discussion about mandatory vaccinations, some experts say that they work while others claim that such a law is difficult to uphold and check. While most experts agree that vaccination is a public and private good, some see mandatory vaccinations as unethical as it takes away the autonomy of the parents (Petts & Niemeyer, 2004). In other countries like Australia it is linked to childcare benefits, and America it is linked to access to day-care centers and schools. However, in America, it is relatively easy to be considered for an exemption on this rule

(Wiegman, 2018). HPV is an

abbreviation for human papillomavirus. It is a sexually transmitted disease that can cause cervical cancer among other symptoms. It is one of the most common sexually transmitted infections (Palefsky, 2010). There are different types of HPV that can have different types of symptoms. In the 1980’s it was discovered that HPV can be the cause of cervical cancer in women. Type 16 and 18 are responsible for 74% of cervical cancer as well as other types of cancer, like throat, anus, and penis for example. Types 6 and 11 cause almost all cases of genital warts. Since this discovery effort has been put into developing a vaccine. It depends on the vaccination which of the types you are protected against or cannot get anymore (Marlow et al., 2012). HPV is most comely spread during vaginal or anal sex. Intimate skin-to-skin contact can facilitate the transmission. However, a hot and wet towel can also be responsible for transmission. HPV does not necessarily show symptoms which makes it harder to detect. Most women discover that they have a form of HPV when they get the results from their PAP smear. It can take years for someone to develop symptoms after they have been

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infected. In a lot of cases, HPV also disappears on its own, without the infection ever showing symptoms. If it does not go away on its own it usually develops into genital warts or cervical cancer. HPV vaccinations are offered to girls between the ages of 12-13. The vaccination is most effective when it is done before the person becomes sexually active. Mainly girls are vaccinated even though boys can get the infection and the matching symptoms as well. But because it causes mainly cervical cancer it was first and foremost offered to girls, the sex with the cervix. Meanwhile, more and more countries are also offering the vaccination to men in the community. Vaccinating men will not only help the men from getting the infection but it will also help to curb the spread of HPV. The infection itself is very common but the serious symptoms (cancers) are very rare. The use of condoms can protect one against HPV but they are not as effective in protecting against it in comparison to other STDs. The biggest problem and criticism on the HPV vaccination is that it only protects against certain types of HPV and not all. Getting the vaccination can give girls a false feeling of safety, being protected for all STDs while that is not actually provided.

Two different companies have developed vaccines. The first one, Gardasil was approved in Europe in 2006 and the second, Cervarix was approved in 2007. In the Netherlands, vaccines are added to the National Vaccination Programme when they meet certain criteria regarding necessity, efficacy, safety, and costs. After it was established that these criteria are up to par it was decided to add the vaccination to the National vaccination programme. Based on price and effectiveness they have selected Cervarix as the vaccination to use. In 2009 they started with the vaccination and it was officially added to the vaccination programme. They also organized a catch-up campaign for girls between the ages 13-16. Since the vaccination is part of the national vaccination programme the vaccination is free and not mandatory (as with all the childhood vaccinations is the Netherlands). Families get an invitation for the vaccination when their child is in the right age group. In the Netherlands, the RIVM the National Institute for Public Health and Environment (RIVM in Dutch, Rijksinstitute voor Volksgezondeheid en Milieu) coordinates the vaccination programme. The execution of the vaccination is done by the GGD, the health services of the municipality (In Dutch de Gemeentelijke Gezondheidsdienst). The vaccination rounds take place in big sport halls or convention centers, not at schools. In the Netherlands about 750 women a year contract HPV and develop cervical cancer. Around 250 fatalities a year, which makes up for 1% of the

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deaths caused by cancer in the Netherlands. The vaccination should diminish this number with 70% since it does not protect against all the forms of HPV. In the Netherlands children between 12 and 18 have different rights when it comes to their health than children younger than 12. Parents of children younger than 12 can decide for them what kind of medical procedures they do want to be subject to and what not. In the case of vaccination, they can decide whether or not they want to vaccinate them. Children younger than 12 do have the right to be adequately informed by a doctor about the procedure. When it comes to children older than 12 not only the consent of the parents counts but the consent of the child itself too. So both parent and child have to agree with the medical procedure. This rule actually has two exceptions. When it comes to vaccination and abortion the child does not need the consent of his or her parents to have this medical procedure performed. So when it comes to HPV vaccination girls can decide for themselves if they want to be vaccinated.

When the RIVM invites the girls for the vaccination they send a few things: In the first place, there is a letter addressed to the parents about the vaccination. This is a sort of a “save the date”. It is an announcement that their child will soon receive the official invite for the vaccination. The girl will receive a same sort of announcement. In this letter, the RIVM encourages parent and child to decide together whether or not to get the vaccination. They also already give some links to where they can find information about the HPV and the vaccine. Secondly, with the official invite and their vaccination card, they will receive information about HPV. This can be a pamphlet or a mini-magazine with information, frequently asked questions that are answered and sometimes also the experiences of other girls or women of the vaccination or HPV.

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4. Methodology

In this thesis 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?” is central. In order to answer this research question, a summary of the events and research is an important point to start.

The research design is a qualitative case study. The bigger picture this thesis is looking at is the vaccination crisis but for this particular research HPV vaccination in the Netherlands has the focus. The case chosen is the HPV vaccination in the Netherlands. Moreover, this case study makes a comparison over time. The points in time that will be compared are 2009 and 2011. For this research, a case study is chosen because it gives the opportunity to look at this case intensively, very detailed and in-depth. Moreover, it is suitable for the more explorative character of the research. Case studies are useful due to their flexibility, applicability, and ease of use. However, case studies also have a lot of disadvantages. With this research, the objective is not to generalize or make bold statements about vaccination or the vaccination crisis in general. It is merely focussing on understanding the situation in which the HPV vaccination can be found. In this case, the theories that are sued are only tested against a single case and the findings that can be concluded from this research are not widely applicable to other cases. Case studies are very specific but that also makes them not suitable for generalization purposes [ CITATION Ido16 \l 1033 ]. Another criticism of case studies that this research deals with is also the lack of rigor. There are not very clear rules on how to conduct case studies. There are no strict guidelines (Yin, 2014). Moreover, this case studies deals like many case studies with qualitative data, not quantitative. This makes it hard to find a constant variable and makes the research harder to duplicate. Because of the qualitative data, the case studies are often seen as biased. Even if the researcher tries to remove his or her opinion from the research, data often times is still interpreted in a certain way, making it less reliable.

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The next step is data collection. The first step was to assess the information that the government has spread about the vaccination and the process of getting it. In order to know what the themes of concern of the target population are Lexis Nexis will be used. Lexis Nexis is a databank that collects all Dutch newspaper publication, online and offline. The entry “HPV” will be used to collect all the publications that are about HPV and the vaccination. Only one entry word will be used so it can get the biggest range of results. All the results will be assessed on usefulness. Publications that do not match the topic of the research and duplicates of publications will be filtered out. Secondly, the articles will be read to see which concern or concerns come to light in this articles. These concerns can be voiced by parents, companies, interest groups, academics or activists. These concerns will then be categorized into different themes. Not only the concerns will be collected but the positive arguments as well, since we are looking for a more complete picture of the situation. Once the different categories of arguments are established the information provided by the government will be looked to see in how far the issues presented are discussed or mentioned in the government information. Two different points in time are chosen to look at the government information. First, we will look at the information provided in the year 2009 when the vaccination programme had just started. The second point in time is 2011, by then the RIVM had changed their vaccination campaign to suit the negative information about the HPV vaccination. As mentioned before, this thesis will use two different theories. This is because there are also two different sides to this research. On the one side, there are the parents with their concerns and worries. For the analysis of the concerns and worries, the risk communication theory will be used. When assessing the articles elements of the risk communication theory will be looked for and described. For the government side, the social marketing theory will be applied. This theory will help to see if and how the government has changed their social marketing in 2011 relative to 2009.

A content analysis of the news articles will be used to answer the research question. In order to find the overarching themes in which the concerns of parents can be found certain words have to be focused on. When a concern if voiced we will be looking at who is voicing the concern, to whom this person is communicating and the message itself of course. Where does this person put the emphasis on? Has it to do with the amount of research or with the subject of sexual education? Where does this

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person get their information from? What is this person concerned for? When talking about a concern this concern can be defined as a negative connotation that is given to the HPV vaccination by the communicator. This person might give arguments why their child will not be vaccinated or why this person is uncertain of what is the right choice or why this person regrets that they have vaccinated their child. Concerns do not necessarily mean that the person will not be vaccinated, they can also be stated to show a more nuanced picture of the situation. Concerns can range from scientific reasons to policy reasons, to religious beliefs, morals, and standards, healthcare reasons, acceptability and trust in government and media outlets. With every overarching theme, a number of articles will be shown in which this theme can be found and how this theme is

expressed. Once all the articles are collected they will

be searched for certain words and coded accordingly. The aim is to subtract three or four main concerns out of the articles. In order to get to these main concerns, certain words will be used to see how often they pop-up. It depends of course on the actual contents what these buzzwords will be. So far the expectation is that words such as religion (In Dutch: religie), church (kerk) and faith (geloof) will be important. Other words such as side-effects (bijwerkingen), dangerous (gevaarlijk) and safety (veiligheid) are also expected to be significant. Words like usefulness (nut), necessity (noodzaak) and PAP smear (uitstrijkje) will also be part of the group of buzzwords. Once the three or four themes are established the coding will be used to show which articles are important for which theme and how often this theme occurs within these articles. For this research thematic coding has been the main method. Every different theme for its individual color and if a sentence showed evidence of a certain concern to be discussed it would get the corresponding color. Whether the person was negative or positive about the HPV vaccination did not matter for the coding. This was not necessarily something that was disregarded but it was a step that was not found necessary

for the coding process. The limitations of

this research are in the first place that this is a case study. Therefore, the findings are only relevant to one case only and it is not possible to derive plausible generalizations from. A second limitation is the fact that this research fully relies on the information out of the news articles to establish the themes of concern. This research could be more well-rounded if surveys among parents and children were included as well as interviews with experts and activists in the field of vaccination. Thirdly, for this research, only one database is used to find the news

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articles. It is possible that this database does not include all the published information. This way it is possible that different databases give a very different result.

5. Timeline

The HPV vaccination was included in the National Vaccination programme in the Netherlands in 2009. When the vaccine was still in the developing stage and not given in any country yet the first news articles in Dutch newspapers started to surface. In 1976 it was established that the HPV infection and cervical cancer were linked. In 2002 the articles about the vaccine, which was now fully developed, reached the Dutch public. The vaccine was presented by American researchers in November 2002. Trouw reported on December 3rd_{in 2002 that the}

vaccine would only work on individuals who had not been sexually active yet, according to American researchers (Becker, 2002). Most of the early coverage of the HPV vaccination was quite neutral in tone, partly because it was of course not sure yet whether or not the vaccination would be introduced to the Netherlands.

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In 2005 the first experiments in the Netherlands were finished and newspapers reported that the vaccination would be available in the next two to three years (Steenhorst, 2005). In 2006 the National Institute for Public Health and Environment (RIVM in Dutch, Rijksinstitute voor Volksgezondeheid en Milieu) announced that they were planning on including the HPV vaccination in the national vaccination programme from 2008 onwards. By then it was also announced that this vaccination would be offered to 12-year-old girls (van Beek, 2006). The Health council (Gezondheidsraad) were still researching the vaccination. The health council has to approve the vaccination before it can be implemented in the programme. The council’s main concerns were whether or not parents would accept the vaccination since its relationship with sexual behavior. The advice of the Health Council includes money, side-effects, and norms and values of the Dutch society. The HPV vaccine was and is a very expensive vaccine. When it is included in the state’s vaccination programme it means that every girl in the Netherlands would get the vaccination for free so it also a very costly step to take for the RIVM (Köhler, 2006). In 2007 to get vaccinated would cost €375 for the three vaccinations that are needed to be fully protected. Only some of the Dutch health insurance companies would reimburse this vaccination and only if the individual in question had one of the most expensive health insurance plans. At this point, it was not clear for how long the vaccination would be effective. Some experts said that they expected the vaccination to act very similar to the vaccination for Hepatitis B, which is effective for a very long time. For other experts, this uncertainty was a reason to not be in favor of the vaccination. In 2007 the Panel of Health insurance (in Dutch College van Zorgverzekeringen, CVZ) advised the minister of Public Health at the time, Ab Klink, to not add the HPV vaccination to the basic health insurance (which every person living in the Netherlands has to have). According to the CVZ, the effectiveness of the vaccination was not proven or not proven enough. They also advised to include it in the state’s vaccination programme in order to obtain a high (enough) percentage of vaccination (Becker, 2007). At that point in time, not many girls were vaccinated against HPV since the vaccination was so expensive. Moreover, it was not clear yet whether or not the vaccination would be included in the state’s programme so most decided to wait it out. In April of 2008, the advice of the Health Council was that the vaccination should be included in the state’s vaccination programme and should be available to girls who reach the age of 12. On the 19th_{of October 2008 the critical television}

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programme “Zembla”, which aired on the National Public Broadcast made a very critical and revealing episode about pharmaceutical companies and the way they promote their drugs. In this episode, the HPV vaccination was used as a prime example of how it was promoted by parents and daughters through magazine articles, television programmes and the like. The vaccination campaign would start in September 2009 for all the girls who turned 12 during the academic year. There would be a catch-up programme for girls between the age of 13 and 16 (NRC Handelsblad, 2008). The catch-up campaign was the first rounds of vaccinations and this started in March of 2009. The RIVM had a campaign to inform parents and their daughters about the vaccination. First, the girls for the catch-up vaccinations were invited and after the summer holiday, all twelve-year-old girls would receive their invitation. The RIVM expected high vaccination rates since the Netherlands has high vaccination rates for the other diseases children are vaccinated against such as polio. The RIVM expected that about 70 percent of the girls would get vaccinated against HPV. This was however not the case. Most vaccination stations got to about 50 percent. In 2017 the vaccinate rate for HPV is around the 45 percent, which is still much lower than the overall vaccination

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is above the 90 percent for most vaccinations.

The cohort of 1997 means that these girls were born in 1997. Children are divided in cohorts in this way since the first vaccination they get are when they are very young and this makes it easier to track who is due for what vaccination. Since these girls are born in 1997 it means that in 2008 they will turn 12 soon, so they are the first cohort. In this case, the cohorts for the catch-up campaigns are not included. Data of the RIVM shows that for the cohort of 1997 (the first cohort of the HPV vaccination) the vaccination rate was 56,0%. The following cohorts were: 58,1% (1997), 58,9% (1998), 58,9% (1999), 61,0% (2000 and 2001), 53,4% (2002) and 45,5% (2003). In the same report of the RIVM (2018, table 3 and 4) it becomes clear that is not just the rate of the HPV vaccination that declines but those of other vaccinations as well. For other vaccinations, the decline is only a few percents. From this one can conclude that between 2009 and 2011 the vaccination rate for HPV increased.

6. Results

When searching on Lexis Nexis for newspaper articles with the search word “HPV” 994 articles are found. Most of them, 894, are published in newspapers. Newswires and press releases are the second category with 63 articles, there are 29 articles published on websites, 10 articles in magazines and journals and 8 articles are published by industry trade press.

Type of news broadcast Number of articles

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Newswires and press releases 63

Websites 29

Magazines and Journals 10

Industry trade press 8

Total 994

The latest news article is published on the 18th_{of May in 2018 and the first}

articles in this category are published on the 19th_{of March in 1993.}

Some articles were duplicates of each other. For this reason, there are 270 articles that cannot be counted as a separate article. Other articles do include the topic of HPV but are not articles that matter for this research so they are excluded as well. These are articles with the topic of a new way of screening for cervical cancer and various other things. This amounts to 175 articles to be excluded. So for the building of the public opinion about the HPV vaccination we end up with 549 articles to use. After narrowing it down to 549 the selection was narrowed down even further. Since we are looking for and focussing on the opinions about the vaccinations in 2009 and 2011 only articles from around that timeframe are included. It was decided to include a few articles from 2008 as well since they can give us a good insight into the climate while the idea of the vaccination being a part of the national programme was introduced. A few articles after 2011 are also included in this selection. For these articles, it was made sure that they discuss the events in 2011, like the results of the new campaign, the vaccination rate or new information that has come out. In the end, 80 articles were used. They are divided into two sections, 2008-2009 and 2010-2013. The first group is the largest with 52 of the articles, while the second group has 38 articles. This can be explained by the fact that while the vaccination was introduced, it enjoyed a lot of media attention and the attention afterward went down. The articles are numbered so it is easier to refer to them. After the selection, we coded the articles. As you can see not all articles are dedicated to a certain section or theme addressed below. However, I did decide to put all the 80 articles in the appendix because they form an important basis of information and were important to get a sense of the kind of news and the tone of the news. Some articles belong in more than one section. These are usually larger articles that discuss more than one theme. In the table, you can see which articles belong to which section.

Themes Article numbers Total number

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31, 32, 56 Safety 19, 67, 53, 1, 30, 24, 25, 32, 59, 58, 26, 39, 56, 14, 22, 75, 33 17 Necessity 50, 24, 19, 67, 25, 30, 78, 79, 80, 53 10

The numbers are in a random order. Since only 35 of the number are displayed the table above it is not to say that the other articles were not important or did not mention any of the themes above. The articles above just mention the topic very clearly and usually also include an opinion. These articles were seen as more

valuable for the analysis. Side

note, some news articles are mentioned in the general bibliography, but not in the appendix. This is because these articles are used for other purposes than the analysis, like establishing the timeline, finding information on other European countries or giving inside in the more recent news reports. Usually, these articles fall outside of the earlier mentioned timeframe and are therefore also not appropriate to be used for the analysis.

7. Analysis news articles

Once the vaccination was formally introduced into the state vaccination programme the resistance started. As expected there was resistance from the religious parents. HPV is a sexually transmitted disease and the risk of contracting HPV is higher when you have multiple sexual partners. Religious parents expect their children to not have sexual contact before marriage and once they're married they will only have sex with their partner, making it impossible to contract HPV, providing both husband and wife did not have sexual contact before marrying. Next to this reasoning, in religious circles, it is also less likely that sexually transmitted diseases are widely discussed. Furthermore, the so-called bible belt in the Netherlands does not vaccinate at all, also not for the other childhood diseases, so the chances of them vaccinating their young daughters for a sexually transmitted infection is also very small. Director Dr. Ruth Seldenrijk of the Dutch Patient association (a Christian patient association, in Dutch the Nederlandse Patiënten Vereniging. NVP) is not pleased with the fact that the RIVM campaign expects that most teenagers and young adults will have sexual contact with different partners. He calls this an uncritical assumption

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(number 36, see appendix). He also adds that he feels that proper sexual education will save more women than the vaccination would. Many of the other resistance was because of the fear campaign that was created, as Roel Coutinho the director of the RIVM at the time called it. Many parents looked for additional information online about the vaccination. Sooner or later these parents found the stories of girls vaccinated in the USA or Japan who died or were paralyzed as a side effect of the vaccine. According to the opposition of the vaccination, the vaccine also caused infertility and chronic fatigue syndrome is most commonly mentioned. Most of this information came from online forums like verontrustemoeders.nl (translation: concerned mothers) or the website of the NKVP (Nederlandse Vereniging Kritisch Prikken), an association that is committed to making parents think more critical about vaccinating their child. Another claim that these organizations make is that the girls are being used as guinea pigs since the vaccine is not tested enough according to their standards. Many of the other articles go into depth about HPV is, how dangerous it is and what the effects of the vaccination will be. Many articles in local newspapers also commented on the turn-out in their area and personal experience of girls and their parents.

8. Dominant themes in media reporting

Religion

The first theme that can be discovered for reasons to criticize the vaccination is a religious theme. In eight articles these religious reasons are used to argue against the vaccination. Most of these have to do with the fact that the expectation is that individuals in the community will lead a life of sexual abstention until they are married. With only one bedpartner the chance to get HPV is substantially lower. Many people in the religious community, therefore, do not see the vaccination as a necessity. Leaders of the religious community also feel offended by the fact that the government sees it as a norm that teenage girls and young women have multiple bedpartners. Another worry for the religious community is that getting the vaccination is seen as a promotion of promiscuous behavior. Now that they are vaccinated the behavior of girls might change. One news article in which the Christian opinion on the vaccination is voiced is article number 23 (see appendix). Christian pathologist Oosterhuis argues that Christians do not have to get vaccinated because of their monogamous lifestyle. He also argues that a promiscuous lifestyle leads to a higher risk of getting HPV.

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Article 45 also shows with its title that the subject is important: “HPV vaccination

is not an invitation for free sex”. It might seem unnecessary to

have a whole separate theme that looks at the religious reasons for people not to vaccinate. However, this also has to do with the fact that the religious community is very prominently represented in the anti-vaccination activism. In the bible belt, the children are structurally less vaccinated and this has been the trend for years, also before the introduction of the HPV vaccination. The fact that HPV a sexually transmitted disease is, of course, adds extra reasons to deny vaccination. To explain the argument even further the arguments to not vaccinated at all will be discussed in this section as well. Pierik (2013) discusses that there is a group of 250 000 people that are fundamentally against vaccination who can be found within the religious community. He argues that most arguments against vaccination are based on the principle of predestination. This entails that everything that happens is someone’s life has been determined by God. Vaccinating someone is seen as interfering with God’s will. It shows a lack of trust in God’s will and plan. Vaccination is also a difficult concept because of its preventive nature which adds to the feeling of denying God’s will. If this child was meant to grow old God would have made sure that he or she would have survived the infection. On the flip side, there are of course religious people who see vaccines and modern medicine as a gift from God. Since God has gifted you with a child is also your responsibility to protect this life. Pierik argues that it is hard to find any part of the Bible that directly argues that vaccination or preventive medicine is not allowed. Part of the reason not to vaccinate is also peer pressure since it has been like this for generations. If children are not vaccinated in certain communities it is also difficult to go against the grain and

decide to vaccinate. Research

done in the Netherlands and outside of the Netherlands shows that vaccination and religion are linked. Research done by Rondy, Van Lier, Van de Kassteele, Rust, and De Melker (2010) suggest that religious political party voters are less likely to accept the HPV vaccination. Research done in America also shows that religious beliefs influence the acceptance of HPV vaccinations a negative way (Marlow, Waller & Wardle, 2007).

Safety

The second theme is safety. There is a much concern about the safety of the vaccine. In 17 articles is the safety of the vaccination a concern by the parents

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and the girls. The safety is a concern because of several reasons. First of all, articles claim that there has not been enough research about the vaccination to determine all the side-effects of the vaccination and the long-term effects. Furthermore, it is not sure how long the vaccination will work and if a follow-up vaccination is needed in 10 years’ time to ensure effectiveness. The research that has been done was on 15-year old girls and not on 12-year-old girls, which some also seen as a problem. Because the vaccination has only existed since 2002 it is impossible to know the long-term effects. This is why associations like NKVP want the government to wait with the vaccination to make sure it is safe. People are scared that it might cause infertility. Girls are warned that they will become a medical experiment by getting the vaccination. Another party that urges the government to wait with the vaccination is the DES center. This is an organization who helps women who were affected by the DES-hormone. The DES-hormone was introduced in 1947 and was supposed to help to prevent miscarriages and was given to most pregnant women at the time. After 30 years the hormone proved to have serious consequences for the mothers, their children and sometimes even their grandchildren. It came to light that the side-effects of the hormone were not researched adequately. The DES center sees a lot of similarities between the HPV vaccination and the DES hormone. An article that was published in 2011 (number 67) urges the RIVM to stop vaccinating girls. They emphasize the fact that the vaccination has been tested on girls older than 12 years old among other criticisms.

Secondly, there are a lot of stories to be found on the internet of girls who suffer from serious side-effects. There are stories of girls who were paralyzed after the vaccination. Chronic fatigue syndrome is also a symptom that is reoccurring in the stories. Neurological problems are reported as well. The television programme Gezond.nu also featured the story of a girl who got the syndrome after the HPV vaccination. This was in 2016 but it does show how this argument is still relevant to the debate. There have also been a lot of stories from negative side-effects all over the world; Sweden, Denmark, the USA, Japan and Spain are some of the countries mentioned. In Japan, these stories are so persistent that only 1 in 100 girls get the vaccination. For complaints about the vaccination, one can contact the pharmacovigilance center Lareb. Here all the stories of side effects are collected and subsequently investigated. So far there has been no evidence found yet that support the stories of the extreme side-effects. The only side-effects so far are normal and can occur by any vaccination

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or injection, like redness or a painful arm for example. In several articles (like number 19) the rumors of possible side-effects are discussed. The RIVM also comments on these side-effects in most of these articles, saying that they are taken seriously, are investigated and so far none of them have given them a reason to stop vaccinating.

The third reason why the safety of the vaccination is debatable stems from the approval of the Health Council. Even though the Council gave a positive advice, they also admit that there are still some uncertainties about the side-effects and the effectiveness of the vaccination. Potential problems should be monitored after the inclusion of the vaccination but the public has a difficult time trusting that the government is also doing this.

Necessity

The third theme is the necessity of the vaccination. In 10 articles the topic of the necessity of the vaccination is discussed. In the Netherlands, all women above 30 have to participate in a smear test once every 5 years until they are 60. This is to test for HPV, among other abnormalities. Since the HPV vaccination does not protect for all the types of HPV that can cause cervical cancer the smear test still has to be done in spite of the vaccination. Many feel like the vaccination, therefore, does not really add anything useful since it does not make this process redundant. Moreover, in the Netherlands, this process is actually very well organized and effective. This is also why the Netherlands is relatively late with the introduction of the vaccination in comparison to other European countries. Around 70% of the women that get the invitation for the smear test participates in the test. Others argue that the vaccination might be enough to protect young women from HPV before they get the regular smear test. Moreover, the 30% of the women that do not take part in the test could benefit from the vaccination. In articles in 2009 the necessity and the usefulness of the vaccination is questioned, for example in article 24. In this article, it is discussed not only the media but also the doctors have their doubts about the utility. The necessity and utility are often linked to the smear test in the articles, like in article 50 published in 2008.

Another argument that questions the necessity of the vaccination is the question of whether or not HPV is “worse enough” to vaccinate against. It might seem like an odd question since HPV can cause cancer. However, in the Netherlands cervical cancer, which the

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vaccine at this point mainly protects against, quite rare. In comparison with other countries our mortality rate caused by cervical cancer is actually quite low (de Kok, Habbema, Mourits, Coebergh & van Leeuwen, 2008). Moreover, HPV usually goes away by itself and does not have any symptoms. The cases in which HPV develops into cervical cancer are rare in general and with the extra screening in the Netherlands even more scarce. However, the people that do get cervical cancer and pass away usually do not participate in the smear test, so there the

vaccination might be able to save some lives. The

third reason that the necessity is questionable is the fact that HPV is a very different sort of virus than other viruses that children are vaccinated against. It does not spread as easily as others meaning that herd immunity is less of an issue with this vaccination. The herd, in this case, is a lot smaller since it will only include the people of the population that are sexually active and have several sexual partners throughout their life. In the long run, the vaccination can create a sort of herd immunity for this group and that will make the virus less prevalent. The HPV vaccination is seen as more of a personal responsibility and benefit than something beneficial for the whole population of the country.

9. Key concerns of parents in the media

Now that the concerns are established the thesis will discuss the concerns and link them to the timeline to highlight changes and similarities over time.

When looking at the news articles it does not seem like the concerns have changed very much. Long-term effects and not enough and not long enough research are still often mentioned by mothers, also in the discussions had in 2018. The stories about chronic fatigue, paralyzed girls and even deaths caused by the vaccination do seem to diminish in effect even though they are still circulating on the internet. The anti-HPV-vaccination-camp in 2010 and 2011 seems to focus more on factual and research-based arguments to fight the facts and the researched based arguments of the RIVM with. Since the RIVM has not changed that much about their communication most of their arguments still stand. The fact the vaccination is two years older also does not make a change for their arguments. The facts and statistics are still the same and new research has not been done yet. Maybe in 15 years there will research that will convince some of the worried parents but for the time being not much will change in that

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other than bruises and headaches, looked into them and declared they had nothing to do with the vaccination since the introduction. However, with the current level of trust in the government, this is not something takes the concern of parents away. Since the HPV infection and the following cervical cancer is something will be discovered in a much later stadium of life for the vaccinated and non-vaccinated girls a logical conclusion is that only time will be able to change the minds of the parents and their daughters. For now all the Dutch and many others can do is to wait for the stories of success or failure of the future. Hopefully the next decades more research will be conducted to take away some of the vague and ambiguous effects and functioning of the vaccination so doubts and worries can be adequately addressed.

Research done in 2011 show that trust in the government and trust in de efficiency and safety of the vaccination were very important factors that determined whether to vaccinate or not vaccinate (Gefenaite et al.).

10. Changes in the vaccination campaign

Now that the general themes of concern are established the attention will turn to the approach of the government. As mentioned before the thesis will start with describing the approach in 2009 when the vaccination was first introduced and will then turn to the situation in 2011.

So in March or September in 2009 the girls and their parents got their invitation for the first round of HPV vaccinations. Since girls do not need the permission of their parents to get the vaccine the letter and the invitation were directed to the girl and not to the parents. The letter did advise the girl to talk about the vaccination with her parents. The letter that parents got about the vaccination was not much different than the letter of their daughter. With the letter, the RIVM also send an information bulletin. In the bulletin, one could find facts and information about HPV and the vaccination and frequently asked questions were