The vac­cine against human papil­loma virus—also known as HPV, which is respon­sible for the majority of cer­vical can­cers in women and other dis­eases in men—has been shown to be highly effec­tive in pre­venting infec­tion and has min­imal side effects. Yet many fam­i­lies in Eastern Europe are still skep­tical of taking the vac­cine, according to Irina Todorova, an asso­ciate clin­ical pro­fessor in the Depart­ment of Health Sci­ences, who con­ducts research in that part of the world.

People see [vac­ci­na­tion deci­sions] based on their per­sonal his­to­ries, cul­tural his­to­ries, their expe­ri­ences in the health­care system,” said Todorova, the interim director of the Mas­ters in Public Health Pro­gram in the Bouvé Col­lege of Health Sci­ences. “A new vac­cine becomes a mirror to society and psy­chology. It’s amazing what people project onto a few drops of a vac­cine. It’s only a few drops of liquid in a syringe, but it is loaded with meaning.”

A new study from Todorova and her col­leagues in Eastern Europe sug­gests that his­tor­i­cally embedded con­cerns about the health­care sys­tems in Bul­garia and Romania are at the heart of the skep­ti­cism that exists there and result in resis­tance to vac­ci­na­tion. In the study, they specif­i­cally looked at feel­ings around the HPV vac­cine. The work—funded by the National Council on Eurasian and East Euro­pean Research—was con­ducted in part­ner­ship with  the Health Psy­chology Research Center in Sofia, Bul­garia, and Babes-​​Bolyai Uni­ver­sity in Cluj-​​Napoca, Romania.

When the Berlin Wall fell in 1989, Eastern Euro­peans entered an era of tur­moil in which they were forced to wade through the rem­nants of defunct gov­ern­ment pro­grams, explained Todorova, who is from Bul­garia and was, at the time, a grad­uate stu­dent there. This was true of the health­care system, too: a rou­tine doctor’s visit became a har­ried, con­fusing expe­ri­ence for most cit­i­zens, she said.

This dis­ori­en­ta­tion and dis­trust likely con­tributed to an unprece­dented rise in mor­tality rates in the years fol­lowing the democ­ra­ti­za­tion of the region. The death rates per year in coun­tries like Russia, Romania, and Bul­garia were already well above their Western Euro­pean coun­ter­parts, but by 1993 those num­bers had soared even higher.

Todorova said that pol­i­cy­makers there need to be more aware that soci­etal trends on a broader level—such as reforms and finan­cial cor­rup­tion in the health­care system—can lead to people avoiding impor­tant pre­ven­tive health inter­ven­tions such as screen­ings and vaccinations.

[We hope the study] will make pol­i­cy­makers or even indi­vidual providers sen­si­tive to the fact that when people are resisting some­thing like a vac­cine, there’s a logic behind it that makes sense,” Todorova said. “It’s not just that they’re avoidant or unin­formed or uneducated—in fact, the more edu­cated people are, the more they’re avoiding it.”

Todorova and her col­leagues spent the past three years researching atti­tudes and beliefs around the HPV vac­cine. They inter­viewed about 30 par­ents from each country who faced the deci­sion of vac­ci­nating their daugh­ters. They also spoke with health­care providers, pol­i­cy­makers, and even phar­ma­ceu­tical com­pany employees, and they ana­lyzed media mate­rials and online dis­cus­sion forums.

They found that fam­i­lies’ deci­sions not to vac­ci­nate their daugh­ters were due not only to dif­fi­cul­ties nav­i­gating the health­care system but also dis­trust and sus­pi­cion of the government’s free vac­ci­na­tion pro­gram. Par­tic­i­pants expressed con­cern about the program’s safety, inad­e­quate quality, and that it was being tested for the first time on Eastern Euro­peans. These fears were evi­dent in Bul­garia but were much stronger in Romania, Todorova said.

Despite Romania’s pro­gram pro­viding free HPV vac­ci­na­tions for teenage girls, the vac­ci­na­tion rate is a mere 2 per­cent. In Bul­garia, the cost of vac­ci­na­tion was greater than the average monthly salary, and thus was also not widely used there. The Bul­garian gov­ern­ment recently began offering insur­ance cov­erage for the vac­cine, but the impact is still unknown.

The new study is an exten­sion of its 2006 study of cer­vical cancer screening prac­tices. Many Bul­garian and Romanian women they inter­viewed per­ceived eco­nomic prob­lems, unem­ploy­ment, stress, and caring for their fam­i­lies as much more impor­tant than receiving pre­ven­ta­tive health­care for them­selves. Fur­ther­more, attempts to reform and over­haul health­care in the years after the Berlin Wall fell led to even more con­fu­sion, and nav­i­gating through the many rule changes fur­ther com­pli­cated people’s ability to receive the health­care they desired.

For cer­vical cancer in par­tic­ular, the num­bers in Romania and Bul­garia were among the highest in Europe and were still rising after 1990.

This is a very con­trol­lable dis­ease it shouldn’t be leading to these kinds of mor­tality rates,” Todorova said.