Case of Paradoxical Cultural Sensitivity: Method Study of Web-Based Health Informational Materials About the Human Papillomavirus Vaccine in Israel

"[T]he major challenge for the health authorities is to find ways to implement the objective of communicating information about the vaccination in a way that is transparent and culturally sensitive, even if this raises questions and fears among the public deriving from their culture."

Culturally sensitive materials based on the intended population's cultural background can affect the understanding and effectiveness of health communication. Despite the importance of audience segmentation and theory-driven development of messages (cultural sensitivity (CS) in this study), health organisations do not always take the dimensions of CS into consideration when designing interventions and formulating messages and informational materials. This study aimed to investigate how CS is articulated in the explanatory materials (Hebrew and Arabic) on the human papillomavirus (HPV) vaccine that are posted on the websites of the Israeli health authorities. In addition, the study examined the effect of transparency on the expression of CS in the informational materials.

The paper examines CS, defined here as "the extent to which the ethnic, cultural, and experiential norms, values, behavior patterns, and beliefs of the target population, as well as the historical, environmental, and social factors are expressed in the design, planning, and evaluation of the informational materials and programs for health promotion." A look at Resnicow's CS model follows. It describes surface dimensions - e.g., the use of people, places, language, music, food, and clothing familiar to the intended audience - and deep dimensions, such as the environmental, cultural, social, psychological, and historical factors related to the intended audience that influence their health behaviour.

In Israel, starting in 2013, the HPV vaccine was included as a part of the routine vaccines given in school to girls in the eighth grade and was later extended to include boys. According to the Ministry of Health, in the 2016 school vaccination campaign, the rate of HPV vaccine uptake among the Arab population reached 84% (96% in the Bedouin sector), compared with 40% for the Jewish population. HPV is transmitted through sexual intercourse; the issue of sexual relations in the context of giving the vaccine increases sensitivity regarding the vaccine, particularly among conservative minority population groups such as the Arabs in Israel. (The majority of the Arabs in Israel are Muslim (97% of the Arabs in Israel), who are indeed defined as conservative.)

According to the researchers, balanced health information regarding the HPV vaccine should include 3 main components: (i) completeness: description of the risk of cervical cancer and the vaccine's advantages and disadvantages; (ii) transparency: presentation of all the vaccine-related risks in absolute numbers and not as relative figures; and (iii) evidence-based correctness: provision of information based on science.

The study employed a quantitative and qualitative content analysis of the Arabic and Hebrew texts of explanatory informational materials - 9 in each language - published on the websites of the Israel Ministry of Health and the Clalit health maintenance organisation (HMO). The content analysis was based on comparison with the scientific literature on cervical cancer and the HPV vaccine. In addition, the materials were analysed with reference to concepts from the field of health and risk communication: CS and transparency in communicating texts about health issues.

The findings revealed the differences in the dimensions of CS (based on the CS model by Resnicow) between the informational materials intended for the majority Jewish population and those intended the minority Arab population. In summary:

• In most (78%) of the Arabic explanatory materials assessed, the surface dimension score was lower than 50%. Surface dimension score was higher than 50% for only 2 out of the 9 materials assessed. Conversely, the surface dimension score was equal to or higher than 50% for all the materials (100%) written in Hebrew, starting from 73% up to 91% in some cases (33%).
• All the Arabic explanatory materials assessed scored below 50% on the deep dimension. Most of the materials did not refer to the social or normative values or to the environmental or cultural-ethical indicators. In contrast, the Hebrew explanatory materials received a deep dimension score exceeding 50% in most (78%) cases.

The qualitative analysis revealed, in brief, that:

• The following main themes emerged in the informational materials written in Arabic: (i) women prefer female physicians to carry out tests, (ii) the HPV vaccine prevents cancer among males, and (iii) the HPV vaccine does not legitimise sexuality.
• The way the information was provided in both languages exhibited a lack of transparency regarding the CS dimensions (surface and deep). The materials state that the HPV vaccine is totally safe and effective but make no reference to a variety of other factors affecting safety and effectiveness. Moreover, the findings show that the explanatory informational materials attempt to depict cervical cancer as a serious disease that endangers public health, whereas the HPV vaccine is portrayed as the ultimate solution for cervical cancer, without any suggested alternatives.

Indeed, the researchers identify a paradox in the findings. On the one hand, the materials appealing to the conservative Arab population exhibited CS in that the sexual context of the vaccine was missing. On the other hand, analysis of Resnicow's deep dimensions showed that disregarding the sexual context does not allow the relevant audience to reflect on the barriers and concerns.

This finding can explain the fact that the rate of HPV vaccination compliance among the Arab minority population is more than double the rate among the Jewish population. "Lack of information about the relationship between sexuality and vaccination and the absence of references to moral concerns about sexual behavior following vaccination result in an uninformed and unwise decision-making process. Hence, the Arab population remains unaware that the HPV virus is transmitted through sexual relations, a fact that is liable to lower their compliance rate." Also, the Jewish population has greater access to the internet than the Arab population, as reported here. Thus, the lack of transparency found in the materials in both languages may not impact them to the same degree: The Jewish population may be more exposed to the scientific controversy surrounding the vaccine's side effects through social networking discussions and searching scientific articles online.

In conclusion, the findings of this study indicated that despite the high uptake rate for HPV vaccination in the Arab population, the health authorities did not exercise full transparency and CS in transmitting the association between engaging in sexual relations and the necessity of the vaccination. Recommendations include:

• Make CS a priority in designing explanatory materials intended for minority population groups. This means providing all the relevant information available in the literature in a manner that is comprehensive, detailed, culturally sensitive, and based on scientific evidence to enable each individual to make an independent and intelligent decision based on informed consent.
• Because the media have the power to influence a person's health-related attitudes and behaviours, use media strategies that implement transparency in providing complete information.