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.