The feasibility of including human papillomavirus vaccine in Iran's national immunization program

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Owing to these pioneering efforts, different vaccines have been produced for many diseases which were previously the source of human pain and suffering.<a class="elsevierStyleCrossRef" href="#bb0005">1</a> Global vaccination has significantly decreased the incidence of much life threatening diseases<a class="elsevierStyleCrossRef" href="#bb0010">2</a> such as pertussis, Tetanus, Diphtheria, Poliomyelitis and Measles.<a class="elsevierStyleCrossRef" href="#bb0015">3</a> In Iran, the national vaccination program which includes oral polio vaccine, inactivated polio vaccine, BCG, hepatitis B, diphtheria, tetanus, whooping cough, measles, rubella, mumps and influenza is implemented based on a certain schedule from the first day of birth throughout life course. Although the immunization program has had significant achievements, some important vaccines like human papillomavirus vaccine which is included in vaccination program of more than seventy countries worldwide like US, Britain, Australia and China is absent in this program.<a class="elsevierStyleCrossRef" href="#bb0020">4</a>Human Papilloma Virus(HPV) is largely a sexually transmitted virus; about 100 types of it have been identified so far, and nearly 35 types of this virus are found in the genital tract.<a class="elsevierStyleCrossRef" href="#bb0025">5</a>Molecular and epidemiological studies suggest that certain types of HPV are the primary cause of cervical cancer. Cervical cancer is the fourth most frequent cancer in women with an estimated 570,000 new cases in 2018, representing 6.6% of all forms of female cancer. Approximately 90% of deaths from cervical cancer occur in low- and middle-income countries. The high mortality rate of cervical cancer worldwide could be reduced through a comprehensive approach, including prevention, early diagnosis, effective screening and treatment programs.<a class="elsevierStyleCrossRef" href="#bb0030">6</a>,<a class="elsevierStyleCrossRef" href="#bb0035">7</a>Epidemiological evidences extracted from studies on factors contributing to HPV carcinogenesis include parity, use of oral contraceptives, tobacco smoking, having other sexually transmitted diseases, and dietary and nutritional factors.<a class="elsevierStyleCrossRef" href="#bb0040">8</a> HPV infection causes almost all cervical cancers, 80% of anal cancers,<a class="elsevierStyleCrossRef" href="#bb0045">9</a> 60% to 80% of vaginal cancers, 40% of vulvar cancers,<a class="elsevierStyleCrossRef" href="#bb0050">10</a> and 20% to 70% of uterus and cervical cancers.<a class="elsevierStyleCrossRef" href="#bb0055">11</a> In addition, HPV 6 and 11 cause 85% to 90% of all genital warts.<a class="elsevierStyleCrossRef" href="#bb0060">12</a>,<a class="elsevierStyleCrossRef" href="#bb0065">13</a>Traditionally, prophylactic vaccines that generate virus- specific neutralizing antibody have been cost- effective means to control viral diseases.<a class="elsevierStyleCrossRef" href="#bb0070">14</a> Fortunately, in 2006, two Cervarix (2vHPV) and Gardasil (9vHPV) vaccines were produced to prevent this disease. The quadrivalent vaccine in 2006, and the bivalent vaccine in 2007 was first licensed in over 100 countries.<a class="elsevierStyleCrossRef" href="#bb0075">15</a>,<a class="elsevierStyleCrossRef" href="#bb0080">16</a>Cervarix, Cecolin, Quadrivalent Gardasil and Gardasil are prophylactic HPV vaccines designed primarily for cervical cancer prevention. Cervarix is effective against HPV-16, -18, -31, -33 and -45. Gardasil is effective against HPV-16, 18 and 31. In addition, Gardasil is effective against HPV-6 and -11, causes of genital warts and respiratory papillomatosis.<a class="elsevierStyleCrossRef" href="#bb0085">17</a> In all studies conducted on HPV, vaccine immunogenicity was more than 90%; it reduced almost 99% of cervical cancer caused by 16 and 18 genotypes and reduced about 81% of vulvar and vaginal cancers.<a class="elsevierStyleCrossRef" href="#bb0090">18</a> Studies conducted in different parts of Iran have clearly shown the causal relationship between HPV and genotype 16 in cervical lesions. Hence, administering HPV vaccine can significantly reduce the incidence of cervical cancer.<a class="elsevierStyleCrossRef" href="#bb0095">19</a> Nowadays, the HPV vaccine has been introduced in more than 150 countries all around the world.<a class="elsevierStyleCrossRef" href="#bb0035">7</a> However, it is mostly used routinely in developed countries, and developing countries do not mainly use it due to its cost and some other factors.<a class="elsevierStyleCrossRef" href="#bb0100">20</a> An important factor that can be considered in the lack of major use of vaccine in Iran are the ethical issues.Making decisions regarding the inclusion of a new vaccine in the national immunization program requires several assessments; in other words, it must be examined from many different aspects in an HTA including economic evaluation, efficacy, effectiveness, and ethical feasibility.<a class="elsevierStyleCrossRef" href="#bb0105">21</a> Therefore, this study is a part of a bigger project<a class="elsevierStyleCrossRef" href="#bb0110">22</a> which is aimed to assess the feasibility of inclusion of the HPV vaccine in the Iran's national immunization program. Various ethical principles can be used to evaluate health policy decisions. The issue of inclusion the HPV vaccine in the vaccination program was studied with regards to ethical principles. These principles consist of justice, patient rights and moral principles. Also to this end, ethical theories of principlism and principle of double effect were applied to prepare the interview guide and to interpret the results.Material and methodsThis is a qualitative case study which recruited semi structured interviews with a purposive sample of 12 participants (Three experienced midwives working in hospitals, three working in health centers and 6 experienced obstetricians working in public and private hospitals) . Thus, it used qualitative research which presented some tools to investigate these factors and helped achieving some deep and good information of samples.<a class="elsevierStyleCrossRef" href="#bb0115">23</a> Purposive sampling was used to collect data from the most knowledgeable people. We identified our samples from different sampling sites including public health centers, public and private hospitals. In- depth and semi-structured interviews explore the experiences of participants and the meanings they attribute to their experience. During the interview, researchers asked open-ended questions, in one-to-one interviews. Tong et al. provided a checklist of 32 items for reporting on qualitative studies.<a class="elsevierStyleCrossRef" href="#bb0120">24</a> The finding was reported) based on items related to sampling method, description of sample, method of data collection, method of recording data, number of data coders, data and findings consistency, data saturation, inclusion of supporting quotations and clarity of major and minor themes.The participants were selected from midwives and obstetricians who were interested in the subject, had some research in this field and those who were willing to participate in the study. In the first step, interview guide was designed reviewing related literature<a class="elsevierStyleCrossRef" href="#bb0125">25</a> and consulting experts. After that, an in-depth pilot interview was conducted with a midwifery school faculty and the interview guide was finalized. Due to the data saturation i.e. the point we felt sufficient data was attained to reach essential conclusions, and any additional data collection would not yield new insights, the process of interviewing was stopped on the 12th session. Every interview lasted between 20 and 30 min. The interviews were recorded and transcribed. Verbal consent of the participants was ensured in advance and we did not reward the interviewees financially.Four criteria of acceptability, transferability, reliability and verifiability were used to ensure the validity, accuracy, and reliability of qualitative data.<a class="elsevierStyleCrossRef" href="#bb0130">26</a> To ensure the acceptability of data, participants were chosen from different hospitals and private clinics; the interviews were conducted in the period of 6 months. Some points such as allocation of sufficient time to collect data, good relationship with the participants in the research and simultaneous note- taking and recording data were taken into consideration during the study. In addition, the codes prepared from the interviews were given to the participants and were approved after necessary corrections. To ensure transferability, all project steps, environment, and the field of implementation is completely explained. To provide the reliability criterion, research process was assessed by experts who had conducted some qualitative research; after reviewing the research process, they confirmed the results. Since three previous criteria of reviewing the validity and reliability of qualitative research were provided in this study, it can be concluded that verifiability was also approved and confirmed.Framework analysis was used to analyze data. Being familiar with the range and diversity of issues, the researchers identified key concepts and issues, designed a framework and finally reviewed all notes related to the individual interviews based on the framework.We also designed a thematic framework according to the resources, compared concepts, contradictions, theories, experiences and research, and extracted necessary patterns and relationships from the findings.<a class="elsevierStyleCrossRef" href="#bb0135">27</a> No software was used during these steps; all steps were done manually. Initial framework consisted of 8 concepts which were later reduced to 6. Subgroups of each of these components also changed. In the findings section, the letter “P” along with a number represents a participant which has been quoted from.ResultsUsing framework analysis to identify feasibility of including HPV vaccine in the national immunization program, 6 themes and 14 subthemes were identified in this research (<a class="elsevierStyleCrossRef" href="#t0005">Table 1</a>).<elsevierMultimedia ident="t0005"></elsevierMultimedia>Theme 1: The need for vaccineAnalyzing the interviews showed that the vaccine is seriously needed in Iran; in this case, we identified four subthemes.Lack of screeningAccording to most experts, one of the most important reasons why vaccine is needed is that Iranian women do not refer to clinics for screening. Owing to women's unawareness of the importance of screening and decreased activity of health centers in this regard, a small number of women refer for screening. One of the interviewees stated that “our women have little information about the screening and its importance; therefore, in many cases they refer at final stages of the disease, which is too late” (P 1).Lack of awareness of the diseaseMost people in the society are not aware of the existence of such a serious disease and its transmission (Medical personnel perception). It means that we have some people who may be carriers of the virus without even knowing; in this case, it is dangerous both for themselves and for their sex partners. In this regard, an interviewee mentioned that “A lot of people have never heard the name of this virus, let alone knowing something about the diseases related to it or how it is transmitted” (P5).The onset of sexual relationships at early agesDue to changes in cultures and traditions, the onset of sexual relationships has decreased to, according to several experts, the age of secondary school. Moreover, the marriage age has increased compared to previous years, which has resulted in increased premarital sexual relationships and increased number of sex partners. One of the interviewees believed that “although it is assumed that the situation in our country is different from the situation in western countries in terms of sexual relations, it is not in reality” (P 8). Another participant said “We really need this vaccine because the onset of sexual relationships has started to be practiced at younger age, There is a 14-year-old girl among my patients” (P 9).EquityOne of the reasons why this vaccine is required is equity. From the equity perspective, all people should have access to health which is a public good, and no one should be deprived of this health right due to financial problems. Since first being licensed at the beginning of 2006, over 270 million doses of HPV vaccines have been distributed globally. GACVS reviewed the safety data of this vaccine. Early on, the Committee was presented signals related to anaphylaxis and syncope. No other adverse reactions have been identified and Global Advisory Committee on Vaccine Safety (GACVS) considers HPV vaccines to be extremely safe. WHO recommends that HPV vaccines be introduced into national immunization programs provided that: prevention of cervical cancer and/or other HPV-related diseases constitute a public health priority; vaccine introduction is programmatically feasible; sustainable financing can be secured; and the cost-effectiveness of vaccination strategies in the country or region is considered.<a class="elsevierStyleCrossRef" href="#bb0140">28</a> but it is not possible in Iran because the vaccine in Iran is not in the national vaccination program and only the rich can afford this vaccine, but those who don't have financial ability and those who really need this vaccine (e.g., sex workers) cannot afford it; and this is against equity. An interviewee stated that “in my opinion, it is completely unfair that only the rich are able to buy this vaccine. That is, the richer you are, the healthier you must be!!!” (P 4).Theme 2: lack of knowledgeAnother issue mentioned by the participants was public unawareness of such vaccine.No exact informationOwing to poor information, almost all people of the society are unaware of the existence of such a vaccine. This reflects poor performance of the relevant departments and mass media. In this case, one of the interviewees believed that “less than 1% of people know this vaccine. Unfortunately, even most of physicians are not familiar with it” (P 6).Theme 3: cost factorsAnother important problem is people's inability to buy this important and essential vaccine.High cost of vaccineCost is a potential barrier for countries that are considering introducing HPV vaccine into national immunization programs, as like other new vaccines; it remains considerably more expensive than traditional vaccines.<a class="elsevierStyleCrossRef" href="#bb0145">29</a> This vaccine costs about 12 million rials (Iranian official currency at the time of study); owing to people's salary level and income distribution in Iran, most people cannot afford this expensive vaccine. According to all interviewees, only high-income groups can buy it. One of the interviewees mentioned that “As far as I know, this vaccine is only used by the physicians due to its high price” (P 12). Another interviewee stated that “people with risky behaviors like sex workers often have financial problems and do not have the ability to buy this vaccine, so the government must support them” (P 11).Theme 4: administration at early agesAdministration of the vaccine at early ages is useful and effective.Lower age of onset of sexual relationshipsAs mentioned above, the onset of sexual relationships has changed a lot compared to the past. It increases the need to have the vaccine at early ages because this vaccine is more effective when the person has not started sexual relationships. Thus, it seems logical that this vaccine be given to people at an early age. One of the interviewees believed that “in the past, all of us were ignorant about sex and sexual matters before the marriage, but nowadays even elementary and secondary school children know these issues and start their sexual relationships at early ages due to curiosity and changes in their culture” (P 4). Another interviewee stated that “According to our data (which is not documented) and a series of statistics extracted by sociologists, more than 60-70% of our teenagers have sex and it is predicted that this numbers will dramatically increase in the near future” (P 1).Theme 5: creating a negative mindsetAlthough this study reflected the need for this vaccine, participants were concerned about the fact that vaccination could have a false sense of safety among the people.Possibility of increased risky sexual behaviorsAn important issue mentioned in the interviews was people's attitudes towards false sense of safety following vaccination; it could increase high-risk sexual behaviors. Most interviewees believed that if people were informed about the exact nature of the vaccine and about the fact that this vaccine can only prevent some diseases and does not immunize them against other dangerous sexual diseases, this problem would not appear. An interviewee said that “If, at the time of injection, the patient and the family are informed that this vaccine can only immunize them against this type of virus and cannot prevent other sexually transmitted diseases (STD) such as HIV and hepatitis, the likelihood of high-risk behaviors will decrease” (P 7).Theme 6: empowering the society and health care systemOne of the issues mentioned in the interviews was having good infrastructures to introduce the vaccine in the community and in the national vaccination program. In order to introduce any new vaccine, its suitable infrastructures must first be provided in the society and among people; otherwise, it is less likely to be accepted.MediaMedia has long played an important role in informing people of the society. Understanding the world around us and knowing the events and incidents show us the key effects of mass media. Due to the influence of the media on all levels and category of the Iranian society and the trust that people have in the media, it can be said that they are one of the strongest communicative tools and bridges to introduce this vaccine to all members of the society. Among these tools, TV has always been selected by the people due to its certain and special attractiveness and has had a key role in informing the people. One of the interviewees stated that “there are few radio and television programs about cancer; therefore, our people have little information about this disease because media authorities have wrong ideas in this regard. That is, media are not very active in informing people, so many Iranian women still do not know what Pap smear is” (P 8). Another interviewee mentioned that “media have profound effects. For example, AIDS was completely unknown in our society a few years ago, but media informed people of this disease and now you can see that most people are familiar with it. We can, in this way, create and increase sensitivity in the society, especially among women” (P 3). If we talk to the experts in this field and if there is an opportunity for questions and answers, we will certainly witness remarkable growth in people's awareness, especially women; subsequently, the consequences of this dangerous disease will decrease. One of the interviewees mentioned that “most of our women are housewives and are always free. If we design a series of programs for them so that they can ask their questions, we will take a big step towards their understanding, and we can encourage them to have screening and vaccination” (P 4).Increasing educational programsOne of the most important and effective ways to increase people's information about this disease and its vaccine is to increase educational programs related to this issue. These programs can be designed in different ways: holding conferences and seminars for the public, having promotional products in various parts of the city, etc. One of the interviewees said that “If we pay more attention to people's health and knowledge instead of advertising chips and snacks, we will certainly have a healthier society” (P 9).Improving the role of health centers and health workersAnother solution is to introduce the vaccines and to highlight the role of health workers and health centers in informing people and having preventive tests for rural women. If these people regularly refer to health centers in rural areas, the disease can be detected sooner and much easier and the burden of worrying about these people decreases. An interviewee stated that “health workers and family physicians know, to huge extent, people with risky behaviors, and can teach them and introduce them for screening” (P 2).Having Pap smearAnother important issue which must be taken into huge consideration is to encourage people to have an annual Pap smear. Providing some facilities such as paying half or, if possible, all the cost of a Pap smear, the government can encourage people to have an annual Pap smear to prevent STDs. One of the interviewees stated that “rural women are at lower risks due to more limited sexual relationships. If we can launch an annual Pap smear program in the health clinics, the follow-up is enough for them” (P 6).Informing peopleGiving accurate and necessary information to the target group and their parents is one of the cases that provides a suitable opportunity to introduce and use this vaccine; otherwise, the culture of the society and parents' thoughts may prevent using such vaccines. An interviewee stated that “If the parents are told why this vaccine is given to their children, they will resist it even if they know that their children have risky behaviors. Thus, it is better to tell them that this vaccine is given only to prevent uterus cancer” (P 10). Another interviewee said that “concerning people's perception, we must give them full explanation of the advantages and disadvantages of the vaccine and also the best time to have the vaccine with regard to age and previous infection with HPV” (P 12).Correcting the attitudes of policy makersPerhaps one of the reasons why HPV vaccine has not been included in the vaccination program is the opposition of policymakers. Since Iran is an Islamic country which has special cultural conditions, policymakers strongly disagree with placing this vaccine in the vaccination program. However, if they become aware of the existing conditions in the society such as the exact number of people who suffer from cervical cancer and the prevalence of sexual relationships at early ages and among adolescents, they may agree with this vaccine. An interviewee stated that “policy-makers disagree with this issue because they believe that we, as an Islamic country, shouldn't have sexual relationships outside family; they also believe that having this vaccine means accepting immoral relations. However, today we need this vaccine due to changes in the culture and emergence of some issues” (P 7). Another interviewee believed that “policy-makers are absolutely wrong, and we must show them the exact statistics so that they can realize that Islamic conditions have not prevented this disease and its high mortality” (P 3). One of the interviewees argued that “policymakers are wrong because even if we have fewer sexual relationships among teenagers compared with advanced countries, we have the issue of temporary marriage in our country, and it is an important factor in having HPV. Thus, this issue must be taken into huge consideration” (P 10).DiscussionThis study determined the feasibility of introducing HPV vaccine in the national immunization program. The probability of getting disease because of unawareness, inability of some at risk groups to buy the vaccine, and the necessity of having the vaccine at early ages, were the factors stressed for inevitability of including the vaccine in the national program,however, to avoid some difficulties the society should be empowered to evade building a false sense of safety against all STDs.This study showed that lack of screening doubles the need for the vaccine. Karimi et al. have also mentioned this problem. In their study conducted in Yazd, only 2% of women with cervical cancer had Pap smear before cancer diagnosis.<a class="elsevierStyleCrossRef" href="#bb0150">30</a> In a study conducted in Tehran, less than 50% of the studied women (aged 15 to 45) had done Pap smear at least once. Half of the women had no information about Pap smear, and less than half of the patients knew the right time to do it.<a class="elsevierStyleCrossRef" href="#bb0155">31</a> In a study carried out by Farajzadegan et al., it was shown that cervical cancer is one of the diseases that is heavily influenced by social, economic, and geographical conditions. Studies conducted in different regions of Iran indicated unsuitable screening conditions for cervical cancer in Iran.<a class="elsevierStyleCrossRef" href="#bb0160">32</a> Given that the annual incidence of this cancer is 4.5 in every 100,000 people,<a class="elsevierStyleCrossRef" href="#bb0165">33</a> it is very essential to have this vaccine in the national vaccination program. However, placing it in the vaccination program does not mean that screening program isn't required anymore and screening and Pap smear still remain important and necessary.People's unawareness of this disease is another reason why this vaccine is needed. In their study, Salehifar et al. examined female students' awareness of cervical cancer and HPV and their attitude towards this vaccine. Their results showed that most of the students (66.8) had little information about this disease and only 5% had good knowledge. About 25% of the students had a positive attitude towards HPV vaccine, while 2.5% had a negative attitude. More than 70% of the participants reported that if the vaccine was available, they wished to receive it.<a class="elsevierStyleCrossRef" href="#bb0170">34</a> Thus, developing programs to improve community's awareness seem appropriate to reduce incidence of cervical cancer.According to the present study, the change in the culture and presence of sexual relationships at an early age is another reason why this vaccine must be introduced in the vaccination program. Results of several studies have shown that premarital sexual relationships have increased in recent years among young people.<a class="elsevierStyleCrossRef" href="#bb0175">35</a>Little research done in this area suggest that premarital sex is increasing in Iran.<a class="elsevierStyleCrossRefs" href="#bb0180">36–38</a> Young generation and risky behaviors among young people have become one of the most alarming factors in Iran.<a class="elsevierStyleCrossRef" href="#bb0195">39</a>,<a class="elsevierStyleCrossRef" href="#bb0200">40</a> The officials are concerned about the possibility of increased AIDS among young people. They consider risky sexual behaviors in this age a factor for the formation of the “third wave of AIDS” in Iran. A complicated problem is emerging, and the prevailing policy is to ignore it.<a class="elsevierStyleCrossRef" href="#bb0205">41</a>In his research, Darznik showed that Iran's society has faced a widespread change in values and many young people considered premarital sex completely healthy and normal. His research revealed that uncontrolled sex has increased in Iran, and that many of the young middle-class and upper-class people do not use tools to prevent STDs. He also showed that it could increase the risk of diseases such as AIDS among them.<a class="elsevierStyleCrossRef" href="#bb0185">37</a>In another study, Azad Armaki and Sharifi Saie showed that illegitimate and anomic behavioral patterns have increased in the society due to the marriage problems and closure of legitimate ways of sexual relationships. People try to seek new ways to satisfy their needs and formation of relationships which in most cases, is based on sexual desires.<a class="elsevierStyleCrossRef" href="#bb0205">41</a> This is in line with the viewpoints of the participants who indicated that there were premarital sexual relationships among Iranian youth and that these relationships would have adverse mental and physical consequences.Whether this vaccine is required in Iran or not, can be examined from the perspective of equity. Health equity is achieved when all people of a society can maintain their full health, and their social and economic status has no effect on their health. In other words, “equal care for equal need”.<a class="elsevierStyleCrossRef" href="#bb0210">42</a> In the current situation, only wealthy people can buy this vaccine. In the definition of vertical Justice, it has been stated that “unequal must be treated differently”. Vertical equity emphasizes that those with additional needs must receive more services and supports.<a class="elsevierStyleCrossRef" href="#bb0215">43</a> However, the opposite is happening under present circumstances, and people in need are not supported. Since people who do not have good financial conditions are mainly at lower cultural and social classes and therefore have more risky behaviors, they need the vaccine more but cannot buy it due to financial problems.One of the issues identified in this study was people's unawareness of this vaccine; it stems from inadequate information in the society. According to the experts, less than 1% of the population is aware of this vaccine.<a class="elsevierStyleCrossRef" href="#bb0220">44</a> Thus, the role of timely information is very important to adopt preventive measures including HPV vaccine administration.The relative high price of the vaccine was another problem stated in the interviews. Health as a public commodity has two major characteristics: 1) its consumption by one person does not affect the consumption by another person (non-competitiveness), and 2) it is not possible to exclude people from consuming it (exceptionality).<a class="elsevierStyleCrossRef" href="#bb0225">45</a> A bigger gap between the richest and the poorest people is equal to the bigger inequality in health.<a class="elsevierStyleCrossRef" href="#bb0230">46</a> The high price of the vaccine prevents people in need from acquiring it; that is, people who are not in good financial conditions do not have access to health which is a public commodity.The lower age of onset of sexual relationships was another matter that necessitated having this vaccine at earlier ages. In their research, Garmaroudi et al. examined 2400 high school students (14 to 17 years old) and concluded that more than 20% of them had experienced sex in their lives.<a class="elsevierStyleCrossRef" href="#bb0190">38</a> Khalajabadi and Mehryar also mentioned that about 25% of single female students at Tehran universities had a kind of sexual relationship in their lives; of them, 10% had full sexual relationship.<a class="elsevierStyleCrossRef" href="#bb0180">36</a> Results of a report by the Ministry of Health revealed that about 20% of boys and less than 10% of girls had experienced sexual relationships before the age of 20. Moreover, more than 30% of boys have had premarital sex before the age of 25.<a class="elsevierStyleCrossRef" href="#bb0235">47</a> In Iran, girls and boys have completely different attitudes towards premarital sex.<a class="elsevierStyleCrossRef" href="#bb0180">36</a> Boys believe that they are socially allowed to have premarital sex without damaging their reputation. As a result, they are encouraged to have premarital sex and to have more sex partners. Owing to these risky behaviors, they, their female sex partners, and their future wives will be at higher risks of STDs, AIDS, unintended pregnancies and unsafe abortions.<a class="elsevierStyleCrossRef" href="#bb0240">48</a>In addition to the onset of sexual relationships among teenagers, their information about sexual health issues is quite divergent, and there are common wrong beliefs about sexual behaviors.<a class="elsevierStyleCrossRef" href="#bb0245">49</a> In a study by Bahrami et al., it was shown that only half of the teenagers knew that condoms should not be used more than once. To them, AIDS was the most known STD. However, they had little information about other diseases and symptoms; they thought that the only symptom of STDs was discharge of pus and blood from penis.<a class="elsevierStyleCrossRef" href="#bb0240">48</a>Results of these studies have shown that social developments in Iran in recent years have changed not only values, but also behaviors of people, including their sexual behaviors. Abnormalities happening in our society act as a bomb which is ready to explode; one of their worst consequences is the incidence of dangerous STDs such as cervical cancer in girls. Placing this vaccine in the vaccination program might prevent these hazardous consequences.Some participants were concerned about the possibility of risky sexual behaviors following the injection of this vaccine resulting from a false sense of safety. However, most interviewees believed that if people became aware of the way how this vaccine exactly works and of the fact that this vaccine does not prevent STDs other than HPV, there would be no problem. In fact, it can be said that placing this vaccine in the national vaccination program is a necessary and preventive measure, and this prevention has nothing to do with risky sexual behaviors because these behaviors are related to the people's wills not to the prevention of the disease.Empowering the society is very necessary to introduce and accept this vaccine. Making use of the media is the first and the most important means of paving the way for the introduction of every technology and service. Nowadays, media has full effects on our daily lives; it is present everywhere, and life of many people is dependent on it. Indeed, today's society is not imaginable without the mass media. In their study on the role of media in Iran's political and social development. Golshani et al. pointed out that the mass media has a key role in cultural development and can play an important role in accepting or rejecting a culture or an idea.<a class="elsevierStyleCrossRef" href="#bb0240">48</a> Obviously, introducing this vaccine through the mass media causes people to accept it much sooner and also it encourages policy makers and researchers to seek more information about it and to think about it more seriously.Holding community meetings on this subject is another appropriate approach to empower society. Therefore, experts have the opportunity to talk about this vaccine and its benefits, and people can ask their questions directly, so the vaccine will be introduced and accepted much easier. Increasing educational programs and improving the role of health centers are other measures that help to introduce the vaccine. In their study, Tabeshian and Firoozeh noted that health education had a positive effect on improving awareness, changing and creating a positive attitude. They also emphasized the necessity of health education concerning women's reproductive system.<a class="elsevierStyleCrossRef" href="#bb0250">50</a> Educational programs increased knowledge, attitude and performance of health workers in the intervention group compared with the control group.<a class="elsevierStyleCrossRef" href="#bb0255">51</a> Therefore, a big step can be taken to strengthen the society and to introduce the vaccine using educational programs, highlighting the role of health centers and health workers and educating them.The next step is to inform target groups and their parents about the vaccine. However, this step is a double-edged blade that, if used inappropriately, can have reverse results and can cause parents' opposition. Owing to religious reasons and rich historical background, Islamic societies have their own special cultural obligations. Determining a series of cultural and ethical frameworks for individuals, Islamic culture has obliged Iranian people to comply with special ethics and traditions. Therefore, parents may disagree with vaccinating and immunizing their daughters against dangerous STDs. In a study conducted in Turkey on the attitude of parents and girls towards HPV vaccine, it was shown that 16% of parents disagreed with vaccination of their daughters because they thought that their daughters were not at risk of premarital sex.<a class="elsevierStyleCrossRef" href="#bb0260">52</a> In this case, it is helpful to educate parents that if this vaccine is injected before the first sexual experience, it can have higher effectiveness even in their sexual relationship with their future husbands.The last step in encouraging the society to accept the vaccine is to correct policy makers' viewpoints. Since Iran is an Islamic country which has special cultural conditions, policymakers oppose placing this vaccine in the vaccination program.There are some limitations on this research:The lack of accurate statistics for people with cervical cancer. We trust the hospital archive statistics due to some norms in the community. It was difficult to get access to obstetricians who are willing to interview devote time to interview. Due to limited time of this study, we were only able to talk with a limited number of experts. If the samples were larger, we could generalize the results more confidently.ConclusionsConcerning findings of this study and strengthening the topics based on the previous studies, including this vaccine in the vaccination program seems completely justifiable, and its absence in the vaccination program violates some of ethical principles. Therefore, the government must include it in the national immunization program or provide some subsidies to enable low- income groups to procure it. People who are at lower cultural and social classes are those who are at higher risks of dangerous diseases. These people who mainly constitute the low-income part of the society are not able to buy this expensive vaccine.In addition to the high cost of the vaccine, another important issue is that public awareness of this virus and its serious diseases was very disappointing according to the present qualitative study. Awareness of this virus was limited to some educated people in particular areas such as medicine and nursing. Therefore, authorities can raise public awareness of HPV and its prevention using regular cultural program and the mass media which are the most powerful cultural tools in every society.FundingThis paper is part of a MS thesis in Health technology assessment which was funded by Kerman University of medical sciences.Conflicts of interest/Competing interestsNothing to declare.Ethics approvalThis study was approved by Ethics committee of Kerman University of medical sciences (IR.KMU.REC.1395.340).Consent to participateAll the interviewees signed a written consent form before participating in the study.Consent for publicationAll participants provided consent for publication after we ensured them that the paper would be published in a way where no identifying information would be disclosed.Authors' contributionsMH and MA developed the ideas, MH and AA conducted the interviews, MA, RG and MH analyzed the data. MH, AA and AP drafted the manuscript, MA and AP finalized the manuscript. All authors read and approved the final version." "textoCompletoSecciones" => array:1 [ "secciones" => array:23 [ 0 => array:3 [ "identificador" => "xres2078638" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "as0005" "titulo" => "Aim" ] 1 => array:2 [ "identificador" => "as0010" "titulo" => "Subject and methods" ] 2 => array:2 [ "identificador" => "as0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "as0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1773351" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2078637" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "as0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "as0030" "titulo" => "Sujeto y métodos" ] 2 => array:2 [ "identificador" => "as0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "as0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1773352" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "s0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "s0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "s0015" "titulo" => "Results" ] 7 => array:3 [ "identificador" => "s0020" "titulo" => "Theme 1: The need for vaccine" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "s0025" "titulo" => "Lack of screening" ] 1 => array:2 [ "identificador" => "s0030" "titulo" => "Lack of awareness of the disease" ] 2 => array:2 [ "identificador" => "s0035" "titulo" => "The onset of sexual relationships at early ages" ] 3 => array:2 [ "identificador" => "s0040" "titulo" => "Equity" ] ] ] 8 => array:3 [ "identificador" => "s0045" "titulo" => "Theme 2: lack of knowledge" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "s0050" "titulo" => "No exact information" ] ] ] 9 => array:3 [ "identificador" => "s0055" "titulo" => "Theme 3: cost factors" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "s0060" "titulo" => "High cost of vaccine" ] ] ] 10 => array:3 [ "identificador" => "s0065" "titulo" => "Theme 4: administration at early ages" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "s0070" "titulo" => "Lower age of onset of sexual relationships" ] ] ] 11 => array:3 [ "identificador" => "s0075" "titulo" => "Theme 5: creating a negative mindset" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "s0080" "titulo" => "Possibility of increased risky sexual behaviors" ] ] ] 12 => array:3 [ "identificador" => "s0085" "titulo" => "Theme 6: empowering the society and health care system" "secciones" => array:6 [ 0 => array:2 [ "identificador" => "s0090" "titulo" => "Media" ] 1 => array:2 [ "identificador" => "s0095" "titulo" => "Increasing educational programs" ] 2 => array:2 [ "identificador" => "s0100" "titulo" => "Improving the role of health centers and health workers" ] 3 => array:2 [ "identificador" => "s0105" "titulo" => "Having Pap smear" ] 4 => array:2 [ "identificador" => "s0110" "titulo" => "Informing people" ] 5 => array:2 [ "identificador" => "s0115" "titulo" => "Correcting the attitudes of policy makers" ] ] ] 13 => array:2 [ "identificador" => "s0120" "titulo" => "Discussion" ] 14 => array:2 [ "identificador" => "s0125" "titulo" => "Conclusions" ] 15 => array:2 [ "identificador" => "s0130" "titulo" => "Funding" ] 16 => array:2 [ "identificador" => "s0135" "titulo" => "Conflicts of interest/Competing interests" ] 17 => array:2 [ "identificador" => "s0140" "titulo" => "Ethics approval" ] 18 => array:2 [ "identificador" => "s0145" "titulo" => "Consent to participate" ] 19 => array:2 [ "identificador" => "s0150" "titulo" => "Consent for publication" ] 20 => array:2 [ "identificador" => "s0155" "titulo" => "Authors' contributions" ] 21 => array:2 [ "identificador" => "xack724187" "titulo" => "Acknowledgements" ] 22 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-01-16" "fechaAceptado" => "2023-06-09" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1773351" "palabras" => array:5 [ 0 => "Feasibility study" 1 => "Human PapillomaVirus" 2 => "HPV" 3 => "Cervical Cancer" 4 => "Vaccine" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1773352" "palabras" => array:5 [ 0 => "Estudio de viabilidad" 1 => "Virus del Papiloma Humano" 2 => "VPH" 3 => "Cáncer de cuello uterino" 4 => "Vacuna" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "AimCervical cancer is the second most common form of cancer in women. In order to prevent this disease, several vaccines like Cervarix [2vHPV], Cecolin, Cervarix quadrivalent and Gardasil [9vHPV]), have been included in the vaccination program of some countries. This study as a part of Health Technology Assessment (HTA), aimed to assess the feasibility of inclusion of Human Papilloma Virus (HPV) vaccine in the national vaccination program of Iran. Subject and methodsThis is a qualitative case study composed of semi structured interviews with a purposive sample of experts working extensively in the field of women's health. Data saturation reached at the 12th interview. The data was analyzed using the framework method. ResultsA total of 14 subthemes under 6 themes of the need for vaccines, lack of knowledge, cost factors, administration at early ages, creating a negative mindset, and empowering the society were identified. ConclusionIncluding HPV vaccine in the national vaccination program not only seems justifiable, but also its absence in the vaccination program violates some aspects of medical ethics principles. Therefore, the government must take steps to increase public awareness about human papillomavirus and include the aforementioned vaccine in the national vaccination program." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "as0005" "titulo" => "Aim" ] 1 => array:2 [ "identificador" => "as0010" "titulo" => "Subject and methods" ] 2 => array:2 [ "identificador" => "as0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "as0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "ObjetivoEl cáncer de cuello uterino es la segunda forma más común de cáncer en las mujeres. Para prevenir esta enfermedad, se han incluido dos vacunas (Cervarix [2vHPV], Cecolin, Cervarix quadrivalent, Gardasil [9vHPV]) y Gardasil [9vHPV]), en el programa de vacunación de algunos países. Este estudio, como parte de la Evaluación de Tecnología Sanitaria (HTA), tuvo como objetivo evaluar la viabilidad de la inclusión de la vacuna contra el Virus del Papiloma Humano (VPH) en el programa nacional de vacunación de Irán. Sujeto y métodosEste fue un estudio de caso cualitativo que reclutó entrevistas semiestructuradas con una muestra intencional de expertos que trabajan extensamente en el campo de la salud de la mujer. Saturación de datos alcanzada en la 12ª entrevista. Los datos se analizaron utilizando el método framework. ResultadosSe identificaron un total de 14 subtemas bajo 6 temas de necesidad de vacunas, falta de conocimiento, factores de costo, administración a edades tempranas, creación de una mentalidad negativa y empoderamiento de la sociedad. ConclusiónLa inclusión de la vacuna contra el VPH en el programa nacional de vacunación no solo parece justificable, sino que su ausencia en el programa de vacunación viola algunos aspectos de los principios de la ética médica. Por lo tanto, el gobierno debe tomar medidas para aumentar la conciencia pública sobre el virus del papiloma humano e incluir la vacuna antes mencionada en el programa nacional de vacunación." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "as0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "as0030" "titulo" => "Sujeto y métodos" ] 2 => array:2 [ "identificador" => "as0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "as0040" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "t0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "al0005" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Themes \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Subthemes \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="4" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="4" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The need for vaccines</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.1. Lack of screening \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.2. Lack of awareness of the disease \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.3. The onset of sexual relationship at early ages \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.4. Equity \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Lack of knowledge \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2.1. No exact information \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cost factors \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3.1. High cost of vaccine \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Administration at early ages \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4.1. Lower age of onset of sexual relationships \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Creating a negative mindset \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.1. Possibility of increased risky sexual behaviors \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="6" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowgroup " rowspan="6" align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Empowering the society and health care system</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.1. Media \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.2. Increasing educational programs \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.3. Improving the role of health centers and health workers \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.4. Having Pap smear \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.5. Informing people \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6.6. 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The feasibility of including human papillomavirus vaccine in Iran's national immunization program

La viabilidad de incluir la vacuna contra el virus del papiloma humano en el programa nacional de inmunización de Irán

Maryam Honarvara, Reza Goudarzib, Mohammadreza Amiresmailic,

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mohammadreza.amiresmaili@gmail.com

Corresponding author.

, Asrin Amirid, Abdul Sami Saeed Paule

a Health Technology Assessment, Faculty of Management and Medical information sciences, Kerman university of Medical Science, Kerman, Iran

b Modeling in Health Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran

c Health in Disasters and Emergencies Research Center, Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran

d Faculty of Management and Medical Informatics, Kerman university of Medical Science, Kerman, Iran

e Faculty of Allied Sciences, Kerman University of Medical Sciences, Kerman, Iran

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        "titulo" => "La viabilidad de incluir la vacuna contra el virus del papiloma humano en el programa nacional de inmunizaci&#243;n de Ir&#225;n"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="s0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0065">Introduction</span><p id="p0005" class="elsevierStylePara elsevierViewall">The system governing immunology is rooted in the early experiments of Edward Jenner and Louis Pasteur in the field of vaccination&#46; Owing to these pioneering efforts&#44; different vaccines have been produced for many diseases which were previously the source of human pain and suffering&#46;<a class="elsevierStyleCrossRef" href="#bb0005"><span class="elsevierStyleSup">1</span></a> Global vaccination has significantly decreased the incidence of much life threatening diseases<a class="elsevierStyleCrossRef" href="#bb0010"><span class="elsevierStyleSup">2</span></a> such as <span class="elsevierStyleItalic">pertussis&#44; Tetanus&#44;</span> Diphtheria&#44; <span class="elsevierStyleItalic">Poliomyelitis and Measles&#46;</span><a class="elsevierStyleCrossRef" href="#bb0015"><span class="elsevierStyleSup">3</span></a> In Iran&#44; the national vaccination program which includes oral polio vaccine&#44; inactivated polio vaccine&#44; BCG&#44; hepatitis B&#44; diphtheria&#44; tetanus&#44; whooping cough&#44; measles&#44; rubella&#44; mumps and influenza is implemented based on a certain schedule from the first day of birth throughout life course&#46; Although the immunization program has had significant achievements&#44; some important vaccines like human papillomavirus vaccine which is included in vaccination program of more than seventy countries worldwide like US&#44; Britain&#44; Australia and China is absent in this program&#46;<a class="elsevierStyleCrossRef" href="#bb0020"><span class="elsevierStyleSup">4</span></a></p><p id="p0010" class="elsevierStylePara elsevierViewall">Human Papilloma Virus&#40;HPV&#41; is largely a sexually transmitted virus&#59; about 100 types of it have been identified so far&#44; and nearly 35 types of this virus are found in the genital tract&#46;<a class="elsevierStyleCrossRef" href="#bb0025"><span class="elsevierStyleSup">5</span></a></p><p id="p0015" class="elsevierStylePara elsevierViewall">Molecular and epidemiological studies suggest that certain types of HPV are the primary cause of cervical cancer&#46; Cervical cancer is the fourth most frequent cancer in women with an estimated 570&#44;000 new cases in 2018&#44; representing 6&#46;6&#37; of all forms of female cancer&#46; Approximately 90&#37; of deaths from cervical cancer occur in low- and middle-income countries&#46; The high mortality rate of cervical cancer worldwide could be reduced through a comprehensive approach&#44; including prevention&#44; early diagnosis&#44; effective screening and treatment programs&#46;<a class="elsevierStyleCrossRef" href="#bb0030"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0035"><span class="elsevierStyleSup">7</span></a></p><p id="p0020" class="elsevierStylePara elsevierViewall">Epidemiological evidences extracted from studies on factors contributing to HPV carcinogenesis include parity&#44; use of oral contraceptives&#44; tobacco smoking&#44; having other sexually transmitted diseases&#44; and dietary and nutritional factors&#46;<a class="elsevierStyleCrossRef" href="#bb0040"><span class="elsevierStyleSup">8</span></a> HPV infection causes almost all cervical cancers&#44; 80&#37; of anal cancers&#44;<a class="elsevierStyleCrossRef" href="#bb0045"><span class="elsevierStyleSup">9</span></a> 60&#37; to 80&#37; of vaginal cancers&#44; 40&#37; of vulvar cancers&#44;<a class="elsevierStyleCrossRef" href="#bb0050"><span class="elsevierStyleSup">10</span></a> and 20&#37; to 70&#37; of uterus and cervical cancers&#46;<a class="elsevierStyleCrossRef" href="#bb0055"><span class="elsevierStyleSup">11</span></a> In addition&#44; HPV 6 and 11 cause 85&#37; to 90&#37; of all genital warts&#46;<a class="elsevierStyleCrossRef" href="#bb0060"><span class="elsevierStyleSup">12</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0065"><span class="elsevierStyleSup">13</span></a></p><p id="p0025" class="elsevierStylePara elsevierViewall">Traditionally&#44; prophylactic vaccines that generate virus- specific neutralizing antibody have been cost- effective means to control viral diseases&#46;<a class="elsevierStyleCrossRef" href="#bb0070"><span class="elsevierStyleSup">14</span></a> Fortunately&#44; in 2006&#44; two Cervarix &#40;2vHPV&#41; and Gardasil &#40;9vHPV&#41; vaccines were produced to prevent this disease&#46; The quadrivalent vaccine in 2006&#44; and the bivalent vaccine in 2007 was first licensed in over 100 countries&#46;<a class="elsevierStyleCrossRef" href="#bb0075"><span class="elsevierStyleSup">15</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0080"><span class="elsevierStyleSup">16</span></a></p><p id="p0030" class="elsevierStylePara elsevierViewall">Cervarix&#44; Cecolin&#44; Quadrivalent Gardasil and Gardasil are prophylactic HPV vaccines designed primarily for cervical cancer prevention&#46; Cervarix is effective against HPV-16&#44; -<span class="elsevierStyleHsp" style=""></span>18&#44; -31&#44; -<span class="elsevierStyleHsp" style=""></span>33 and&#8239;-45&#46; Gardasil is effective against HPV-16&#44; 18 and 31&#46; In addition&#44; Gardasil is effective against HPV-6 and -11&#44; causes of genital warts and respiratory papillomatosis&#46;<a class="elsevierStyleCrossRef" href="#bb0085"><span class="elsevierStyleSup">17</span></a> In all studies conducted on HPV&#44; vaccine immunogenicity was more than 90&#37;&#59; it reduced almost 99&#37; of cervical cancer caused by 16 and 18 genotypes and reduced about 81&#37; of vulvar and vaginal cancers&#46;<a class="elsevierStyleCrossRef" href="#bb0090"><span class="elsevierStyleSup">18</span></a> Studies conducted in different parts of Iran have clearly shown the causal relationship between HPV and genotype 16 in cervical lesions&#46; Hence&#44; administering HPV vaccine can significantly reduce the incidence of cervical cancer&#46;<a class="elsevierStyleCrossRef" href="#bb0095"><span class="elsevierStyleSup">19</span></a> Nowadays&#44; the HPV vaccine has been introduced in more than 150 countries all around the world&#46;<a class="elsevierStyleCrossRef" href="#bb0035"><span class="elsevierStyleSup">7</span></a> However&#44; it is mostly used routinely in developed countries&#44; and developing countries do not mainly use it due to its cost and some other factors&#46;<a class="elsevierStyleCrossRef" href="#bb0100"><span class="elsevierStyleSup">20</span></a> An important factor that can be considered in the lack of major use of vaccine in Iran are the ethical issues&#46;</p><p id="p0035" class="elsevierStylePara elsevierViewall">Making decisions regarding the inclusion of a new vaccine in the national immunization program requires several assessments&#59; in other words&#44; it must be examined from many different aspects in an HTA including economic evaluation&#44; efficacy&#44; effectiveness&#44; and ethical feasibility&#46;<a class="elsevierStyleCrossRef" href="#bb0105"><span class="elsevierStyleSup">21</span></a> Therefore&#44; this study is a part of a bigger project<a class="elsevierStyleCrossRef" href="#bb0110"><span class="elsevierStyleSup">22</span></a> which is aimed to assess the feasibility of inclusion of the HPV vaccine in the Iran&#39;s national immunization program&#46; Various ethical principles can be used to evaluate health policy decisions&#46; The issue of inclusion the HPV vaccine in the vaccination program was studied with regards to ethical principles&#46; These principles consist of justice&#44; patient rights and moral principles&#46; Also to this end&#44; ethical theories of principlism and principle of double effect were applied to prepare the interview guide and to interpret the results&#46;</p></span><span id="s0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0070">Material and methods</span><p id="p0040" class="elsevierStylePara elsevierViewall">This is a qualitative case study which recruited semi structured interviews with a purposive sample of 12 participants &#40;Three experienced midwives working in hospitals&#44; three working in health centers and 6 experienced obstetricians working in public and private hospitals&#41; &#46; Thus&#44; it used qualitative research which presented some tools to investigate these factors and helped achieving some deep and good information of samples&#46;<a class="elsevierStyleCrossRef" href="#bb0115"><span class="elsevierStyleSup">23</span></a> Purposive sampling was used to collect data from the most knowledgeable people&#46; We identified our samples from different sampling sites including public health centers&#44; public and private hospitals&#46; In- depth and semi-structured interviews explore the experiences of participants and the meanings they attribute to their experience&#46; During the interview&#44; researchers asked open-ended questions&#44; in one-to-one interviews&#46; Tong et al&#46; provided a checklist of 32 items for reporting on qualitative studies&#46;<a class="elsevierStyleCrossRef" href="#bb0120"><span class="elsevierStyleSup">24</span></a> The finding was reported&#41; based on items related to sampling method&#44; description of sample&#44; method of data collection&#44; method of recording data&#44; number of data coders&#44; data and findings consistency&#44; data saturation&#44; inclusion of supporting quotations and clarity of major and minor themes&#46;</p><p id="p0045" class="elsevierStylePara elsevierViewall">The participants were selected from midwives and obstetricians who were interested in the subject&#44; had some research in this field and those who were willing to participate in the study&#46; In the first step&#44; interview guide was designed reviewing related literature<a class="elsevierStyleCrossRef" href="#bb0125"><span class="elsevierStyleSup">25</span></a> and consulting experts&#46; After that&#44; an in-depth pilot interview was conducted with a midwifery school faculty and the interview guide was finalized&#46; Due to the data saturation i&#46;e&#46; the point we felt sufficient data was attained to reach essential conclusions&#44; and any additional data collection would not yield new insights&#44; the process of interviewing was stopped on the 12th session&#46; Every interview lasted between 20 and 30&#8239;min&#46; The interviews were recorded and transcribed&#46; Verbal consent of the participants was ensured in advance and we did not reward the interviewees financially&#46;</p><p id="p0050" class="elsevierStylePara elsevierViewall">Four criteria of acceptability&#44; transferability&#44; reliability and verifiability were used to ensure the validity&#44; accuracy&#44; and reliability of qualitative data&#46;<a class="elsevierStyleCrossRef" href="#bb0130"><span class="elsevierStyleSup">26</span></a> To ensure the acceptability of data&#44; participants were chosen from different hospitals and private clinics&#59; the interviews were conducted in the period of 6&#8239;months&#46; Some points such as allocation of sufficient time to collect data&#44; good relationship with the participants in the research and simultaneous note- taking and recording data were taken into consideration during the study&#46; In addition&#44; the codes prepared from the interviews were given to the participants and were approved after necessary corrections&#46; To ensure transferability&#44; all project steps&#44; environment&#44; and the field of implementation is completely explained&#46; To provide the reliability criterion&#44; research process was assessed by experts who had conducted some qualitative research&#59; after reviewing the research process&#44; they confirmed the results&#46; Since three previous criteria of reviewing the validity and reliability of qualitative research were provided in this study&#44; it can be concluded that verifiability was also approved and confirmed&#46;</p><p id="p0055" class="elsevierStylePara elsevierViewall">Framework analysis was used to analyze data&#46; Being familiar with the range and diversity of issues&#44; the researchers identified key concepts and issues&#44; designed a framework and finally reviewed all notes related to the individual interviews based on the framework&#46;</p><p id="p0060" class="elsevierStylePara elsevierViewall">We also designed a thematic framework according to the resources&#44; compared concepts&#44; contradictions&#44; theories&#44; experiences and research&#44; and extracted necessary patterns and relationships from the findings&#46;<a class="elsevierStyleCrossRef" href="#bb0135"><span class="elsevierStyleSup">27</span></a> No software was used during these steps&#59; all steps were done manually&#46; Initial framework consisted of 8 concepts which were later reduced to 6&#46; Subgroups of each of these components also changed&#46; In the findings section&#44; the letter &#8220;P&#8221; along with a number represents a participant which has been quoted from&#46;</p></span><span id="s0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0075">Results</span><p id="p0065" class="elsevierStylePara elsevierViewall">Using framework analysis to identify feasibility of including HPV vaccine in the national immunization program&#44; 6 themes and 14 subthemes were identified in this research &#40;<a class="elsevierStyleCrossRef" href="#t0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="t0005"></elsevierMultimedia></span><span id="s0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0080">Theme 1&#58; The need for vaccine</span><p id="p0070" class="elsevierStylePara elsevierViewall">Analyzing the interviews showed that the vaccine is seriously needed in Iran&#59; in this case&#44; we identified four subthemes&#46;</p><span id="s0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0085">Lack of screening</span><p id="p0075" class="elsevierStylePara elsevierViewall">According to most experts&#44; one of the most important reasons why vaccine is needed is that Iranian women do not refer to clinics for screening&#46; Owing to women&#39;s unawareness of the importance of screening and decreased activity of health centers in this regard&#44; a small number of women refer for screening&#46; One of the interviewees stated that &#8220;our women have little information about the screening and its importance&#59; therefore&#44; in many cases they refer at final stages of the disease&#44; which is too late&#8221; &#40;P 1&#41;&#46;</p></span><span id="s0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0090">Lack of awareness of the disease</span><p id="p0080" class="elsevierStylePara elsevierViewall">Most people in the society are not aware of the existence of such a serious disease and its transmission &#40;Medical personnel perception&#41;&#46; It means that we have some people who may be carriers of the virus without even knowing&#59; in this case&#44; it is dangerous both for themselves and for their sex partners&#46; In this regard&#44; an interviewee mentioned that &#8220;A lot of people have never heard the name of this virus&#44; let alone knowing something about the diseases related to it or how it is transmitted&#8221; &#40;P5&#41;&#46;</p></span><span id="s0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0095">The onset of sexual relationships at early ages</span><p id="p0085" class="elsevierStylePara elsevierViewall">Due to changes in cultures and traditions&#44; the onset of sexual relationships has decreased to&#44; according to several experts&#44; the age of secondary school&#46; Moreover&#44; the marriage age has increased compared to previous years&#44; which has resulted in increased premarital sexual relationships and increased number of sex partners&#46; One of the interviewees believed that &#8220;although it is assumed that the situation in our country is different from the situation in western countries in terms of sexual relations&#44; it is not in reality&#8221; &#40;P 8&#41;&#46; Another participant said &#8220;We really need this vaccine because the onset of sexual relationships has started to be practiced at younger age&#44; There is a 14-year-old girl among my patients&#8221; &#40;P 9&#41;&#46;</p></span><span id="s0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0100">Equity</span><p id="p0090" class="elsevierStylePara elsevierViewall">One of the reasons why this vaccine is required is equity&#46; From the equity perspective&#44; all people should have access to health which is a public good&#44; and no one should be deprived of this health right due to financial problems&#46; Since first being licensed at the beginning of 2006&#44; over 270 million doses of HPV vaccines have been distributed globally&#46; GACVS reviewed the safety data of this vaccine&#46; Early on&#44; the Committee was presented signals related to anaphylaxis and syncope&#46; No other adverse reactions have been identified and Global Advisory Committee on Vaccine Safety &#40;GACVS&#41; considers HPV vaccines to be extremely safe&#46; WHO recommends that HPV vaccines be introduced into national immunization programs provided that&#58; prevention of cervical cancer and&#47;or other HPV-related diseases constitute a public health priority&#59; vaccine introduction is programmatically feasible&#59; sustainable financing can be secured&#59; and the cost-effectiveness of vaccination strategies in the country or region is considered&#46;<a class="elsevierStyleCrossRef" href="#bb0140"><span class="elsevierStyleSup">28</span></a> but it is not possible in <span class="elsevierStyleUnderline">Iran</span> because the vaccine in Iran is not in the national vaccination program and only the rich can afford this vaccine&#44; but those who don&#39;t have financial ability and those who really need this vaccine &#40;e&#46;g&#46;&#44; sex workers&#41; cannot afford it&#59; and this is against equity&#46; An interviewee stated that &#8220;in my opinion&#44; it is completely unfair that only the rich are able to buy this vaccine&#46; That is&#44; the richer you are&#44; the healthier you must be&#33;&#33;&#33;&#8221; &#40;P 4&#41;&#46;</p></span></span><span id="s0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0105">Theme 2&#58; lack of knowledge</span><p id="p0095" class="elsevierStylePara elsevierViewall">Another issue mentioned by the participants was public unawareness of such vaccine&#46;</p><span id="s0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0110">No exact information</span><p id="p0100" class="elsevierStylePara elsevierViewall">Owing to poor information&#44; almost all people of the society are unaware of the existence of such a vaccine&#46; This reflects poor performance of the relevant departments and mass media&#46; In this case&#44; one of the interviewees believed that &#8220;less than 1&#37; of people know this vaccine&#46; Unfortunately&#44; even most of physicians are not familiar with it&#8221; &#40;P 6&#41;&#46;</p></span></span><span id="s0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0115">Theme 3&#58; cost factors</span><p id="p0105" class="elsevierStylePara elsevierViewall">Another important problem is people&#39;s inability to buy this important and essential vaccine&#46;</p><span id="s0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0120">High cost of vaccine</span><p id="p0110" class="elsevierStylePara elsevierViewall">Cost is a potential barrier for countries that are considering introducing HPV vaccine into national immunization programs&#44; as like other new vaccines&#59; it remains considerably more expensive than traditional vaccines&#46;<a class="elsevierStyleCrossRef" href="#bb0145"><span class="elsevierStyleSup">29</span></a> This vaccine costs about 12 million rials &#40;Iranian official currency at the time of study&#41;&#59; owing to people&#39;s salary level and income distribution in Iran&#44; most people cannot afford this expensive vaccine&#46; According to all interviewees&#44; only high-income groups can buy it&#46; One of the interviewees mentioned that &#8220;As far as I know&#44; this vaccine is only used by the physicians due to its high price&#8221; &#40;P 12&#41;&#46; Another interviewee stated that &#8220;people with risky behaviors like sex workers often have financial problems and do not have the ability to buy this vaccine&#44; so the government must support them&#8221; &#40;P 11&#41;&#46;</p></span></span><span id="s0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0125">Theme 4&#58; administration at early ages</span><p id="p0115" class="elsevierStylePara elsevierViewall">Administration of the vaccine at early ages is useful and effective&#46;</p><span id="s0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0130">Lower age of onset of sexual relationships</span><p id="p0120" class="elsevierStylePara elsevierViewall">As mentioned above&#44; the onset of sexual relationships has changed a lot compared to the past&#46; It increases the need to have the vaccine at early ages because this vaccine is more effective when the person has not started sexual relationships&#46; Thus&#44; it seems logical that this vaccine be given to people at an early age&#46; One of the interviewees believed that &#8220;in the past&#44; all of us were ignorant about sex and sexual matters before the marriage&#44; but nowadays even elementary and secondary school children know these issues and start their sexual relationships at early ages due to curiosity and changes in their culture&#8221; &#40;P 4&#41;&#46; Another interviewee stated that &#8220;According to our data &#40;which is not documented&#41; and a series of statistics extracted by sociologists&#44; more than 60-70&#37; of our teenagers have sex and it is predicted that this numbers will dramatically increase in the near future&#8221; &#40;P 1&#41;&#46;</p></span></span><span id="s0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0135">Theme 5&#58; creating a negative mindset</span><p id="p0125" class="elsevierStylePara elsevierViewall">Although this study reflected the need for this vaccine&#44; participants were concerned about the fact that vaccination could have a false sense of safety among the people&#46;</p><span id="s0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0140">Possibility of increased risky sexual behaviors</span><p id="p0130" class="elsevierStylePara elsevierViewall">An important issue mentioned in the interviews was people&#39;s attitudes towards false sense of safety following vaccination&#59; it could increase high-risk sexual behaviors&#46; Most interviewees believed that if people were informed about the exact nature of the vaccine and about the fact that this vaccine can only prevent some diseases and does not immunize them against other dangerous sexual diseases&#44; this problem would not appear&#46; An interviewee said that &#8220;If&#44; at the time of injection&#44; the patient and the family are informed that this vaccine can only immunize them against this type of virus and cannot prevent other sexually transmitted diseases &#40;STD&#41; such as HIV and hepatitis&#44; the likelihood of high-risk behaviors will decrease&#8221; &#40;P 7&#41;&#46;</p></span></span><span id="s0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0145">Theme 6&#58; empowering the society and health care system</span><p id="p0135" class="elsevierStylePara elsevierViewall">One of the issues mentioned in the interviews was having good infrastructures to introduce the vaccine in the community and in the national vaccination program&#46; In order to introduce any new vaccine&#44; its suitable infrastructures must first be provided in the society and among people&#59; otherwise&#44; it is less likely to be accepted&#46;</p><span id="s0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0150">Media</span><p id="p0140" class="elsevierStylePara elsevierViewall">Media has long played an important role in informing people of the society&#46; Understanding the world around us and knowing the events and incidents show us the key effects of mass media&#46; Due to the influence of the media on all levels and category of the Iranian society and the trust that people have in the media&#44; it can be said that they are one of the strongest communicative tools and bridges to introduce this vaccine to all members of the society&#46; Among these tools&#44; TV has always been selected by the people due to its certain and special attractiveness and has had a key role in informing the people&#46; One of the interviewees stated that &#8220;there are few radio and television programs about cancer&#59; therefore&#44; our people have little information about this disease because media authorities have wrong ideas in this regard&#46; That is&#44; media are not very active in informing people&#44; so many Iranian women still do not know what Pap smear is&#8221; &#40;P 8&#41;&#46; Another interviewee mentioned that &#8220;media have profound effects&#46; For example&#44; AIDS was completely unknown in our society a few years ago&#44; but media informed people of this disease and now you can see that most people are familiar with it&#46; We can&#44; in this way&#44; create and increase sensitivity in the society&#44; especially among women&#8221; &#40;P 3&#41;&#46; If we talk to the experts in this field and if there is an opportunity for questions and answers&#44; we will certainly witness remarkable growth in people&#39;s awareness&#44; especially women&#59; subsequently&#44; the consequences of this dangerous disease will decrease&#46; One of the interviewees mentioned that &#8220;most of our women are housewives and are always free&#46; If we design a series of programs for them so that they can ask their questions&#44; we will take a big step towards their understanding&#44; and we can encourage them to have screening and vaccination&#8221; &#40;P 4&#41;&#46;</p></span><span id="s0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0155">Increasing educational programs</span><p id="p0145" class="elsevierStylePara elsevierViewall">One of the most important and effective ways to increase people&#39;s information about this disease and its vaccine is to increase educational programs related to this issue&#46; These programs can be designed in different ways&#58; holding conferences and seminars for the public&#44; having promotional products in various parts of the city&#44; etc&#46; One of the interviewees said that &#8220;If we pay more attention to people&#39;s health and knowledge instead of advertising chips and snacks&#44; we will certainly have a healthier society&#8221; &#40;P 9&#41;&#46;</p></span><span id="s0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0160">Improving the role of health centers and health workers</span><p id="p0150" class="elsevierStylePara elsevierViewall">Another solution is to introduce the vaccines and to highlight the role of health workers and health centers in informing people and having preventive tests for rural women&#46; If these people regularly refer to health centers in rural areas&#44; the disease can be detected sooner and much easier and the burden of worrying about these people decreases&#46; An interviewee stated that &#8220;health workers and family physicians know&#44; to huge extent&#44; people with risky behaviors&#44; and can teach them and introduce them for screening&#8221; &#40;P 2&#41;&#46;</p></span><span id="s0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0165">Having Pap smear</span><p id="p0155" class="elsevierStylePara elsevierViewall">Another important issue which must be taken into huge consideration is to encourage people to have an annual Pap smear&#46; Providing some facilities such as paying half or&#44; if possible&#44; all the cost of a Pap smear&#44; the government can encourage people to have an annual Pap smear to prevent STDs&#46; One of the interviewees stated that &#8220;rural women are at lower risks due to more limited sexual relationships&#46; If we can launch an annual Pap smear program in the health clinics&#44; the follow-up is enough for them&#8221; &#40;P 6&#41;&#46;</p></span><span id="s0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0170">Informing people</span><p id="p0160" class="elsevierStylePara elsevierViewall">Giving accurate and necessary information to the target group and their parents is one of the cases that provides a suitable opportunity to introduce and use this vaccine&#59; otherwise&#44; the culture of the society and parents&#39; thoughts may prevent using such vaccines&#46; An interviewee stated that &#8220;If the parents are told why this vaccine is given to their children&#44; they will resist it even if they know that their children have risky behaviors&#46; Thus&#44; it is better to tell them that this vaccine is given only to prevent uterus cancer&#8221; &#40;P 10&#41;&#46; Another interviewee said that &#8220;concerning people&#39;s perception&#44; we must give them full explanation of the advantages and disadvantages of the vaccine and also the best time to have the vaccine with regard to age and previous infection with HPV&#8221; &#40;P 12&#41;&#46;</p></span><span id="s0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0175">Correcting the attitudes of policy makers</span><p id="p0165" class="elsevierStylePara elsevierViewall">Perhaps one of the reasons why HPV vaccine has not been included in the vaccination program is the opposition of policymakers&#46; Since Iran is an Islamic country which has special cultural conditions&#44; policymakers strongly disagree with placing this vaccine in the vaccination program&#46; However&#44; if they become aware of the existing conditions in the society such as the exact number of people who suffer from cervical cancer and the prevalence of sexual relationships at early ages and among adolescents&#44; they may agree with this vaccine&#46; An interviewee stated that &#8220;policy-makers disagree with this issue because they believe that we&#44; as an Islamic country&#44; shouldn&#39;t have sexual relationships outside family&#59; they also believe that having this vaccine means accepting immoral relations&#46; However&#44; today we need this vaccine due to changes in the culture and emergence of some issues&#8221; &#40;P 7&#41;&#46; Another interviewee believed that &#8220;policy-makers are absolutely wrong&#44; and we must show them the exact statistics so that they can realize that Islamic conditions have not prevented this disease and its high mortality&#8221; &#40;P 3&#41;&#46; One of the interviewees argued that &#8220;policymakers are wrong because even if we have fewer sexual relationships among teenagers compared with advanced countries&#44; we have the issue of temporary marriage in our country&#44; and it is an important factor in having HPV&#46; Thus&#44; this issue must be taken into huge consideration&#8221; &#40;P 10&#41;&#46;</p></span></span><span id="s0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0180">Discussion</span><p id="p0170" class="elsevierStylePara elsevierViewall">This study determined the feasibility of introducing HPV vaccine in the national immunization program&#46; The probability of getting disease because of unawareness&#44; inability of some at risk groups to buy the vaccine&#44; and the necessity of having the vaccine at early ages&#44; were the factors stressed for inevitability of including the vaccine in the national program&#44;however&#44; to avoid some difficulties the society should be empowered to evade building a false sense of safety against all STDs&#46;</p><p id="p0175" class="elsevierStylePara elsevierViewall">This study showed that lack of screening doubles the need for the vaccine&#46; Karimi et al&#46; have also mentioned this problem&#46; In their study conducted in Yazd&#44; only 2&#37; of women with cervical cancer had Pap smear before cancer diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bb0150"><span class="elsevierStyleSup">30</span></a> In a study conducted in Tehran&#44; less than 50&#37; of the studied women &#40;aged 15 to 45&#41; had done Pap smear at least once&#46; Half of the women had no information about Pap smear&#44; and less than half of the patients knew the right time to do it&#46;<a class="elsevierStyleCrossRef" href="#bb0155"><span class="elsevierStyleSup">31</span></a> In a study carried out by Farajzadegan et al&#46;&#44; it was shown that cervical cancer is one of the diseases that is heavily influenced by social&#44; economic&#44; and geographical conditions&#46; Studies conducted in different regions of Iran indicated unsuitable screening conditions for cervical cancer in Iran&#46;<a class="elsevierStyleCrossRef" href="#bb0160"><span class="elsevierStyleSup">32</span></a> Given that the annual incidence of this cancer is 4&#46;5 in every 100&#44;000 people&#44;<a class="elsevierStyleCrossRef" href="#bb0165"><span class="elsevierStyleSup">33</span></a> it is very essential to have this vaccine in the national vaccination program&#46; However&#44; placing it in the vaccination program does not mean that screening program isn&#39;t required anymore and screening and Pap smear still remain important and necessary&#46;</p><p id="p0180" class="elsevierStylePara elsevierViewall">People&#39;s unawareness of this disease is another reason why this vaccine is needed&#46; In their study&#44; Salehifar et al&#46; examined female students&#39; awareness of cervical cancer and HPV and their attitude towards this vaccine&#46; Their results showed that most of the students &#40;66&#46;8&#41; had little information about this disease and only 5&#37; had good knowledge&#46; About 25&#37; of the students had a positive attitude towards HPV vaccine&#44; while 2&#46;5&#37; had a negative attitude&#46; More than 70&#37; of the participants reported that if the vaccine was available&#44; they wished to receive it&#46;<a class="elsevierStyleCrossRef" href="#bb0170"><span class="elsevierStyleSup">34</span></a> Thus&#44; developing programs to improve community&#39;s awareness seem appropriate to reduce incidence of cervical cancer&#46;</p><p id="p0185" class="elsevierStylePara elsevierViewall">According to the present study&#44; the change in the culture and presence of sexual relationships at an early age is another reason why this vaccine must be introduced in the vaccination program&#46; Results of several studies have shown that premarital sexual relationships have increased in recent years among young people&#46;<a class="elsevierStyleCrossRef" href="#bb0175"><span class="elsevierStyleSup">35</span></a></p><p id="p0190" class="elsevierStylePara elsevierViewall">Little research done in this area suggest that premarital sex is increasing in Iran&#46;<a class="elsevierStyleCrossRefs" href="#bb0180"><span class="elsevierStyleSup">36&#8211;38</span></a> Young generation and risky behaviors among young people have become one of the most alarming factors in Iran&#46;<a class="elsevierStyleCrossRef" href="#bb0195"><span class="elsevierStyleSup">39</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bb0200"><span class="elsevierStyleSup">40</span></a> The officials are concerned about the possibility of increased AIDS among young people&#46; They consider risky sexual behaviors in this age a factor for the formation of the &#8220;third wave of AIDS&#8221; in Iran&#46; A complicated problem is emerging&#44; and the prevailing policy is to ignore it&#46;<a class="elsevierStyleCrossRef" href="#bb0205"><span class="elsevierStyleSup">41</span></a></p><p id="p0195" class="elsevierStylePara elsevierViewall">In his research&#44; Darznik showed that Iran&#39;s society has faced a widespread change in values and many young people considered premarital sex completely healthy and normal&#46; His research revealed that uncontrolled sex has increased in Iran&#44; and that many of the young middle-class and upper-class people do not use tools to prevent STDs&#46; He also showed that it could increase the risk of diseases such as AIDS among them&#46;<a class="elsevierStyleCrossRef" href="#bb0185"><span class="elsevierStyleSup">37</span></a></p><p id="p0200" class="elsevierStylePara elsevierViewall">In another study&#44; Azad Armaki and Sharifi Saie showed that illegitimate and anomic behavioral patterns have increased in the society due to the marriage problems and closure of legitimate ways of sexual relationships&#46; People try to seek new ways to satisfy their needs and formation of relationships which in most cases&#44; is based on sexual desires&#46;<a class="elsevierStyleCrossRef" href="#bb0205"><span class="elsevierStyleSup">41</span></a> This is in line with the viewpoints of the participants who indicated that there were premarital sexual relationships among Iranian youth and that these relationships would have adverse mental and physical consequences&#46;</p><p id="p0205" class="elsevierStylePara elsevierViewall">Whether this vaccine is required in Iran or not&#44; can be examined from the perspective of equity&#46; Health equity is achieved when all people of a society can maintain their full health&#44; and their social and economic status has no effect on their health&#46; In other words&#44; &#8220;equal care for equal need&#8221;&#46;<a class="elsevierStyleCrossRef" href="#bb0210"><span class="elsevierStyleSup">42</span></a> In the current situation&#44; only wealthy people can buy this vaccine&#46; In the definition of vertical Justice&#44; it has been stated that &#8220;unequal must be treated differently&#8221;&#46; Vertical equity emphasizes that those with additional needs must receive more services and supports&#46;<a class="elsevierStyleCrossRef" href="#bb0215"><span class="elsevierStyleSup">43</span></a> However&#44; the opposite is happening under present circumstances&#44; and people in need are not supported&#46; Since people who do not have good financial conditions are mainly at lower cultural and social classes and therefore have more risky behaviors&#44; they need the vaccine more but cannot buy it due to financial problems&#46;</p><p id="p0210" class="elsevierStylePara elsevierViewall">One of the issues identified in this study was people&#39;s unawareness of this vaccine&#59; it stems from inadequate information in the society&#46; According to the experts&#44; less than 1&#37; of the population is aware of this vaccine&#46;<a class="elsevierStyleCrossRef" href="#bb0220"><span class="elsevierStyleSup">44</span></a> Thus&#44; the role of timely information is very important to adopt preventive measures including HPV vaccine administration&#46;</p><p id="p0215" class="elsevierStylePara elsevierViewall">The relative high price of the vaccine was another problem stated in the interviews&#46; Health as a public commodity has two major characteristics&#58; 1&#41; its consumption by one person does not affect the consumption by another person &#40;non-competitiveness&#41;&#44; and 2&#41; it is not possible to exclude people from consuming it &#40;exceptionality&#41;&#46;<a class="elsevierStyleCrossRef" href="#bb0225"><span class="elsevierStyleSup">45</span></a> A bigger gap between the richest and the poorest people is equal to the bigger inequality in health&#46;<a class="elsevierStyleCrossRef" href="#bb0230"><span class="elsevierStyleSup">46</span></a> The high price of the vaccine prevents people in need from acquiring it&#59; that is&#44; people who are not in good financial conditions do not have access to health which is a public commodity&#46;</p><p id="p0220" class="elsevierStylePara elsevierViewall">The lower age of onset of sexual relationships was another matter that necessitated having this vaccine at earlier ages&#46; In their research&#44; Garmaroudi et al&#46; examined 2400 high school students &#40;14 to 17&#8239;years old&#41; and concluded that more than 20&#37; of them had experienced sex in their lives&#46;<a class="elsevierStyleCrossRef" href="#bb0190"><span class="elsevierStyleSup">38</span></a> Khalajabadi and Mehryar also mentioned that about 25&#37; of single female students at Tehran universities had a kind of sexual relationship in their lives&#59; of them&#44; 10&#37; had full sexual relationship&#46;<a class="elsevierStyleCrossRef" href="#bb0180"><span class="elsevierStyleSup">36</span></a> Results of a report by the Ministry of Health revealed that about 20&#37; of boys and less than 10&#37; of girls had experienced sexual relationships before the age of 20&#46; Moreover&#44; more than 30&#37; of boys have had premarital sex before the age of 25&#46;<a class="elsevierStyleCrossRef" href="#bb0235"><span class="elsevierStyleSup">47</span></a> In Iran&#44; girls and boys have completely different attitudes towards premarital sex&#46;<a class="elsevierStyleCrossRef" href="#bb0180"><span class="elsevierStyleSup">36</span></a> Boys believe that they are socially allowed to have premarital sex without damaging their reputation&#46; As a result&#44; they are encouraged to have premarital sex and to have more sex partners&#46; Owing to these risky behaviors&#44; they&#44; their female sex partners&#44; and their future wives will be at higher risks of STDs&#44; AIDS&#44; unintended pregnancies and unsafe abortions&#46;<a class="elsevierStyleCrossRef" href="#bb0240"><span class="elsevierStyleSup">48</span></a></p><p id="p0225" class="elsevierStylePara elsevierViewall">In addition to the onset of sexual relationships among teenagers&#44; their information about sexual health issues is quite divergent&#44; and there are common wrong beliefs about sexual behaviors&#46;<a class="elsevierStyleCrossRef" href="#bb0245"><span class="elsevierStyleSup">49</span></a> In a study by Bahrami et al&#46;&#44; it was shown that only half of the teenagers knew that condoms should not be used more than once&#46; To them&#44; AIDS was the most known STD&#46; However&#44; they had little information about other diseases and symptoms&#59; they thought that the only symptom of STDs was discharge of pus and blood from penis&#46;<a class="elsevierStyleCrossRef" href="#bb0240"><span class="elsevierStyleSup">48</span></a></p><p id="p0230" class="elsevierStylePara elsevierViewall">Results of these studies have shown that social developments in Iran in recent years have changed not only values&#44; but also behaviors of people&#44; including their sexual behaviors&#46; Abnormalities happening in our society act as a bomb which is ready to explode&#59; one of their worst consequences is the incidence of dangerous STDs such as cervical cancer in girls&#46; Placing this vaccine in the vaccination program might prevent these hazardous consequences&#46;</p><p id="p0235" class="elsevierStylePara elsevierViewall">Some participants were concerned about the possibility of risky sexual behaviors following the injection of this vaccine resulting from a false sense of safety&#46; However&#44; most interviewees believed that if people became aware of the way how this vaccine exactly works and of the fact that this vaccine does not prevent STDs other than HPV&#44; there would be no problem&#46; In fact&#44; it can be said that placing this vaccine in the national vaccination program is a necessary and preventive measure&#44; and this prevention has nothing to do with risky sexual behaviors because these behaviors are related to the people&#39;s wills not to the prevention of the disease&#46;</p><p id="p0240" class="elsevierStylePara elsevierViewall">Empowering the society is very necessary to introduce and accept this vaccine&#46; Making use of the media is the first and the most important means of paving the way for the introduction of every technology and service&#46; Nowadays&#44; media has full effects on our daily lives&#59; it is present everywhere&#44; and life of many people is dependent on it&#46; Indeed&#44; today&#39;s society is not imaginable without the mass media&#46; In their study on the role of media in Iran&#39;s political and social development&#46; Golshani et al&#46; pointed out that the mass media has a key role in cultural development and can play an important role in accepting or rejecting a culture or an idea&#46;<a class="elsevierStyleCrossRef" href="#bb0240"><span class="elsevierStyleSup">48</span></a> Obviously&#44; introducing this vaccine through the mass media causes people to accept it much sooner and also it encourages policy makers and researchers to seek more information about it and to think about it more seriously&#46;</p><p id="p0245" class="elsevierStylePara elsevierViewall">Holding community meetings on this subject is another appropriate approach to empower society&#46; Therefore&#44; experts have the opportunity to talk about this vaccine and its benefits&#44; and people can ask their questions directly&#44; so the vaccine will be introduced and accepted much easier&#46; Increasing educational programs and improving the role of health centers are other measures that help to introduce the vaccine&#46; In their study&#44; Tabeshian and Firoozeh noted that health education had a positive effect on improving awareness&#44; changing and creating a positive attitude&#46; They also emphasized the necessity of health education concerning women&#39;s reproductive system&#46;<a class="elsevierStyleCrossRef" href="#bb0250"><span class="elsevierStyleSup">50</span></a> Educational programs increased knowledge&#44; attitude and performance of health workers in the intervention group compared with the control group&#46;<a class="elsevierStyleCrossRef" href="#bb0255"><span class="elsevierStyleSup">51</span></a> Therefore&#44; a big step can be taken to strengthen the society and to introduce the vaccine using educational programs&#44; highlighting the role of health centers and health workers and educating them&#46;</p><p id="p0250" class="elsevierStylePara elsevierViewall">The next step is to inform target groups and their parents about the vaccine&#46; However&#44; this step is a double-edged blade that&#44; if used inappropriately&#44; can have reverse results and can cause parents&#39; opposition&#46; Owing to religious reasons and rich historical background&#44; Islamic societies have their own special cultural obligations&#46; Determining a series of cultural and ethical frameworks for individuals&#44; Islamic culture has obliged Iranian people to comply with special ethics and traditions&#46; Therefore&#44; parents may disagree with vaccinating and immunizing their daughters against dangerous STDs&#46; In a study conducted in Turkey on the attitude of parents and girls towards HPV vaccine&#44; it was shown that 16&#37; of parents disagreed with vaccination of their daughters because they thought that their daughters were not at risk of premarital sex&#46;<a class="elsevierStyleCrossRef" href="#bb0260"><span class="elsevierStyleSup">52</span></a> In this case&#44; it is helpful to educate parents that if this vaccine is injected before the first sexual experience&#44; it can have higher effectiveness even in their sexual relationship with their future husbands&#46;</p><p id="p0255" class="elsevierStylePara elsevierViewall">The last step in encouraging the society to accept the vaccine is to correct policy makers&#39; viewpoints&#46; Since Iran is an Islamic country which has special cultural conditions&#44; policymakers oppose placing this vaccine in the vaccination program&#46;</p><p id="p0260" class="elsevierStylePara elsevierViewall">There are some limitations on this research&#58;</p><p id="p0265" class="elsevierStylePara elsevierViewall">The lack of accurate statistics for people with cervical cancer&#46; We trust the hospital archive statistics due to some norms in the community&#46; It was difficult to get access to obstetricians who are willing to interview devote time to interview&#46; Due to limited time of this study&#44; we were only able to talk with a limited number of experts&#46; If the samples were larger&#44; we could generalize the results more confidently&#46;</p></span><span id="s0125" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0185">Conclusions</span><p id="p0270" class="elsevierStylePara elsevierViewall">Concerning findings of this study and strengthening the topics based on the previous studies&#44; including this vaccine in the vaccination program seems completely justifiable&#44; and its absence in the vaccination program violates some of ethical principles&#46; Therefore&#44; the government must include it in the national immunization program or provide some subsidies to enable low- income groups to procure it&#46; People who are at lower cultural and social classes are those who are at higher risks of dangerous diseases&#46; These people who mainly constitute the low-income part of the society are not able to buy this expensive vaccine&#46;</p><p id="p0275" class="elsevierStylePara elsevierViewall">In addition to the high cost of the vaccine&#44; another important issue is that public awareness of this virus and its serious diseases was very disappointing according to the present qualitative study&#46; Awareness of this virus was limited to some educated people in particular areas such as medicine and nursing&#46; Therefore&#44; authorities can raise public awareness of HPV and its prevention using regular cultural program and the mass media which are the most powerful cultural tools in every society&#46;</p></span><span id="s0130" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0190">Funding</span><p id="p0280" class="elsevierStylePara elsevierViewall">This paper is part of a MS thesis in Health technology assessment which was funded by Kerman University of medical sciences&#46;</p></span><span id="s0135" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0195">Conflicts of interest&#47;Competing interests</span><p id="p0285" class="elsevierStylePara elsevierViewall">Nothing to declare&#46;</p></span><span id="s0140" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0200">Ethics approval</span><p id="p0290" class="elsevierStylePara elsevierViewall">This study was approved by Ethics committee of Kerman University of medical sciences &#40;IR&#46;KMU&#46;REC&#46;1395&#46;340&#41;&#46;</p></span><span id="s0145" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0205">Consent to participate</span><p id="p0295" class="elsevierStylePara elsevierViewall">All the interviewees signed a written consent form before participating in the study&#46;</p></span><span id="s0150" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0210">Consent for publication</span><p id="p0300" class="elsevierStylePara elsevierViewall">All participants provided consent for publication after we ensured them that the paper would be published in a way where no identifying information would be disclosed&#46;</p></span><span id="s0155" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0215">Authors&#39; contributions</span><p id="p0305" class="elsevierStylePara elsevierViewall">MH and MA developed the ideas&#44; MH and AA conducted the interviews&#44; MA&#44; RG and MH analyzed the data&#46; MH&#44; AA and AP drafted the manuscript&#44; MA and AP finalized the manuscript&#46; All authors read and approved the final version&#46;</p></span></span>"
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              "titulo" => "Lack of awareness of the disease"
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              "titulo" => "The onset of sexual relationships at early ages"
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          "titulo" => "Theme 2&#58; lack of knowledge"
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          "titulo" => "Theme 3&#58; cost factors"
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              "titulo" => "High cost of vaccine"
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          "titulo" => "Theme 4&#58; administration at early ages"
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              "titulo" => "Lower age of onset of sexual relationships"
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          "titulo" => "Theme 5&#58; creating a negative mindset"
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          "identificador" => "s0085"
          "titulo" => "Theme 6&#58; empowering the society and health care system"
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            0 => array:2 [
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              "titulo" => "Increasing educational programs"
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            2 => array:2 [
              "identificador" => "s0100"
              "titulo" => "Improving the role of health centers and health workers"
            ]
            3 => array:2 [
              "identificador" => "s0105"
              "titulo" => "Having Pap smear"
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            4 => array:2 [
              "identificador" => "s0110"
              "titulo" => "Informing people"
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            5 => array:2 [
              "identificador" => "s0115"
              "titulo" => "Correcting the attitudes of policy makers"
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    "pdfFichero" => "main.pdf"
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    "fechaRecibido" => "2023-01-16"
    "fechaAceptado" => "2023-06-09"
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            1 => "Human PapillomaVirus"
            2 => "HPV"
            3 => "Cervical Cancer"
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          "palabras" => array:5 [
            0 => "Estudio de viabilidad"
            1 => "Virus del Papiloma Humano"
            2 => "VPH"
            3 => "C&#225;ncer de cuello uterino"
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="as0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0010">Aim</span><p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">Cervical cancer is the second most common form of cancer in women&#46; In order to prevent this disease&#44; several vaccines like Cervarix &#91;2vHPV&#93;&#44; Cecolin&#44; Cervarix quadrivalent and Gardasil &#91;9vHPV&#93;&#41;&#44; have been included in the vaccination program of some countries&#46; This study as a part of Health Technology Assessment &#40;HTA&#41;&#44; aimed to assess the feasibility of inclusion of Human Papilloma Virus &#40;HPV&#41; vaccine in the national vaccination program of Iran&#46;</p></span> <span id="as0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0015">Subject and methods</span><p id="sp0015" class="elsevierStyleSimplePara elsevierViewall">This is a qualitative case study composed of semi structured interviews with a purposive sample of experts working extensively in the field of women&#39;s health&#46; Data saturation reached at the 12th interview&#46; The data was analyzed using the framework method&#46;</p></span> <span id="as0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0020">Results</span><p id="sp0020" class="elsevierStyleSimplePara elsevierViewall">A total of 14 subthemes under 6 themes of the need for vaccines&#44; lack of knowledge&#44; cost factors&#44; administration at early ages&#44; creating a negative mindset&#44; and empowering the society were identified&#46;</p></span> <span id="as0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0025">Conclusion</span><p id="sp0025" class="elsevierStyleSimplePara elsevierViewall">Including HPV vaccine in the national vaccination program not only seems justifiable&#44; but also its absence in the vaccination program violates some aspects of medical ethics principles&#46; Therefore&#44; the government must take steps to increase public awareness about human papillomavirus and include the aforementioned vaccine in the national vaccination program&#46;</p></span>"
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          1 => array:2 [
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            "titulo" => "Subject and methods"
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          2 => array:2 [
            "identificador" => "as0015"
            "titulo" => "Results"
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        "resumen" => "<span id="as0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0035">Objetivo</span><p id="sp0030" class="elsevierStyleSimplePara elsevierViewall">El c&#225;ncer de cuello uterino es la segunda forma m&#225;s com&#250;n de c&#225;ncer en las mujeres&#46; Para prevenir esta enfermedad&#44; se han incluido dos vacunas &#40;Cervarix &#91;2vHPV&#93;&#44; Cecolin&#44; Cervarix quadrivalent&#44; Gardasil &#91;9vHPV&#93;&#41; y Gardasil &#91;9vHPV&#93;&#41;&#44; en el programa de vacunaci&#243;n de algunos pa&#237;ses&#46; Este estudio&#44; como parte de la Evaluaci&#243;n de Tecnolog&#237;a Sanitaria &#40;HTA&#41;&#44; tuvo como objetivo evaluar la viabilidad de la inclusi&#243;n de la vacuna contra el Virus del Papiloma Humano &#40;VPH&#41; en el programa nacional de vacunaci&#243;n de Ir&#225;n&#46;</p></span> <span id="as0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0040">Sujeto y m&#233;todos</span><p id="sp0035" class="elsevierStyleSimplePara elsevierViewall">Este fue un estudio de caso cualitativo que reclut&#243; entrevistas semiestructuradas con una muestra intencional de expertos que trabajan extensamente en el campo de la salud de la mujer&#46; Saturaci&#243;n de datos alcanzada en la 12&#170; entrevista&#46; Los datos se analizaron utilizando el m&#233;todo framework&#46;</p></span> <span id="as0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0045">Resultados</span><p id="sp0040" class="elsevierStyleSimplePara elsevierViewall">Se identificaron un total de 14 subtemas bajo 6 temas de necesidad de vacunas&#44; falta de conocimiento&#44; factores de costo&#44; administraci&#243;n a edades tempranas&#44; creaci&#243;n de una mentalidad negativa y empoderamiento de la sociedad&#46;</p></span> <span id="as0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="st0050">Conclusi&#243;n</span><p id="sp0045" class="elsevierStyleSimplePara elsevierViewall">La inclusi&#243;n de la vacuna contra el VPH en el programa nacional de vacunaci&#243;n no solo parece justificable&#44; sino que su ausencia en el programa de vacunaci&#243;n viola algunos aspectos de los principios de la &#233;tica m&#233;dica&#46; Por lo tanto&#44; el gobierno debe tomar medidas para aumentar la conciencia p&#250;blica sobre el virus del papiloma humano e incluir la vacuna antes mencionada en el programa nacional de vacunaci&#243;n&#46;</p></span>"
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                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Themes&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1</td><td class="td-with-role" title="\n
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                  \t\t\t\t">The need for vaccines</td><td class="td" title="\n
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                  \t\t\t\t">1&#46;1&#46; Lack of screening&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;2&#46; Lack of awareness of the disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;3&#46; The onset of sexual relationship at early ages&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">1&#46;4&#46; Equity&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n
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                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Lack of knowledge&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;1&#46; No exact information&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="" valign="\n
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                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Cost factors&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#46;1&#46; High cost of vaccine&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">4&#46;1&#46; Lower age of onset of sexual relationships&nbsp;\t\t\t\t\t\t\n
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Article information

ISSN: 24451460
Original language: English

DOI:10.1016/j.vacune.2023.10.006

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