The Chasm We Must Cross in Japan for Re-Promotion of the HPV Vaccine a C Yutaka Ueda1, Kayoko Katayama2, Asami Yagi1, and Tadashi Kimura1

CANCER PREVENTION RESEARCH | COMMENTARY

The Chasm We Must Cross in Japan for Re-promotion of the HPV Vaccine A C Yutaka Ueda1, Kayoko Katayama2, Asami Yagi1, and Tadashi Kimura1

ABSTRACT ◥ In Japan, the human papillomavirus (HPV) vaccination an important determinate of whether a new product will rate has decreased from around 70% to less than 1% due to penetrate the market. By various initiatives, vaccination repeated media reports of diverse symptoms after HPV coverage has recently risen to about 10%; however, there is vaccination, and to suspension of the governmental recom- still a large chasm difficult to cross before reaching the mendation. The challenges for re-promotion of the vaccine majority of individuals. To cross that chasm, peer education will be discussed from a marketing perspective. The adopter will be essential. First, community health workers will need to categories by which a new product penetrates the market can be educated so that they have a firm understanding of HPV be divided into five groups, including Innovators, Early vaccine and can confidently recommend vaccination to the adopters, Early majority, Late majority, and Laggards. The targeted population. That population will be expected to pass 16.0% line, which is the sum of the percentages of the on that recommendation to their acquaintances, resulting in innovators and the early adopters, is thought to be widening dissemination of HPV vaccine among the majority.

In recent years, the incidence of cervical cancer has been gorizes the process by which a new service or product pene- decreasing in developed countries; the same downward trend in trates the market into five groups (Fig. 1A). Innovators, who incidence had been previously observed in Japan; however, it actively gather information and are the first to adopt and has recently reversed and has now started to increase (1). promote new products and services, account for 2.5% of the Following the successful introduction of the human papillo- market. Early adopters are those who adopt new products and mavirus (HPV) vaccine into Japan in the fiscal year (FY) 2009, services after judging their merits, as promoted by the inno- public subsidy for vaccination of all 13–16 years old girls was vators, and have a significant impact on the overall market started in FY2010; the nationwide vaccination rate soon penetration, accounting for 13.5% of the market. Early majority reached 70% for the first dose. By April of 2013, HPV vacci- is the group that more cautiously adopts new products and nation had become routine for girls ages 12 to 16. However, the services, accounting for 34% of the market. Late majority (34% media repeatedly reported the girls with diverse symptoms of the market) is the category that adopts new products and including chronic pain and motor impairment after vaccina- services after they have penetrated the market to some extent. tion. As a precaution, the Ministry of Health, Labor, and Laggards are the most conservative group, they are the slowest Welfare (MHLW) quickly suspended its governmental recom- to adopt new products and services, accounting for 16% of the mendation for HPV vaccine in June. The vaccination rate market. decreased drastically, from 70% to almost zero (2–5). The diffusion of innovations theory emphasizes the impor- The challenges Japan face as a nation in recovering from this tance of the 16.0% line, which is the sum of the percentages of hiatus in HPV vaccination are immense. We have decided to Innovators and Early adopters, in determining whether a new approach the problem of the re-promotion of HPV vaccine into product introduced to the market will penetrate. The theory Japan from a purely marketing perspective using the concept of says that when the penetration rate reaches 16.0%, the product “Diffusion of Innovations,” which is a marketing theory, that will boom and the demand will accelerate rapidly. On the other seeks to explain how, why, and at what rate new ideas and hand, according to the “Chasm Theory,” there is a large chasm technology spread into the marketplace (6). The theory cate- between the early market, consisting of Innovators and Early adopters, and the mainstream market, which consists of Early majority and Late majority, that cannot be easily crossed (7). 1Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Suita, Osaka, Japan. 2Kanagawa Cancer Center Research Institute, For example, a Japanese company developing a free market Yokohama, Kanagawa, Japan. application "Mercari" succeeded in raising awareness by adopt- ’ Corresponding Author: Yutaka Ueda, Department of Obstetrics and Gynecol- ing a large-scale commercial strategy at a time when the app s ogy, Osaka University Graduate School of Medicine, Yamadaoka 2-2, Suita, popularity was stagnant, approaching a chasm (https://forbes Osaka 565-0871, Japan. Phone: 81-6-6879-3351; Fax: 81–6-6879-3359; E-mail: japan.com/articles/detail/23652; in Japanese). [email protected] The widespread cessation and future re-promotion of HPV Cancer Prev Res 2021;14:683–6 vaccine will be discussed from the perspectives of the diffusion doi: 10.1158/1940-6207.CAPR-21-0091 of Innovations and Chasm theories. During the period when Ó2021 American Association for Cancer Research. HPV vaccine had been well received under the widely accepted

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ABThe chasm Early Early Late Early Late Innovator Laggards Innovator Early adopter majority majority adopter majority majority Laggards

16% Vaccinaon Market share

70% 30% 2.5% 13.5% 34% 34% 16% Time Time

Inial market Mainstream market Vaccinated Unvaccinated

CDThe chasm The chasm Early Early Late Innovator majority Laggards Early Late adopter majority Early Laggards adopter majority majority Peer educaon Innovator Vaccinaon Vaccinaon

0.2% 3.9% 16.9% 50.7% 28.2% Time When the gave No mme If the 10% 90% prec ntal If many of the same Would not vaccinate ondi recomme acquaintances ons daon get vaccinated generaon get vaccinated Time is resu med Vaccinated Unvaccinated

Figure 1. Marketplace principles and re-promoting HPV vaccine. A, Diffusion of Innovations and Chasm theories. The process of market diffusion of a new product or service. Adoption of a new product or service (i.e., "innovation") does not happen simultaneously in a social system. The criterion for adopter categorization is innovativeness. There are five established adopter categories, and the majority of the general population tends to fall in the middle categories. According to the diffusion of innovations theory, demand is thought to be going to accelerate rapidly to the mainstream market, which consists of the initial majority and late majority, when the innovation penetrates the early market, which consists of Innovators and Early adopters. However, according to the Chasm theory, there is a huge chasm at the penetration rate of 16% between the initial market and the mainstream market that cannot be easily crossed. B, High coverage of the HPV vaccine in the period of FY2010–2012. The HPV vaccination rate was 55.5%, 73.5%, 78.2%, 78.8%, 78.7%, and 68.9% in the girls born in FY1994–1999 during the period of public subsidies for HPV vaccine—before the governmental recommendation was suspended, which meant HPV vaccine was disseminated not only to innovator and early adopters but also to the early and late majorities. C, Preconditions mothers would require before recommending HPV vaccination, in the FY2013 period of suspension of the governmental recommendation. The preconditions that mothers would require before promoting or allowing their daughters’ HPV vaccination might potentially associate with the innovativeness of the mothers. D, HPV vaccination coverage has slightly recovered, future challenges remain. Because of several measures, the HPV vaccination rate in Japan has improved to around 10%. For the vaccination rate to cross the 16% market chasm, awareness of the importance of the HPV vaccine needs to spread to the majority of the target population and their guardians. Education of community health workers, including public health nurses, will lead to their firm understanding of the importance of the HPV vaccine and their confident recommendation of HPV vaccination to the target population and their guardians, who are them expected to recommend the HPV vaccine to their friends by so-called peer education.

public subsidies in FY2010–2012, the chasm that existed vaccine’s safety, despite HPV vaccine became free of charge between Early adopters and Early majority was easily overcome since FY2013. Almost no one else was getting vaccinated in (Fig. 1B). However, after the reports of diverse symptoms after Japan. In the era of HPV vaccine suspension, there was thus a HPV vaccination and then the suspension of the governmental large and unusual chasm between Innovators and Early adop- recommendation for HPV vaccine FY2013, HPV vaccination ters that could not be crossed. decreased to the point where less than 1% of eligible girls were We previously conducted an Internet survey, in May 2015, of accepting the vaccine. 2,060 mothers of the girls eligible for HPV vaccine to ask them For this discussion, those few girls who received the HPV what preconditions they would impose on their daughters’ vaccine and their guardians who promoted it to them under HPV vaccination under the suspension of the government that unique situation, could be regarded as Innovators who recommendation of HPV vaccine (8). The percentage of value newness and innovation. In general, Innovators are respondents who answered, "No preconditions" was 0.2%, and followed by Early adopters, but in this case, Early adopters that was very close to the vaccination rate at that time; that is, could not follow Innovators because, due to concerns about the these were the rare Innovators (Fig. 1C). Those who responded

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"When the governmental recommendation is resumed" was messages base on behavioral economics (16). We conducted 3.9%, which potentially corresponded to Early adopters. Those a behavioral economics approach to the failed HPV vacci- who said, "If her acquaintances get vaccinated" and "If many of nation program in Japan (8, 17). Appealing of increasing her same generation gets vaccinated" were 16.9% and 50.7%, incidence and seriousness of cervical cancer was found to which would correspond the category of Early majority and increase mothers’ intention to get their daughters inoculat- Late majority, respectively. Those who said, "I would not get my ed. However, mothers’ intention to inoculate their daugh- daughter vaccinated," was 28.2%, which was the slowest to ters could not be increased sufficiently due to the significant adopt new products and services, and was considered to be impact of repeated media reports of girls with diverse Laggards. In this online survey, there was no difference by the symptoms after HPV vaccination. The HPV vaccine issue respondents’ region of residence. in Japan is no longer at a stage where resumption of the More than 7 years have now passed since the governmental governmental recommendation one effective message based recommendation was suspended in Japan. During this time, on behavioral economics or health care marketing and can more than sufficient evidence for the safety and efficacy of HPV raise vaccination rates. vaccine has been demonstrated (9–12). The news media has To spread the vaccine to those of Early majority and Late even begun to focus on the negative effects of the continuing majority categories, it is necessary to help the targeted girls suspension. Acceptance—the intention to receive the HPV and their guardians to become aware that HPV vaccine has vaccine—has improved significantly, from 6.7% to 11.5%, in already been given to thousands and millions of other girls in our most recent Internet survey conducted in November Japan. To achieve this, it is important that the HPV vaccine 2019 (13). For the resumption of the governmental recom- be discussed among those who are eligible for vaccination. It mendation of HPV vaccine, academic societies have repeatedly is especially critical that those who have already been vac- issued the statements (14) and the National Diet members have cinated tell others about the vaccine and the important also formed a parliamentary group. benefits. To this end, it is essential that community health The MHLW has also drastically revised its HPV informa- workers, including public health nurses, are educated so that tional pamphlet, which at one time focused on the possible they have a firm understanding of the importance of HPV symptoms after getting an HPV vaccination. In the munici- vaccine and they can confidently and convincingly recom- palities where the vaccine leaflets were sent individually to the mend vaccination to the target population and their guar- age-targeted girls, the vaccination rate recovered to about dians. The vaccinated girls and their guardians are expected, 10% (15). In addition, in an Internet survey, we found that in the same way, to have a relatively firm understanding of the intention to vaccinate increased to 9.2% when the contents the importance of HPV vaccine and confidently recommend of the leaflet were changed to be more positive, irrespective of vaccination to their friends and acquaintances, resulting in the respondents’ region of residence (13). re-dissemination of HPV vaccine among Early to Late As a result of these initiatives, HPV vaccination coverage and majority. This strategy would suggest that the innovator intentions have improved, in other words, the HPV vaccine has model can be utilized to help cross the chasm by rapidly penetrated the “market” represented by age-eligible girls and increasing the number of girls who make a decision to get their guardians, herein categorized as Early adopters, who vaccinated as a result of so-called peer education or peer joined the category of innovators who had already been promotion. Previously, we demonstrated the success of vaccinated (Fig. 1D). However, as Moore has said, “There is intervention with mothers by sending them a cervical cancer something fundamentally different between a sale to an Early information leaflet with a request that they recommend that adopter and a sale to Early majority” (7). There is still the next their daughter receive cervical cancer screening, which sig- large chasm, the one between Early adopters and Early majority nificantly improved their daughters’ screening rate (18, 19). that will be difficult to overcome. Peer education among non-health professionalsisapotential How can we re-promote the HPV vaccine beyond the tool that triggers expansive market penetration. Positive chasm between Early adopters and Early majority?Of media reports on HPV vaccine will potentially enhance the course, resumption of the governmental recommendation effectiveness of this strategy to penetrate HPV vaccine. is essential. In reality, the safety and efficacy of the HPV Doctors also need to provide appropriate explanations to the vaccine have been widely demonstrated and positive leaflets girls and their mothers. In a questionnaire survey conducted at of HPV vaccine had started to be sent to each target obstetrics and gynecology clinics, among the female patients population. Nevertheless, the vaccination rate remains stuck who were given sufficient explanations from their doctors at around 10%. According to our previous Internet survey, regarding cervical cancer and HPV vaccine, 6.7% said that only about an additional 3.9% of the respondents were going they would have their daughters vaccinated immediately, and to be vaccinated—if the governmental recommendation was 37.8% said that they felt more positive about vaccinating their resumed (8). daughters (20). Another study we conducted in 2020 showed Strategies based on marketing theory has been used that 7 (30%) of 21 mothers who became more willing to to improve health care. Cancer screening rates were dem- inoculate their daughters after appropriate explanation about onstrated to be improved by effective recommendation HPV vaccine from a doctor in an obstetrics and gynecology

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clinic returned to the clinic immediately to get their daughters Authors’ Disclosures vaccinated (21). We believe that the family doctor has a major Y. Ueda reports grants from the Japan Agency for Medical Research and influence on vaccination decisions. Because the attitudes of Development and personal fees from Merck Sharp & Dohme during the Japanese obstetricians and gynecologists regarding the HPV conduct of the study. T. Kimura reports grants from Merck Sharp & Dohme vaccine have recently been found to be improving (22), they are during the conduct of the study. No disclosures were reported by the other expected to provide more positive explanation to the targeted authors. girls and their mothers. Acknowledgments It has long been thought that the only way to re-promote We would like to thank G. S. Buzard for his constructive critique and HPV vaccine in Japan for the MHLW to resume its recom- editing of our article, and also Hazuki Abe for her support to create the mendation and the doctors and public health nurses would figures. have to give the appropriate explanations to the target popu- Yutaka Ueda received a grant (15ck0106103h0102) from the Japan lation and their guardians to address their fear of cervical Agency for Medical Research and Development, and lecture fees from cancer and the importance of HPV vaccine, and educate them Merck Sharp & Dohme. T. Kimura received research funds from Merck how to tell their acquaintances about it. We sincerely hope that Sharp & Dohme. HPV vaccine will penetrate the category of Early and one as Received March 3, 2021; revised March 26, 2021; accepted April 26, 2021; soon as possible. published first June 22, 2021.

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686 Cancer Prev Res; 14(7) July 2021 CANCER PREVENTION RESEARCH

Yutaka Ueda, Kayoko Katayama, Asami Yagi, et al.

Cancer Prev Res 2021;14:683-686.

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