Individual and cultural differences (attitudes, intentions, beliefs, subjective norms, and the like) moderate the effects of health promotion interventions and influence how individuals make decisions [1].

Segmentation and determination of a specific target audience aim to identify the characteristics, needs, social structures, and perceived costs and benefits of the audience relative to specific health behavior. Identifying all these factors in the target audience can contribute to the development of an effective health communication [2].

Studies show that messages are more thoroughly processed and defined as convincing and effective if their content is adapted to the cognitive, emotional, and motivational characteristics that in most cases are determined by the cultural background of the target audience [3].

Culturally sensitive materials based on the target population’s cultural background can affect the understanding and effectiveness of health communication [4]. Moreover, culturally sensitive materials increase the awareness of recommended behavior, improve decision making, make messages more persuasive, and lead to deeper processing and understanding in the context of health promotion. Sensitive cultural communication reduces gaps in health outcomes by making messages equally meaningful and effective [5].

When the information provided matches cultural values, the content is likely to lead to deeper reflection on the potential benefits and adverse effects, in turn leading to more appropriate and informed choices in the decision-making process [6].

Despite the emphasis on the importance of audience segmentation and theory-driven development of messages (cultural sensitivity [CS] in this study), health organizations do not always take the dimensions of CS into consideration when designing interventions and formulating messages and informational materials [7,8].

Culture is a typical mediator in the decision-making process of individuals with respect to the recommended health behavior [9-11]. CS is defined as the extent to which the ethnic, cultural, and experiential norms, values, behavior patterns, and beliefs of the target population, as well as the historical, environmental, and social factors are expressed in the design, planning, and evaluation of the informational materials and programs for health promotion [12].

Many theories and models have discussed cultural competence and CS to various ethnic minority groups in different intervention programs [7,13-16]. The cultural competence or CS of materials used for health education and publicity is measured by different tools focusing on the use of culturally adapted language, graphics, and illustrations as well as the use of personages from the community [9,17].

Over the years, many studies have shown that CS is not limited to language or illustrations, suggesting that deep dimensions require additional measures. According to Resnicow's definition [15], CS is conceptualized in terms of 2 main measures: deep dimensions and surface dimensions.

Surface dimensions include the use of people, places, language, music, food, and clothing familiar to the target audience. The measure also includes channel identification (media), level of literacy, relevance of recommended behavior to the target audience, marketing sites (eg, schools and churches) appropriate for transmitting messages and intervention programs, and the use of a suitable communicator [12].

These surface dimensions are intended to make communication more effective by increasing its attractiveness, relevance, and familiarity as well as by increasing source reliability with respect to the target population [1].

Deep dimensions, in contrast, examine the environmental, cultural, social, psychological, and historical factors related to the target audience that influence their health behavior. The measure makes specific reference to the arts, values, shared experiences, moral concerns, cultural barriers, perceptions regarding those who determine behavior, and perceptions regarding recommended behavior [15].

These dimensions are related to the understanding and interpretation of health communication, which depend on the models that explain the health and illness status of the target population [15].

The human papillomavirus (HPV) is one of the most common sexually transmitted infections worldwide [18,19]; this contrasts with the situation in Israel, where morbidity and mortality rates caused by HPV infections are the lowest in the West [20]. Some studies indicate that ongoing infection with high-risk HPV strains can develop into cervical cancer. HPV can also cause other cancers (cancers of the vagina, vulva, penis, anus, rectum, and oropharynx) and genital warts [21-23]. High-risk HPV strains include HPV 16 and 18, which cause approximately 70% of cervical cancers [22,24].

In addition to the Papanicolaou (Pap) smear screening procedure for cervical cancer that has significantly reduced the morbidity and mortality rates for cervical cancer in many western countries [25], the HPV vaccine is the first vaccine targeted at preventing cervical cancer [26].

According to the World Health Organization (WHO), since 2006, around 100 nations worldwide have approved the HPV vaccine, and as of 2012, approximately 40 countries have included the vaccine in their immunization programs [27]. HPV vaccine programs vary from country to country with respect to the type of vaccine, implementation strategies, compliance rates, and payment policies [28-30].

According to recent data from the Israel Ministry of Health [20], the age-adjusted incidence rates (per 100,000) of invasive cervical cancer in 2012 were 5.08 in Jewish women and 2.97 in Arab women. The age-adjusted incidence rates (per 100,000) of stage 0 cervical cancer in 2012 were 22.5 in Jewish women and 4.2 in Arab women. The age-adjusted mortality rates (per 100,000) from cervical cancer in 2012 were 1.50 in Jewish women and 0.94 in Arab women. The data show that the rates of HPV infections are even lower.

Starting in 2007, the HPV vaccine was available in Israel in exchange for payment. In December 2012, Israeli health authorities decided to include the HPV vaccine in the medical services basket of medical services provided free of charge. The vaccine included in the basket is for women, boys, and men up to the age of 26 years, who constitute the population at risk for HPV infection [31]. Starting in 2013, the vaccine was included as a part of the routine vaccines given in school to girls in the eighth grade and was later extended to include boys [31,32]. According to the Ministry of Health [20], in the 2016 school vaccination campaign, the rate of HPV vaccine uptake among the Arab population reached 84% (96% in the Bedouin sector) compared with 40% for the Jewish population.

Experts from across the globe recommend additional monitoring of HPV vaccine effectiveness and safety [33]. This recommendation derives from the scientific controversy regarding the effectiveness and safety of this vaccine since its inclusion in vaccination programs worldwide. On the one hand, a large body of studies indicate that the vaccine is effective. For example, various meta-analyses and research studies have attested to the vaccine's high immunological effectiveness, approaching 93% to 100%, against the papilloma virus and other precancerous cervical lesions [28,34-38]. In addition, recent research emphasizes the effectiveness of the HPV vaccine in reducing preinvasive cervical disease and increasing clinical herd protection in unvaccinated women [39]. Yet, the literature still includes studies pointing to a variety of factors that can affect the vaccine’s effectiveness, such as age, the type of virus strain, and the individual’s immune system [40-44].

On the other hand, other studies point to negative consequences after vaccine uptake. Similar to any other vaccine, the HPV vaccine can cause major pain at the injection site as well as fainting and dizziness [45-47]. However, there have also been reports of more serious side effects [48-59]. With the rising number of these reports, experts around the world have been calling for more studies and improved postmarketing surveillance [56,59].

Balanced health information regarding the HPV vaccine should include 3 main components: (1) completeness—description of the risk of cervical cancer and the vaccine’s advantages and disadvantages; (2) transparency—presentation of all the vaccine-related risks in absolute numbers and not as relative figures; and (3) evidence-based correctness—providing information based on science [60].

Transparency is an essential component in effective health communication and in designing messages and explanatory materials intended to promote various health behaviors [61-64]. Studies that examined transparency in providing information on the HPV vaccine to target populations were conducted mainly in Germany [60,65]. These studies emphasized that the German health agencies and the German media as well provided only partial information regarding the risks of cervical cancer and the papilloma virus and used statistics that were not transparent in describing the vaccine’s effectiveness and safety. The statistics in the marketing materials provided inaccurate numbers regarding the vaccine’s effectiveness, showing absolute effectiveness. Moreover, most of the marketing leaflets did not mention the vaccine’s side effects [60,65]. Most studies examining decision making in the context of the HPV vaccine emphasize the importance of transmitting information that is fully transparent and understandable to enable parents to sign the informed consent forms for the vaccination [66-68]. Some studies indicate that people do not always read the forms to the end or do not understand what they read, so, in essence, they sign the forms without their informed consent [66,69,70]. Moreover, most of the scientific literature indicates that in the case of the HPV vaccine, the parents indicate that their knowledge about the vaccine is limited [71-74]. This makes the informed-consent decision-making process to the HPV vaccine more challenging [71,75-77]. The studies show that people often make decisions about HPV vaccination without having sufficient knowledge as required to make age-appropriate health decisions [74,77-82].

Furthermore, providing complete, comprehensive, and transparent information about HPV vaccination helps parents in making a decision about whether to vaccinate their children [66,67]. Parental decision making regarding the vaccination is dependent upon perceptions of the risks with respect to their children’s sexual activity [72,74,82,83]. Studies indicate that parents who perceived the risk of sexual activity among their children to be high were more willing to give their children the vaccination. In contrast, parents who perceived the risk of sexual activity among their children to be low because of their cultural or religious background were less willing to give their children the vaccine [72,73,75,79].

The HPV vaccine is intended to protect the individual from contracting the papilloma virus, which is transmitted through sexual intercourse [19]. The Food and Drug Administration recommends vaccinating boys and girls against the virus during adolescence, before they become sexually active [84]. Research studies have raised parental concerns and fears regarding the vaccine from different population groups worldwide because of their belief that the vaccine legitimizes sexual activity and promotes sexual abuse [85-87]. Some of these concerns were derived from media coverage that represented giving the vaccine as an act that encourages sexual relations, sexual promiscuity, and sexual abuse [88,89]. Despite these parental concerns, several scientific research studies showed that the HPV vaccine has no impact on the sexual behavior of adolescents [90-93]. Nonetheless, the issue of sexual relations in the context of giving the vaccine increases sensitivity regarding the vaccine [94], particularly among conservative minority population groups such as the Arab minority in Israel [95,96].

Constituting around 20% of the general population, the Arab population in Israel is a minority with unique national, religious, linguistic, and cultural attributes. Relations between Arabs and Jews are mainly minority-majority relations. Israel must deal with the internal problems of minority groups for whom issues of justice and equality are central to their relations within the state [97].

The socioeconomic disparities between the Jews and the Arabs are the result of a historical-geographic reality in which most of the Arab population lives in the spatial periphery, thus limiting their access to the country's main labor markets and services. These disparities find expression in unequal allocation of resources for economic development and infrastructure in the local authorities and unequal employment opportunities for Arabs [97].

In addition, the culture of Arab society differs from that of Jewish society. These cultural differences are related to language, religion, nationality, cultural heritage, family structure, values, and primary lifestyles. Traditionalism dominates Arab society, in that the religion is a central component of cultural life (religious self-definition and prayer frequency). Moreover, the Arab population still lives within the framework of a conservative family and community and is characterized by less openness, autonomy, development of personal inclinations, freedom, and the like. This is not the case among the predominantly secular Jewish population, which espouses individualism, competitiveness, achievements, ambitions, career development, materialism, and consumerism [97].

Even though the Arabs in Israel usually live in separate localities marked by lower educational and socioeconomic levels, their exposure to Jewish society is high, which has led to social, cultural, and economic processes of change that have made Arab society more modern. This modernization is characterized by a gradual shift from a collectivist to an individualist orientation, manifested in a rise in the age at first marriage, a drop in the number of children, an increase in the educational level, use of preventive health services, and more years of education among women than among men [98].

Yet, Arab culture is still conservative regarding sexuality and sees sexual relations before marriage as improper and prohibited. Indeed, in most Arab communities, such relations are taboo [99-101]. One of the typical barriers preventing parents from the Arab minority in Western countries from vaccinating their daughters against the papilloma virus is their concern of encouraging unlimited sexual behavior and sexual promiscuity [102-104].

To the best of our knowledge, no studies have examined the topic of CS in explanatory materials geared at promoting the administration of HPV vaccine. Therefore, the purpose of this study was to investigate the following question: How is CS articulated in the explanatory informational materials about the HPV vaccine posted on the websites of Israeli health authorities?

To investigate how CS is articulated in the explanatory informational materials about the HPV vaccine posted on the websites of the Israeli health authorities, we examined 3 specific questions:

The research method entailed quantitative and qualitative content analysis of the texts of explanatory informational materials published on the Arabic and Hebrew websites of the Israel Ministry of Health and the Clalit HMO.

The research was conducted under the approval of the Faculty of Social Welfare and Health Sciences Ethics Committee for research with human subjects at the University of Haifa (approval no.118/16). The researchers analyzed these materials for 6 months (October 2017-March 2018).

The sample comprised 18 instances of explanatory materials published on the Hebrew and Arabic websites of the Clalit HMO and the Ministry of Health and updated after the vaccine was included in the basket of health services (after 2012). These instances had identical content and headings in Hebrew and in Arabic (9 in each language).

Excluded from the study were materials published on sites that did not have an Arabic website, websites that had not been updated after the vaccine was included in the Israeli basket of health services (2012) and those that had original materials from the WHO that were not translated into Hebrew or Arabic and were omitted because of the Arab population’s low level of literacy in English [105].

The rationale behind selecting all the explanatory informational materials for the HPV vaccine after it was included in the medical services basket is as follows. Although the vaccine is free and available in school settings, parents are still aware of the scientific controversy surrounding the vaccine’s efficacy and effectiveness as publicized in the media. Therefore, they still seek information about the vaccine, its efficacy, and its safety in deciding whether to vaccinate their children [33].

The following health authority websites and the HPV vaccine materials were retrieved:

The following keywords were examined: cervical cancer, vaccine against cervical cancer, vaccine against the human papilloma virus, human papilloma virus, condyloma, and genital warts.

It is important to clarify that these sites address most of the Jews and Arabs living in Israel. Most of the Jewish population is secular and, therefore, tends toward more liberal views, except for the conservative ultraorthodox Jews who are in the minority [106]. Similarly, the majority of the Arabs in Israel are Muslim (97% of the Arabs in Israel), who are indeed defined as conservative [107].

The explanatory materials were analyzed using 2 parallel methods: quantitative content analysis based on index-coding criteria and qualitative content analysis to interpret and explain the index score.

This study is based on a variety of methods used to analyze rhetorical and aesthetic elements and scientific facts. The use of a combination of several research methods increases the reliability and validity of the findings [112-115] The CS index constructed by the researchers was based on Resnicow’s model of CS [12,15], a valid theoretical model. The researchers, among them experts in health communication and CS worked together to investigate the cultural attributes of the Arab Jewish populations in Israel in the context of the HPV vaccine, adapt these attributes to the index, define the dimensions, and formulate the questions. The researchers are able to read and analyze texts written in Hebrew and in Arabic. One of the researchers is a member of the Arab minority group, Arabic is her native language, and she can distinguish cultural uses of the language. The coders performed their coding separately, then compared their coding and found it to be almost identical. The third researcher reviewed all the findings after coding and gave his analysis of CS. Coding that was not equivalent was resolved through discussions between the research team members. A high level of interrater reliability (98%) emerged. An intercoder agreement coefficient exceeding 0.7 suggests an acceptable level of reliability [116].

Furthermore, Scott’s pi indicator was calculated by the reliability calculation for the masses, to reinforce the indicator of intercoder reliability. Scott’s pi value was 0.9685, thus ensuring valid internal coding reliability [117].

In the qualitative analysis of the texts, the researchers reviewed materials posted on the websites of the Ministry of Health and the Clalit HMO. Together, they determined the inclusion criteria and decided which materials would be included in the research. The major categories and themes emerging from the web-based explanatory materials were discussed and agreed upon [109,110].

This section describes the CS index implementation scores for the HPV vaccine materials published in Arabic and Hebrew on the websites of the Ministry of Health and the Clalit HMO. Implementation of the index included coding the nominal categorical indicators of each dimensions (surface and deep) with 1 of 2 values: yes/no (Multimedia Appendix 1) and calculating 2 scores: specific scores for the deep and surface dimensions and an overall CS index score (Multimedia Appendix 2).

In most (78%) of the Arabic explanatory materials assessed, the surface dimension score was lower than 50%. Surface dimension score was higher than 50% for only 2 out of the 9 materials assessed. Conversely, surface dimension score was equal to or higher than 50% for all the materials (100%) written in Hebrew, starting from 73% up to 91% in some cases (33%).

The majority of the Arabic and Hebrew materials included some surface dimension indicators, such as mentioning the target audience (Arab population), use of suitable people (photos of Arab physicians recommending and explaining about the vaccine), language appropriate to the target audience (Arabic), compatibility with the literacy level (minimal use of scientific terminology), and presentation of the effectiveness and advantages of the recommended behavior (uptake of HPV vaccine).

Furthermore, most of the Arabic materials did not refer to the indicators of appropriate media channels (Arab-language television and radio stations or local websites targeting the Arab population), appropriate communicators (key Arab health and medical personnel), places suitable for transmitting the message (mosques, churches, and schools), and organizations acceptable to the minority target audience (educational originations and the Child and Family Care centers). In contrast, as mentioned, these indicators appeared in materials written in Hebrew, resulting in a surface dimension score equal to or higher than 70%. Moreover, most of the materials written in both languages, Hebrew and Arabic, did not address all the implications of vaccine uptake or the relevance of the vaccine or cervical cancer to both populations.

A chi-square test of independence of the surface dimensions reveals significant interaction between the explanatory materials written in Arabic and those written in Hebrew with respect to the following items: HPV vaccine, HPV vaccine for eighth-grade girls, vaccine to protect against cervical cancer caused by the papilloma virus, and a PowerPoint presentation about HPV vaccine.

All the Arabic explanatory materials assessed scored below 50% on the deep dimension . Most of the materials did not refer to the social or normative values or to the environmental or cultural-ethical indicators.

Most of the materials that scored 20% on the deep dimension included 1 deep dimension indicator: either normative or social indicators. The normative indicator referred to Arab women’s preference for female gynecologists, particularly for Pap smear. The social indicator referred to providing explanations for giving the vaccine to males. These indicators were also referenced in some of the Hebrew informational materials.

Moreover, it is important to note that sexuality is related to the HPV vaccine even though the topics of sexuality and sexual discourse are known to be taboo among the Arab population. The data show that the Arabic explanatory materials made no reference whatsoever to the population’s moral concerns regarding sexual relations and promiscuity or to values and perceptions related to sexual relations before marriage.

In contrast, these indicators were referred to and mentioned in Hebrew explanatory materials, resulting in a deep dimension score exceeding 50% in most (78%) cases. Environmental factors, such as the impact of the sexual behavior of the nation’s majority population on the sexual concepts of the minority population, were absent from the informational materials in both languages.

A chi-square test of independence of the deep dimensions revealed significant interaction between the explanatory materials written in Arabic and those written in Hebrew with respect to the following items: information sheet before and after administering HPV vaccine, HPV vaccine, HPV vaccine for eighth-grade boys, and vaccine to protect against cervical cancer caused by the papilloma virus.

The overall CS index score calculated for all the explanatory materials targeting the Arab minority points to a low level of CS, in contrast to the CS expressed in materials targeting the Jewish population. The low score reflects only a partial and superficial degree of CS and refers only to a minor portion of CS indicators. The overall CS index score based on the surface indicators, among them using Arabic, mentioning the Arab population, using Arab figures, and referring to the population’s low level of literacy, was higher than the score for the deep dimension indicators. The overall CS index score for deep dimension indicators included at most 1 deep indicator, without any reference to normative, social, cultural, traditional, and ethical indicators of the Arab minority population in Israel. Related issues affecting the decision-making process of this population regarding vaccines in general were not addressed, and reference to the issue of sexuality associated with the HPV vaccine was notably absent.

For the overall CS index score, a chi-square test of independence reveals significant interaction between the materials written in Arabic and those written in Hebrew on all the items except for HPV vaccine.

Moreover, a chi-square test of independence between CS and language (Hebrew vs Arabic) for all the explanatory materials revealed significant interaction on all the dimensions: deep dimensions, surface dimensions, and overall CS index score.

This study examined web-based explanatory materials published on the websites of official health authorities in Israel. The research did not include flyers, pamphlets, posters, or information brochures that might be distributed in health clinics or other health institutions. Nevertheless, today, the HPV vaccine is not given in clinics or other health institutions because it is part of the routine school vaccine program. Therefore, it is reasonable to assume that the study included most of the existing informational materials.

As stated, the study included only the informational materials appearing on websites. Considering the 70% internet access rate of the Israeli population in general and the 50% access rate of the Arab population in particular, it is possible that not all of the population was exposed to these materials. However, it is reasonable to assume that if the public needs information about the HPV vaccine or any other health information, it prioritizes the official health authorities’ websites.

Moreover, this study was based mainly on qualitative and quantitative content analysis of explanatory materials targeting different population groups in Israel. The research did not consider how these materials were received and accepted by the public, that is, it did not assess their effectiveness among the public. Future research on audience analysis is recommended to examine how the public receives the explanatory materials. In addition, for the deep dimensions, the number of indicators was quite small (5 indicators). Therefore, drawing statistical conclusions was problematic in the comparison between materials written in Hebrew and those written in Arabic.

The research focused on official health authorities’ informational materials and did not generalize to the materials of other countries. Other studies might be comparative and study the transfer of information between different countries.

The public health authorities have 2 main objectives in the context of vaccinations. One is to raise the vaccination rates and the other is to provide full and culturally sensitive information to give the public the tools to make intelligent decisions. The findings of this study indicated that despite the high uptake rate for HPV vaccination in the Arab population, the health authorities did not exercise full transparency and CS in transmitting the association between engaging in sexual relations and necessity of the vaccination. Thus, the major challenge for the health authorities is to find ways to implement the objective of communicating information about the vaccination in a way that is transparent and culturally sensitive, even if this raises questions and fears among the public deriving from their culture.

Specifically, explanatory health materials in general and those promoting the HPV vaccine in particular must provide all the relevant information available in the literature today in a manner that is comprehensive, detailed, culturally sensitive, and based on scientific evidence to enable each individual to make an independent and intelligent decision based on informed consent.

The main recommendation of this study is to make CS the first priority in designing explanatory materials targeting minority population groups. Referring to the cultural attributes of ethnic minority groups in such explanatory materials is important for empowering the population and stimulating open and appropriate discourse.

In addition, because the media have the power to influence a person’s health views and behaviors, the research recommends using media strategies that implement transparency in providing complete information.