Knowledge and awareness of HPV and the HPV vaccine among young women in the first routinely vaccinated cohort in England
Highlights
► Little is known about HPV knowledge in vaccinated cohorts of girls in the UK. ► We surveyed girls in the first vaccinated cohort, three years after vaccination. ► Knowledge was low, with a fifth unaware of HPV. ► Many girls were unaware of the link between HPV infection and cervical cancer, and the need for cervical screening post-vaccination. ► There will be a need for targeted information when this cohort reaches screening age.
Introduction
In September 2008, a free national programme was introduced in the UK offering 12–13 year old females a bivalent vaccination that protects against the two high-risk types of human papillomavirus (HPV) responsible for approximately 70% of cervical cancers [1]. Prior to vaccination all eligible girls are provided with an information leaflet from the Department of Health, sent to their homes by post. The leaflet includes information about the link between HPV and cervical cancer, the sexually transmitted nature of HPV, the need for three doses of the vaccine and the need to attend cervical screening in the future [2]. Most girls in the first routine cohort were offered the vaccine at school (94.2%) within the UK [3]. Uptake rates have been relatively high, with 84% of girls offered the vaccine receiving all three doses in 2010/2011 in England [4] and similar coverage in Scotland and Wales [5], [6].
Prior to the introduction of HPV vaccination programmes, awareness of HPV and its relationship with cervical cancer was low in a variety of population groups, both in the UK [7], [8], [9], [10], [11] and elsewhere [12]. Recently published data from the UK showed that a year after the start of the programme, fewer than half (46%) of the adult women surveyed were able to recognise HPV infection as a risk factor for cervical cancer development [13]. Studies assessing HPV knowledge in young females have generally focused on knowledge prior to the introduction of the HPV vaccine [14], but it is also important to assess the knowledge of those who have been involved in the vaccination programme, as this could potentially have an impact on future behaviours relating to sexual health and cervical screening attendance. It has been suggested that HPV vaccination could provide a ‘teachable moment’ for parents to discuss sex and sexual health with their adolescent daughters [15], [16]. Equally, it could provide an opportunity to inform girls about cervical cancer and the recommendation to attend for screening when they are invited (currently at 25 years in England; 20 years in Scotland and Wales). With the time delay between HPV vaccination (12–13 years) and cervical screening attendance (20–25 years) it will be important to reiterate these messages closer to the time of the first screening invitation.
Little is known about HPV knowledge in girls who have been offered the vaccine. A small body of qualitative research focusing on vaccinated cohorts suggests that HPV knowledge is generally low. These studies suggest that girls know little about how the human papillomavirus is transmitted [17], how to reduce the risk of HPV infection [18], or about the link between HPV and cervical cancer [17], [18]. Furthermore, girls are unclear about the level or duration of protection the HPV vaccine offers [17], [18], [19] and lack knowledge about the need for future cervical screening [17]. In one study involving 87 girls, just over half were aware of cervical screening and the need to attend in the future [18]. While these qualitative studies have helped to map the range of girls’ knowledge after the implementation of HPV vaccination programmes, larger quantitative studies are needed in order to ascertain knowledge within a representative sample. Previous studies in the US have shown that vaccinated and unvaccinated girls have similar levels of knowledge about HPV and the HPV vaccine [20], [21]. Licht et al. [20] found that regardless of vaccine status, respondents lacked knowledge about the link between HPV and genital warts, HPV transmission and the fact that HPV infection is as common in men as in women. The only statistically significant difference in knowledge by vaccine status was a greater awareness in those individuals who had received at least one dose of the HPV vaccine, that HPV causes genital warts. Caskey et al. [21] found that vaccinated respondents were more likely to know that the HPV vaccine protects against cervical cancer, and that women who receive the HPV vaccine should continue using condoms during sexual intercourse.
This study aimed to extend this research to the UK, using quantitative methods to examine knowledge about HPV and the HPV vaccine, in girls based in London, England, three years after the introduction of routine school-based vaccination.
Section snippets
Materials and methods
In September 2011, young women in school Year 11 (aged 15–16 years) were recruited from 13 schools in London, England. These girls were part of the first cohort to have been offered the HPV vaccine in the NHS school-based vaccination programme in 2008–9. A sampling frame was created using level of Free School Meal Eligibility (FSME)1 and General Certificate in
Sample characteristics
Over 98% of girls approached agreed to participate in the study (n = 1033; see Fig. 1). Non-participation was either due to parental (n = 5) or participant (n = 9) refusal to consent. Demographic characteristics of the sample are shown in Table 1. All participants were 15 or 16 years old. Most were of White or Black ethnicity, were Christian or had no religious affiliation, and free school meal eligibility was 27%, in line with national figures [23].
Individuals who had received at least one dose of
Discussion
This study is the first, to our knowledge, to use quantitative methods to measure awareness and knowledge of HPV in a cohort of girls who have been offered the HPV vaccine in the UK. Three years after being offered the HPV vaccine in school as part of the national programme in England, girls in our sample, 77% of whom reported having received at least one vaccine dose, demonstrated low HPV knowledge. A fifth of our respondents reported that they had not heard of HPV, which may reflect the fact
Conclusions
Despite having been offered the HPV vaccine three years previously as part of the national HPV vaccination programme in England, a significant proportion of girls in this study reported being unaware of HPV. Those who were aware of HPV had low knowledge about the virus, the vaccine and the need for future screening. Our study provides a benchmark of knowledge about HPV and its relationship with cervical cancer development in a vaccinated cohort, which could be used in developing health
Acknowledgements
This work was carried out as part of a Cancer Research UK project grant (A13254, PI Professor John Edmunds). We are grateful to the schools that worked with us to facilitate data collection and the girls who took part in the study.
Conflict of interest: All authors declare no conflict of interest that may have influenced this work.
Author contributions: JW conceived of the study. HB and JW collected the data for the study. HB, LM and JW contributed to the analyses of the study and all authors
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2019, Journal of Pediatric and Adolescent GynecologyCitation Excerpt :This apparent failure to provide the planned information at vaccine delivery should be addressed; for example, were health teams adequately trained, or, because not all schools have health teams, whether teachers can be trained instead to provide the information. It is possible also that the participants did receive the information but simply could not recall having done so; the effectiveness of the material and appropriateness of the method of delivery would need to be assessed by skilled educators and redeveloped as necessary, to ensure that giving information does in fact result in better knowledge.8 Several studies suggested that if HPV vaccination and school-based education is also accompanied by a nationwide awareness campaign, which would also educate adults of influence (such as school staff, family, and friends), students’ knowledge and awareness would also increase.11–16
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