Girls' Explanations for Being Unvaccinated or Under Vaccinated Against Human Papillomavirus

A Content Analysis of Survey Responses

Alice S. Forster; Jo Waller; Harriet L. Bowyer; Laura A. V. Marlow


BMC Public Health. 2015;15(1278) 

In This Article


In 2008, vaccination against human papillomavirus (HPV) was recommended in the United Kingdom (UK) for 12 and 13 year old girls. The vaccine protects against the two oncogenic HPV types most strongly associated with cervical cancer (HPV 16 and 18) and is over 99 % effective at preventing precancerous lesions associated with these virus types.[1,2] In the UK, quadrivalent HPV vaccine is currently delivered almost exclusively through schools. A three-dose schedule over a six month period was used from 2008 until September 2014, when a two-dose schedule was adopted. Uptake of HPV vaccination in England is high overall (90 % for the first dose and 80 % for all three doses in 2013/2014), but uptake varies widely across England.[3]

Understanding the reasons why some girls remain un-/under vaccinated will help to identify targets for information campaigns or wider policy changes that can help establish and maintain high coverage across all areas. To date, only a few, mainly qualitative studies have explored the reasons for being un-/under vaccinated among girls in England.[4–8] Girls in these studies generally lacked knowledge about the vaccine and were unclear about why it was needed, largely because of the novelty of the vaccine and because they did not feel at risk of HPV infection. Some studies have also highlighted that physical discomfort may be a barrier to girls completing the vaccination series.[6,7] In other countries with school-based vaccination programmes, similar themes have been identified.[9]

Research exploring the association between socio-demographic characteristics and uptake of HPV vaccination at a population-level has suggested that girls from some ethnic minority backgrounds are less likely to receive HPV vaccination than girls from White backgrounds.[10,11] This remains the case when controlling for deprivation.[12] In particular, certain areas of the UK with large ethnic minority populations appear to have the poorest uptake. In London, where the population is highly ethnically diverse,[3] mean uptake is 76 % and is as low as 67 % in some areas. No studies have explored why this might be. A review of studies conducted before HPV vaccination was introduced suggested that mothers from ethnic minority backgrounds were unsure of the need for HPV vaccination, particularly for 12–13 year olds.[13]

Often research exploring attitudes towards HPV vaccination has been conducted with parents, for example.[14–16] However, because uptake of HPV vaccination in the UK is high,[17] studies of British parents are often comprise samples of parents who intend to or have accepted HPV vaccination for their child.[18–20] Parents who actively decline the vaccine are likely to be over-represented in the 'unvaccinated' group. Identifying non-accepting parents, particularly those from ethnic minority backgrounds, and those who may not have actively engaged with the vaccine offer, is therefore a research challenge. However, evidence suggests that girls are also involved in the decision-making process,[4,21] and in the class-room context recruitment is likely to reflect a more representative sample of those who are un-/under vaccinated. In the present study we therefore qualitatively assessed reasons for being un-/under vaccinated among a sample of girls (aged 15 to 16 years) from a diverse range of ethnic backgrounds.