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


Sample Characteristics

Over two waves of data collection 2,163 girls completed the questionnaire (78 % of those registered at the schools). After excluding those who did not know or did not report their vaccine status or who reported that they had not been offered the vaccine (309 girls, 14.3 %), 19.2 % (355/1,854) had not been fully vaccinated. These 355 girls had either received one or two doses of the HPV vaccine (under vaccinated) or had been offered the vaccine but had not had it (unvaccinated). The present analyses include data from 259 of these girls (74 %) who provided a reason for their un-/under vaccinated status. Of these, 202 (78 %) were unvaccinated and 57 (22 %) were under vaccinated (comprising girls from all 12 of the participating schools). The majority of included participants provided one sentence answers to the free-text question.

Girls were mostly from White (31 %), Black (29 %) or Asian backgrounds (20 %). Around 2 % did not provide their ethnicity and just under a fifth of girls were from an ethnic background other than White, Black or Asian; mostly mixed backgrounds. In terms of religion, 42 % were Christian, 24 % were Muslim, 24 % had no religion, 9 % had another religion and less than 1 % did not provide their religion. Of girls who reported having a religion, 66 % said they were practising. Mean affluence score was 5.49 (SD = 1.84, range 1–10). Providing a reason was not significantly associated with ethnicity, practising a religion or family affluence, but was associated with religion ( Table 1 ). Girls who were Christian or Muslim were less likely to provide a reason than girls from other religions or those reporting no religion. Among individuals who provided a reason, there were no demographic differences between those who were under vaccinated and those who were unvaccinated.

Reasons for Being Un-/Under Vaccinated

For unvaccinated girls the most common reasons given to explain their vaccination status were lack of parental consent (41 %, 82/202), safety concerns (25 %, 51/202) and believing that they did not need the vaccination (19 %, 38/202). For under vaccinated girls, the main reasons for their vaccination status were practical problems, including administrative problems (51 %, 29/57, for example, being absent from school on the day of vaccination) and needing more information (11 %, 6/57). Health reasons (9 %, 5/57, for example, existing health conditions perceived to be contraindications for vaccination) and procedural reasons (5 %, 3/57, for example, fear of needles) were also given by a few of these girls. Reasons offered by girls themselves and their beliefs about their parents' decisions are provided in Table 2 and by ethnic group in Table 3 . Quotes provided below are accompanied by the participants' self-reported ethnicity and participant number in parentheses.

Lack of Parental Consent. Among unvaccinated girls, the most commonly cited reason for their vaccination status was parental refusal, cited by 41 % (82/202) of girls. Around two thirds of these girls gave a reason for their parents' refusal (63 %, 52/82), while a third offered no explanation (37 %, 30/82). Parental concerns were rarely mentioned by the girls who were under vaccinated.

Concordance between girls' and parents' decision making was evident for some cases.

"My mother and I decided I should have the vaccine when I was older" (Mixed White/Asian, TS099).

In other cases there were conflicts between parents and daughters, and even between parents.

"My mother didn't want me to have it, even though I did" (Black Caribbean, BC351)
"I didn't have it because my mum didn't agree with having lots of vaccines but my dad was fine with it. But I didn't have it in the end"(Mixed White/Black Caribbean, HPS314).

There were also examples of girls who disagreed with their parents' reasoning, but still remained unvaccinated.

"My parents objected because of the death of one girl who was given the vaccine, even though it was a different batch and she had underlying medical conditions" (Black Caribbean, WHS277).

Safety Concerns. Unvaccinated girls reported having concerns about the safety of the vaccine (25 % 51/202), but this was only expressed by two under vaccinated girls (4 %, 2/57), who presumably felt the vaccine was safe enough for them to have at least one dose. Many of the unvaccinated girls' concerns related to the novelty of the vaccine, and fear that vaccination could cause unforeseen side-effects.

"The repercussions of the vaccination are not known. Long term side effects may accumulate over the year. We are the 'guinea pigs' this is being tested on" (Mixed White/Asian, BC109).

Some of these girls said that their parents did not trust that sufficient research had been done to guarantee the safety of the vaccine. Others said that they would be allowed to have it in the future.

"My mum didn't trust the vaccine because it was new" (Turkish, HF085).
"My family wanted to wait for further research" (Mixed White/Black Caribbean, ES293).

The Vaccine Isn't Needed. Feeling that the HPV vaccine was unnecessary was another frequently cited reason for being unvaccinated (19 %, 38/202). Some felt this was because of the sexually transmitted nature of HPV.

"Because I am not sexually active so I wouldn't need it" (Mixed Black Jamaican/Asian, WHS217)
"Because I am not going to have sex before marriage" (Pakistani, TS137)

Others felt that being the first generation to have HPV vaccination, a perception of low prevalence of HPV or a lack of family history meant it was unnecessary.

"My mother never had it, so I didn't need it" (Black Caribbean, RF208)
"The cancer looked very rare, cancerous diseases don't run in my family" (White British, MA048).

Unvaccinated girls also reported that their parents thought the vaccine was not necessary because their daughters would not have multiple sexual partners or because their mothers did not have the vaccine themselves and had not developed cervical cancer. Many girls simply said that their parents did not think the vaccine was necessary.

"Mother didn't believe it was necessary…, recently migrated here, HPV is not common in Africa" (Black African, BTG055)
"My mum did not think it was necessary for me to have the vaccine since I won't be sleeping around" (Filipino, BC116).

Administrative Reasons. Administrative issues were the reasons most frequently reported by under vaccinated girls (51 %, 29/57), but were also reported by a small proportion of unvaccinated girls (13 %, 26/202). These issues were not related to a decision not to vaccinate, but were explanations for missing doses for practical reasons. School absence was cited by 19 girls, 13 reported that they did not want to have the vaccine in school (some preferred to have it with their family doctor), 13 said that they had not returned the vaccination consent form, seven girls reported that they had recently moved schools and missed the vaccination being offered and three reported that they were not in the country.

"I never got round to having the 3rd one [dose] because I switched schools" (Indian, TS091).
"I never brought back the letter because I had lost it and when I had it signed it was too late" (Black Caribbean, RF211).

Need for More Information

Around 11 % of girls who were under vaccinated reported that their vaccination status was a result of needing more information (6/57). In particular, these girls did not understand that multiple doses of the vaccine were needed. This was not cited by as many unvaccinated girls (only 4 % reported this, 8/202), suggesting that they or their parents felt they had sufficient information to decide not to receive the vaccine. Although under vaccinated girls and their parents may have received enough information to obtain the first or second vaccination dose, girls were not aware that they needed to obtain further doses.

"Not sure. I don't understand it well enough" (Mixed White/Black Caribbean, HPS231)
"Don't know, the school only offered 2 [doses]" (Polish, BTG040)

Procedural Issues. Fear of needles and dislike of injections were reported by around 11 % of unvaccinated girls (22/202), and a smaller proportion of under vaccinated girls (5 %, 3/57).

"I hate needles" (Mixed White/Black Caribbean, CEB025)

General Vaccination Beliefs. Having generally negative beliefs about vaccinations was reported by a few unvaccinated girls (3 %, 5/202), with all of these girls believing that their parents' beliefs about vaccination in general influenced their decision to withhold their consent for the HPV vaccine.

"Mum didn't think it was natural to have it" (White British, TS198).

Health Reasons. Existing health conditions, including epilepsy and organ transplantation, were cited by a few unvaccinated girls, as well as some girls believing they were allergic to ingredients in the vaccine (5 % of unvaccinated girls, 9/202, and 9 % of under vaccinated girls, 5/57). Some under vaccinated girls had reactions following early doses of the HPV vaccine, which they attributed to the vaccine and decided not to finish the course.

"After the first vaccine, I started to feel lighted headed, also fainted a few times, doctor told me not to complete it" (Mixed White/Black Caribbean, HF045).

Other Reasons. Around 11 % of unvaccinated girls (22/202) and 19 % of under vaccinated girls (11/57) did not provide a clear explanation for their vaccination status other than that they did not want the vaccine or that they could not remember their own or their parents' decision making process.

Reasons for Being Un-/Under Vaccinated by Ethnic Group

Among girls from White ethnic backgrounds, lack of parental consent (with explanation) was the most frequently cited reason for being un-/under vaccinated (28 %), but it was also often cited by girls from Black (22 %) and Other ethnic backgrounds (18 %; and less so among girls from Asian backgrounds, 12 %). Safety concerns were frequently cited by girls from White (26 %), Black (24 %) and Other ethnic backgrounds (16 %), but less commonly among girls from Asian backgrounds (12 %). Administrative reasons were the most commonly cited reason among girls from Asian (26 %) and Other ethnic backgrounds (23 %), but also often mentioned by girls from White backgrounds (23 %). Girls from Black backgrounds were likely to cite lack of parental consent without providing further explanation (20 %) and girls from Asian backgrounds commonly stated that they (or their parents) did not think the vaccine was needed (22 %), although this was also mentioned by a notable proportion of girls from Black backgrounds (17 %).