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


This study explored girls' reasons for being un-/under vaccinated against HPV in a free-at-the-point-of-receipt school-based HPV vaccination programme. Based in London, the sample included girls from a diverse range of ethnic backgrounds. The reasons for being unvaccinated and being under vaccinated appeared to differ. Unvaccinated girls cited lack of parental consent, their own and their parents' safety concerns about a new vaccine and the perception that they did not need the vaccine. Conversely, under vaccinated girls were more likely to cite practical problems to explain their vaccination status, including administrative issues (e.g. school absence), needing more information (e.g. that multiple doses were required), health and procedural concerns (e.g. fear of needles). In general, girls from different ethnic backgrounds cited similar reasons to explain their un-/under vaccinated status. However there was some suggestion that girls from Black and Asian backgrounds (or their parents) more commonly thought that the vaccine was not needed. Girls from Black backgrounds were most likely to report lack of parental consent without providing further explanation.

Girls in this study were 12 and 13 when they were offered HPV vaccination and among unvaccinated girls, parents played an important role in the decision to be vaccinated. In particular, these girls perceived that their parents were concerned about the novelty of the vaccine and potential unknown long-term side effects, something that has been expressed in previous research.[15,28,29] Some unvaccinated girls reported that they or their parents believed that the vaccine was not needed and this was commonly cited by girls from Black and Asian backgrounds. This echoes parents' previously reported concerns about vaccinating their daughters against a sexually transmitted infection when they are not yet sexually active[30] and has previously been expressed by mothers from ethnic and religious minority groups.[15,28]

Parental concerns about vaccination were rarely reported by girls who had initiated but not finished the vaccination course, but were reported by girls who had not started the series, whereas under vaccinated girls reported reasons that related to the girls' own behaviour (e.g. being absent from school). This suggests that parents may influence vaccination receipt and girls may influence series completion. Interventions to address HPV vaccination uptake may benefit from targeting parents for the initial dose of the vaccination series and adolescents for future doses. There is evidence that immunisation nurses are already chasing-up under vaccinated girls,[31] however future efforts to facilitate girls completing the vaccination course is likely to increase the workload of immunisation nurses further.[32] Now that the vaccination course has been changed to two doses only, practical problems may become less of an issue. Needing more information was only important to under vaccinated girls, suggesting that current vaccination information materials are considered sufficient by many girls and their parents. However, for girls who were under vaccinated, it appears that ensuring awareness of the number of doses required would be beneficial. Presumably this is only an issue for girls who were absent from school on vaccination days, as those with consent to receive the vaccination and who were present in school, would have been offered it during the school day. Immunisation programme coordinators may wish to address this in information resources targeted at girls who miss vaccination doses.

There are a number of limitations to this study. Girls were asked to respond about the HPV vaccine three years after they had been offered it, so recall bias may have occurred in girls' recollection of their HPV vaccine status or the reason for their vaccination status. Review of medical records would have been the gold standard for assessing vaccination status, but it was not feasible to do this for the present study. However girls were offered the option of responding 'don't know' if they were uncertain of their vaccination status. Although HPV vaccine coverage has increased since the programme began, uptake in London remains lower than the national average,[3] which limits the generalizability of the findings of this study. The vaccine schedule and vaccine offered have changed since the study was conducted, however the findings of the present study are likely to remain relevant as girls are still required to receive a series of immunisations. Unfortunately, for the 16 % of girls who did not provide a reason for their vaccination status, we are unable to offer any further explanation. These data represent the reasons girls gave for remaining un-/under vaccinated, and while it is likely that there is concordance between parents' and daughters' reasoning, it is also possible that their parents might give may give different explanations. In the UK, parental consent for HPV vaccination is desirable, yet the vaccination can still be offered without it. At 12 years old girls are able to make their own decision if they are deemed competent to do so, and their understanding about HPV vaccination may also have implications for future cancer prevention behaviours. An unvaccinated girl may have to take more responsibility to have the vaccination in the future and to ensure she attends cervical screening. Girls' attitudes may reflect their own opinions, or those of their parents.

Despite being part of a large study of almost 2,000 girls with a good overall response rate, the range of reasons given and our decision to present the findings by vaccine status means the numbers are too small to explore ethnic differences statistically. However we felt that it was meaningful to offer a descriptive analysis of the reasons given by different ethnic groups. We hope that these findings will give an indication of the themes that should be addressed in information about HPV vaccination and the reasons that may need to be considered when looking directly at un-/under vaccinated girls either across the population or if focussing on ethnic minority groups. Future research with larger samples will allow us to explore ethnic, as well as socioeconomic and geographical differences.