Public knowledge and attitudes towards Human Papilloma Virus (HPV) vaccination

Since the 1970's it has been known that one of the causes of cervical cancer is through infection with Human Papilloma Virus (HPV) [1] subtypes of HPV causing malignant transformation of the cervical epithelium [1, 2]. This breakthrough led to the possibility that some cervical cancers could be preventable by vaccination [1, 2]. There are approximately one hundred different genotypes of HPV. [3] Forty of these types infect the genitalia, and fifteen put women at a high risk of cervical cancer [3, 4]. In the UK and many other countries, HPV-16 and 18 are the most common subtypes associated with cervical carcinoma and are believed to be implicated in the aetiology of 70% of malignancies [2, 3].

An HPV vaccine has been developed by two separate drug companies: Merck, which produces Gardasil, and GlaxoSmithKline, which produces Cervarix [5]. Both drugs have undergone phase III trials, and were approved for use in the USA in 2006, the Merck vaccine was also approved for use in the UK in 2006 [1, 6‐10]. To maximise effectiveness, the vaccine needs to be given to girls before they are sexually active [11]. Initial discussions for a UK vaccination programme suggested targeting girls aged 10–12 years [12]. On 26^th October 2007, the Department of Health (England) announced the Government immunisation programme would commence in 2009 with HPV vaccination of girls aged 12–13 years [13, 14].

Despite HPV vaccination being a relatively new concept, there are a number of studies that have discussed the effectiveness of the vaccine and how it works [6‐9, 15]. However, relatively few investigations have addressed the public's support for vaccinating school age children. The majority of the research that has been undertaken has not been based in the UK [16‐20] and reports parental (especially maternal) and adolescent attitudes towards HPV vaccination, rather than the attitudes of the general public [19‐22].

A Finnish study reported 86% of parents and adolescents approved of the vaccine [19] and over 90% of mothers in Vietnam were in favour of their daughters receiving the vaccine although only 1% had previous awareness of the possibility of vaccination [20]. Such findings are re-enforced by a recent review of the literature on HPV vaccine acceptability which reported that many women had a poor knowledge about HPV but, nevertheless, most parents are interested in having their children vaccinated [23].

A Canadian study, published in 2000, assessing public knowledge reported that only 13% of adolescents had heard about HPV [24], however a more recent study, conducted 2006–07, reported that 70% of respondents with female children intended to have their daughters vaccinated [25]. A study, in Georgia, undertook 35 focus groups with stratification by gender, race and location. Knowledge, attitude and beliefs about HPV were explored. Low knowledge and the association of the vaccine with STD were concluded to be barriers to future acceptance of the vaccine [26].

The relatively small number of UK based studies undertaken to date also tend to report that people generally know little about HPV, but after the provision of information, most support the introduction of the vaccine [27‐30]. A recent survey of British women aged 16–97 used an open question to elicit the causes of cervical cancer; only 2.5% mentioned HPV and 7% mentioned an unspecified sexually transmitted virus/infection [28]. However, the majority of parents of 11–12 year old school children state that they would allow their child to be vaccinated [27, 30] and only a minority express concern that it may encourage unsafe sexual behaviour [27, 30]. This latter issue has appeared in national newspapers, with one paper leading with the headline "NHS giving out 'promiscuity jab' by the backdoor" [31].

In summary the literature published to date shows low levels of public knowledge about HPV and its links to cervical cancer. However, the majority of studies also show that people are generally in favour of vaccination.

This study aimed to determine public awareness of, and attitudes towards, HPV vaccination in three urban areas of Birmingham. Secondary aims were to determine the effect of social class and ethnicity on attitudes towards the proposed vaccine. A better understanding of factors that may be associated with low knowledge or negative attitudes to screening being important to inform the targeting of future awareness campaigns.

One hundred and forty people in each of the three locations were recruited, generating a total sample of 420 (Table 1). Of the 420 people, 315 (75%) were white and 105 (25%) ethnic minorities. The non-manual group (social classes I – IIIM) comprised 241 (57.4%) people with 179 (42.6%) in the manual (social classes IV – V). 159 (37.9%) participants were male and 261(62.1%) female. There were 20%–30% participants in (each of the four age group bands). Fifty-nine per cent of the 420 participants were parents.

This study assessed knowledge and attitudes towards HPV vaccination at a time before the UK Government announced its plans for a vaccination programme. Participants aged 16–54 were recruited from three different areas of Birmingham. The majority of participants had little awareness of HPV or HPV vaccination and 81% had a knowledge score of zero. Nevertheless, after the provision of brief HPV related information messages (Table 4), most (88%) participants were supportive of HPV vaccination. These findings are in accordance with previous UK-based studies which have demonstrated that people generally know little about HPV, but after the provision of information, most support the introduction of the vaccine [27‐30] and re-enforce the need for more educational intervention in order to raise awareness [36].

Although generally low, knowledge scores were higher in the white ethnic group than in the minority ethnic groups and in the non-manual worker group compared to the manual worker group. The white ethnic group were more in favour of HPV vaccination than the minority ethnic group. Both the social class groups were willing to accept HPV vaccination. Stepwise modelling selected social class in preference to the other explanatory variables in predicting attitudes towards HPV vaccination. There was a high degree of correlation between ethnicity, social class group and area of residence and each of these factors may be a surrogate for educational attainment.

However, a relatively large proportion of participants (34.3%) reported concern at the proposed target age group (10–12 years old). Most participants that disagreed with this target group reported that they felt the age group was too young. This survey was undertaken at when the likely age-group for vaccination was believed to be 10–12 years. The recent announcement that the target age group has been increased to 12–13 years may result in increased acceptability. This supports the findings of previous studies in both the USA [37] and UK [38] which have reported less parental support for vaccination in younger age groups.

The small group of the public (6%) who expressed no opinion towards the vaccination could be due to the fact that they had no or very little knowledge about the vaccination and didn't feel informed enough to form an opinion. Increased awareness and relating to vaccination and the reasons for vaccinating girls at age 12–13 years may address this.

The vast majority (83.6%) of participants (parents and non-parents) would consent for their child to be vaccinated. This implies a high uptake of the vaccination within the UK population, although reported action does not always reflect actual behaviour.

Limitations of this study include the possibility of sampling bias. As with most cross-sectional surveys, this street survey was only completed by a self-selected group of individuals who may not be representative of the general population. Similarly, the language barrier may have affected uptake ratio in the ethnic minority population, however, the vast majority of the people approached were fluent in English even if it was not their first language. It is probable that those not confident in written English were enabled to participate by the use of a semi-structured interview rather than a postal questionnaire.

Pilot work identified that the initial approach to the public was important; initial reactions often being that the interviewers were attempting to sell a product. Therefore, in the actual survey, all participants were approached by medical students who stated that this was a University research project.

People who failed to take part in the study might differ in their attitudes towards HPV vaccination. Unfortunately, due to the nature of the street survey (purposive sampling) refusal rates were not collected and it was not possible to establish the characteristics of non-participants. It is probable that those with no knowledge of HPV would be less inclined to participate. Knowledge of HPV and the proposed vaccination programme may therefore be over-estimated and social desirability bias may mean that reported acceptability of vaccination is over-reported.

This study involved researcher/participant discussion about a Sexually Transmitted Infection (STI). STI's are a sensitive subject especially within different cultures. Questioning people's attitudes towards HPV could be potentially embarrassing for the participant and may have deterred honest responses. To minimise the embarrassment experienced by participants a very simple knowledge score comprising only six questions was used; this may not have been as sensitive as more detailed surveys [25].

This study supports the findings of previous studies in respect to the public's knowledge and attitudes to HPV and the vaccination. The majority of the existing research has assessed the attitudes and knowledge of adolescents and their parents, especially mothers [16‐18]. This survey has demonstrated that, in the UK, the attitudes and knowledge of parents and non-parents are similar and it therefore may be possible to generalise from studies focussing on parents to the wider population.

The study confirms that there is still a lack of information or access to information about HPV and that more needs to be done to raise awareness of HPV and HPV vaccination especially amongst the minority ethnic groups and the lower social classes. Nevertheless, if the vaccination is introduced it appears that a significant number of people would be agreeable to vaccination after the provision of the quite simple messages.

There is a need for the health care service and other agencies to play a more active role in publicising, educating and informing patients on HPV and potential value of HPV vaccination.

Further work is required to look at the attitudes of health professionals in the UK towards HPV vaccination.

In conclusion, the success of the newly proposed HPV vaccination will depend on public attitudes and acceptance. This study demonstrates that most people state that they would accept the vaccination if it were offered, but more information is needed to increase knowledge. Despite the general view being positive, many people expressed a wish to know more about vaccination. Possible side effects, efficacy, costs and the age group were highlighted as areas of concern.