Hendry2013 PDF

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Contents lists available at ScienceDirect
Vaccine
journal homepage: www.elsevier.com/locate/vaccine
1 Review
2 “HPV? Never heard of it!”: A systematic review of girls’ and parents’

3 information needs, views and preferences about human
4 papillomavirus vaccination
5 Q1 Maggie Hendry a,∗,1 , Ruth Lewis a,1 , Alison Clements b,1 , Sarah Damery c,1 ,
6 Clare Wilkinson a,1
7 Q2 a
North Wales Centre for Primary Care Research, Bangor University, United Kingdom
b
8 Department of Primary Care Health Sciences, University of Oxford, United Kingdom
c
9 School of Health and Population Sciences, University of Birmingham, United Kingdom
10
11 a r t i c l e i n f o a b s t r a c t
12
13 Article history: Background and objective: Two human papillomavirus vaccines were licenced in 2006/2007 for cervical
14 Received 9 May 2013 cancer prevention. National vaccination programmes for schoolgirls were subsequently introduced in
15 Received in revised form 22 August 2013 some European countries, North America and Australia. To understand factors influencing vaccine uptake
16 Accepted 28 August 2013
and to inform the development of appropriate UK educational materials, we aimed to synthesise evidence
Available online xxx
of girls’ and parents’ information needs, views and preferences regarding HPV vaccination.
17
Design: Systematic review and mixed method synthesis of qualitative and survey data.
18 Keywords:
Data sources: 12 electronic databases; bibliographies of included studies 1980 to August 2011.
19 Human papillomavirus
20 Vaccination
Review methods: Two reviewers independently screened papers and appraised study quality. Studies were
21 Cervical cancer synthesised collaboratively using framework methods for qualitative data, and survey results integrated
22 Systematic review where they supported, contrasted or added to the themes identified.
Results: Twenty-eight qualitative studies and 44 surveys were included. Where vaccination was offered,
uptake was high. Intention to decline was related to a preference for vaccinating later to avoid appearing to
condone early sexual activity, concerns about vaccine safety and low perception of risk of HPV infection.
Knowledge was poor and there were many misconceptions; participants tried to assess the potential
benefits and harms of vaccination but struggled to interpret limited information about HPV in the context
of existing knowledge about sexually transmitted infections and cancer.
Conclusion Many girls and their parents have limited understanding to an extent that impinges on their
ability to make informed choices about HPV vaccination and could impact on future uptake of cervical
screening. This is a considerable challenge to those who design and provide information, but getting the
messages right for this programme could help in developing patient information about other HPV related
cancers.
© 2013 Published by Elsevier Ltd.
23 Contents
24 1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
25 2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
26 3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
27 3.1. Summary of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
28 3.2. Study quality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
29 3.3. Emergent themes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
30 3.3.1. Trying to decide on HPV vaccination – unanswered questions and concerns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
31 3.3.2. The benefits, harms and misconceptions of HPV vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
∗ Corresponding author. Tel.: +44 1978 727427.

E-mail address: m.hendry@bangor.ac.uk (M. Hendry).
1
On behalf of the HPV Core Messages Team. Roopa Adke, Christine Campbell, Ben Carter, Alison Clements, Sarah Damery, Maggie Hendry, Chris Hurt, Ruth Lewis, Richard
Neal, Di Pasterfield, Julietta Patnick, Mark Pickett, Peter Sasieni, David Weller, Clare Wilkinson.
0264-410X/$ – see front matter © 2013 Published by Elsevier Ltd.

http://dx.doi.org/10.1016/j.vaccine.2013.08.091
Please cite this article in press as: Hendry M, et al. “HPV? Never heard of it!”: A systematic review of girls’ and parents’ information needs, views
and preferences about human papillomavirus vaccination. Vaccine (2013), http://dx.doi.org/10.1016/j.vaccine.2013.08.091
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3.3.3. The perceived need for vaccination was affected by participants’ interpretation, or misinterpretation, of their own or their
children’s risk of HPV infection Confusion about the best method of HPV prevention was a barrier to vaccine acceptance . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
4.1. Summary of main findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
4.2. How this study fits in . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
4.3. Study strengths and limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
4.4. Implications for research, and UK policy and practice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
5. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
Appendix A. Supplementary data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 00
32 1. Introduction treated as primary data and extracted verbatim, excluding quo- 81
tations. Sources on qualitative review methodology differ on what 82
33Q3 Sexually transmitted human papillomavirus (HPV) types 16 and counts as data from qualitative studies [10]; we considered authors’ 83
34 18 account for 70% of cervical cancers. Two vaccines (Gardasil® findings to be syntheses of entire primary data-sets, of which 84
35 and Cervarix TM ), licenced in 2006 and 2007 respectively, were quotations were illustrative examples. Studies were synthesised 85
36 recommended for girls and young women aged 9–26 years. Both collaboratively using the framework approach [11]. Data were 86
37 are effective against HPV types 16 and 18 (Gardasil® additionally repeatedly read to achieve familiarity, themes were identified and 87
38 protects against HPV types 6 and 11, implicated in genital warts), organised into categories, reviewed and refined until both review- 88
39 and are recommended for large-scale use in national immunisa- ers agreed on the validity of the thematic framework. Data were 89
40 tion programmes [1]. Vaccination programmes typically target girls then coded, the framework applied and again reviewed and refined 90
41 aged 11–13 (i.e. before the age of likely sexual debut and there- until consensus was reached [12]. We first identified themes in the 91
42 fore exposure to HPV viruses) to provide maximum protection [2]. qualitative studies, as the best source of rich data that was most 92
43 Their success is dependent on high uptake, which is likely to be likely to illuminate people’s opinions, perceptions, attitudes and 93
44 influenced by people’s views, perceptions and understanding of experiences in relation to HPV vaccination. We organised the sur- 94
45 HPV infection and the principles of vaccination. This presents a vey data in a summary table and, in keeping with the principle of 95
46 challenge to those who provide information to explain these com- data saturation [13], we compared the survey results with the qual- 96
47 plex issues with sufficient clarity [3]. In this systematic review itative results and looked for evidence that supported, contrasted 97
48 of the international literature, we aimed to synthesise qualitative with or added new themes, which was then integrated into the 98
49 and quantitative evidence of people’s information needs, views and mixed methods synthesis. 99
50 preferences regarding HPV vaccination, to inform the development

51 of HPV educational materials appropriate for the UK vaccination 3. Results 100
52 programme to achieve the key outcomes of informed choice, mini-
53 mal anxiety and adequate uptake needed for disease control. Latest 3.1. Summary of included studies 101
54 available figures for England issued in 2012 indicate that for Cohort
55 9 there was 91% coverage for dose 1 and 87% for all three doses; Seventy-two studies met our inclusion criteria (Fig. 1). Studies 102
56 however, for Cohort 10 coverage for dose 1 was down to 82.5% reporting results in more than one publication were consolidated. 103
57 (figures not available for doses 2 and 3) [4]. Publication dates ranged between 2004 and 2011; many of the 104
studies reflected findings which pre-dated HPV vaccination pro- 105
grammes with their associated public information. Twenty-eight 106

58 2. Methods
qualitative studies were included [14–41]. Twenty-three of these 107
were from the USA, UK and Australia. Two were from Malaysia, two 108
59 The review was conducted using methodology reported in the
from India and one from Hong Kong. Forty-four surveys [42–85] 109
60 NHS Centre for Reviews and Dissemination (CRD) report 4, [5] sup-
were included; Again the majority were from North America (23), 110
61 plemented by Harden’s recommendations for systematic reviews
twelve from Western Europe and one from Australia. The remain- 111
62 of qualitative studies [6]. We also adhered to guidance on meth-
der (9) were from Malaysia, Hong Kong, Brazil, Vietnam, South 112
63 ods for conducting and reporting systematic reviews in the PRISMA
Korea, Thailand, Taiwan and El Salvador. Study characteristics are 113
64 statement, where it could be applied to mixed method reviews [7].
described in Tables 2 and 3. 114
65 We searched 12 electronic databases including MEDLINE,
66 EMBASE, CINAHL and PsycINFO using thesaurus terms and key-
67Q4 words relating to HPV and vaccination or testing (Appendix 1). 3.2. Study quality 115
68 Reference lists of included studies were hand-searched. Inclusion

69 and exclusion criteria are detailed in Table 1. Searches were con- All but one of the included qualitative studies were considered 116
70 ducted in June 2009, updated in August 2011; and limited to 1980 to be of good to moderately good standard (Table 4). Approxi- 117
71 onwards when relevant papers began to appear. Two (out of four) mately a third of the surveys were well conducted and five of these 118
72 reviewers (MH, RL, DP and RA) independently screened titles and had a sample size greater than 600 respondents and a response 119
73 abstracts for relevance, assessed the relevant papers against the rate greater than 70%; the remaining studies varied in quality from 120
74 inclusion criteria, and considered study quality. Differences were moderately good to poor (Table 5). 121
75 resolved by discussion or, if necessary, a third reviewer.

76 Qualitative studies were appraised using a quality checklist 3.3. Emergent themes 122
77 developed by the National Institute for Health and Clinical Excel-

78 lence (NICE) [8], and surveys using a checklist adapted from Three main themes emerged from the qualitative and quantita- 123
79 Pettigrew and Roberts [9]. Details of the qualitative studies were tive data. Text in italics is quoted verbatim from the qualitative 124
80 extracted into pre-defined forms. The authors’ findings were studies in order to illustrate the themes and subthemes. Girls 125
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Table 1
Inclusion and exclusion criteria for studies of HPV vaccination.
Inclusion Exclusion
Population Any participants who could be involved in HPV vaccination including Studies where the study population is not appropriate to the
parents of children aged 9–15, young women up to the age of 26 (i.e. intervention, e.g. adults over the age of 26, unless questions relate to
those for whom the vaccine is licenced), healthcare professionals third parties who would be eligible for the intervention
Intervention HPV vaccination in clinical trials or in clinical practice Hypothetical vaccination for STIs
Outcomes People’s views of HPV vaccination, such as their understanding, Studies that assess participants’ knowledge and/or behaviour, not their
attitude, perception, acceptability, concerns and information needs views
Studies that look at participant characteristics that influence the
uptake of HPV vaccination, e.g. smoking, social class, not their views
Study design Any study design used to elicit qualitative or quantitative data relating
to participants’ views on HPV vaccination
Reporting Studies must be reported in sufficient detail for meaningful Studies with insufficient detail, e.g. available only as abstracts
data-extraction
Records idenfied through Records idenfied through

database searching hand searches
(n = 23,010) (n = 4)
Records aer duplicates removed

(n = 9,319)
Records screened Records excluded

(n = 9,319) (n = 8,972)
Full-text arcles excluded

(n = 243)
Full-text arcles Excluded intervenon (n=51)
assessed for eligibility Excluded populaon (n=39)
Excluded outcomes (n=89)
(n = 347)
Excluded study design (n=15)
Unobtainable (n=24)
Insufficient data (n=25)
Studies included
(n = 89*)
(104 arcles)
Studies on HPV Studies on HPV

tesng vaccinaon
(n = 17*) (n = 72*)
(19 arcles) (85arcles )
Qualitave Surveys
studies (n = 44*)
(n = 28*) (52 arcles)
(33 arcles)
*Some studies were reported in more than one publicaon
Fig. 1. PRISMA flowchart. *Some studies were reported in more than one publication.
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Table 2
Summary of qualitative studies investigating views and attitudes towards HPV vaccination.
Study, location Data collection method and date Participant details Analysis Type of data collected or relevant questions asked
Al Naggar, 2010 Face to face interviews January 30 unvaccinated female students aged 19–26 years recruited Thematic analysis Current level of HPV knowledge, mode of transmission,
Shah Alam, Malaysia 2010 from a variety of university faculties. 20% were married. 60% causes of cervical cancer, reasons for/against
were from urban areas. 50% Malay, 23% Indian, 20% Chinese vaccination
Bair, 2008 Face to face interviews 40 Latina mothers aged 24–40 with unvaccinated daughters Thematic content General knowledge of HPV and HPV vaccine, factors
Indiana, USA November 2004–March 2005 aged 7–14 years recruited in an urban paediatric care clinic. analysis influencing acceptance/refusal of HPV vaccine
95% reported religion was very important to them. 60% <high
school education
Bernard, 2011 Focus groups and face to face 130 vaccinated girls aged 12–16; 38 parents; 10 teachers; 7 Constant comparative Attitudes towards HPV vaccine, the decision making
Sydney, Australia interviews vaccination nurses purposively sampled from Catholic, method process, knowledge and understanding, experience of
Date not reported independent and state schools vaccination, discussion with family and friends,
questions and concerns
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Cooper Robbins, 2010 Focus groups and interviews 130 vaccinated and vaccine declined adolescent girls in year Thematic analysis Necessity of vaccination, vaccine and Pap smear
NSW, Australia Date not reported 7 or 9/10 purposively sampled from 9 Catholic, state and connection, myths and rumours, need for more
independent schools, and 38 parents information
Dempsey, 2009 Telephone survey 52 mothers of vaccinated and vaccine declined daughters Thematic analysis Acceptance of HPV vaccine, factors influencing
Michigan, USA January–April 2007 aged 11–17, recruited in University family medicine or decision, perceived risk of HPV, vaccine safety
paediatric clinics. 37% declined vaccination. 90% had college
education or higher
M. Hendry et al. / Vaccine xxx (2013) xxx–xxx

Henderson, 2011 Face to face interviews 37 parents and 44 vaccinated and vaccine declined girls aged Constant comparative Protection of HPV vaccine, role of vaccine in future
S.E. England, UK October 2008–April 2010 12–13, recruited via 4 general practices and 39 city, rural, method cervical screening behaviour, need for more
state, faith, independent, single-sex and mixed-sex schools information
Hilton, 2011 Focus groups December 2009–May 87 girls aged 12–18 recruited via advertisements in Framework analysis Understanding of HPV and link to cervical cancer, link
Nationwide, UK 2010 community venues, local newspapers, social networking and between safe sex and HPV, concerns, vaccination
selected websites. 90% had received HPV vaccine, 4.5% experiences, importance of cervical cancer screening
declined, 4.5% were undecided
Hopfer, 2011 Face to face interviews 36 female students aged 18–26 assigned to the study to fulfil Constant comparative Factors influencing HPV vaccine attitudes and beliefs;
N.E. USA April 2nd–May 5th 2008 a university course requirement. 53% sexually active and 6% method peer, family, and health care provider messages;
diagnosed with HPV. 39% had received HPV vaccine. 90% vaccine attitudes related to sexual activity
were White
Humiston, 2009 Focus groups and face to face 45 paediatricians, family physicians and nurses from urban Grounded theory Thoughts on vaccine, recommendations to patients,
Monroe County, NY, USA interviews and suburban practices and 24 key informants (physicians impact of cost on delivery of vaccine
2005 and nurses) representing specialty, region, practice type and
population
Kahn, 2007 Face to face interviews 31 practicing paediatricians purposively selected according Framework analysis Knowledge of HPV, awareness of HPV vaccine,
Ohio, Kentucky and Indiana, 2005 to demographic and practice characteristics. 55% female. 58% attitudes towards recommending HPV vaccine,
USA White, 29% Black, 13% Latino. 45% Urban practitioners, 52% intention to recommend vaccine, reasons underlying
sub-urban intentions
Katz, 2009 Focus groups; 1 face to face 37 health care providers: 89% White; 89% college educated Thematic analysis Acceptance of HPV vaccine, attitudes and beliefs
Ohio Appalachia USA interview 31 community leaders: 71% White; 68% college educated 19 regarding HPV vaccine, barriers to acceptance of
Summer 2007 parents of girls: 97% White; 37% college educated 27 women vaccine
eligible for vaccine: 93% White; 26% college educated
Krupp, 2010 Face to face interviews 20 physicians aged 28–43, recruited by snowballing. 60% Framework analysis Attitudes towards HPV vaccine, intention to
Mysore, India June–August 2008 female. 30% specialised in obs/gynae, 45% in paediatrics, 25% recommend HPV vaccine, barriers to delivery of
in family or general practice. 75% practiced in urban settings vaccine
Kwan, 2008 Focus groups 64 unvaccinated girls aged 13–20 years purposively sampled Thematic analysis Knowledge of HPV vaccine, attitudes towards HPV
Hong Kong Date not reported in a community youth centre and a school vaccine, barriers to acceptance of vaccine, discussion of
vaccine with family members
Leask, 2009 Face to face interviews 24 key health care professionals and vaccination programme Framework analysis Knowledge of HPV vaccine, opinions regarding HPV
Sydney, Australia September 2007 staff involved in a primary care programme vaccine community acceptance of vaccine, barriers and
facilitators to effective implementation
Madhivanan, 2009 Focus groups 44 parents of unvaccinated daughters aged 9–15 recruited Framework analysis Knowledge of HPV infection and cervical cancer,
Mysore, India 2008 by health education events, referred by community beliefs and intentions regarding HPV vaccine, factors
organisations, and by snowballing. 52% mothers. 69% had influencing opinions of HPV vaccine, access to vaccine
only primary education or less
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Table 2 (Continued)
Study, location Data collection method and date Participant details Analysis Type of data collected or relevant questions asked
Marlow, 2009 Face to face interviews 20 Black and Asian mothers, born in the UK were recruited Framework analysis Attitudes to HPV vaccination, concerns about
UK April–August 2008 (method not reported). 8 Christian, 6 Muslim, 4 Hindu. 75% vaccination, barriers to acceptance of vaccine, social
were home-owners, 95% car-owners. 50% were influences on opinion of vaccine
degree-educated, 85% were employed
Mays, 2004 Face to face interviews 34 parents of children aged 8–17 recruited from 2 paediatric Thematic analysis Attitudes towards HPV vaccine, decision making
Indiana, USA January–June 2000 primary care sites (1 urban, low income; 1 rural, narrative, likelihood of immunising their children,
middle-class). 85% were mothers. 71% white, 29% African rationale for decision
American. 50% college educated
McClelland, 2006 Face to face interviews 14 unvaccinated men and women aged 18–23, recruited by Thematic analysis Knowledge of, and attitudes towards HPV vaccine, the
Melbourne, Australia Date not reported snowballing. 50% female. 43% Catholic, 14% Anglican; 43% link between HPV and cervical cancer, knowledge of
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had no religion. 43% were in relationships. 50% had tertiary clinical trials of HPV vaccine, factors influencing
education vaccine acceptance
Noakes, 2006 Focus groups 27 (±2) parents of boys and girls aged 8–10 were recruited Not reported Knowledge of HPV, attitudes towards sexually
London and Nottingham, UK August–September 2005 (method not reported), excluding outright rejecters of the transmitted nature of HPV, timing of vaccination,
immunisation programme. Exact numbers and demographic barriers to acceptance of HPV vaccine
data not reported

Olshen, 2005 Focus groups face to face 25 parents of unvaccinated children aged 10–15. 12 from an Thematic analysis Knowledge of HPV, perceived risk of HPV infection,
North-eastern USA interviews urban clinic were Black/Hispanic, on Medicaid/no insurance. attitudes towards HPV vaccine, optimal age for vaccine
September 2003–March 2004 13 from a suburban practice were White, better educated, delivery
had private insurance
Racktoo, 2009 Focus groups 21 girls aged 12–13 were recruited in a high school that Framework analysis Concerns about HPV vaccine, acceptability of
Leeds, UK Date not reported delivered an HPV vaccination programme. All had received vaccination programme, factors influencing decision
HPV vaccine. No demographic data were reported regarding HPV vaccination
Stretch, 2009 Face to face interviews 15 NHS school nurses were recruited. All had taken part in a Thematic analysis Attitudes towards HPV vaccine, concerns regarding
Manchester, UK From July 2008 study in which girls age 12–13 were vaccinated at schools in HPV vaccine, importance of parental consent
2 Primary Care Trusts
Sussman, 2007 Face to face interviews 37 primary care clinicians caring for adolescents (aged Thematic analysis The nature of adolescent consultations regarding
New Mexico, USA July 2004–May 2005 10–20) were purposively recruited based on location, cultural and community context and sexual risk,
specialty and gender. 86% female; 32% obstetricians, 14% counselling relating to HPV, knowledge and barriers to
paediatricians, 35% family practice delivery of HPV vaccine
Tissot, 2007 Face to face interviews A purposive sample (gender, race, ethnicity, and practice Framework analysis Attitudes about HPV vaccination delivery, cultural
Ohio, Indiana and Kentucky, Date not reported setting) of 31 paediatricians was recruited. 45% male. 58% considerations, targeted versus universal or mandatory
USA White, 29% African American. 61% primary care. 48% urban, strategies, and components of successful delivery
48% suburban, 3% rural
Toffolon-Weiss, 2008 Focus groups A convenience sample of 80 parents of unvaccinated girls Not reported Knowledge of cervical cancer, HPV and HPV vaccine,
Alaska, USA January–March 2007 aged 9–18 from 3 communities (urban 67%, hub 43%, and decision to vaccinate, barriers to vaccination, attitude
village 6%) was recruited by advertisement. 80% were to vaccine, information required for informed decision
mothers
Waller, 2006 Focus groups 24 women aged 31–48, with unvaccinated daughters aged Framework analysis Discussion about HPV and HPV vaccination developed
London, UK August–November 2005 8–14 were recruited by snowballing. 83% were married. 83% after women were given information about it and had
were home-owners. 50% educated to degree level, 54% their questions answered
employed/self-employed
Williams, 2010 Face to face interviews A purposive sample of 10 girls aged 17–18 who had been Framework analysis Knowledge of cervical cancer and HPV, their own and
London, UK March–May 2009 offered HPV vaccination. 60% were White, no religion; half of friends’ attitudes towards HPV vaccine, factors
these had declined vaccination. 40% were Asian/Muslim and influencing decision to accept/refuse vaccine
vaccinated
Wong, 2008 7 focus groups 40 unmarried, unvaccinated Malaysian women aged 13–27 Not reported Risk of HPV infection, necessity of vaccine, barriers to
Malaysia Date not reported recruited using snowball and purposive sampling to vaccine acceptance, stigma of sexual transmission,
represent young Malaysian women. 42% Malay, 33% Chinese, importance of physician recommendations, concerns
10% Indian. 58% were students
5
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Table 3
Summary of quantitative studies investigating views and attitudes towards HPV vaccination.
Study, Country Setting Data collection method, date Participant details Summary of relevant questions Brief Summary of Key Results
and response rate
Allen, 2009 Private university On-line questionnaire 2007 1897 female students Age not Perceived benefits of and barriers 93% had heard of HPV and 87% of HPV
New England, USA 40% RR reported 78% white 47% to HPV vaccination; peers receipt vaccination. 65% had had or were planning to
sexually active of vaccine (social norms); have the vaccine; 15% were undecided. There
perception of significant others’ was a strong correlation between social and
approval (subjective norms) subjective norms and later stages of adoption
Askelson, 2010a Rural mid-west state Postal questionnaire Date not 217 mothers of 9–15 year-old Attitudes, subjective norms, and 48% intended to vaccinate their daughters;
Iowa, USA reported 25% RR daughters; 63% college perceived behavioural control; mothers indicated a high perceived
graduates; most had income mothers’ perception of risk to their behavioural control. Most perceived their
≥$50,000 and health insurance
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daughters, vaccine promotion of daughters had a low risk of infection; almost
sexual activity all strongly agreed that the vaccine would have
no impact on their daughter’s sexual activity
Askelson, 2010b Rural mid-west state Postal questionnaire 207 primary care physicians. Intention to vaccinate against HPV, 87% intended to vaccinate female patients and
Iowa, USA March–April 2007 25% RR 79% participated in the Vaccine correct age for delivery of vaccine, mean age preferred was 11 years
for Children programme attitudes (social norms; perceived (recommended) but the range was 6–21 years.
behavioural control), barriers to Intention to vaccinate was driven by subjective

delivery of vaccine norms and perceived behavioural control.
Costs and parents were perceived as barriers
Brabin, 2009 Two primary care trusts in Postal questionnaire. October 553 girls aged12-13 94% had Vaccination decisions and parental Reasons for vaccine acceptance were HPV
Manchester, UK Greater Manchester 2007–September 2008 51% RR received HPV vaccination; consent, information received, prevention (70%) and cervical cancer
parents of 6% withheld consent importance of vaccination, fear of prevention (90%). 77% shared the vaccine
it, the experience of it and sexual decision. 49% heard scare stories about
messages vaccination, 20% felt ill after it. 21% were
embarrassed, 25% wouldn’t tell a boyfriend
Brabin, 2006 7 randomly selected state, Postal questionnaire 317 parents of year 7 children Optimum age of vaccination, 81% agreed to vaccination before sexual debut;
Manchester UK fee-paying and faith March–April 2005 22% RR (aged 11–12) 65% white desirability of universal 72% to age 11–14. Vaccine acceptance was
schools. vaccination, decision-making and associated with effectiveness, safety and
informed consent perception of risk; barriers were anxiety about
safety, perception of condoning sexual activity
and strong religious or cultural views
Burke, 2010 Large south-eastern Online questionnaire Date not 875 female students 90% aged Intention to get the HPV 77% intended to receive the vaccine. Barriers to
East Carolina, USA university reported 85% RR 17–20 76% White; 15% Black vaccination and barriers to acceptance of vaccine included possible side
3% Hispanic vaccination effects (43%), costs (42%), lack of information
(36%), indifference (21%), not being sexually
active (19%), and fear of needles (15%)
Bynum, 2009 1 teen clinic; low income, Questionnaire self-completed 73 females aged 14–20 80% Knowledge of HPV, Pap tests and 40% had heard of HPV vaccine and 80% said
South Carolina, USA mainly African American in clinic January–April 2007 RR Black, 4% had had a previous cervical cancer, perceptions and they were likely to get the vaccination. 34%
population not reported HPV diagnosis knowledge of HPV vaccine, and reported cost and 22% lack of transportation as
barriers to vaccine acceptance barriers to vaccination
Caskey, 2009 US household research On-line survey November 2007 1011 females aged 13–26. 63% Knowledge and sources of 84% of vaccinated and 51% not vaccinated girls
Nationwide, USA database 54% RR white; 40% had income <$35 K; information about the HPV vaccine. knew the vaccine protects against cervical
18% had HPV vaccination (≥1 Reason for declining vaccine cancer. 77% reported healthcare provider as
dose) their most trusted source. Barriers were not
being sexually active (30%), safety concerns
(24%), cost (21%), and effectiveness (16%)
Chan, 2009 One paediatric and Questionnaire self-completed 250 females aged 12–19 Knowledge: genital warts and 35% intended to be vaccinated before reading
Region not reported adolescent gynaecology in clinic. Date not reported 96% attending clinic mainly for cervical cancer. Attitudes about an information pamphlet; 69% after.
Hong Kong clinic RR menstrual problems HPV vaccine: who should receive Vaccination negatively correlated with
the vaccine, normative beliefs and normative belief but positively correlated with
intention to be vaccinated health belief and belief in who should receive it
JVAC 14625 1–16
G Model
Table 3 (Continued)
and response rate
Chow, 2010 10 randomly selected In-home, interview. Date not 1617 women with daughters Knowledge about of cervical 98% of women had heard of cervical cancer but
Korea, Taiwan, districts within 4 Asian reported. RR not reported. aged 10–26 who had access to cancer, HPV, vaccination, and <10% had knowledge of HPV and 65% were not
Thailand and Malaysia capital cities. In-office, interview. Date not HPV vaccination and could perceived risk. Factors associated aware of HPV vaccination. 88% thought
reported. RR not reported. afford it. 480 physicians who with vaccine acceptance. daughters’ at low risk of cervical cancer. 83% of
had prescribed or administered Knowledge about of cervical women would be most influenced to vaccinate
HPV vaccine within the last cancer, HPV, vaccination, and by doctors’ recommendations. 48% of
month perceived risk. Factors associated physicians were not confident in discussing
with vaccine recommendation HPV related issues and wanted more
information or training. Only 56% had initiated
conversations with patients about HPV
vaccination and only 2/3 of these were
ARTICLE IN PRESS
comfortable in doing so
Dahlstrom, 2009 The Swedish Population Postal invitation to online 13,946 parents, 11,187 of girls Perception and concerns about HP 76% would accept vaccination; 63% even if not
Nationwide Sweden Register questionnaire and 2759 of boys aged 12–15 V vaccination and correlations of free. 70% preferred vaccination at ≥15 years.
January–May 2007 70% RR years. 87% Swedish, 87% acceptance and willingness to pay 54% of girls’ parents wanted vaccination for
employed for it. Preferred age of vaccination boys. Prior awareness of HPV increased
and vaccination need for boys acceptance; safety concerns decreased it. Well
educated/unemployed less willing to pay

Daley, 2006 A national network of Internet and postal 294 paediatricians Mean age Intention to recommend 46% would vaccinate 10–12 year old girls; 37%
Nationwide USA primary care paediatricians questionnaire 48 46% female 86% in private quadrivalent HPV vaccination to 10–12 year old boys 89% would vaccinate
October 2005 68% RR practice 10–12 year old girls, older girls up 16–18 year old girls; 82% 16–18 year old boys
to 18, and adolescent boys 88% were comfortable discussing sexuality
with adolescents girls 10% were unlikely to
recommend to any age group
De Carvalho, 2009 Medical school of the Survey distributed in medical 252 of which 49% medical Intention to prescribe the vaccine, 89% would prescribe the vaccine; 55% for
Parana, Brazil Federal University of school students, 51% physicians 52% to what age and gender, and 10–15 year olds.48% would vaccinate boys as
Parana August 2006– December 2007 female 80% aged 20–40 knowledge regarding HPV well as girls. 65% believed HPV vaccine
63% RR vaccination provides lasting immunity. 75% disagreed that
vaccination would diminish the need for
annual cervical screening
de Visser, 2008 18 schools and 2 Survey completed online or on 353 parents (286 mothers) of Knowledge of HPV and cervical 73% would accept vaccination for sons; 75% for
Sussex, UK universities in Brighton paper 663 children aged 4–16 years cancer; subjective norms related to their daughters. Acceptability for girls (not
and Hove January–March 2008 73% RR (50% boys) HPV vaccination; whether they boys) was associated with subjective norms for
would have their son(s) or HPV vaccination. Acceptability for both was
daughter(s) vaccinated against HPV associated with safety, efficacy and belief it
would not encourage unsafe sex
Di Giuseppe, 2008 Classrooms in 2 Questionnaire self-completed 1341 women and adolescents Knowledge about HPV, cervical 30% had heard about HPV vaccine; 53% of
Naples, Italy universities and 6 public in class (aged 14–24 years) cancer; Perceived risk of cervical cancer. 42% knew the vaccine was a
secondary schools, S Italy March–May 2007 RR not contracting HPV and/or developing preventative measure against cervical cancer;
reported cervical cancer; benefits of 82% intended to obtain HPV vaccine in the
vaccination and willingness to future
receive it
Dinh, 2007 Da Nang General Hospital Completed in clinic with help if 181 women visiting the Knowledge of HPV vaccination, Only 11% had heard of HPV vaccine; 94%
Da Nang, Vietnam needed. June 2005 RR not hospital or attending perceived risk of cervical cancer, thought it would be effective. 90% did not
reported well-woman clinics (i.e. not ill) beliefs about vaccine effectiveness think their daughter would have sex earlier if
with daughters aged 10–18 and effect on sexual behaviour. vaccinated. 91% would get their daughter
years Intention to have daughter vaccinated if available that day. 95% though
vaccinated doctor’s recommendation very important
Duval, 2007 Provincial medical Postal questionnaire 1282 physicians Intention to recommend 88% intended to prescribe HPV vaccines. 95%
Provinces: BC, PQ, NS association April–December 2006 51% RR (obstetrician/gynaecologists, vaccination and appropriate age. thought they should be given to girls before
Canada paediatricians, family Perception of vaccine acceptability sexual debut. 75% believed parents would
physicians). 59% female to parents. Impact of vaccination accept vaccination for girls aged less than 14
on screening frequency years. 65% expected the frequency of screening
to be reduced for vaccinated women
7
8
JVAC 14625 1–16

G Model
Table 3 (Continued)
and response rate
Duval, 2009 Provincial nursing Postal questionnaire 946 nurses. 68% involved in Knowledge about HPV and 85% would recommend HPV vaccines; 93% if
Provinces: NS, QC, ON, associations 2007 53% RR vaccine administration. 58% in vaccination. Intention to free. 91% thought vaccination should be before
BC Canada practice for ≥ 20 years recommend HPV vaccination, sexual debut but 82% also thought all sexually
appropriate age and acceptability active women should be vaccinated.46%
to parents. Impact on screening expected the frequency of screening to be
frequency reduced for vaccinated women
Fang, 2010 Subset of Health Postal questionnaire 1383 individuals who had a Acceptability of HPV vaccination 58% would have a daughter aged 11–12 years
Nationwide USA Information National 2007 RR unclear (<40%) female child aged less than 18 for a daughter aged 11–12 years old vaccinated. Reasons for saying no were lack
Trends Survey years in their household of knowledge (48%), safety concerns (20%);
child not sexually active (9%) or too young
(3%); doctor hasn’t recommended it (6%); more
ARTICLE IN PRESS
research needed (3%)
Feemster, 2008 Paediatric network On-line questionnaire 105 paediatric clinicians 76% HPV knowledge, endorsement of 78% would recommend HPV vaccine to 11–12
Philadelphia, USA affiliated to a metropolitan December 2006–February female 86% white HPV vaccines, attitudes about HPV year old girls Vaccine safety and efficacy
children’s hospital 2007 59% RR vaccination and intention to concerns were barriers to recommendation;
recommend for 11–12 year old parental concerns or concerns about sexuality
girls were not

Ferris, 2010 Clinics and community Paper questionnaire 325 parents of children aged Should HPV vaccination be 43% thought HPV vaccination should be a
Georgia and South sites including hair salons self-completed on site 9–17. 88% female, 58% white, mandatory for school entry and, if mandatory requirement for school entry.
Carolina, USA Autumn 2008 89% RR 58% college +, 68% private it were mandatory would you have Parents with lower incomes, less health
health insurance your child vaccinated? insurance and previous HPV infection were
more likely to agree
Forster 2010 8 Further Education Paper q’naire self-completed in 617 girls aged 16–18 years due Knowledge about HPV and 70% intended to have the vaccine; 27% were
S.E. England, UK colleges class to be offered HPV vaccination. intention to receive the vaccine unsure; 3% did not intend to have it. Girls
March 2009 94% RR 55% white; 30% Black/British or reporting Christian or no religious beliefs had
Asian/British higher intentions than Muslim girls. White
girls had higher intentions than those from
Black, Asian or ‘other’ racial/ethnic
backgrounds
Gerend, 2009 Examination rooms in 4 Paper questionnaire 82 parents with ≤1 children HPV related knowledge, beliefs and 92% had heard of HPV; 88% had heard of HPV
South East USA paediatric clinics self-completed on site aged ≤18. 95% female; 78% had attitudes, and intentions to vaccine; 18% had already had a daughter
January–June 2008 RR not a daughter. 71% White. 77% ≥ vaccinate a daughter/son in the vaccinated. Excluding parents with a
reported college education future vaccinated daughter, those with higher
income, married and comfortable with new
vaccines were likely to vaccinate in the future
Gottvall, 2009 24 classes in 1 private and Paper q’naire self-completed in 608 students aged 14 –19; 57% Knowledge about HPV and 5% of the girls knew they were vaccinated
1 unnamed County 6 public schools, urban and class girls. 69% on academic and 31% vaccination; attitudes towards HPV against HPV; 65% of the students did not know.
Sweden rural Autumn 2008 86%RR on vocational courses. 24% vaccination 85% had not heard of HPV, 94% of the vaccine.
immigrant 84% wanted to be vaccinated but only 12% of
those intended to. Barriers: cost, low
perception of risk and fear of needles
Hopkins, 2009 A regional mailing list of Email invitation and online 222 paediatricians, GPs and Knowledge about HPV vaccination. Only 38% felt adequately informed but 87%
N.W. England UK physicians in West questionnaire. June–August obstetrician/gynaecologists. Support for a national HPV were in favour of a national vaccination
Yorkshire. 2007 23%RR 53% female, median age group vaccination campaign and for NHS campaign and 82% supported total NHS
30–39 funding of HPV vaccination funding. Older and more experienced doctors
were significantly more in favour of
vaccination
Ishibashi, 2008 American Association of Email invitation and online 373 paediatricians, 52% female, Attitudes and intended practices 99% supported the use of HPV vaccine; 88%
Nationwide USA Paediatrics directory questionnaire. median age 48 years. 57% with respect to HPV vaccination. would give it to all their eligible patients; 92%
October–November 2006 Christian, 22% Jewish Barriers to recommending the would give the vaccine to their own child, or
50%RR vaccine and whether they would that of a close friend. 74% would try to
vaccinate their own/a friend’s child persuade those who are reluctant. Barriers
were cost (6%) and safety concerns (3%)
JVAC 14625 1–16
G Model
Table 3 (Continued)
and response rate
Jensen, 2009 University database of Postal questionnaire. 204 healthcare professionals: Intentions to recommend HPV 95% were willing to recommend HPV
Wisconsin USA physicians in Dane County. September 2006 39%RR 91% physicians, 9% nurse vaccination to male and female vaccination, 67% to female patients only. 58%
practitioners. 45% urban, 38% patients were very comfortable vaccinating 10–14
suburban, 12% rural year-olds, 76% 15–18 year-olds and 75% >18
year-olds
Kahn, 2009 Primary care membership Email invitation and online 1122 primary care physicians. HPV knowledge, barriers to HPV 44% wanted more information about HPV. 49%
Texas, USA of the American Medical questionnaire 64.% white, 55% male vaccines, reasons for and against always recommended HPV vaccination to girls;
Association September–November 2008 mandated HPV vaccination, 68% were likely to recommend it to boys; 42%
14.4% RR intention to recommend the HPV agreed with mandated vaccination. Barriers
vaccine to boys were parental refusal or inadequate insurance
coverage
Kang, 2010 16 colleges located across Paper q’naire self-completed in 1359 female Korean college Intentions to be vaccinated, 64% wanted to know more about the vaccine
ARTICLE IN PRESS
Nationwide South Korea class students aged 18–32 years. concerns about vaccine, but 78% thought it was too expensive.
Korea April–June 2008 87% RR 26% Christian, 13% Catholic. vaccination and unsafe sexual Intention to be vaccinated was higher when
1.3% HPV vaccinated behaviour recommended by a physician
Lenselink, 2008 17 urban primary schools Postal invitation and telephone 356 parents with children aged Knowledge of the risk factors for 30% of parents had heard of HPV, 14% of
Nijmegan Netherlands interview 10–12 years. 91% mothers, 51% cervical cancer, the transmission of parents understood its relationship with
Date not reported 31% RR. had higher education HPV, its relationship with cervical cervical cancer. 6% had heard of HPV
cancer and the acceptance of HPV vaccination 88% would accept vaccination of

vaccination their children 88% Believed that both girls and
boys should be vaccinated
Marlow, 2007 10 schools in city, Postal questionnaire. February 684 mothers of daughters aged Rates of vaccine acceptance, 75% would accept HPV vaccine for their
SE England UK suburban and rural settings 2006 57% RR. 8–14 years. 93% white, 80% optimum age of vaccination, daughter. 80% thought age10–14 most
employed, 48% had higher attitudes towards vaccination, appropriate. 70% would be glad if it meant an
education demographic and attitudinal end to smear tests and 92% if it also prevented
predictors of acceptance genital warts. 65% worried about side-effects
and18% about an increase in unprotected sex
Marlow, 2009 National survey. 2 further Face to face interview at home 332 mothers of daughters aged Mothers asked whether HPV 23% of mothers agreed that girls would be
Nationwide and SE education colleges with for mothers <16 years. Mothers aged vaccination would make girls more more likely to have sex and 25% unprotected
England UK contrasting socioeconomic November 2006–February 18–64, 91% White, 44% likely to have sex or to have sex following HPV vaccination. Black, Asian
profiles 2007 54% RR employed. 386 female college unprotected sex. Girls were asked and low-income mothers were more likely to
Girls completed paper students aged 16–19 years. about vaccine acceptability and agree. 89% of girls would accept vaccination
questionnaire in class 58% White, 25% Black, 13% whether HPV vaccination would but 76% worried about side-effects, 43% feared
April–July 2007 98% RR Asian. 69% had no religion make them more likely to have sex needles. 32% thought vaccination would make
or to have unprotected sex girls more likely to have sex and 38%
unprotected sex. Those from the largely white,
affluent college were more likely to accept
vaccination and less likely to think it would
encourage sex
McRee, 2010 1 urban, 4 rural areas with Telephone interview 783 carers of unvaccinated Attitudes and beliefs regarding In multivariate analyses parents perceived HPV
South-eastern North high rate of invasive 2007 73% RR girls aged 10–18. 94% female, HPV vaccination and its benefits, vaccine to be moderately effective but many
Carolina, USA cervical cancer 69% White, 23% Black, 63% concerns and barriers to had uncertainty and believed it to have
income ≥$50 K acceptance potential harms. However most parents
intended to get their daughter vaccinated
within the next year
Ogilvie, 2008 Random digit dialling Telephone interview 2083 parents of children aged Parents of boys and girls were 53% heard of HPV; 27% knowledge of HPV
Nationwide Canada across Canada June 2006–March 2007 53% RR 8–18. 74% female, 83% white, asked about vaccination behaviour, transmission. 74% girls’ parents intended to
73% had more than high school knowledge of HPV and cervical have daughter vaccinated in a school-based
education cancer and attitudes towards HPV programme, 68% of parents of boys intended to
vaccination vaccinate sons
Pearce, 2009 Private paediatric/family Postal questionnaire 95 physicians No further Opinions on routine administration 78% were comfortable with providing the
Tennessee, USA practice or hospital in June 2006 59% RR details reported of the HPV vaccine, willingness to vaccine; 63% thought the vaccine should be
Chattanooga recommend the vaccine universal; 54% that the appropriate age for
vaccination is 10–14; 63% that both males and
females should receive it. None reported
feeling the vaccine promoted promiscuity
9
10
JVAC 14625 1–16

G Model
Table 3 (Continued)
and response rate
Podolsky, 2009 Waiting rooms in 2 Self- or 148 Latina mothers in New Knowledge about HPV and 88% New York and 30% Salvadoran women had
El Salvador and USA hospitals in disadvantaged researcher-administered in York, 160 in San Vicente, of acceptability of HPV vaccination, heard of HPV. 68% NY and 88% Salvadoran
communities clinic children aged 8–18. 53% which was available in New York, women would accept vaccination for their
Date not reported 95% RR ≤elementary education but not in El Salvador daughter; 59% and 88% for sons. The most
common reason given for refusing the vaccine
was lack of knowledge (41%)
Riedesel, 2005 Membership of the Postal questionnaire 145 physicians (58% in HPV knowledge, attitudes to HPV Important factors were thought to be long
Nationwide USA American Academy of Date not reported 16% RR urban/suburban practice) vaccination and intention to lasting immunity (96%), few side effects (95%)
Family Physicians Mean age 44 59% male administer vaccine recommendation by professional bodies (98%)
and cost (90%). Barriers were parental
concerns about vaccine safety (73%), risky
behaviour (49%) and vaccination against STIs
ARTICLE IN PRESS
Rosenthal, 2008 A university-based primary Self complete survey, method 153 female carers of 11–17 Perceptions of HPV related disease 44% had been offered vaccination, 60% of
Texas, USA care clinic not reported year-old girls. Aged 27–77 39% severity, susceptibility and barriers whom had accepted. 57% agreed HPV
April 2007–January 2008 83% African-American, 34% White, to vaccination, whether vaccination would be safe, 75% that it could
RR 78% > high school vaccination had been offered and, protect against cervical cancer and genital
if so, reasons for acceptance/refusal warts. 11% against vaccination per se, 9%
thought cost too high, 18% thought daughter

not at risk
Songthap, 2009 3 government and 1 Self complete survey, method 200 female nurses, mean age Knowledge and attitudes regarding 46% nurses and 74% doctors considered HPV
Bangkok, Thailand private hospital not reported 36; 97% Buddhist 100 doctors, HPV, HPV vaccine and vaccine vaccine safe. 37% nurses and 71% doctors
June–August 2008. RR not 55% female, mean age 40, 96% acceptability disagreed that having HPV vaccine can lead to
reported Buddhist increased risky sexual behaviour. 63% nurses
and 80% doctors thought both boys and girls
should get HPV vaccine
Tariq, 2009 Primary care clinics Postal survey 300 primary care physicians Practices and attitudes concerning 73% currently offered the vaccine. Girls aged
Arkansas, USA state-wide Date not reported 20% RR No further details reported HPV vaccine 15–19 years were the most frequently
vaccinated (41%). Barriers were cost (62%) and
parental belief that it promoted sexual activity
(20%). 61% believed that males should be
vaccinated
Tozzi, 2009 A database of participants Telephone survey 807 mothers of daughters aged Knowledge of HPV and vaccination 54% had heard of HPV, 63% of the vaccination
Nationwide Italy in previous surveys October–December 2007 92% 10–12, 86% employed, 54% and whether they would allow campaign. 84% would have their daughters
RR white collar workers, 54% high their daughters to be vaccinated vaccinated, 83% would pay if daughter out of
school diploma free vaccination age. Only 9% thought
vaccination would encourage sexual
promiscuity
Weisberg, 2009 2 family planning clinics Questionnaire self-completed 294 women aged 15–26 years. Knowledge, attitudes and 83% of respondents had heard of HPV vaccine.
New S Wales, Australia in clinic. May–June 2008 57% 46% had higher education, 36% experience of HPV vaccine 69% felt they had enough information to make
RR were students, 53% employed a decision about it. 58% had had at least 1 dose
of HPV vaccine, 23% planned to get it. 78%
thought HPV vaccination important for
women, 28% for men
Wong, 2009 All private practices Postal questionnaire. 247 physicians aged 31–68, Recommendation and vaccination 56% always or usually recommended HPV
Nationwide Malaysia purchasing/using HPV June–August 2008 41% RR 64% male, 68% Chinese, 17% behaviour, who was most likely to vaccination. 83% preferred to recommend to
vaccine Indian, 15% Malay accept vaccination, factors women aged ≥18 years and 94% thought
influencing decisions and barriers Chinese women most accepting. 78% identified
against vaccination cost as the key barrier to patients, 13% thought
safety concerns
Yeganeh, 2010 1 free community clinic in Face-to-face interview 95 mothers of daughters aged Whether parents had heard of HPV, 77% had heard of HPV vaccination; of these
California, USA Los Angeles completed in clinic. May–June 11–17. 91% Latino, 77% if so, whether their daughter was 37% had daughter vaccinated, 36% had refused.
2008 RR not reported Catholic, 62% < high school, vaccinated or why they had Refusers wanted more information (55%), had
60% <$25 K refused vaccination; opinions on safety concerns (18%), daughter did not need it
mandating vaccination for school (15%) or doctor did not offer it (21%). 65%
agreed with school mandate
ARTICLE IN PRESS
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JVAC 14625 1–16
126 described as “unvaccinated” had not been offered vaccination (yet); A few parents believed that the HPV vaccine should be offered to 185
127 girls who had been offered the vaccination and refused it are adolescents when they can take part in the decision whether to be 186
128 described as “vaccine declined”. immunised. (parents of unvaccinated children, USA) [33] 187
Many participants voiced specific concerns that HPV vaccines given 188
129 3.3.1. Trying to decide on HPV vaccination – unanswered to 11 year olds would not prevent infection late in adolescence. 189
130 questions and concerns (healthcare professionals, USA) [22] 190
131 3.3.1.1. Knowledge was poor and there were misconceptions.
132 Although acceptability and uptake of the vaccine, where offered, 3.3.1.4. Participants questioned the rationale for not vaccinating 191
133 were high, people’s level of knowledge was poor. A common boys. A majority of healthcare professionals supported vaccinat- 192
134 thread that permeated their narratives related to unanswered ing boys [69] [69,76,80,81] and parents also thought it important 193
135 questions, concerns and misconceptions [14–16,20,25,26,38]. Par- [24,32,33,41,69]. Some reasoned that this would prevent trans- 194
136 ticipants struggled to make sense of the limited information mission to girls [32,33] and others that it would emphasise boys’ 195
137 available to them and understand how it fitted in with their exist- responsibilities with regard to sex and sexual health [32]. Target- 196
138 ing knowledge of vaccination, cervical cancer, viral infections and ing girls with the vaccine was seen to stigmatise them [24]. Support 197
139 STIs [16,17,20,26]. for male vaccination was evident in four surveys of parents where 198
140 The majority of participants had never heard of HPV. (female stu- a majority of 54–88% were in favour [52,71,75,77]. 199
141 dents, unvaccinated, Malaysia) [14] [About two thirds] of participants reported that they would be 200
142 Typically, participants knew very little about HPV infection and its equally likely to give the HPV vaccine to girls and boys; the pri- 201
143 transmission...Around half the girls were aware that HPV infection mary rationale given was that vaccinating boys should protect girls 202
144 could lead to the development of cervical cancer, but there was also by preventing HPV transmission. (healthcare professionals, USA) 203
145 some confusion about whether cancer could actually be prevented. [23] 204
146 (girls, vaccinated, vaccine declined and undecided) [20] Another topic that emerged was that only girls were being blamed 205
for HPV by targeting the vaccine only towards young girls. (health- 206
147 3.3.1.2. Poor information was a barrier to acceptance. Lack of care providers, community leaders, parents and women eligible 207
148 information was cited in several surveys of parents and young for vaccine) [24] 208
149 women; up to 55% said it was a barrier to vaccine acceptance Most parents thought that the HPV vaccine should be given to boys 209
150 [47,52,60,70,77,79,83,85]. Many participants expressed dissatis- and girls, even though the vaccine has less direct benefit for boys. 210
151 faction with the information available to them and stressed the Most parents felt that immunising boys was important to protect 211
152 importance to both girls and parents that they had sufficient future partners and to reduce disease transmission. (parents of 212
153 clear and understandable information to enable them to make an unvaccinated children, USA) [33] 213
154 informed decision about vaccination [18,19,28,30,38,40,41]. Some
155 girls described how having more knowledge might help them be
3.3.2. The benefits, harms and misconceptions of HPV vaccination 214
156 less confused and more positive about the vaccination experience
3.3.2.1. Cancer prevention was the most important influence in vac- 215
157 [16].
cine acceptability. An obvious benefit of the vaccine was seen to 216
158 Three of the 10 parents who declined the vaccines said they had be cervical cancer prevention [20–22]; some participants knew of, 217
159 insufficient information with which to make an informed decision. or had nursed, people who had died of cancer, sometimes after 218
160 HPV elicited responses of being unfamiliar with the disease and/or a prolonged illness, and were motivated by the desire to protect 219
161 being uniformed about its prevalence or threat to teens. (parents themselves and their loved ones from cancer [28,35]. 220
162 of children aged 8–17, USA) [30]

Two nurses had cared for patients with severe cervical dysplasia 221
163 Many girls described how an understanding of why they were and having seen “the trauma they have been through” had decided 222
164 being vaccinated and the benefits of HPV vaccination would help to that the benefits of preventing HPV infection outweighed the risk 223
165 reduce their fear...Nurses agreed the lack of information played a of possible long-term side effects. (NHS school nurses, UK) [35] 224
166 role in girls’ responses to vaccination. (girls, vaccinated, parents,

167 teachers and school nurses, Australia) [16] 3.3.2.2. Some were encouraged to accept HPV vaccination as they mis- 225
interpreted it as an attractive alternative to cervical screening. For a 226
168 3.3.1.3. Limited understanding about the young age of vaccination number of UK mothers, the erroneous assumption that HPV vac- 227
169 was a barrier to some parents. Parents appeared not to under- cination obviated the necessity for cervical screening appeared to 228
170 stand the reason for targeting HPV vaccination programmes at be a major factor in giving consent for their daughters’ vaccina- 229
171 pre-pubertal girls before sexual debut (i.e. to prevent the most tion [19,39]. This sentiment was supported in one survey of 684 230
172 cases of cervical cancer for a given public expenditure) and ques- mothers also from UK, 70% of whom said they would be glad if HPV 231
173 tioned the need for vaccinating their daughters at such a young vaccination meant an end to cervical screening [73]. 232
174 age [17,29,34,40]. They reasoned that their child was not ready and . . .there were also girls that were certain that Pap smears were now 233
175 would not be sexually active for many years to come, by which unnecessary. . .Parents on the other hand, were more likely to think 234
176 time the effect of the vaccine may have worn off [22,26,41]. Older that girls who had been vaccinated still needed to have Pap smears, 235
177 girls were thought more able to understand the implications of although some were unsure. A few parents stated that they had 236
178 HPV vaccination and therefore to participate in the consent process not heard anything about Pap smear guidelines after vaccination. 237
179 [15,18,33]. (girls, vaccinated and vaccine declined, and parents, Australia) 238
180 There was confusion as to why the vaccination programme has [17] 239
181 been targeted at their age group. The majority of participants did It became clear that some parents had made the decision about 240
182 not understand that this was because the vaccine is most effective whether their daughter would receive the HPV vaccine based on 241
183 when administered before any sexual activity. (girls, vaccinated, misconceptions about the need for cervical screening in the future. 242
184 UK) [34] Several parents had believed that the vaccine would eliminate 243
ARTICLE IN PRESS
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JVAC 14625 1–16
244 the need for cervical screening. (girls, vaccinated and vaccine surveys [45,47,52,60,61,67,73,74,78–80,84–86,88]; where about 304
245 declined, and parents) [19] three quarters of mothers and young women expressed such wor- 305
ries. Some people were reassured by Government endorsement 306
246 3.3.2.3. Trusting existing cancer prevention methods was a barrier of the vaccine [20,28,33], although others were suspicious of the 307
247 to acceptance. However, some participants did not see vaccina- medical establishment and pharmaceutical companies [24,37]. 308
248 tion as beneficial; they interpreted HPV vaccination and cervical

One issue that resonated with most participants was the concern 309
249 screening as alternative rather than complementary strategies
about the lack of long term research about the new vaccine and 310
250 [17,19,20,26,27,39,86]. They felt that the current screening pro-
the concern that it may harm the future reproductive capabili- 311
251 gramme was tried, trusted and effective in detecting and treating
ties of young women. (healthcare providers, community leaders, 312
252 abnormalities at an early stage and therefore saw vaccination as
parents and women eligible for vaccine) [24] 313
253 superfluous [39].
Most expressed very positive feelings towards government immu- 314
254 For some others, cervical cancer was not much of a worry, and they
nisation programmes and seemed to have a great confidence in both 315
255 felt Pap tests provided adequate protection. (mothers of unvacci-
efficacy and safety of government recommended vaccines. (parents 316
256 nated daughters, UK) [39]
of unvaccinated girls, India) [28] 317
257 3.3.2.4. A minority of parents and some physicians had reservations Some ethnic minority participants had concerns relating to the 318
258 about a vaccination for a sexually transmitted infection. Resistance to content of the vaccine and perceived biological differences between 319
259 HPV vaccination was largely related to HPV as a sexually transmit- different racial groups that might provoke or exacerbate side- 320
260 ted infection. The provision of HPV vaccination was seen by some as effects [29,41]. 321
261 appearing to condone or even promote promiscuous or early sex-

Most of the Muslim respondents were concerned that because it is 322
262 ual activity, with the associated stigma [22,24,29,30,32,33,39,41].
a western product and related to a sexually transmitted disease, 323
263 This was also identified as a barrier to vaccination in six surveys
the vaccine may contain alcohol or may be made from non-halal 324
264 of UK [45,72,73], US [44], Vietnamese [57] and Italian parents [82];
sources. Many stressed that they would refuse the vaccine if it was 325
265 however in all six it was a minority view (9–25%). To parents of
non-halal. (women and girls, unvaccinated, Malaysia) [41] 326
266 younger children, acceptability was partly dependent on their abil-
267 ity to imagine or accept that their children would, one day, become One additional safety-related concern that was raised by several of 327
268 sexually active and this could be out of the parents’ control and the black Caribbean mothers was the effect of biological differences 328
269 potentially at a relatively young age [25,32,40]. across ethnic groups and difference in disease risk, with examples 329
given of sickle cell anaemia or increased risk of diabetes. (Black and 330
270 Muslim respondents were more uneasy about this issue. Several...
Asian mothers, UK) [29] 331
271 feared that the vaccine will encourage children to engage in sex-
272 ual activity sooner than they would otherwise. (women and girls,
273 unvaccinated, Malaysia [41] 3.3.2.6. Some girls were afraid of having injections. In both quali- 332
tative studies and surveys of girls, anxiety related to vaccination 333

274 Some women were reluctant to entertain the idea of vaccinating
at school was commonplace, particularly fear of needles and pain 334
275 young girls because to have the vaccination seemed to involve an
[16,20,34,46,47,65,88]. In some cases alarming rumours about the 335
276 acceptance of the fact that the child would one day become sexually
size of the needle or the content of the vaccine (“cancer cells”) 336
277 active. (girls, vaccinated and vaccine declined) [40]
had spread [20,46]. However none of the studies reported that this 337
278 Although physician recommendation was acknowledged as adversely affected vaccination uptake. 338
279 being highly influential in vaccine acceptance [21] (up to 95%

Typical rumours were that each injection was more painful than 339
280 in surveys [51,57,60,70,86]), some physicians were reluctant to
the previous one; that the needles got larger and that the dose got 340
281 recommend HPV vaccination either because they had difficulty
“thicker”. (girls, vaccinated, vaccine declined and undecided, UK) 341
282 discussing sexual matters with young people or because they antic-
[20] 342
283 ipated parental disapproval [22,23,25,36]. Physicians were aware
284 of religious and cultural sensitivities and perceived potential prob-
285 lems in recommending HPV vaccination to some groups [36,87]. 3.3.3. The perceived need for vaccination was affected by 343
286 However in two surveys of physicians [51,53] the majority were participants’ interpretation, or misinterpretation, of their own or 344
287 confident in discussing HPV vaccination with patients; whilst in their children’s risk of HPV infection Confusion about the best 345
288 two more [78,81], only a minority said parental concern about pro- method of HPV prevention was a barrier to vaccine acceptance 346
289 moting sexual behaviour was a barrier to vaccination uptake. Participants in some studies, interpreting HPV infection in the 347
context of other STIs, did not see the need for vaccination because 348
290 Participants’ decision narratives that indicated vaccine accep-
they erroneously assumed that HPV could be managed by preven- 349
291 tance included discussion with health care providers who explicitly
tive tactics such as condom use [20,21,30,32,40]. Others preferred 350
292 encouraged and recommended HPV vaccination. (female students,
to advocate abstinence or monogamy [20,21,29], but some failed 351
293 some vaccinated, USA) [21]
to recognise that having a number of partners consecutively might 352
294 . . .physician related barriers to recommending HPV vac- present a risk [21]. 353
295 cine...included personal reluctance to discuss sexuality with

Some held misconceptions about the protective effect of condoms 354
296 patients [and] low self-efficacy to convince parents of the need for
and for that reason had a low perceived risk of HPV. (girls, vacci- 355
297 vaccination. . . (healthcare professionals, USA) [23]
nated and vaccine declined, UK) [40] 356
298 3.3.2.5. Concern about vaccine safety was a barrier to acceptance. Responses reflected the false belief, in many cases, that monogamy 357
299 Participants worried about vaccine safety [21,24,28,29,34,38,40], was protective. . . vaccination was only considered when events 358
300 and voiced fears of the possible consequences of having a new occurred, such as breaking up, which then prompted consideration 359
301 vaccine [24,29,40], particularly relating to adverse effects on fer- of the vaccine. Women acknowledged the potential for HPV vul- 360
302 tility [24,28], and the lack of research into its long term effects nerability because of having multiple partners, or after breaking up 361
303 [24,38]. Concerns about vaccine safety were also evident in with their partner. Participants never acknowledged the possibility 362
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363 of serial monogamy as a transmission mode. (female students, Monogamous relationships were perceived to be safe regardless of 423
364 some vaccinated) [21] women’s or their partners’ previous sexual history. Some moth- 424
ers could not imagine their daughters becoming sexually active for 425
365 3.3.3.1. Misperception of risk of acquiring an HPV infection could be many years and therefore saw no urgency for vaccination. 426
366 a barrier to acceptance. Interest in HPV vaccination was influenced

367 by young women’s perception of their risk, or parents’ perception 4.2. How this study fits in 427
368 of their children’s risk, of acquiring an HPV infection. A low percep-
369 tion of HPV risk amongst a minority of participants was identified Ours is the most comprehensive systematic review of people’s 428
370 in four surveys of parents in the UK [45], and US [43,79,85], and views on HPV vaccination. We found ten systematic reviews look- 429
371 one of Swedish students [65]. In qualitative studies, some partici- ing at the acceptability and uptake of HPV vaccination that were 430
372 pants believed that only women who engage in promiscuous sexual published in 2007–2013 [89–98] (summarised in Table 4), though 431
373 behaviour were at high risk [21,24]. Women in monogamous rela- none was as inclusive as our review in terms of period of literature 432
374 tionships perceived themselves to be at low risk, and some did covered, population or study type included. Whilst five of these 433
375 not take into account that the current relationship could be one reviews included qualitative studies, the results were synthesised 434
376 of a series, or that their partner may have had previous partners quantitatively or in a narrative summary. Their conclusions were 435
377 [21,29,31]. Some mothers believed their daughters would not be broadly consistent with ours, but we included a wider range of stud- 436
378 sexually active currently or in the near future and therefore saw ies and by conducting a qualitative synthesis we add further depth 437
379 no urgency for vaccination [18,28,41]; and this was supported in and insight into people’s views, and particularly into the sometimes 438
380 two US surveys of young women [47,86] and one of US parents faulty reasoning processes involved in utilising limited information 439
381 [60] where for a minority this was a barrier to acceptance. Oth- to weigh up individual risk of HPV infection and the potential harms 440
382 ers acknowledged the reality of teenage sexuality [15,23,29] or and benefits of HPV vaccination. 441
383 conceded that vaccination would protect under unforeseen circum-
384 stances such as rape [38,41].
4.3. Study strengths and limitations 442
385 In their decision narratives, a recurring theme among the women
386 was the belief that only women who were promiscuous, careless, This study is timely; the UK HPV vaccination programme began 443
387 or “not smart about sex” were at risk from HPV. These stigmatising in 2008, accompanied by significant publicity; and although uptake 444
388 peer messages were reportedly reinforced by parental messages. is currently high, there is evidence that it may not be sustained [4]. 445
389 (female students, some vaccinated) [21] The results are important in terms of the urgent need for wider 446
390 Mothers declining the vaccine perceived their daughters to be at low education about HPV. It is also important as the findings can inform 447
391 risk for HPV-primarily because they did not believe their daughter the broadening of HPV vaccination programmes, as other cancers 448
392 was likely to be sexually active currently or in the near future. These are attributed to HPV viruses, for example, oropharangeal and anal 449
393 mothers lacked a sense of urgency about the need for vaccination cancers. 450
394 before the onset of sexual activity. (mothers of vaccinated and Our review was comprehensive; however it was limited by the 451
395 vaccine declined daughters) [18] scope of the primary studies. Only seven out of 28 qualitative stud- 452
ies and 10 out of 44 surveys questioned girls or parents in the 453

396 Another theme that was mentioned by at least one parent in each context of an actual, rather than an anticipated, HPV vaccination 454
397 community was that often sexual exposure was not under the con- decision. Studies of health professionals tended to focus on the 455
398 trol of the young woman, as in the case of rape, and this vaccine practicalities of immunisation. 456
399 would offer the young woman protection from HPV. (parents of There was very limited consideration of views about the vac- 457
400 unvaccinated girls, USA) [38] cination of boys or the benefits that might accrue to them; there 458
was scarcely a mention of genital warts and none at all of other 459
401 4. Discussion cancers (e.g. ano-genital, head and neck) that could be prevented 460
by HPV vaccination. There was little exploration of the differences 461
402 4.1. Summary of main findings in views between ethnic groups; the Marlow review [93] focussed 462
on ethnic minorities in the UK and also noted a weakness in the 463
403 Overall the acceptability of HPV vaccination was high. How- research in this area, though there was some evidence that religion 464
404 ever, people had insufficient knowledge and understanding about was an important factor in acceptability but socioeconomic status 465
405 HPV vaccination and a poor grasp of the facts was revealed, with was not. 466
406 participants struggling to interpret limited information in the con- Study populations were heterogeneous in terms of geog- 467
407 text of existing knowledge, impacting on the ability to make raphy, culture, health system and time (i.e. before or after 468
408 informed choices. This lack of understanding permeated all our vaccination programmes). However, since most of the studies 469
409 findings. were set in high-income countries, the review is well placed 470
410 Participants tried to weigh the benefits of HPV vaccination to inform UK vaccination campaign materials. The majority of 471
411 against the possible harms; as well as the clear benefit of cer- studies were conducted in the context of an expectation of 472
412 vical cancer prevention, some participants erroneously perceived vaccination being offered as part of a national programme. In 473
413 a benefit that vaccination would avoid the need for cervical this context, there was no discernible difference in responses 474
414 screening. Others saw no “added value” of vaccination in addi- between those who were making an actual versus a future vaccine 475
415 tion to what they perceived as a tried and tested screening choice. 476
416 programme. Potential harms were perceived to be the encourage- We did not report in detail the impact of vaccine cost, although 477
417 ment of early or promiscuous sexual activity and adverse vaccine it was mentioned by participants in many studies, because it did 478
418 effects, with some girls expressing fear of the vaccination process not impact on people’s views about the vaccine itself or its accept- 479
419 itself. ability. However we acknowledge cost as a major barrier to vaccine 480
420 The risk of HPV infection was interpreted in the context of uptake for some. Socio-economically marginalised women suffer a 481
421 other STIs and it was assumed that only the sexually promiscu- disproportionately large burden of cervical cancer; for HPV vacci- 482
422 ous were at high risk, and that condoms would be fully protective. nation to provide a public health solution in developing economies 483
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484 cheaper vaccines as well as improved health education and screen- 5. Conclusions 547
485 ing are needed [99].

These findings highlight the emerging problem that many girls 548
and their parents are poorly informed, have limited understanding 549
486 4.4. Implications for research, and UK policy and practice and many unanswered questions, which impinges on their ability 550
to make informed choices about HPV vaccination and could impact 551
487 Our most striking finding was the lack of knowledge and under- on future uptake of cervical screening. 552
488 standing among the public though, given the complexity of HPV
489 related issues, this is not wholly surprising. More worrying perhaps Acknowledgements 553
490 is that UK general practitioners and practice nurses are concerned
491 about the adequacy of information given in schools and their own We acknowledge the contributions of Sue Wilson, Theresa 554
492 ability to explain and manage conflicts between parents and chil- Marteau, Kirsten McCaffery and the late Joan Austoker to study 555
493 dren [100]. Sound information that can be readily understood by design, and thank Sally Warmington, Annie Hendry, Ellen Richards, 556
494 parents and girls, and straightforwardly delivered in school and pri- Barbara France and the staff of John Spalding Library, Wrexham 557
495 mary care settings is needed. Consideration also needs to be given Medical Institute for their help. 558
496 to the information needs of ethnic minorities to ensure information This review is part of the multi-method HPV Core Messages 559
497 that is relevant to those groups. project, funded by Cancer Research UK (Ref. C1273/A9479) to 560
498 In England the first tranche of vaccinated young women will inform the development of evidence-based informational material 561
499 be eligible to enter the cervical screening programme in 2016. for use in the context of HPV vaccination and testing programmes. 562
500 In light of the evident uncertainty about the need for vaccinated
501 women to participate in cervical screening, this should empha-
Appendix A. Supplementary data 563
502 sised in the information relating to both vaccination and screening
503 programmes, and the screening behaviour of vaccinated women
Supplementary data associated with this article can be 564
504 should be monitored.
found, in the online version, at http://dx.doi.org/10.1016/ 565
505 Furthermore, given the increased incidence of HPV-related
j.vaccine.2013.08.091. 566
506 cancers, public concern regarding vaccination of boys is an addi-
507 tional relevant factor for increasing pressure to vaccinate both
508 genders in the UK. Newman et al. [98] conducted a systematic References 567
509 review and meta-analysis of HPV acceptability among men but

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ARTICLE IN PRESS

Vaccine xxx (2013) xxx–xxx

Contents lists available at ScienceDirect

2 “HPV? Never heard of it!”: A systematic review of girls’ and parents’

∗ Corresponding author. Tel.: +44 1978 727427.

0264-410X/$ – see front matter © 2013 Published by Elsevier Ltd.

2 M. Hendry et al. / Vaccine xxx (2013) xxx–xxx

32 1. Introduction treated as primary data and extracted verbatim, excluding quo- 81

tations. Sources on qualitative review methodology differ on what 82

50 preferences regarding HPV vaccination, to inform the development

studies reﬂected ﬁndings which pre-dated HPV vaccination pro- 105

grammes with their associated public information. Twenty-eight 106

68 Reference lists of included studies were hand-searched. Inclusion

75 resolved by discussion or, if necessary, a third reviewer.

77 developed by the National Institute for Health and Clinical Excel-

M. Hendry et al. / Vaccine xxx (2013) xxx–xxx 3

Records idenﬁed through Records idenﬁed through

Records aer duplicates removed

Records screened Records excluded

Full-text arcles excluded

Studies on HPV Studies on HPV

*Some studies were reported in more than one publicaon

JVAC 14625 1–16

M. Hendry et al. / Vaccine xxx (2013) xxx–xxx

M. Hendry et al. / Vaccine xxx (2013) xxx–xxx

JVAC 14625 1–16

M. Hendry et al. / Vaccine xxx (2013) xxx–xxx

M. Hendry et al. / Vaccine xxx (2013) xxx–xxx

JVAC 14625 1–16

M. Hendry et al. / Vaccine xxx (2013) xxx–xxx

M. Hendry et al. / Vaccine xxx (2013) xxx–xxx

JVAC 14625 1–16

M. Hendry et al. / Vaccine xxx (2013) xxx–xxx

M. Hendry et al. / Vaccine xxx (2013) xxx–xxx 11

162 of children aged 8–17, USA) [30]

166 role in girls’ responses to vaccination. (girls, vaccinated, parents,

interpreted it as an attractive alternative to cervical screening. For a 226

12 M. Hendry et al. / Vaccine xxx (2013) xxx–xxx

ries. Some people were reassured by Government endorsement 306

248 tion as beneﬁcial; they interpreted HPV vaccination and cervical

261 appearing to condone or even promote promiscuous or early sex-

tative studies and surveys of girls, anxiety related to vaccination 333

279 being highly inﬂuential in vaccine acceptance [21] (up to 95%

295 cine...included personal reluctance to discuss sexuality with

M. Hendry et al. / Vaccine xxx (2013) xxx–xxx 13

366 a barrier to acceptance. Interest in HPV vaccination was inﬂuenced

ies and 10 out of 44 surveys questioned girls or parents in the 453

by HPV vaccination. There was little exploration of the differences 461

on ethnic minorities in the UK and also noted a weakness in the 463

14 M. Hendry et al. / Vaccine xxx (2013) xxx–xxx

485 ing are needed [99].

509 review and meta-analysis of HPV acceptability among men but

M. Hendry et al. / Vaccine xxx (2013) xxx–xxx 15

16 M. Hendry et al. / Vaccine xxx (2013) xxx–xxx

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