HPV attitudinal research

General attitudes to the vaccine across waves

Although health and cervical cancer were not major concerns for either age group or their parents, the idea of a vaccine against cervical cancer was well received, with most in the sample being positive about its introduction.  It was seen as a scientific breakthrough offering valuable protection.  Typically across the Yr 8 sample the parents were more interested than the girls.  On the whole across the 17-18 sample there was general interest from both the parent and daughter samples.  Across both audiences mothers tended to be much more knowledgeable about cervical cancer than their children.

Evidence from the three waves of research conducted shows that the HPV vaccine has been well received and that the programme is running smoothly and has been generally supported by parents, girls and health professionals.  Offering the programme through schools/educational establishments is strongly supported.

Wave One Management summary - 16-18 year old girls catch up programme

Background attitudes to health and cervical cancer

This research demonstrated that health was not a major concern for 16-18 year olds.

Cervical cancer had low salience and relevance amongst this audience who were ‘pre-programme’, being less well known and less well understood than Breast Cancer.  Understanding of the causes of cervical cancer was also low, with many assuming that it ‘just develops’.  Some had heard of a link to sexual behaviour although they were not clear about this - it was mainly understood as being caused by having multiple partners or having sex young. The presence of a vaccine is starting to increase interest and relevance of the disease.

Knowledge of and reactions to the HPV vaccine

This audience had some awareness of a vaccine against cervical cancer, but most, who had not yet been invited for the vaccine, did not know it was available to them.

Typically they had very little knowledge about HPV, how it is spread and its link to cervical cancer.  If the term HPV was even known it was often assumed to be the name of the cervical cancer vaccine.  For most, the vaccine was referred to as the vaccine against cervical cancer, not the HPV vaccine.

There was significant interest in the vaccine for offering protection against cancer which is a ‘scary’ disease.  No major negatives were uncovered with most in this sample anticipating take up of the vaccine.  However, although interest was widespread there was some potential to delay decision making due to low understanding of the risks of cervical cancer, teenage apathy and issues such as fear of needles or side effects.

For the older girls, the idea that it may be too late to have the vaccine was at times raised once sexual transmission of HPV was understood and some felt this belief could act as a barrier to uptake.  Most tended to feel on thought that the sexually active would look to the future and wish to be vaccinated anyway however it was considered important to ensure materials were clear about the value of vaccination even if the girl had already been sexually active.

17-18 year olds in this sample prided themselves on independent choice and felt it was very much their decision whether they had the vaccine or not – as such it felt appropriate to them that consent should be given by them and it was often seen as a personal decision to take.  They felt they would consult their mothers if they had a close and open relationship with her, but they may also consult close friends or other close family members and they considered peer uptake important in influencing those who may delay.

Attitudes to Campaign Material

Awareness of the catch up advertising campaign was low.  Contextual issues such as lack of knowledge of cervical cancer and a potential for apathy, suggest that the campaign can afford to be harder hitting to drive engagement and pro-activity amongst this age group.

Currently, although it was liked as a campaign, concerns were raised that it did not work hard enough to grab attention and quickly and clearly communicate that the ads were for the cervical cancer vaccine which was now being offered to 17-18s.

Although positive, the messages used were often considered soft, not affording sufficient importance to the vaccine.  The concern raised was that they would not encourage sufficient action amongst this target audience who need to make a pro-active response. 

Harder hitting messages regarding the dangers of cervical cancer and protection levels noted in the leaflets such as the number of deaths per year and the fact that this is the second most common cancer in women worldwide, were considered motivating and powerful facts.  The logo was also well liked with calls for increased prominence.

Response to the leaflet:

The 17-18 leaflet was well received overall although the front cover received a mixed response in terms of engagement.  It was felt to be tonally appropriate, covered key information needs and was motivating.  It worked to provide key information without being too frightening although the detail on side effects and language used to describe previous infection did raise fears.

Elements from other leaflets were also liked such as the message in the general leaflet that 3000 new cases of cervical cancer are diagnosed each year and the line from the 12-13 leaflet – ‘by having the vaccination you will reduce your risk of getting cervical cancer by over 70%’

Wave 2: Evaluation of programme - Health Professionals

Attitudes to the programme:

Nurses in this sample were positive about the HPV vaccination programme and its implementation.   They thought it was a valuable vaccination, that they would accept for their own children and they recognized that HPV was a significant risk.

Some questions were raised despite an overall positive response to the programme, mainly regarding the cost effectiveness of the programme, the choice of vaccine, decision not to also vaccinate boys, or provision to support those who miss vaccination and any effect on the national screening programme.

Despite a quick turnaround at the beginning of the programme which caused some logistical problems in terms of set up, nurses reported higher levels of take up than expected, good relationships with schools and were positive about the chance to interact with girls as this can open the door to other health education issues. 

Nurses felt that the public have responded well to the programme with no major barriers being raised, although they acknowledge it may be too early for analysis of rejecters.  Although nurses did not report significant concerns and questions raised by parents the following were noted: safety issues, the newness of the vaccine, the potential for increased sexual promiscuity.  Some argued that the legacy of the questions about MMR meant that parents do question the need for vaccines rather than just accepting them. 

The nurses generally felt well supported in terms of general help, equipment and information provided, however there were examples of some practical problems often due to speed of implementation, for example some nurses based in GP surgeries had not received the Health Professional packs.

The Health Professional information was seen as thorough and comprehensive with no major information gaps although information specifically designed for parent and child sessions would be helpful.

Media support for the programme was appreciated by nurses although they can argue for an increased media presence particularly for the catch-up programme.

Wave 3 - Evaluation of programme – 12-13 year olds and their parents; 17-18 year olds and their parents

General Learnings across sample

It was clear across this part of the sample that cervical cancer was better known than HPV with the vaccination being known as the cervical cancer ‘jab’.  The causes of cervical cancer and the fact that HPV is sexually transmitted were still not well understood across the whole sample.  Those with the highest levels of knowledge tended to be those who had received and read the leaflet or had attended nurse meetings.

The question of ‘Why Year 8’ was raised by some parents supporting the fact that parents are not universally aware that HPV is sexually transmitted and its link to cervical cancer.  Even when HPV was known by parents, they often assumed that this was not the only way cervical cancer developed.  The sexual nature of the cause of cervical cancer can start to change its image for them linking it to ‘dirtiness’ and promiscuity.

Four ‘decision maker’ typologies emerged in this research and evidence suggests they exist amongst both parents (of 12-13 year olds) and 17-18 year old girls: immediate acceptors, accept the programme with little question considering it an easy decision to make; considerers have questions, but are generally positive; passive rejecters, can be considers whose questions go unanswered; active rejecters have specific reasons for rejection such as religious/moral reasons, concerns about side effects, feelings their daughters are simply too young/ vaccine is too new or outright vaccine rejection.

17-18 year olds and their parents

Attitudes to and awareness of the vaccine

Wave 3 confirmed earlier indications at Wave 1, that although generally positive some 17-18 year olds have some potential to delay having the vaccination.  The two types of rejecters that emerged in this audience were passive rejecters who did not have concrete reasons for rejection, but had dropped out of the system due to issues discussed above encouraging delay; and active rejecters with more specific questions and concerns such as safety, needle phobia or eligibility because they have started having sex.

Questions were raised by both 17-18 year olds and parents of 17-18s regarding eligibility for the vaccine if the girl had previously been sexually active.  It was therefore considered important that all communications (for Year 8s and 17-18s) conveyed the same message regarding eligibility and the value of vaccination even if there had been previous sexual contact. 

Process issues

The process of invitation for 17-18 year olds varied across the country.  Although all received a letter, not all received a leaflet which was key to considerers and passive rejecters.  Some were given a specific time and date of vaccination; others were invited to make an appointment.  Typically 2-5 weeks was given for decision making.

Key to maximising the process appeared to be making engagement with the programme as easy as possible, particularly given the fact that this audience may need to be proactive in their response. Providing the leaflet alongside an engaging invitation letter, ideally with the time, date and place of the vaccination would be the preferred route, with the option to change the times if necessary.

There was evidence that mothers can play an important role in encouraging girls to have the vaccination and ‘making it happen’ where there is apathy.  This included booking appointments as well as encouraging their daughters and discussing reasons for vaccination.

Booking all three vaccinations at the same time, or encouraging booking after each dose was also recommended, as girls may forget to rebook and like to plan ahead. 

The vaccination itself was felt to go smoothly.  Although some nerves were evident there was no hysteria and most reported the vaccination was not too bad, although some suffered pain for a few days which was longer than they expected.

Reminder communications by post were expected and text reminders were also interesting.  Those who liked this idea were prepared to pay for initial set up costs (within reason).

Communications

The leaflet was again well liked across both parent and 17-18 year old audiences and it was felt to be a motivating piece of communication.   However there was evidence of skim reading, particularly of the HPV section and fears were again raised by the paragraph discussing previous infection of HPV, which felt negative.

‘Sexual contact’ as a phrase was not well understood with the sample tending to automatically assume it meant ‘sexual intercourse’.

Although the vaccination was not considered too painful, some argued that the paragraph discussing immediate side effects down played the experience.  Respondents do not want to be frightened when they read this section but they do want the information to be realistic and those who had had more severe side effects did worry that their experience was not normal.  This indicates that additional reassurance about side effects could be provided at point of vaccination so as not to raise fears before.

12-13 year old girls and their parents

Awareness of and attitudes to the vaccine

This research showed that parents, particularly those in the faith samples see Year 8 girls as on the cusp of growing up and they often do not want to encourage their children to grow up too quickly or expose them to grown up matters, feeling concerned about the early onset of ‘teenage’ issues.  Neither parents nor children have significant health concerns for this age group, and certainly do not worry about cervical cancer. 

Although all the girls and their parents know they have been (or can be) vaccinated against cervical cancer, knowledge and understanding of HPV was mixed across the sample of girls and their parents.  The girls tended to know there was a connection between cervical cancer and sex, but they typically did not demand a great deal of detail. Their primary concerns related to immediate side effects of having the vaccine - i.e. will it hurt? 

Despite these initial concerns, girls tended to be positive about the vaccine and felt well enough informed about it.  They were typically made aware of the vaccine initially through the Year 8 TV campaign and then informed via school nurse meetings which were found to be invaluable.

Parents tended to hear initially about the vaccination through the Year 8 advertising campaign, or news reports and often commented that the time between initial awareness and invitation to vaccination was surprisingly quick which did occasionally raise fears about testing.

Immediate acceptors tended to accept quickly without much question, seeing the vaccine as part of the routine vaccination programme and holding the view that it was too good an opportunity to turn down.  This type may not even consult the leaflet as the decision was so straightforward, although some would read out of interest or to confirm decision making.

Considerer parents tended to need additional reassurance and guidance in making their decision and they had the potential to become passive rejecters if their needs were not met.  They raised the issue of longer term side effects and nervousness at this being a new vaccine.  They can question why Year 8s are being targeted.

Two key types of parent rejecters emerged...those who were ill-informed and felt they needed more information; and those who had active reasons for rejection such as traditional religious views, concerns about the age being offered to the girls, concerns about long term side effects and/or belief in alternative medicine and anti-vaccines generally.  Faith rejecters firmly believed in no sex before marriage and therefore felt it was unnecessary to vaccinate their daughters or that it would give out an inconsistent message with their beliefs and an inappropriate moral code.

Process issues

Overall the experience of the programme for both Yr 8 girls and their parents has been positive.  Offering the programme through schools was strongly welcomed by parents and children for making it simple, offering peer support and helping to legitimise the importance of the vaccine.

The decision to have the vaccine was mainly made by mothers although there was some parent/child consultation.  Alongside the parental decision, peer influence was important in encouraging vaccination as girls did not want to feel left out. 2-4 weeks was typically allowed for decision making.

Not all parents or girls were offered the leaflet and whilst there was evidence of non use, and skim reading, the leaflet was felt to be valuable by considerer and passive rejecter parents and they recommended that it was included in information sent to parents.

The school nurse meetings or assemblies were also found to be useful by the Year 8 girls for disseminating key facts and parents who attended sessions held by nurses also found them useful.

Hype and hysteria amongst Year 8 girls was reported on the day of vaccination with their mothers expressing momentary concerns.  Although peers offered each-other support, there was evidence of group hysteria when large groups of girls were taken for vaccination together. 

Most agreed the vaccination was not as bad as expected, although some reported more severe and longer lasting side effects than expected which raised concerns. 

On the day of vaccination there was no evidence of the widespread distribution of supporting literature which could offer valuable reassurance for girls and parents.

Parents and girls expect communications for each vaccine to come via the school.  There was debate over whether girls should be provided with the date of vaccination although on balance informing them and their parents of the actual date did allow for preparation, and for parents to look out for side effects.

Communications – Year 8 Campaign (girls)

The Year 8 TV ad was felt to be particularly strong and well remembered.  The message was well understood, felt to be appropriate, and the music was liked for being cool. There was low recall of the radio execution, although it was liked on prompting. The press ad received a more mixed response in terms of engagement and appeal, although its message was seen as reassuring. The logo was well liked and seen as a positive statement of unity and strength whilst also being cool.

Communications – Year 8 Campaign (parents)

Although parents were engaged by images of similar age children in the press campaign, there were some calls for more engaging images and ads that more clearly communicated the subject matter quickly maybe via stronger use of the logo and strap line. 

The headline of the magazine ad received a mixed response.  Although the line ‘alive’ was engaging, the careers highlighted can feel too aspirational for some parents, or the ad can immediately be dismissed as a careers ad.

The copy of the magazine ad was particularly liked for its detail and clear explanations about HPV, sexual contact and why it was being offered to Year 8 girls. It was felt to be tonally strong, although some moral objectors did not like the implications that this is the best way to protect your daughter over a strong moral code.

The copy of the press ads was liked although it was not as emotionally engaging as the magazine ad copy.  Parents also liked copy referring to saving women’s lives per year.

There was some recall of the TV campaign amongst parents and although the message was seen as clear, the ad was seen as targeted at girls rather than parents.  There was some, albeit low recall of the parent’s radio campaign.  The opening line was felt to be engaging for mothers and they agreed with the sentiment of protecting, although some found it slightly irritating.

Leaflet

The Year 8 leaflet was liked across both parent and child audiences. 

The front cover was seen as appropriate for the age group and clear.  The leaflet content was seen as approachable and informative, although slightly long for some Yr 8s which encouraged skimming. 

Parents were generally supportive of the information the leaflet contains although some more protective parents wondered whether all the detail was necessary.  On balance they decided it was although they did believe that it was preferable for a gatekeeper (i.e. them or the school) to inform their children of the more sensitive details.

Certain key changes are recommended to the leaflet as discussed in the conclusions.

Conclusions and key recommendations

Key to maximising the process for 17-18 year olds is making engagement with the programme as easy as possible as there is potential to delay take up of the vaccine.

The 17-18 year old advertising campaign could more quickly communicate the subject matter and relevance of the vaccine to this target audience, making more use of the logo and using stronger messages about the dangers of cervical cancer.

Providing the leaflet alongside an engaging invitation letter, ideally with the time, date and place of vaccination would be the preferred route, with the option to change the times if necessary.

Booking all three vaccinations at the same time, or encouraging booking after each dose is also recommended as girls may forget to rebook and like to plan ahead.  Reminder communications by post are expected and text reminders are also interesting.

The 17-18 year old leaflet is well liked, however, certain changes are recommended: Rewording/bullet pointing the HPV section to help with engagement; explaining what is meant by or rewording ‘sexual contact’; using the term ‘smear tests’; rewording the paragraph about previous infection to focus on the positive need for vaccination for future protection even if there has been previous sexual contact (i.e. ensuring they are clear that it is not too late).  There is also the potential to link existing infection to smear tests to show problems will be uncovered and direct to a helpline if concerns are held.

The Year 8 programme is also going well.  Holding nurses talks in schools and where possible parent evening sessions, work to help maximise take up alongside comprehensive distribution of leaflets and clear communications about when the vaccination is taking place so parents can plan, prepare and watch for side effects.

There are some recommendations for the Year 8 leaflet as follows: restructuring the ‘HPV and how it spreads’ information to make it more punchy and engaging; using ‘smear test’ rather than ‘cervical screening’; rewording ‘having the vaccination’ as ‘you need to have’ implies it is too late if you have already had sex which is a negative for older siblings and urban myth generation.  ‘recommended... Protect you as early as possible’ can imply this is the age they may be starting to have sex, for example ‘to ensure you are protected later in life when you are sexually active’ – implies a longer time frame.  Clarifying transmission feels important as parents assume it is transmitted via intercourse not sexual contact and providing a sense of the whole programme so it is clear that older girls are being offered it too feels important. Some parents ask for additional safety reassurances such as where else in the world is the vaccine available and for how long has it been available as they are looking for additional evidence to reassure them of the robustness of testing.  The length of protection could also be addressed on the website.

It feels important that all communications should communicate the same message about the eligibility of those who have had sex already, but that materials do not imply that offering the vaccine routinely to Year 8 is suggesting that this is the age they become sexually active.