Adolescents’ beliefs about their parents’ human papillomavirus vaccination decisions
Dr J Waller, Cancer Research UK Health Behaviour Research Centre, Department of Epidemiology and Public Health, University College London, Gower Street, London, WC1E 6BT, UK. Email email@example.com
Please cite this paper as: Forster A, Marlow L, Waller J. Adolescents’ beliefs about their parents’ human papillomavirus vaccination decisions. BJOG 2010;117:229–233.
A significant minority of parents are concerned that human papillomavirus vaccination will affect sexual behaviour. We explored this issue with 162 adolescent girls. Most (between 90 and 92%) did not perceive a connection between parental consent to vaccination and parental authorisation for sexual activity, but a small percentage believed that vaccination consent implied that they were old enough to have sex (8%), or that it was okay for them to be sexually active (10%). The findings are broadly reassuring, but highlight the need for vaccination information materials to clarify why the vaccine is administered before sexual debut.
Oncogenic strains of human papillomavirus (HPV) cause 99% of cervical cancers1 and are usually sexually transmitted. Prophylactic vaccines have been developed to protect against the two most common oncogenic HPV types (16 and 18) which cause around 70% of cervical cancers.2 The vaccines are believed to be close to 100% effective at preventing infection with these HPV types if given to individuals who are naive to infection (this is normally equivalent to not having had sexual contact).2 In the UK, 12–13-year-old girls are now offered a course of the three-dose HPV vaccine as part of the childhood immunisation programme, and adolescents up to the age of 18 years will be offered vaccination as part of a one-off ‘catch-up’ programme.
There is evidence that a significant proportion of parents are concerned about the safety and efficacy of the vaccine, and these concerns seem to be associated with weaker intentions to vaccinate.3 An additional concern among parents is that the vaccine may encourage risky sexual behaviour. It has been suggested that adolescents will believe that, by allowing them to have the vaccine, their parents are implicitly giving them ‘carte blanche’ approval for sexual activity, and this might encourage an earlier sexual debut.4 A mother in a qualitative study conducted by Bair et al.4 summarised this succinctly: ‘We are giving them permission to have sex’. Although implicit approval does not necessarily mean that adolescents will engage in risky sexual behaviour, mothers have reported reservations about the HPV vaccine for this reason.3
There is a growing body of literature on parental attitudes to the HPV vaccine, although, as the immunisation programme has only recently been introduced, most studies have assessed beliefs hypothetically. There are fewer studies assessing adolescent attitudes and none that have asked girls about the meaning they take from their parents’ agreement to or denial of the vaccine. Research has not examined the validity of parents’ concerns about vaccination or, more subtly, parental approval for vaccination providing ‘carte blanche’ approval for sexual activity. The present study explored whether adolescents intend to have the HPV vaccination, their beliefs about whether their parents would consent to vaccination, and their interpretation of the meaning of their parents’ decision.
Female adolescents in UK school year 10 (age 14–15 years) were recruited from a high-achieving, state-funded, single-sex secondary school in London. This age group was chosen as these children will be involved in the HPV vaccination ‘catch-up’ programme, and the school was chosen opportunistically. During a school lesson, the adolescents read a leaflet that provided information about HPV, cervical cancer, the HPV vaccine and cervical screening. The leaflet was developed following a series of interviews and focus groups. Participants were given as much time as they needed to read the leaflet and then completed a questionnaire anonymously. There was no incentive to complete the questionnaire.
The questionnaire assessed demographic characteristics (age, ethnicity, religion and whether they were practising that religion), vaccination intentions and perceptions of parents’ beliefs about sexual behaviour and vaccination. Parental beliefs about HPV vaccination have been elicited in previous research.3,5 The items were generated using this previous work and were piloted with a small opportunistic sample to minimise ambiguity.
Vaccination intentions were assessed by asking participants to indicate their own intention to receive the HPV vaccine using a four-point scale (ranging from ‘very unlikely’ to ‘very likely’). Participants were also asked: ‘do you think that your parents would let you have the HPV vaccine’ (‘no’, ‘not sure’, ‘yes’).
We examined adolescents’ perceptions of their parents’ beliefs by asking them to respond to five statements assessing what they thought it would mean if their parents allowed them to have the HPV vaccine (responding on a five-point scale from ‘strongly disagree’ to ‘strongly agree’). Beliefs about sexual behaviour were examined in two statements (e.g. ‘If my parents let me have the HPV vaccine, it would mean that they think that I am old enough to have sex’), and three statements examined beliefs about vaccination/cancer (e.g. ‘If my parents let me have the HPV vaccine, I would know that they agreed with vaccinations in general’). The study was approved by the University College London research ethics committee, the school provided proxy consent for parents and all participants provided informed consent.
There were 173 adolescents who completed the survey from one school year, and no-one refused to complete the survey. Eleven cases were excluded because of large amounts of missing data (>50%), leaving responses from 162 adolescents in the analysis. Data were analysed in SPSS version 15.0. Preliminary analysis demonstrated that the data were not normally distributed, and this was resolved using logarithmic transformations. Hypothesis testing is dependent on data being normally distributed and logarithms provide a method for normalising skewed data. We have presented the nontransformed data for descriptive analysis to make the interpretation simpler, but inferential analysis used the transformed scores. Too few participants identified themselves as belonging to certain ethnic and religious groups to make statistical comparisons, and so these groups were aggregated and labelled as ‘other’. Analyses of variance (ANOVAs) were performed to establish differences between groups for intention to receive the vaccine. Pearson’s correlations and ANOVAs were used to explore whether the statements assessing the perceptions of meaning behind parents’ HPV vaccination consent could be predicted by the variables under investigation. As there were a large number of items assessing perceptions of meaning behind parents’ HPV vaccination consent, a significance level of P < 0.01 was used for the analysis of these items to reduce the risk of a type 1 error.
The mean age of the respondents was 14.6 years (range 14–15 years). The majority described themselves as white (73%), with 11% Asian, 11%‘other’ and 6% who did not respond to the ethnicity question. Christian religious denomination was the most common (55%), with 22% having no religion, 9% Muslim, 5%‘other’ and 18% did not respond. Of those who reported having a religion, 24% said they were practising it (64% were not and 9% did not respond).
Most girls said that they were ‘very likely’ or ‘likely’ to have the HPV vaccination if they were offered it (91%), and 72% believed that their parents would let them have it (4% did not think their parents would let them have the vaccine, 15% were not sure and 10% did not respond). Intention to receive the vaccine was not related to age [F(1,160) = 2.59, P = 0.11], ethnicity [F(2,150) = 0.34, P = 0.71], religion [F(3,134) = 1.84, P = 0.14], whether they were practising a religion [F(1,86) = 3.63, P = 0.06] or whether they believed that their parents would let them have the vaccine [F(2,143) = 0.32, P = 0.73].
Some adolescents ‘strongly agreed’ or ‘slightly agreed’ that parental consent to vaccination implied that they were old enough to have sex (8%; Table 1) or that it was okay for them to be sexually active (10%). However, most adolescents would take positive health messages from parental consent to HPV vaccination, seeing it as indicating general approval of vaccinations (54%‘strongly agreed’ or ‘slightly agreed’) and a desire to protect their daughter against cervical cancer (88%‘strongly agreed’ or ‘slightly agreed’) and sexually transmitted infections (80%‘strongly agreed’ or ‘slightly agreed’).
Table 1. Number and percentage of adolescents agreeing with each attitude statement and by intention (total sample n = 162)
|If my parents let me have the HPV vaccine, it would mean that they think that I am old enough to have sex|
|Strongly disagree||32 (19.8)||0 (0)||0 (0)||14 (18.9)||18 (24.7)||r = −0.14, P = 0.07|
|Slightly disagree||71 (43.8)||5 (71.4)||5 (62.5)||28 (37.8)||33 (45.2)|
|Unsure||47 (29.0)||1 (14.3)||2 (25.0)||26 (35.1)||18 (24.7)|
|Slightly agree||9 (5.6)||0 (0)||1 (12.5)||6 (8.1)||2 (2.7)|
|Strongly agree||3 (1.9)||1 (14.3)||0 (0)||0 (0)||2 (2.7)|
|If my parents let me have the HPV vaccine, I would know that they think it is ok for me to be sexually active|
|Strongly disagree||23 (14.2)||1 (14.3)||0 (0)||11 (14.9)||11 (15.1)||r = −0.11, P = 0.15|
|Slightly disagree||78 (48.1)||3 (42.9)||3 (37.5)||34 (45.9)||38 (52.1)|
|Unsure||45 (27.8)||1 (14.3)||2 (25.0)||24 (32.4)||18 (24.7)|
|Slightly agree||12 (7.4)||1 (14.3)||3 (37.5)||4 (5.4)||4 (5.5)|
|Strongly agree||4 (2.5)||1 (14.3)||0 (0)||1 (1.4)||2 (2.7)|
|If my parents let me have the HPV vaccine, it would mean that they wanted to protect me against sexually transmitted infections|
|Strongly disagree||2 (1.2)||0 (0)||0 (0)||0 (0)||2 (2.7)||r = 0.13, P = 0.11|
|Slightly disagree||4 (2.5)||0 (0)||0 (0)||2 (2.7)||2 (2.7)|
|Unsure||26 (16.0)||4 (57.1)||1 (12.5)||13 (17.6)||8 (11.0)|
|Slightly agree||87 (53.7)||3 (42.9)||6 (75.0)||47 (63.5)||31 (42.5)|
|Strongly agree||43 (26.5)||0 (0)||1 (12.5)||12 (16.2)||30 (41.1)|
|If my parents let me have the HPV vaccine, it would mean that they wanted to protect me from cervical cancer|
|Strongly disagree||2 (1.2)||0 (0)||1 (12.5)||0 (0)||1 (1.4)||r = 0.16, P = 0.05|
|Slightly disagree||3 (1.9)||0 (0)||0 (0)||1 (1.4)||2 (2.7)|
|Unsure||14 (8.6)||1 (14.3)||0 (0)||9 (12.2)||4 (5.5)|
|Slightly agree||92 (56.8)||6 (85.7)||6 (75.0)||50 (67.6)||30 (41.1)|
|Strongly agree||51 (31.5)||0 (0)||1 (12.5)||14 (18.9)||36 (49.3)|
|If my parents let me have the HPV vaccine, I would know that they agreed with vaccinations in general|
|Strongly disagree||3 (1.9)||0 (0)||0 (0)||0 (0)||3 (4.1)||r = 0.13, P = 0.09|
|Slightly disagree||17 (10.5)||2 (28.6)||1 (12.5)||5 (6.8)||9 (12.3)|
|Unsure||54 (33.3)||3 (42.9)||4 (50.0)||35 (47.3)||12 (16.4)|
|Slightly agree||70 (43.2)||2 (28.6)||3 (37.5)||32 (43.2)||33 (45.2)|
|Strongly agree||18 (11.1)||0 (0)||0 (0)||2 (2.7)||16 (21.9)|
None of the items assessing perceptions of the meanings behind parents’ HPV vaccination consent were related to whether adolescents believed their parents would consent to vaccination, nor could they be predicted by the adolescents’ own intention to receive the vaccine, age, ethnicity, religion or whether they were practising a religion.
In this questionnaire study, we explored whether female adolescents intended to receive the HPV vaccine and whether they thought their parents would consent to them having the vaccine. We also assessed what adolescents believed their parents’ HPV vaccination decisions would mean with regard to their expectations about sexual behaviour.
We found that beliefs about vaccination decisions were mostly positive, with adolescents expressing strong intentions to receive the vaccine. Most believed their parents would let them have the vaccine, and this finding is somewhat comparable with the levels of vaccine acceptance from other UK studies of parents’ intentions (72% compared with 81%),3 but lower than initial reports of actual vaccination uptake (86%).6 The adolescents reported that they would infer fairly positive messages about vaccination and cancer prevention if their parents consented to vaccination. Almost all the adolescents agreed that being allowed the HPV vaccine meant that their parents wanted to protect them against cervical cancer and sexually transmitted infections. Most adolescents did not believe that vaccination consent implied approval for them to be sexually active. Parents concerned about negative changes in sexual behaviour following vaccination may be reassured by this.
However, some adolescents stated that they would perceive implicit approval for sexual activity if they were allowed the vaccine. These beliefs provide some confirmation of concerns previously expressed by parents,4 indicating some support for the ‘carte blanche’ concern about a change in adolescent sexual behaviour following HPV vaccination, and highlight the importance of parent–daughter communication about sex. These findings are concerning and have implications for the sexual behaviour of adolescent girls; however, caution is needed, as this was a small study, the effect sizes were small and the predefined items might have primed the girls to agree with issues that they may not have considered previously. In addition, even if adolescents believe that sexual activity has been condoned, this does not mean that they will necessarily become sexually active. Studies of adolescents’ responses to these items in alternative settings, and assessments of their freely recalled beliefs about the HPV vaccine, would be valuable.
Adolescents may benefit from talking to their parents about the HPV vaccine. Although the vaccination is being presented in the UK as a vaccination against cervical cancer, the sexually transmitted nature of the virus is referenced in information leaflets designed for adolescents. Providing parents with guidance on how to have conversations about sex with their daughters, so that they feel confident that vaccination will not influence their sexual behaviour, and helping parents explain why the vaccine is being given might be useful strategies. Furthermore, vaccination programme coordinators should ensure that information materials and campaigns highlight the reason why the vaccine is being given before the onset of sexual activity, explain that adolescents do not have to wait until they are ready to have sex before having the vaccine (as is the case with the current leaflet used by the NHS in England, Wales and Northern Ireland) and emphasise that the vaccine is protective against HPV only and not against other sexually transmitted infections.
Participants in the present study were slightly older than the cohort who will receive the vaccine as part of the standard immunisation programme; however, this age group will be included in the one-off ‘catch-up’ series. Girls who are already sexually active may be more liable to change their sexual behaviour following vaccination, and this older age group are more likely to have begun engaging in sexual relationships than 12–13 year olds in the main immunisation programme. Furthermore, young women who receive the vaccine as part of the routine immunisation programme will approach sexual debut knowing that they are protected against HPV, and it is important to explore what older adolescents believe about the vaccine and the protection it affords. Thus, this study examines and improves the understanding of the issues relating to sexual behaviour in an appropriate age group.
The participants of the study attended one high-achieving secondary school, the majority were white and the sample size was small. We did not ask about the sexual status of the adolescents, which may have influenced how they responded. This limits how generalisable the results are to other British adolescents. Adolescents’ intentions in the present study were assessed hypothetically; actual uptake in the UK will not be known until the end of 2009 when the first cohort has completed the vaccination course. In addition, adolescents may have inaccurate beliefs about their parents’ vaccination intentions, although the findings of this study are comparable with those of studies assessing actual parental vaccination intentions.3
This study provides an insight into the beliefs of adolescent girls who are due to receive the HPV vaccine as part of the ‘catch-up’ programme. The majority of girls intended to be vaccinated, and would infer positive messages if their parents consented to them having the vaccination. However, a small minority of the adolescents would infer permissive messages about sexual behaviour from being allowed the vaccine. Information materials must highlight the reason why the vaccine is being given before the onset of sexual activity, and that adolescents do not have to wait until they are ready to have sex before having the vaccine.
Disclosure of interests
We have received funding or honoraria from Sanofi Pasteur MSD and GSK Biologicals, both of whom manufacture HPV vaccines.
Contribution to authorship
AF, LM and JW designed the study, AF drafted the paper and all the investigators contributed to its writing and reviewing.
Details of ethics approval
This study received ethical approval from the University College London research ethics committee (1399/001, approved 8 February 2008).
Jo Waller and Laura Marlow are supported by Cancer Research UK. Alice Forster is supported by a studentship from the University College London medical school.
We would like to thank Professor Jane Wardle for her comments on drafts of this article.