Factors affecting exposure to health promotion about HPV vaccine in England and variations in uptake of HPV vaccine in secondary schools in the West Midlands

Background: In 2008, the health departments of the United Kingdom implemented a routine and catch-up HPV immunization programme in schools to reduce the incidence of cervical cancer. European studies conducted from 2007 to 2012 showed inconsistent results on HPV vaccine uptake in relation to ethnicity and girls’ age. Aim: To examine the relationship between area deprivation and the take-up of informative materials related to HPV vaccination in secondary schools in England. Another aim was to investigate the association between uptake of HPV vaccine and area deprivation, ethnicity and religion and to explore the views and experiences of girls, teachers and health providers on the HPV vaccine to understand how mechanisms of programme delivery, strategies and practices contributed to HPV vaccine uptake in a city in the West Midlands. Methods: Secondary data about uptake of professionally developed teaching materials by 4,750 schools in England was employed to explain the relationship between the takeup of the materials and the level of social deprivation of the area within which the school was located using logistic regression. Other secondary data about uptake of the third dose of HPV vaccine by year 8 girls in a city in the West Midlands was used to explain the variability of uptake across 20 schools between 2008 and 2012. Analytic statistics included simple and multivariate linear regressions. Qualitative data was collected through 47 semi-structured individual interviews with nine nurses, four school staff and 34 year 8 girls as well as through non-participant observations in 12 secondary schools between February and September 2013. Thematic analysis identified major themes related to the school context of implementation of the HPV vaccine programme as well as facilitators and barriers to uptake of HPV vaccine in the city of the study. Results: Of all secondary schools in England invited to receive the HPV educational materials, 1,395 schools (30.17%) responded. These schools were in the largest quintile of school size as well as maintained schools. After controlling for other covariates, it was found that schools in the least deprived quintile had 1.31 the odds of requesting materials compared with the schools in the most deprived areas (95% CI=1.05-2.53). Deprivation of school address postcode remained statistically significantly associated with uptake of HPV vaccine after controlling for ethnicity, school type and academic year. Similarly, the academic year 2009/10 remained statistically significantly associated with uptake of HPV vaccine adjusting for geographic and school factors. Deprivation of school catchment area was no longer statistically significantly associated with uptake of HPV vaccine when the other variables were held constant and the same was true for the association between ethnicity and uptake. Thematic analysis showed that school based HPV vaccination programme was accepted by most of the schools in the city of study and was delivered by a mobile clinic aiming to vaccinate all eligible girls. Chasing up the consent forms and communication with the parents were the most challenging activities in the HPV vaccination administration. However, they were essential for a high HPV vaccine uptake. The manner in which the school staff and nurses sought parents’ and girls’ consent before and on the day of vaccination was often very persuasive and not entirely ethically justified. The HPV vaccine was poorly promoted in the school environment because of tight curriculum for compulsory subjects and the lack of adequate staff. A number of other influences affected girls’ choices about receiving the vaccine. The family played the most important role for daughters’ emotional support as also did the provision of information to help girls understand and make their own decision about the vaccine. The interactions with friends and nurses were beneficial for girls’ confidence and feelings on the day of vaccination. Girls’ fear of injection caused by their poor knowledge, rumors spread by peers and parental negative attitudes about HPV vaccine were major obstacles to uptake before and on the day of vaccination. The main parental reasons for vaccine refusal were lack of understanding of the information about HPV vaccine, which they received from the school, their inadequate information, obtained from sources other than health professionals, their misconceptions about the safety of the vaccine and their religious beliefs related to their daughters’ sexual activity in the future. Conclusion: The impact of the HPV vaccination education campaign suggests differential level of exposure due to unevenly distributed requests for the materials across England. At local level, the HPV programme was not equally well implemented across the schools in the city. This was mainly due to school factors, including the location as well as the organization of delivery. The findings highlight the need for further investigation of factors associated with uptake of HPV vaccine to guide health policy and public health interventions for effective implementation of the HPV vaccination programme in all schools.