|"HPV? Never heard of it!" A systematic review of girls' and parents' information needs, views and preferences about human papillomavirus vaccination
|Hendry M, Lewis R, Clements A, Damery S, Wilkinson C
This well-reported review found that many girls and their parents had limited understanding about HPV vaccination, which affected their ability to make informed choices, and could affect future uptake of cervical screening. The authors' conclusions appear to be reliable.
To understand the factors influencing human papillomavirus (HPV) vaccine uptake, to inform the development of HPV educational materials, for the UK.
The authors searched 12 electronic databases, including MEDLINE, EMBASE, CINAHL, and PsycINFO, for articles from 1980 to August 2011. Search terms were presented. Reference lists of included studies were handsearched.
Studies of any design that elicited participants' views on HPV vaccination were eligible. Participants could be parents of children aged nine to 15 years, young women up to age 26 years, or health care professionals. The intervention was HPV vaccination, in the context of a clinical trial or in clinical practice. Relevant outcomes were participants' views, understanding, attitude, perceptions, acceptability, concerns and information needs, relating to the HPV vaccine. Studies of participants' knowledge or behaviour in relation to vaccination were excluded, as were studies of the influence of participant characteristics on the uptake of vaccination.
The included studies were qualitative or quantitative, published between 2004 and 2011. The qualitative studies collected data by face-to-face interviews, telephone or focus groups, and used a variety of methods of analysis. Quantitative studies were conducted by post, telephone, online, face-to-face, or completed by the participant in a clinic, in a class, or at home. Participants varied including those who had accepted the vaccine, those who had declined the vaccine, and those who had not yet been offered the vaccine. Most studies were of an anticipated, rather than an actual, HPV vaccination decision. Most were in the context of an expected national programme of vaccination. Many studies reported findings before the implementation of HPV vaccination and associated public information. Most of the qualitative studies were conducted in the USA, UK, or Australia; most of the quantitative surveys were conducted in North America.
Two reviewers independently screened studies for inclusion, with discrepancies resolved by discussion or with a third reviewer.
Assessment of study quality
The qualitative studies were assessed, using the National Institute for Health and Care Excellence (NICE) checklist, for the theoretical approach, study design, data collection, validity, methods of analysis, and ethics.
The quantitative surveys were assessed, using a checklist, for the response rate, clarity of aims and method, selection of the sample, measurement issues, survey methods, data and statistical issues, and bias. Studies were given a rating of good, moderate, or poor.
Two reviewers were assessed study quality. Discrepancies were resolved by discussion or with a third reviewer.
The authors' findings, from the qualitative studies, were extracted verbatim, as primary data, into a predefined form, excluding any direct quotations.
Two reviewers extracted the data, with disagreements resolved by consensus.
Methods of synthesis
The study data were synthesised using the framework approach. Detailed summary tables were presented. Themes were identified from the qualitative studies, and then categorised and refined until agreement between reviewers was reached on the thematic framework.
The data from quantitative surveys were reported in a summary table, and any evidence that supported, contrasted with, or added new themes was integrated into a mixed-methods synthesis. The themes and their associated sub-themes were presented with supporting quotations.
Results of the review
Seventy-two studies were included; 28 were qualitative and 44 were quantitative. All but one of the qualitative studies were considered to be of good-to-moderate quality. A third of the quantitative surveys were good, but the others varied from moderate to poor.
Three main themes, with various sub-themes, were identified. The first theme was trying to decide on HPV vaccination - unanswered questions and concerns. The second was the benefits, harms and misconceptions of vaccination. The third was the perceived need for vaccination was affected by participants' interpretation or misinterpretation of their own or their children's risk of HPV infection.
The overall acceptability of the vaccine was high, but 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, within the context of existing knowledge about sexually transmitted infections and cancer. The intention to decline the vaccine related to the avoidance of appearing to condone early or promiscuous sexual activity, concerns about vaccine safety, and the perception of a low risk of HPV infection.
Many girls and their parents had a limited understanding of HPV vaccination, which affected their ability to make informed choices and could affect future uptake of cervical screening.
This review had defined inclusion criteria, and was underpinned by a thorough search for studies. Study quality was assessed appropriately, but it was unclear how the quality results were taken into account within the synthesis. More than one reviewer was involved in the processes of study selection, data extraction, and quality assessment, which should minimise bias and error. The use of framework analysis to identify the themes and integrate the quantitative survey results, with the qualitative data, appears to have been appropriate.
The authors' conclusions appear to be reliable, but most studies were of anticipated HPV decisions.
Implications of the review for practice and research
Practice: The authors stated that there was an urgent need for wider education on HPV. Information should be easy to understand for parents and girls, and delivered in schools and primary care settings. It could be tailored to the needs of various ethnic minority groups, and it should emphasise that girls receiving the vaccine still need to take part in cervical screening; their screening behaviour should be monitored. Widespread media campaigns were needed to raise the understanding of HPV infection and vaccination in the UK.
Research: The authors stated that qualitative research was needed to explore the knowledge, views and information needs of parents and boys. Research into the most appropriate method of conveying information about HPV vaccination was needed.
Funded by Cancer Research UK.
Hendry M, Lewis R, Clements A, Damery S, Wilkinson C. "HPV? Never heard of it!" A systematic review of girls' and parents' information needs, views and preferences about human papillomavirus vaccination. Vaccine 2013; 31(45): 5152-5167
Subject indexing assigned by NLM
Child; Female; Health Knowledge, Attitudes, Practice; Humans; Papillomavirus Infections /complications /prevention & Papillomavirus Vaccines /administration & Parents; Patient Acceptance of Health Care; Uterine Cervical Neoplasms /prevention & Vaccination /methods /utilization; control; control; dosage /immunology
Date bibliographic record published
Date abstract record published
This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.