Vaccine 33 (2015) 826–831
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Asking about human papillomavirus vaccination and the usefulness of registry validation: A study of young women recruited using Facebook Bharathy Gunasekaran a,b , Yasmin Jayasinghe b,c,d , Julia M.L. Brotherton e,f , Yeshe Fenner b,g,1 , Elya E. Moore g,1 , John D. Wark h,i , Ashley Fletcher b,g,1 , Sepehr N. Tabrizi b,c,g , Suzanne M. Garland b,c,g,j,∗ a
Melbourne Medical School, University of Melbourne, Parkville, Victoria 3052, Australia Department of Microbiology and Infectious Diseases, The Royal Women’s Hospital, Parkville, Victoria 3052, Australia c Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria 3052, Australia d Department of Gynaecology, Royal Children’s Hospital, Parkville, Victoria 3052, Australia e National HPV Vaccination Program Register, VCS Inc., East Melbourne, Victoria 8002, Australia f School of Population and Global Health, University of Melbourne, Parkville, Victoria 3010, Australia g Infection and Immunity Theme, Murdoch Childrens Research Institute, Parkville, Victoria 3052, Australia h Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, Victoria 3050, Australia i Bone and Mineral Medicine, Royal Melbourne Hospital, Parkville, Victoria 3052, Australia j Microbiology, Royal Children’s Hospital, Parkville, Victoria 3050, Australia b
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Article history: Received 25 April 2014 Received in revised form 31 October 2014 Accepted 2 November 2014 Available online 12 November 2014 Keywords: Human papillomavirus Vaccine Knowledge Uptake Young women Australia
a b s t r a c t Background: Australia was the first country to implement a government-funded National Human Papillomavirus (HPV) Vaccination Programme. We assessed HPV vaccine uptake comparing self-reported and Register validated estimates, and the knowledge and attitudes of young women with regards to HPV vaccination post-implementation of the programme. Methods: Females, aged 16–25 years living in Victoria, Australia, were recruited using targeted advertising on Facebook from May to September 2010, to complete a web-based questionnaire. Results: Geographic distribution, Indigenous and socio-economic status of the 278 participants were representative of the target population. Overall, 210/278 (76%) had heard of HPV vaccines, with 162/278 (58%) reporting receipt of at least one dose of vaccine, and 54 (19%) unsure. Verification of HPV vaccination status of 142 consenting participants (51%) showed 71% had received at least one dose. Main reasons for vaccination were for protection against HPV infection and cervical cancer (96%) and because it was free (87%), whereas unvaccinated women were uncertain of their eligibility (50%), concerned about adverse reactions (32%), or perceived that vaccination was not needed if they were monogamous (32%). Conclusion: The potential utility of a vaccination register in the context of a national programme is apparent from the large proportion of young women who were unsure of their vaccine status. HPV vaccine knowledge among participants was relatively high suggesting the national programme has successfully communicated to the majority of eligible women, the purpose and limitations of the vaccine. Vigilance is needed to ensure that young women follow through with Pap testing in vaccine eligible cohorts. The ongoing vaccination programme for pre-adolescent girls and boys should communicate to parents that those with one sexual partner can still acquire HPV and that the safety of the vaccine is now well demonstrated. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction ∗ Corresponding author at: Department of Microbiology and Infectious Diseases, The Royal Women’s Hospital, Locked Bag 300, Parkville, Victoria 3052, Australia. Tel.: +61 38345 3671; fax: +61 39347 8235. E-mail address: [email protected] (S.M. Garland). 1 Former affiliations of researchers. http://dx.doi.org/10.1016/j.vaccine.2014.11.002 0264-410X/© 2014 Elsevier Ltd. All rights reserved.
In April 2007, Australia became the first country to implement a government funded National Human Papillomavirus (HPV) Vaccination Programme [1]. From April 2007 to December 2009, there was a catch-up programme for 13–18 year old girls in schools, whilst from July 2007 to December 2009, there was a catch-up
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programme available to 13–26 year old women through general practice and community-based programmes [2]. Presently, there is an ongoing school-based vaccination programme providing the HPV vaccine free to all boys and girls aged 12 to 13 years, with a two year catch-up programme for 14–15 year old boys until the end of 2014 [3]. Australia has a National HPV Vaccination Programme Register (NHVPR) to monitor the uptake and effectiveness of the national HPV vaccination programme [4]. The HPV vaccination programme has had notable success. Notified vaccination coverage for girls aged 12–17 years nationally was 83% for dose one, 78% for dose two and 70% for dose three. Of these notified doses, 14% were delivered by general practitioners, ranging from 8% in 12 year olds to 28% in 17 year olds [4]. Victoria recorded the highest three-dose coverage for the 12–17 year old cohort at 75% [4]. However, this is a minimum coverage estimate for the population as notification of HPV vaccination to the NHVPR is only obligatory in the school-based programme, with an estimated 10–20% underreporting for doses delivered outside schools [5,6]. Previous studies conducted in Australia and worldwide show that knowledge about HPV was low amongst the general population prior to vaccination programmes, with evidence of a gradual increase over time in many populations after vaccine availability [7–13]. It is therefore of significant interest to assess recall of HPV vaccination status and HPV vaccine knowledge amongst young women of vaccine eligible age in Victoria, Australia, just a few years post-implementation of the national HPV vaccination programme. As Australia is unique in establishing a programme specific national vaccine register for HPV, it is of importance to establish how well the register has recorded vaccinations in the catch-up programme, where notifications by general practitioners were not compulsory. The objectives of this study were to assess HPV vaccine uptake by self-report and register validation as well as HPV vaccine knowledge and attitudes among young women in Victoria, Australia recruited using Facebook, a social networking site highly accessed by the target group.
2. Methods 2.1. Sample Participants were recruited as a volunteer sample via targeted advertising on Facebook from the 19th of May to the 30th of September 2010. This was a pilot study for a planned longitudinal study on women’s health, The Young Female Health Initiative (YFHI) study. Detailed methods have been previously reported [14]. Briefly, participants were eligible if they identified themselves as female, were 16–25 years of age, and lived in Victoria, Australia. Participants were offered AU$25 compensation for their time if they visited the study site and travel costs (up to AU$70) if they travelled from regional areas, whilst those who completed the survey remotely were offered AU$15 compensation for their time (AU$1 = USD $0.93).
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of their vaccination status against the NHVPR. The questionnaire took approximately 15–25 min to complete. 2.3. Analysis Statistical analyses were performed using STATA software, version 11.1. When analysing participants’ demographic information, the Australian Bureau of Statistics (ABS) Census 2006 was used as a comparison [17]. Univariate analyses were used to measure the differences between the demographics of the study cohort and the general population of the same gender and age group. The primary outcome variables described in this paper are HPV vaccine awareness and HPV vaccination status, as well as knowledge and attitudes towards HPV vaccination. The results for knowledge of HPV, cervical cancer and chlamydia have been previously reported [18,19]. HPV vaccine awareness was defined by a “yes” response using the question “Have you ever heard of the vaccine for human papillomavirus?”. To estimate the proportion of participants who had received the HPV vaccine, participants were asked whether they had been vaccinated and the number of doses they had received. Where consent was obtained, identifying information was used to identify whether vaccine doses were held on the NHVPR in order to verify self-reported doses. Where no record was found on the NHVPR, but the woman reported vaccination and health provider details, NHVPR staff attempted to contact the provider and verify vaccination receipt. Questions regarding HPV vaccine knowledge were directed to those participants who had heard of HPV vaccines, and measured using five true/false/don’t know questions about HPV vaccines. One point was given for each correct answer and a knowledge scale of 0–5 was constructed (participants who had not heard of HPV vaccines were allocated a score of zero). The HPV vaccine knowledge scale was collapsed into three subgroups; low (0–1), moderate (2–3) and high knowledge (4–5). Attitudes towards HPV vaccination were assessed by examining the reasons given for vaccination and non-vaccination. All questions were asked in a set order, some of which were structured by dropdown boxes. Logistic regression models were used to estimate independent predictors of self-reported HPV vaccination status and HPV vaccine knowledge. Adjusted odds ratios were calculated adjusting for age and socioeconomic status. Socioeconomic status was assigned using the ABS’s Socio-Economic Indexes for Areas (SEIFA) and the 2006 Postal Area Index of Relative Socio-economic Advantage and Disadvantage, which is a continuum of advantage to disadvantage scores, with a lower score corresponding to a more disadvantaged area [20]. Statistical significance for all tests was set at P ≤ 0.05. Ethics approval was obtained through the Human Research and Ethics Committees at the Royal Women’s Hospital, Melbourne and informed consent was obtained from all participants. 3. Results 3.1. Recruitment and participation
2.2. Data collection The questionnaire was developed by a team of multidisciplinary researchers using new questions, as well as questions from previously published Australian studies [15,16] and was pilot-tested with fifteen study-eligible females. The domains covered in this questionnaire included participant demographics; sexual history; knowledge regarding chlamydia, cervical cancer, HPV and HPV vaccines; attitudes towards HPV vaccination and self-reported vaccine status. Participants were also asked to give consent for validation
Participant characteristics have been described elsewhere [14]. Briefly, 551 women responded to the advertisements with an expression of interest, 426 were contactable, and 278 completed the questionnaire. Mean age of participants was 20.8 years. The geographic distribution of residence, country of birth, Indigenous status and socio-economic status of the participants did not differ from ABS distributions. However, women aged 16–17, and those whose highest level of education completed was below Year 12 (final year of high school) were under-represented. The average
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Table 1 Self-reported HPV vaccination of participants and odds ratios (OR) of self-reported HPV vaccination compared to participants who reported non-vaccination or were unsure of their HPV vaccination status using univariate and multivariate analyses. Self-reported HPV vaccination status
No/Don’t know 116/278 (42%) nb (%)
Yes 162/278 (58%) nb (%)
Adjusted ORc (95% CI)
Age (years) 16–17 18–21 22–25
18 (47) 49 (43) 49 (39)
20 (53) 66 (57) 76 (61)
1.0 1.1 (0.51–2.3) 1.3 (0.60–2.7)
SEIFAa 80 (highest SES)
44 (53) 36 (41) 34 (32.1)
39 (47) 51 (59) 72 (67.9)
1.0 1.6 (0.86–2.9) 2.4 (1.3–4.3)
23 (43) 71 (68) 68 (57)
1.0 3.3 (1.4–7.8) 1.6 (0.67–3.6)
Highest level of education completed Year 12 52 (43) Country of birth Overseas Australia
32 (70) 84 (37)
14 (30) 146 (63)
1.0 5.2 (2.5–11)
Use of contraception at first vaginal intercourse 19 (66) 10 (34) No Yes 61 (36) 107 (64)
1.0 3.5 (1.5–8.4)
HPV knowledge Low (0–1) Moderate (2–4) High (5–6)
82 (74) 18 (25) 16 (17)
29 (26) 53 (75) 80 (83)
1.0 8.8 (4.3–18) 15 (7.1–30.1)
HPV, human papillomavirus; OR, odds ratio; SEIFA, Socio-economic Indexes for Areas. a SEIFA is a classification system developed by the Australian Bureau of Statistics that ranks areas in Australia according to relative socio-economic advantage and disadvantage, with a lower score corresponding to a more disadvantaged area [20]. b Numbers may not add up to the total number due to missing data. c Odds ratios adjusted for age and SEIFA.
cost in advertising fees per completing participant was US$20 for this study. 3.2. HPV vaccine awareness and vaccination status Most participants (94%) were aware of the existence of cancer vaccines for women. In an open-ended question asking participants to name the cancer (s) the vaccine(s) protected against, 246 participants (89%) named cervical cancer and/or HPV vaccines. However, when asked specifically whether they had heard of HPV vaccines, only 210 women (76%) said they had. Overall, 162 participants (58%) reported having received the vaccine. Of those who reported HPV vaccination, 146 (90%) selfreported receipt of all three doses, giving a three dose coverage of 52% in the surveyed population overall. Table 1 shows the predictors of self-reported HPV vaccination. Based on multivariate analyses, Australian-born participants and those with high HPV and HPV vaccine knowledge were more likely to report HPV vaccination. This is similar to our findings when we excluded the “Don’t know” responses from the analysis. Verification of the HPV vaccination status of 142 participants (51%) either through NHVPR verification or following provider verification is shown in the figure below (Fig. 1). Of these 142 participants, 111 (78%) had completed the survey at the study site. Verification of self reported vaccination status was compared with self reported place(s) of vaccination. Of the 28 participants who reported HPV vaccination only at a school, verification from the registry showed 25 received all three doses, two participants
Table 2 Responses to each HPV vaccine question among the 210 participants who were aware of HPV vaccines. Incorrect response n(%)
Don’t know n(%)
True/False statements
Correct response n(%)
HPV-vaccinated women do not need Pap smears in the future (False) The vaccine will protect against around 80% of cervical cancers, but not the remaining 20% of cervical cancers (True) HPV-vaccinated women will never have a Pap abnormality after vaccination (False) Pap abnormalities which require monitoring and treatment may still occur after HPV vaccination (True) If a Pap abnormality occurs, then the vaccine has failed to do its job (False)
203 (96.7)
0 (0.0)
7 (3.3)
139 (66.2)
10 (4.8)
61 (29.0)
191 (91.8)
1 (0.5)
16 (7.7)
189 (90.4)
7 (3.3)
13 (6.2)
167 (80.3)
2 (1.0)
39 (18.8)
Note: Numbers may not add up to the total number due to missing data.
received two doses and one participant’s vaccination details were not in the register or in the health provider records. In comparison, of the 50 participants who reported HPV vaccination only at the local doctor’s office, registry verification showed 38 participants received three doses, six participants had two doses and five participants did not have their vaccination details in the register or health provider records. 3.3. HPV vaccine knowledge HPV vaccine knowledge was only assessed among the 210 participants who had heard specifically of HPV vaccines (Table 2). Self-reported HPV vaccination was a significant predictor of correctly answering each of the HPV vaccine questions in univariate analyses and remained a significant predictor in multivariate analyses. The mean score on the HPV vaccine knowledge scale, including the participants who stated that they were not aware of HPV vaccines, was 3.2 of 5 (95% CI: 3.0–3.4). Overall, 40% correctly answered all HPV vaccine questions. Table 3 shows the predictors of high HPV vaccine knowledge. In multivariate analyses, Australian birth and awareness of Chlamydia were the only significant predictors of high HPV vaccine knowledge. 3.4. Attitudes towards HPV vaccination Participants were presented with possible reasons for getting or not getting the HPV vaccine and were asked to select all that applied. The most common reasons for HPV vaccination were for protection against HPV infection and cervical cancer (96%), because it was free (87%), and ‘to join the fight against cervical cancer’ (73%). The most common reasons for not receiving the vaccine were because of uncertainty of eligibility (50%), concerns about a bad reaction to the vaccine (32%) and a perception that the
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Fig. 1. Comparison between self reported and verified HPV vaccination status and number of doses in the National HPV Vaccination Programme Register (NHVPR).
vaccine was not needed as they were in a monogamous relationship (32%). 3.5. Sources of HPV vaccine information The most common source of HPV vaccine information was school (52%), followed by television (50%), GP or personal physician (48%), and friends or family (43%). Information sources were grouped into four broad categories: (1) media, (2) school, (3) healthcare providers (HCPs), and (4) friends and family. There were no statistically significant differences in HPV vaccine knowledge among participants who had heard of HPV vaccines through these different sources (data not shown). 4. Discussion The National HPV Vaccination Programme for young women has been implemented with notable success in Australia [4]. Underpinning success in HPV-related disease reduction is high coverage of the target population. Consistent with other Australian studies, self-reported HPV vaccination status was associated with country of birth [5,21], with Australian-born participants more likely to report HPV vaccination compared to overseas-born participants. A possible reason is that the funded catch-up vaccination programme was intended for Australian residents, with cost representing a major barrier as HPV vaccines are not covered under overseas students’ health insurance. For those who are not eligible for the free vaccination, the cost is AU$150 per dose (AU$450 for all three doses) and this does not include the cost of the visit to the local doctor who must prescribe the vaccine (AU$1 = USD $0.93) [22]. Indeed, cost and uncertainty about eligibility were reported as barriers or possible barriers by 70% and 64% of overseas-born participants who reported non-vaccination, respectively.
In this study, 58% reported receipt of the HPV vaccine, but 19% were unsure of their vaccination status. The large percentage of uncertainty in this study could be due to the wording of the question which asked participants whether they had the ‘HPV vaccine’ instead of the ‘cervical cancer vaccine’. As described earlier, 94% were aware of cancer vaccines and most of these respondents knew it was for cervical cancer. However, only 76% knew of HPV vaccines. This could be due to the strategy adopted during the launch of the vaccination programme to describe the vaccines as cervical cancer vaccines in media and public health messages. These results highlight that health providers and researchers must be aware of the language that young women are familiar with, in order to determine vaccination status more accurately and to potentially avoid unnecessary multiple dosing. This highlights the important role that the NHPVR will continue to play. The language around HPV vaccination in this study could have been better clarified with the use of terms such as the cervical cancer vaccine or Gardasil vaccine which are better known. This could have resulted in a lower proportion of women who were vaccinated not actually being sure of their vaccination status, possibly related to the nature of the questions asked. However, specificity was quite high. Of the 88 participants who self-reported being vaccinated, 80 (91%) had at least one dose held in the register. Of the 26 participants who stated that they had not received the vaccine, only three had their doses recorded in the register. There are pros and cons to referring to the vaccine as the cervical cancer vaccine. On one hand, at that time, the term HPV was unfamiliar to most of the population and the idea of cancer prevention through vaccination was new. Using cancer prevention terminology may increase vaccine acceptance. It is also advantageous for parents who may not yet be comfortable discussing issues of sexuality and an STI with pre-adolescents. However, promotion of HPV vaccines as cervical cancer vaccines may create the impression that HPV is only linked to cervical cancer and not to other
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Table 3 HPV vaccine knowledge of participants and odds ratios (OR) of high HPV vaccine knowledge compared to low/moderate HPV vaccine knowledge using univariate and multivariate analyses. HPV vaccine knowledgea
Low/Moderate (0–3) 103/278 (37%) nc (%)
High (4–5) 175/278 (63%) nc (%)
Adjusted ORd (95% CI)
Age (years) 16–17 18–21 22–25
20 (53) 45 (39) 38 (30)
18 (47) 70 (61) 87 (70)
1.0 1.3 (0.53–3.1) 2.1 (0.84–5.3)
SEIFAb 80 (highest SES)
38 (46) 28 (32) 35 (33)
45 (54) 59 (68) 71 (67)
1.0 1.7 (0.90–3.2) 1.5 (0.83–2.8)
27 (50) 69 (66) 79 (66)
1.00 1.6 (0.72–3.7) 1.2 (0.54–2.9)
Highest level of education completed Year 12 41 (34) Country of birth Overseas Australia
22 (48) 80 (35)
24 (52) 150 (65)
1.0 2.2 (1.1–4.4)
Chlamydia awareness No Yes
32 (52) 68 (32)
29 (48) 145 (68)
1.0 2.3 (1.3–4.3)
HPV vaccination status No Yes Don’t know
37 (60) 20 (12) 46 (85)
25 (40) 142 (88) 8 (15)
1.0 12 (5.7–26) 0.3 (0.11–0.74)
HPV, human papillomavirus; OR, odds ratio; SEIFA, Socio-economic Indexes for Areas. a HPV vaccine knowledge scale was derived from responses to five true/false/don’t know questions about HPV vaccines for a total possible score of five and subsequently collapsed into three categories: low (0–1), moderate (2–3) and high (4–5) knowledge. b SEIFA is a classification system developed by the Australian Bureau of Statistics that ranks areas in Australia according to relative socio-economic advantage and disadvantage, with a lower score corresponding to a more disadvantaged area [20]. c Numbers may not add up to the total number due to missing data. d Odds ratios adjusted for age, SEIFA and education.
anogenital cancers. It may also give rise to the perception that HPV vaccines only have a role in female health, rather than that of both sexes. Consequently, a gender-neutral approach to promoting the vaccines as HPV vaccines has been adopted now that the vaccine programme has been expanded to include boys in Australia [3]. By acknowledging that HPV is very common amongst both sexes and its sexually transmitted nature, HPV vaccination can also be used as an opportunity to introduce discussions regarding sexual and reproductive health with adolescents. However, this approach has been shown to be less successful in more conservative cultural or religious communities [23]. In this study, HPV vaccine knowledge among participants was relatively high. However, a few concerns were highlighted. In those who knew of the HPV vaccine, despite the high awareness of the need for Pap smears post-vaccination, almost 20% were unsure if Pap abnormalities after vaccination implied vaccine failure. Although both currently licensed HPV vaccines are highly efficacious in HPV-naïve individuals, they have limitations. As immunity obtained from vaccination is largely type-specific, they do not offer protection against all oncogenic HPV types. Therefore, cervical screening is required despite vaccination and Pap abnormalities after vaccination do not imply vaccine failure. Thus, it is important for both providers and women to be aware of these issues. HPV vaccination was a significant predictor of high HPV vaccine knowledge, once again possibly related to the nature of questions asked as stated above. In order to recognise that they had received
the HPV vaccine, participants had to be aware of what HPV is. Another explanation could be the provision of HPV vaccine information before vaccination which could have contributed to the higher knowledge. Alternatively, women with inherently higher HPV vaccine knowledge had chosen to get vaccinated, given the positive correlation between knowledge and intention to vaccinate [24,25]. Interestingly, participants who reported HPV vaccination at the GP’s office were significantly more likely to have high HPV knowledge compared to participants who reported HPV vaccination at schools, even after correcting for age. In this study, HPV vaccination was also significantly associated with contraceptive use during first sexual intercourse. Findings from this study indicate that those with higher knowledge and perhaps more motivated in preventative health behaviours are more likely to be vaccinated. This potentially highlights the fact that those most at need of a HPV vaccination may be less likely to be vaccinated. The decision to introduce a government funded vaccination programme in Australia has significantly impacted HPV vaccine uptake, and can mitigate to some extent the impact of lower levels of knowledge. Indeed, this study demonstrated that a funded programme was one of the most significant factors for vaccination, with 87% reporting that they received the vaccine because it was free. Limitations of the study included the low participation rate, with only 50% of those who responded to the questionnaire and 65% of those who were contactable subsequently completing the survey. Since the time of the survey the materials and messages used for communication about the vaccination programme have also changed following the completion of the catch up programme and then the inclusion of males. The vaccine is now referred to as the HPV vaccine, rather than the cervical cancer vaccine. Other limitations include the study sample that was not completely representative of the target population, as they were more educated and is a similar finding to other convenience methods of sampling. The study is also based on a small sample of Facebook users in Victoria and may not be generalisable to all women in Victoria. Although the geographic distribution of respondents was representative, it is possible that individuals without Internet access and with poor education and healthcare were not included in the study. Nonetheless, Facebook is the biggest social media site in Australia with nine million Australians (almost 40% of the population) visiting Facebook every day [26]. At the time of this study, there were no suitable standardised questionnaires available. Furthermore, the structured questionnaire methodology and the use of closed questions may have produced higher levels of knowledge. However, the use of some questions from previously published studies allowed comparisons to be made with those studies [15,16]. Among the strengths of this study was the verification of HPV vaccination status using the NHVPR which helped interpret the validity of self-report. This was the earliest study in Australia to do so and has helped develop a pathway for other studies to do the same [27]. This study provides an important guide for educational initiatives by identifying the misconceptions and gaps in HPV vaccine knowledge, and the attitudes towards HPV vaccination. Strategies to increase HPV vaccine uptake include addressing the issues raised by individuals as reasons for not receiving the vaccine. Thirty-two percent of participants who reported non-vaccination stated concerns of bad reactions to the vaccine as a reason and 16% stated that they were unsure if the vaccine gives a person HPV. The ongoing school programme should provide information to parents and adolescents that the HPV vaccines are safe, are not live vaccines and are generally well-tolerated. Other reasons for not receiving the vaccine included the perception that HPV vaccines were not needed if the individual was in a monogamous relationship (32%) or if they were not sexually active (25%). It is important for parents and adolescents to understand that there is still a risk of acquiring
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HPV infections despite remaining monogamous [28] and that vaccine efficacy is highest if administered before initiation of sexual activity [29]. This study also allows future research assessing HPV vaccine knowledge among young women in Victoria to make comparisons with findings of this study and to assess changes in knowledge over time. This study has demonstrated that it is possible to recruit a reasonably representative sample of young women using Facebook and that Facebook can be a cost-effective and relatively simple method of recruiting young people for health research. Authors’ contribution SMG, JDW, YJ, EEM and SNT conceived the study. The original research protocol was jointly written by YJ, EEM, SMG, and JDW. All authors participated in the study design. YF was responsible for executing the study with assistance from BG. Statistical analysis was done by BG with input from EEM, YF and AF, and BG was responsible for drafting the manuscript. JB supervised the verification of vaccination data with the NHVPR and assisted with interpretation of data. All authors had full access to all of the data in the study, and read, revised, and approved the final manuscript.
[6]
[7]
[8]
[9]
[10] [11]
[12]
[13]
[14]
Funding [15]
This work was supported by a grant from the Dean Robert Winter Trust, which is managed by the ANZ Trustees, and the National Health and Medical Research Council (Programme Grant No. 568971), and the Victorian Government’s Operational Infrastructure Support Programme. Conflict of interest statement SMG has received advisory board fees and grant support from CSL and GlaxoSmithKline, and lecture fees from Merck, GSK and Sanofi Pasteur. In addition, she has received funding through her institution to conduct HPV vaccine studies for MSD and GSK. SMG is a member of the Merck Global Advisory Board as well as the Merck Scientific Advisory Committee for HPV. JB has been an investigator on investigator designed unrestricted epidemiological research grants partially funded through bioCSL/Merck but has received no personal financial benefits. Acknowledgements The authors wish to thank the members of our Young Women’s Advisory Group for their feedback about the study website, logo, advertisements and questionnaire. We also thank Daniela Petrovski and Genevieve Chappell at the NHVPR and all the young women who took part in this study.
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[17]
[18]
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[26]
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Attitudes about human papillomavirus vaccine in young women. Int J STD AIDS 2003;14:300–6. Davis K, Dickman ED, Ferris D, Dias JK. Human papillomavirus vaccine acceptability among parents of 10 to 15-year-old adolescents. J Low Genit Tract Dis 2004;8:188–94. Godfrey M. Facebook checked by 9 million Australians every day. Sydney Morning Herald 20 August 2013. Available from: http://www.smh.com.au/ digital-life/digital-life-news/facebook-checked-by-9-million-australiansevery-day-20130820-2s7wo.html [accessed 05.03.14]. Young EJ, Tabrizi SN, Brotherton JML, Wark JD, Pyman J, Saville M, et al. Measuring effectiveness of the cervical cancer vaccine in an Australian setting (the VACCINE study). BMC Cancer 2013;13:296, http://dx.doi.org/10.1186/1471-2407-13-296. Winer RL, Feng Q, Hughes JP, O Reilly S, Kiviat NB, Koutsky LA. Risk of female human papillomavirus acquisition associated with first male sex partner. J Infect Dis 2008;197:279–82. World Health Organisation (WHO). 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Asking about human papillomavirus vaccination and the usefulness of registry validation: A study of young women recruited using Facebook Bharathy Gunasekaran a,b , Yasmin Jayasinghe b,c,d , Julia M.L. Brotherton e,f , Yeshe Fenner b,g,1 , Elya E. Moore g,1 , John D. Wark h,i , Ashley Fletcher b,g,1 , Sepehr N. Tabrizi b,c,g , Suzanne M. Garland b,c,g,j,∗ a
Melbourne Medical School, University of Melbourne, Parkville, Victoria 3052, Australia Department of Microbiology and Infectious Diseases, The Royal Women’s Hospital, Parkville, Victoria 3052, Australia c Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria 3052, Australia d Department of Gynaecology, Royal Children’s Hospital, Parkville, Victoria 3052, Australia e National HPV Vaccination Program Register, VCS Inc., East Melbourne, Victoria 8002, Australia f School of Population and Global Health, University of Melbourne, Parkville, Victoria 3010, Australia g Infection and Immunity Theme, Murdoch Childrens Research Institute, Parkville, Victoria 3052, Australia h Department of Medicine (Royal Melbourne Hospital), University of Melbourne, Parkville, Victoria 3050, Australia i Bone and Mineral Medicine, Royal Melbourne Hospital, Parkville, Victoria 3052, Australia j Microbiology, Royal Children’s Hospital, Parkville, Victoria 3050, Australia b
a r t i c l e
i n f o
Article history: Received 25 April 2014 Received in revised form 31 October 2014 Accepted 2 November 2014 Available online 12 November 2014 Keywords: Human papillomavirus Vaccine Knowledge Uptake Young women Australia
a b s t r a c t Background: Australia was the first country to implement a government-funded National Human Papillomavirus (HPV) Vaccination Programme. We assessed HPV vaccine uptake comparing self-reported and Register validated estimates, and the knowledge and attitudes of young women with regards to HPV vaccination post-implementation of the programme. Methods: Females, aged 16–25 years living in Victoria, Australia, were recruited using targeted advertising on Facebook from May to September 2010, to complete a web-based questionnaire. Results: Geographic distribution, Indigenous and socio-economic status of the 278 participants were representative of the target population. Overall, 210/278 (76%) had heard of HPV vaccines, with 162/278 (58%) reporting receipt of at least one dose of vaccine, and 54 (19%) unsure. Verification of HPV vaccination status of 142 consenting participants (51%) showed 71% had received at least one dose. Main reasons for vaccination were for protection against HPV infection and cervical cancer (96%) and because it was free (87%), whereas unvaccinated women were uncertain of their eligibility (50%), concerned about adverse reactions (32%), or perceived that vaccination was not needed if they were monogamous (32%). Conclusion: The potential utility of a vaccination register in the context of a national programme is apparent from the large proportion of young women who were unsure of their vaccine status. HPV vaccine knowledge among participants was relatively high suggesting the national programme has successfully communicated to the majority of eligible women, the purpose and limitations of the vaccine. Vigilance is needed to ensure that young women follow through with Pap testing in vaccine eligible cohorts. The ongoing vaccination programme for pre-adolescent girls and boys should communicate to parents that those with one sexual partner can still acquire HPV and that the safety of the vaccine is now well demonstrated. © 2014 Elsevier Ltd. All rights reserved.
1. Introduction ∗ Corresponding author at: Department of Microbiology and Infectious Diseases, The Royal Women’s Hospital, Locked Bag 300, Parkville, Victoria 3052, Australia. Tel.: +61 38345 3671; fax: +61 39347 8235. E-mail address: [email protected] (S.M. Garland). 1 Former affiliations of researchers. http://dx.doi.org/10.1016/j.vaccine.2014.11.002 0264-410X/© 2014 Elsevier Ltd. All rights reserved.
In April 2007, Australia became the first country to implement a government funded National Human Papillomavirus (HPV) Vaccination Programme [1]. From April 2007 to December 2009, there was a catch-up programme for 13–18 year old girls in schools, whilst from July 2007 to December 2009, there was a catch-up
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programme available to 13–26 year old women through general practice and community-based programmes [2]. Presently, there is an ongoing school-based vaccination programme providing the HPV vaccine free to all boys and girls aged 12 to 13 years, with a two year catch-up programme for 14–15 year old boys until the end of 2014 [3]. Australia has a National HPV Vaccination Programme Register (NHVPR) to monitor the uptake and effectiveness of the national HPV vaccination programme [4]. The HPV vaccination programme has had notable success. Notified vaccination coverage for girls aged 12–17 years nationally was 83% for dose one, 78% for dose two and 70% for dose three. Of these notified doses, 14% were delivered by general practitioners, ranging from 8% in 12 year olds to 28% in 17 year olds [4]. Victoria recorded the highest three-dose coverage for the 12–17 year old cohort at 75% [4]. However, this is a minimum coverage estimate for the population as notification of HPV vaccination to the NHVPR is only obligatory in the school-based programme, with an estimated 10–20% underreporting for doses delivered outside schools [5,6]. Previous studies conducted in Australia and worldwide show that knowledge about HPV was low amongst the general population prior to vaccination programmes, with evidence of a gradual increase over time in many populations after vaccine availability [7–13]. It is therefore of significant interest to assess recall of HPV vaccination status and HPV vaccine knowledge amongst young women of vaccine eligible age in Victoria, Australia, just a few years post-implementation of the national HPV vaccination programme. As Australia is unique in establishing a programme specific national vaccine register for HPV, it is of importance to establish how well the register has recorded vaccinations in the catch-up programme, where notifications by general practitioners were not compulsory. The objectives of this study were to assess HPV vaccine uptake by self-report and register validation as well as HPV vaccine knowledge and attitudes among young women in Victoria, Australia recruited using Facebook, a social networking site highly accessed by the target group.
2. Methods 2.1. Sample Participants were recruited as a volunteer sample via targeted advertising on Facebook from the 19th of May to the 30th of September 2010. This was a pilot study for a planned longitudinal study on women’s health, The Young Female Health Initiative (YFHI) study. Detailed methods have been previously reported [14]. Briefly, participants were eligible if they identified themselves as female, were 16–25 years of age, and lived in Victoria, Australia. Participants were offered AU$25 compensation for their time if they visited the study site and travel costs (up to AU$70) if they travelled from regional areas, whilst those who completed the survey remotely were offered AU$15 compensation for their time (AU$1 = USD $0.93).
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of their vaccination status against the NHVPR. The questionnaire took approximately 15–25 min to complete. 2.3. Analysis Statistical analyses were performed using STATA software, version 11.1. When analysing participants’ demographic information, the Australian Bureau of Statistics (ABS) Census 2006 was used as a comparison [17]. Univariate analyses were used to measure the differences between the demographics of the study cohort and the general population of the same gender and age group. The primary outcome variables described in this paper are HPV vaccine awareness and HPV vaccination status, as well as knowledge and attitudes towards HPV vaccination. The results for knowledge of HPV, cervical cancer and chlamydia have been previously reported [18,19]. HPV vaccine awareness was defined by a “yes” response using the question “Have you ever heard of the vaccine for human papillomavirus?”. To estimate the proportion of participants who had received the HPV vaccine, participants were asked whether they had been vaccinated and the number of doses they had received. Where consent was obtained, identifying information was used to identify whether vaccine doses were held on the NHVPR in order to verify self-reported doses. Where no record was found on the NHVPR, but the woman reported vaccination and health provider details, NHVPR staff attempted to contact the provider and verify vaccination receipt. Questions regarding HPV vaccine knowledge were directed to those participants who had heard of HPV vaccines, and measured using five true/false/don’t know questions about HPV vaccines. One point was given for each correct answer and a knowledge scale of 0–5 was constructed (participants who had not heard of HPV vaccines were allocated a score of zero). The HPV vaccine knowledge scale was collapsed into three subgroups; low (0–1), moderate (2–3) and high knowledge (4–5). Attitudes towards HPV vaccination were assessed by examining the reasons given for vaccination and non-vaccination. All questions were asked in a set order, some of which were structured by dropdown boxes. Logistic regression models were used to estimate independent predictors of self-reported HPV vaccination status and HPV vaccine knowledge. Adjusted odds ratios were calculated adjusting for age and socioeconomic status. Socioeconomic status was assigned using the ABS’s Socio-Economic Indexes for Areas (SEIFA) and the 2006 Postal Area Index of Relative Socio-economic Advantage and Disadvantage, which is a continuum of advantage to disadvantage scores, with a lower score corresponding to a more disadvantaged area [20]. Statistical significance for all tests was set at P ≤ 0.05. Ethics approval was obtained through the Human Research and Ethics Committees at the Royal Women’s Hospital, Melbourne and informed consent was obtained from all participants. 3. Results 3.1. Recruitment and participation
2.2. Data collection The questionnaire was developed by a team of multidisciplinary researchers using new questions, as well as questions from previously published Australian studies [15,16] and was pilot-tested with fifteen study-eligible females. The domains covered in this questionnaire included participant demographics; sexual history; knowledge regarding chlamydia, cervical cancer, HPV and HPV vaccines; attitudes towards HPV vaccination and self-reported vaccine status. Participants were also asked to give consent for validation
Participant characteristics have been described elsewhere [14]. Briefly, 551 women responded to the advertisements with an expression of interest, 426 were contactable, and 278 completed the questionnaire. Mean age of participants was 20.8 years. The geographic distribution of residence, country of birth, Indigenous status and socio-economic status of the participants did not differ from ABS distributions. However, women aged 16–17, and those whose highest level of education completed was below Year 12 (final year of high school) were under-represented. The average
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Table 1 Self-reported HPV vaccination of participants and odds ratios (OR) of self-reported HPV vaccination compared to participants who reported non-vaccination or were unsure of their HPV vaccination status using univariate and multivariate analyses. Self-reported HPV vaccination status
No/Don’t know 116/278 (42%) nb (%)
Yes 162/278 (58%) nb (%)
Adjusted ORc (95% CI)
Age (years) 16–17 18–21 22–25
18 (47) 49 (43) 49 (39)
20 (53) 66 (57) 76 (61)
1.0 1.1 (0.51–2.3) 1.3 (0.60–2.7)
SEIFAa 80 (highest SES)
44 (53) 36 (41) 34 (32.1)
39 (47) 51 (59) 72 (67.9)
1.0 1.6 (0.86–2.9) 2.4 (1.3–4.3)
23 (43) 71 (68) 68 (57)
1.0 3.3 (1.4–7.8) 1.6 (0.67–3.6)
Highest level of education completed Year 12 52 (43) Country of birth Overseas Australia
32 (70) 84 (37)
14 (30) 146 (63)
1.0 5.2 (2.5–11)
Use of contraception at first vaginal intercourse 19 (66) 10 (34) No Yes 61 (36) 107 (64)
1.0 3.5 (1.5–8.4)
HPV knowledge Low (0–1) Moderate (2–4) High (5–6)
82 (74) 18 (25) 16 (17)
29 (26) 53 (75) 80 (83)
1.0 8.8 (4.3–18) 15 (7.1–30.1)
HPV, human papillomavirus; OR, odds ratio; SEIFA, Socio-economic Indexes for Areas. a SEIFA is a classification system developed by the Australian Bureau of Statistics that ranks areas in Australia according to relative socio-economic advantage and disadvantage, with a lower score corresponding to a more disadvantaged area [20]. b Numbers may not add up to the total number due to missing data. c Odds ratios adjusted for age and SEIFA.
cost in advertising fees per completing participant was US$20 for this study. 3.2. HPV vaccine awareness and vaccination status Most participants (94%) were aware of the existence of cancer vaccines for women. In an open-ended question asking participants to name the cancer (s) the vaccine(s) protected against, 246 participants (89%) named cervical cancer and/or HPV vaccines. However, when asked specifically whether they had heard of HPV vaccines, only 210 women (76%) said they had. Overall, 162 participants (58%) reported having received the vaccine. Of those who reported HPV vaccination, 146 (90%) selfreported receipt of all three doses, giving a three dose coverage of 52% in the surveyed population overall. Table 1 shows the predictors of self-reported HPV vaccination. Based on multivariate analyses, Australian-born participants and those with high HPV and HPV vaccine knowledge were more likely to report HPV vaccination. This is similar to our findings when we excluded the “Don’t know” responses from the analysis. Verification of the HPV vaccination status of 142 participants (51%) either through NHVPR verification or following provider verification is shown in the figure below (Fig. 1). Of these 142 participants, 111 (78%) had completed the survey at the study site. Verification of self reported vaccination status was compared with self reported place(s) of vaccination. Of the 28 participants who reported HPV vaccination only at a school, verification from the registry showed 25 received all three doses, two participants
Table 2 Responses to each HPV vaccine question among the 210 participants who were aware of HPV vaccines. Incorrect response n(%)
Don’t know n(%)
True/False statements
Correct response n(%)
HPV-vaccinated women do not need Pap smears in the future (False) The vaccine will protect against around 80% of cervical cancers, but not the remaining 20% of cervical cancers (True) HPV-vaccinated women will never have a Pap abnormality after vaccination (False) Pap abnormalities which require monitoring and treatment may still occur after HPV vaccination (True) If a Pap abnormality occurs, then the vaccine has failed to do its job (False)
203 (96.7)
0 (0.0)
7 (3.3)
139 (66.2)
10 (4.8)
61 (29.0)
191 (91.8)
1 (0.5)
16 (7.7)
189 (90.4)
7 (3.3)
13 (6.2)
167 (80.3)
2 (1.0)
39 (18.8)
Note: Numbers may not add up to the total number due to missing data.
received two doses and one participant’s vaccination details were not in the register or in the health provider records. In comparison, of the 50 participants who reported HPV vaccination only at the local doctor’s office, registry verification showed 38 participants received three doses, six participants had two doses and five participants did not have their vaccination details in the register or health provider records. 3.3. HPV vaccine knowledge HPV vaccine knowledge was only assessed among the 210 participants who had heard specifically of HPV vaccines (Table 2). Self-reported HPV vaccination was a significant predictor of correctly answering each of the HPV vaccine questions in univariate analyses and remained a significant predictor in multivariate analyses. The mean score on the HPV vaccine knowledge scale, including the participants who stated that they were not aware of HPV vaccines, was 3.2 of 5 (95% CI: 3.0–3.4). Overall, 40% correctly answered all HPV vaccine questions. Table 3 shows the predictors of high HPV vaccine knowledge. In multivariate analyses, Australian birth and awareness of Chlamydia were the only significant predictors of high HPV vaccine knowledge. 3.4. Attitudes towards HPV vaccination Participants were presented with possible reasons for getting or not getting the HPV vaccine and were asked to select all that applied. The most common reasons for HPV vaccination were for protection against HPV infection and cervical cancer (96%), because it was free (87%), and ‘to join the fight against cervical cancer’ (73%). The most common reasons for not receiving the vaccine were because of uncertainty of eligibility (50%), concerns about a bad reaction to the vaccine (32%) and a perception that the
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Fig. 1. Comparison between self reported and verified HPV vaccination status and number of doses in the National HPV Vaccination Programme Register (NHVPR).
vaccine was not needed as they were in a monogamous relationship (32%). 3.5. Sources of HPV vaccine information The most common source of HPV vaccine information was school (52%), followed by television (50%), GP or personal physician (48%), and friends or family (43%). Information sources were grouped into four broad categories: (1) media, (2) school, (3) healthcare providers (HCPs), and (4) friends and family. There were no statistically significant differences in HPV vaccine knowledge among participants who had heard of HPV vaccines through these different sources (data not shown). 4. Discussion The National HPV Vaccination Programme for young women has been implemented with notable success in Australia [4]. Underpinning success in HPV-related disease reduction is high coverage of the target population. Consistent with other Australian studies, self-reported HPV vaccination status was associated with country of birth [5,21], with Australian-born participants more likely to report HPV vaccination compared to overseas-born participants. A possible reason is that the funded catch-up vaccination programme was intended for Australian residents, with cost representing a major barrier as HPV vaccines are not covered under overseas students’ health insurance. For those who are not eligible for the free vaccination, the cost is AU$150 per dose (AU$450 for all three doses) and this does not include the cost of the visit to the local doctor who must prescribe the vaccine (AU$1 = USD $0.93) [22]. Indeed, cost and uncertainty about eligibility were reported as barriers or possible barriers by 70% and 64% of overseas-born participants who reported non-vaccination, respectively.
In this study, 58% reported receipt of the HPV vaccine, but 19% were unsure of their vaccination status. The large percentage of uncertainty in this study could be due to the wording of the question which asked participants whether they had the ‘HPV vaccine’ instead of the ‘cervical cancer vaccine’. As described earlier, 94% were aware of cancer vaccines and most of these respondents knew it was for cervical cancer. However, only 76% knew of HPV vaccines. This could be due to the strategy adopted during the launch of the vaccination programme to describe the vaccines as cervical cancer vaccines in media and public health messages. These results highlight that health providers and researchers must be aware of the language that young women are familiar with, in order to determine vaccination status more accurately and to potentially avoid unnecessary multiple dosing. This highlights the important role that the NHPVR will continue to play. The language around HPV vaccination in this study could have been better clarified with the use of terms such as the cervical cancer vaccine or Gardasil vaccine which are better known. This could have resulted in a lower proportion of women who were vaccinated not actually being sure of their vaccination status, possibly related to the nature of the questions asked. However, specificity was quite high. Of the 88 participants who self-reported being vaccinated, 80 (91%) had at least one dose held in the register. Of the 26 participants who stated that they had not received the vaccine, only three had their doses recorded in the register. There are pros and cons to referring to the vaccine as the cervical cancer vaccine. On one hand, at that time, the term HPV was unfamiliar to most of the population and the idea of cancer prevention through vaccination was new. Using cancer prevention terminology may increase vaccine acceptance. It is also advantageous for parents who may not yet be comfortable discussing issues of sexuality and an STI with pre-adolescents. However, promotion of HPV vaccines as cervical cancer vaccines may create the impression that HPV is only linked to cervical cancer and not to other
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Table 3 HPV vaccine knowledge of participants and odds ratios (OR) of high HPV vaccine knowledge compared to low/moderate HPV vaccine knowledge using univariate and multivariate analyses. HPV vaccine knowledgea
Low/Moderate (0–3) 103/278 (37%) nc (%)
High (4–5) 175/278 (63%) nc (%)
Adjusted ORd (95% CI)
Age (years) 16–17 18–21 22–25
20 (53) 45 (39) 38 (30)
18 (47) 70 (61) 87 (70)
1.0 1.3 (0.53–3.1) 2.1 (0.84–5.3)
SEIFAb 80 (highest SES)
38 (46) 28 (32) 35 (33)
45 (54) 59 (68) 71 (67)
1.0 1.7 (0.90–3.2) 1.5 (0.83–2.8)
27 (50) 69 (66) 79 (66)
1.00 1.6 (0.72–3.7) 1.2 (0.54–2.9)
Highest level of education completed Year 12 41 (34) Country of birth Overseas Australia
22 (48) 80 (35)
24 (52) 150 (65)
1.0 2.2 (1.1–4.4)
Chlamydia awareness No Yes
32 (52) 68 (32)
29 (48) 145 (68)
1.0 2.3 (1.3–4.3)
HPV vaccination status No Yes Don’t know
37 (60) 20 (12) 46 (85)
25 (40) 142 (88) 8 (15)
1.0 12 (5.7–26) 0.3 (0.11–0.74)
HPV, human papillomavirus; OR, odds ratio; SEIFA, Socio-economic Indexes for Areas. a HPV vaccine knowledge scale was derived from responses to five true/false/don’t know questions about HPV vaccines for a total possible score of five and subsequently collapsed into three categories: low (0–1), moderate (2–3) and high (4–5) knowledge. b SEIFA is a classification system developed by the Australian Bureau of Statistics that ranks areas in Australia according to relative socio-economic advantage and disadvantage, with a lower score corresponding to a more disadvantaged area [20]. c Numbers may not add up to the total number due to missing data. d Odds ratios adjusted for age, SEIFA and education.
anogenital cancers. It may also give rise to the perception that HPV vaccines only have a role in female health, rather than that of both sexes. Consequently, a gender-neutral approach to promoting the vaccines as HPV vaccines has been adopted now that the vaccine programme has been expanded to include boys in Australia [3]. By acknowledging that HPV is very common amongst both sexes and its sexually transmitted nature, HPV vaccination can also be used as an opportunity to introduce discussions regarding sexual and reproductive health with adolescents. However, this approach has been shown to be less successful in more conservative cultural or religious communities [23]. In this study, HPV vaccine knowledge among participants was relatively high. However, a few concerns were highlighted. In those who knew of the HPV vaccine, despite the high awareness of the need for Pap smears post-vaccination, almost 20% were unsure if Pap abnormalities after vaccination implied vaccine failure. Although both currently licensed HPV vaccines are highly efficacious in HPV-naïve individuals, they have limitations. As immunity obtained from vaccination is largely type-specific, they do not offer protection against all oncogenic HPV types. Therefore, cervical screening is required despite vaccination and Pap abnormalities after vaccination do not imply vaccine failure. Thus, it is important for both providers and women to be aware of these issues. HPV vaccination was a significant predictor of high HPV vaccine knowledge, once again possibly related to the nature of questions asked as stated above. In order to recognise that they had received
the HPV vaccine, participants had to be aware of what HPV is. Another explanation could be the provision of HPV vaccine information before vaccination which could have contributed to the higher knowledge. Alternatively, women with inherently higher HPV vaccine knowledge had chosen to get vaccinated, given the positive correlation between knowledge and intention to vaccinate [24,25]. Interestingly, participants who reported HPV vaccination at the GP’s office were significantly more likely to have high HPV knowledge compared to participants who reported HPV vaccination at schools, even after correcting for age. In this study, HPV vaccination was also significantly associated with contraceptive use during first sexual intercourse. Findings from this study indicate that those with higher knowledge and perhaps more motivated in preventative health behaviours are more likely to be vaccinated. This potentially highlights the fact that those most at need of a HPV vaccination may be less likely to be vaccinated. The decision to introduce a government funded vaccination programme in Australia has significantly impacted HPV vaccine uptake, and can mitigate to some extent the impact of lower levels of knowledge. Indeed, this study demonstrated that a funded programme was one of the most significant factors for vaccination, with 87% reporting that they received the vaccine because it was free. Limitations of the study included the low participation rate, with only 50% of those who responded to the questionnaire and 65% of those who were contactable subsequently completing the survey. Since the time of the survey the materials and messages used for communication about the vaccination programme have also changed following the completion of the catch up programme and then the inclusion of males. The vaccine is now referred to as the HPV vaccine, rather than the cervical cancer vaccine. Other limitations include the study sample that was not completely representative of the target population, as they were more educated and is a similar finding to other convenience methods of sampling. The study is also based on a small sample of Facebook users in Victoria and may not be generalisable to all women in Victoria. Although the geographic distribution of respondents was representative, it is possible that individuals without Internet access and with poor education and healthcare were not included in the study. Nonetheless, Facebook is the biggest social media site in Australia with nine million Australians (almost 40% of the population) visiting Facebook every day [26]. At the time of this study, there were no suitable standardised questionnaires available. Furthermore, the structured questionnaire methodology and the use of closed questions may have produced higher levels of knowledge. However, the use of some questions from previously published studies allowed comparisons to be made with those studies [15,16]. Among the strengths of this study was the verification of HPV vaccination status using the NHVPR which helped interpret the validity of self-report. This was the earliest study in Australia to do so and has helped develop a pathway for other studies to do the same [27]. This study provides an important guide for educational initiatives by identifying the misconceptions and gaps in HPV vaccine knowledge, and the attitudes towards HPV vaccination. Strategies to increase HPV vaccine uptake include addressing the issues raised by individuals as reasons for not receiving the vaccine. Thirty-two percent of participants who reported non-vaccination stated concerns of bad reactions to the vaccine as a reason and 16% stated that they were unsure if the vaccine gives a person HPV. The ongoing school programme should provide information to parents and adolescents that the HPV vaccines are safe, are not live vaccines and are generally well-tolerated. Other reasons for not receiving the vaccine included the perception that HPV vaccines were not needed if the individual was in a monogamous relationship (32%) or if they were not sexually active (25%). It is important for parents and adolescents to understand that there is still a risk of acquiring
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HPV infections despite remaining monogamous [28] and that vaccine efficacy is highest if administered before initiation of sexual activity [29]. This study also allows future research assessing HPV vaccine knowledge among young women in Victoria to make comparisons with findings of this study and to assess changes in knowledge over time. This study has demonstrated that it is possible to recruit a reasonably representative sample of young women using Facebook and that Facebook can be a cost-effective and relatively simple method of recruiting young people for health research. Authors’ contribution SMG, JDW, YJ, EEM and SNT conceived the study. The original research protocol was jointly written by YJ, EEM, SMG, and JDW. All authors participated in the study design. YF was responsible for executing the study with assistance from BG. Statistical analysis was done by BG with input from EEM, YF and AF, and BG was responsible for drafting the manuscript. JB supervised the verification of vaccination data with the NHVPR and assisted with interpretation of data. All authors had full access to all of the data in the study, and read, revised, and approved the final manuscript.
[6]
[7]
[8]
[9]
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[12]
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Funding [15]
This work was supported by a grant from the Dean Robert Winter Trust, which is managed by the ANZ Trustees, and the National Health and Medical Research Council (Programme Grant No. 568971), and the Victorian Government’s Operational Infrastructure Support Programme. Conflict of interest statement SMG has received advisory board fees and grant support from CSL and GlaxoSmithKline, and lecture fees from Merck, GSK and Sanofi Pasteur. In addition, she has received funding through her institution to conduct HPV vaccine studies for MSD and GSK. SMG is a member of the Merck Global Advisory Board as well as the Merck Scientific Advisory Committee for HPV. JB has been an investigator on investigator designed unrestricted epidemiological research grants partially funded through bioCSL/Merck but has received no personal financial benefits. Acknowledgements The authors wish to thank the members of our Young Women’s Advisory Group for their feedback about the study website, logo, advertisements and questionnaire. We also thank Daniela Petrovski and Genevieve Chappell at the NHVPR and all the young women who took part in this study.
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