Written by Jessica Blackwell
Immunisation is a topic in which there are often strong views, whether for or against. In recent years our childhood vaccination levels throughout New Zealand (NZ) have been increasing, which has been seen as an accomplishment (Ministry of Health, 2016). However, the Human Papillomavirus (HPV) vaccine uptake is lower than the vaccinations for children five and under. This literature review will explore what HPV is, what influences a person’s decision to consent to the HPV vaccine, and how vaccination levels may be increased. The HPV virus can lead to genital warts and cervical cancer, and around 50 women die of cervical cancer in New Zealand yearly. It is therefore an important vaccine for girls to have access to. Knowledge, or lack thereof, about HPV, its links to cancers, and the vaccine, is a major problem for the general population. Knowledge levels need to be increased to give people a better chance of making an educated and informed decision about the vaccine. Nurses can be proactive in the promotion of the HPV vaccine to ensure as many girls in NZ are protected as possible by being up to date with current and appropriate research, knowing which areas of the topic to focus on, and being involved in education sessions with school staff, parents and girls.
I had not thought about the HPV vaccine since I received it while at school, and had just assumed that every other girl had been vaccinated too. However, when speaking with friends, the topic of the HPV vaccine came up. I found a number of people I knew had not received it, which prompted me to pursue the topic further to see if there were many people who had not had the vaccine. I was also interested in the reasons people had for not getting it, or not consenting for their children to get it.
To start the search I explored the parameters for people eligible for the HPV vaccine in NZ, and looked at the evidence of the vaccines efficacy. I found that while there were articles and statistics from NZ, I would need to widen the parameters to other countries to be able to get a larger variety and amount of research on the topic. I could get information specific to NZ and then also have information from other countries that could be applied to NZ. I was able to re-form the question from: What is the HPV vaccines use like in NZ? To a refined research question of: What influences the decision to consent to the HPV vaccine in New Zealand, and how can nurses promote the vaccine to increase its uptake?
HPV stands for Human Papillomavirus (Ministry of Health, 2013a). It encompasses a group of over 100 related viruses, with each virus in the group given an identifying number (Ministry of Health, 2013b). The HPV virus spreads from intimate skin-to-skin contact, mostly during vaginal, anal and oral sex (Ministry of Health, 2013a). HPV is classed as a sexually transmitted infection and is one of the most common in NZ, with around 80% of men and women having it at some stage of their lives (Ministry of Health, 2013b). People may never show any signs or symptoms of the virus, but some types lead to genital warts and cancer, with cervical cancer being the most common cancer resulting from the HPV infection (Ministry of Health, 2013b). The Ministry of Health (2014b) shows the link between HPV and cervical cancer, stating that 99.7% of people with cervical cancer have HPV. In NZ genital warts affect approximately one in ten people (Ministry of Health, 2014b). In 2010, cervical cancer affected 180 New Zealanders with 52 of those dying from it (Ministry of Health, 2014b). A vaccine is available in NZ which covers HPV types 6, 11, 16 and 18 (Ministry of Health, 2014b). Types 6 and 11 are some of the types that lead to genital warts, and types 16 and 18 are classed as high risk HPV types as they can lead to the development of cancers of the cervix, anogenital and oropharyngeal regions (Ministry of Health, 2014b). With high percentages of young adults affected by HPV in NZ, it is an issue that is important to focus on. By reviewing the literature to see how these levels can be decreased, and then by implementing these recommendations, we can hope to decrease the incidences of genital warts and cancers related to HPV in NZ.
The HPV vaccine Gardasil was introduced in NZ in 2008, with a school based immunisation programme beginning in 2009 and is also funded for girls under 20 years (Rose et al., 2011). In America, a study was done to evaluate the HPV vaccines efficacy in relation to prevalence of HPV in girls since the vaccines introduction (Markowitz et al., 2013). The data suggested that the decrease in levels of HPV in females was due to the vaccine and that the vaccine has a high effectiveness (Markowitz et al., 2013). The levels of genital warts have also been shown to have decreased dramatically in Australia and NZ since the introduction of the vaccine (Mariani, Vici, Suligoi, Checcucci-Lisi, & Drury, 2015). The Ministry of Health targets for the three dose HPV coverage was originally 60%, but has now risen to 65% (Ministry of Health, 2015). In 2014 the uptake for the 2001 cohort was 57%, and this rose in 2015 where the uptake for the 2002 cohort was 62.1% (Ministry of Health, 2015). This is a definite increase in coverage from the beginning of the programme where the 1991 cohort had only a 48% uptake (Ministry of Health, 2014a). While the increase in the uptake is a good sign, the coverage levels for HPV are still nowhere near the levels for childhood vaccinations, which range from 80%-90% (Ministry of Health, 2016). This lower uptake of the HPV vaccine is seen in other countries as well. The Centre for Disease Control and Prevention (2013) report that in 2012 only 33.4% of American girls had received the three doses of the vaccine and highlights parents’ education, health-care provider inconsistency, and missing vaccination opportunities, as reasons the levels are low. However, this is a start contrast to England and Scotland, where Hilton and Smith (2011) report that in Scotland, 89% of the cohort received three doses of the vaccine with England being slightly less at 76.4%. This difference in uptake between countries is thought-provoking.
In a study on promoting HPV uptake in NZ, Rose, Lanumata, and Lawton (2011), focussed on the knowledge and views of school staff, prior to the school based immunisation programmes implementation in 2009. It was found that only 58% of participating school staff knew that there is a link between cervical cancer and HPV (Rose, Lanumata and Lawton, 2011). This lack of knowledge is concerning because school staff are shown to play an important role in school based vaccination programmes, with parents often asking teachers for advice about the vaccination (Rose, Lanumata and Lawton, 2011). Teachers play an important role in a child’s life and parents often see teachers as credible sources of information. Therefore, teachers and school staff need to be able to answer questions appropriately and accurately, and know when to refer to the school nurse or a doctor. Parents and guardians also play an important role in uptake of the HPV vaccination, as they need to give their consent for their child to be able to receive it through the school. From a multi-ethnic survey of 769 NZ parents, Rose, Lawton, Lanumata, Hibma and Baker (2012) concludes that a parent’s decision to get their daughter vaccinated was significantly associated with four main areas. These areas were; having less negative views about the vaccination, having received appropriate and accurate information, perceiving that cervical cancer and HPV were serious and have a high prevalence in young adults, and lastly believing the vaccine works and to be safe (Rose et al. 2012). Information and knowledge are areas that both of the above studies highlight as being vital predictors to how the HPV vaccine is perceived and this can influence its uptake. Teachers and parents alike should be appropriately informed about all aspects of the HPV vaccine, so parents can make informed decisions on behalf of their daughters, and so that teachers can guide parents and girls if they are asked questions regarding the vaccine. It should be noted that although parental consent is required for the school based programme, if no consent is given but the girl expresses an interest, she is able to go to her general practice or family planning to receive it (Ministry of Health, 2013c). There is no particular age of consent for someone to receive the vaccine without parental consent, as long as the person giving the vaccine is happy that the person receiving it understands all of the benefits and risks associated with it (Ministry of Health, 2013c).
While this research is focussed on what influences New Zealanders’ decisions on the vaccine, information and results from international studies on the same subject can be useful and important and can be applied to a NZ context. An Italian study on girls’ knowledge of the HPV vaccine supported the results of Rose, Lanumata, and Lawton (2011). The Italian study found that on the topic of HPV, misconceptions were high in teenaged participants, with many having incorrect views on how HPV is spread (Sopracordevole et al., 2013). However, the study did find that 95% of vaccinated girls were aware that they still needed to have regular cervical smears when appropriate, which is a sign that there was good information given about this aspect (Sopracordevole et al., 2013). Though the participants in the study by Rose, Lanumata, and Lawton (2011) were adult school staff and the participants of the Italian study were girls, both studies lead to similar conclusions around lack of knowledge and education about HPV. This leads to the assumption that lack of knowledge is not just limited to girls getting the injections, but also to adults. A study in Britain also focussed on girls’ understanding of the HPV vaccine, and yielded similar results. It found that out of 87 girls who took part in focus groups, only two knew how prevalent the HPV infection was (Hilton & Smith, 2011). A majority of girls said that their mothers had been influential in the decision to get the vaccine or not, and some knew little about HPV but were getting the vaccine because their parents told them to (Hilton & Smith, 2011). Torres et al., (2013) suggests that the recommendation of a doctor plays an important role in whether parents choose to consent to the HPV vaccination. A parent may ask their doctor about the vaccine and their views on it, and it is important that comprehensive information is given so informed consent can be provided (La Torre et al., 2013). While a doctor is not necessarily involved directly in the decision in NZ, as the consent form is sent from school to parents; parents may choose to speak to the doctor or practice nurse if they are visiting the GPs practice, or they may actively seek them out to discuss it. This means health professionals should all have the appropriate current information to ensure they are actively promoting the vaccine.
Another predictor that influences a parents’ decision in consenting to the HPV vaccination is that it is a topic that many parents do not want to bring up with their young girls, sex (Rose et al., 2012). It has been found that many people have the belief that allowing their child to get vaccinated will be seen as a sign that the child is old enough to have sexual relations (Rose et al., 2012). One study’s data suggested that girls believe they do not need the vaccine because they are not sexually promiscuous, so will not catch HPV (Hilton & Smith, 2011). These misconceptions that the vaccine will promote sexual risk-taking or one does not need the vaccine because they are not sexually active need to be addressed. The reason the vaccine is given to 11-13 year olds is because studies have been done to show the highest effectiveness for the vaccine is at ages 11-13 (Mariani et al., 2015). A Swedish study suggested that the reason for the ages 11-13 being where the vaccine was most effective, was that it was less likely that they have been exposed to any type of HPV at that age (Mariani et al., 2015). The New Zealand Immunisation Handbook states that in the first two years of sexual activity there is a 40% chance of becoming infected with HPV, so girls need to be protected before they are exposed (Ministry of Health, 2014b). Informing parents and girls of the facts about why the vaccine is given at an early age, and how the vaccine does not lead to or mean a girl is sexually promiscuous, is important. If people are aware of this, then they may be more receptive to the vaccine itself.
Bach and Manton (2014) state that there are significant inequalities regarding early childhood dental caries in preschool children in New Zealand due to economic status. Maori and Pacific children dental caries were poorer in the 1990’s. Non-Maori were more than three times likely not to have dental caries then Maori children with no further change in the trend. Bach, & Manton also found that Maori children start brushing their teeth at a later age and do not brush their teeth as frequently. They will also only seek dental help when they become symptomatic. Following this Birse (2004) claims that Maori have a younger maternal age than non-Maori as well as a level of academic achievement that is lower than non-Maori. Stating that for oral health to relate to Maori the health message must relate to them in their communities. Therefore, implying that education based on oral health should be community based within the Maori support groups. This means that the nurse is to work with the family members of the Maori community to provide support and education based on oral health (Birse, 2004).
An implication for practice is levels of HPV prevalence and genital warts in young people decreasing due to the vaccination, and how this affects treatment and care costs. Research has shown that after the implementation of the HPV vaccination programme, genital warts decreased in NZ females under 20 by 62.8% (Mariani et al., 2015). The decrease means less people need treatment and care for genital warts, which can be an embarrassing subject to discuss, even with a doctor. By decreasing the HPV prevalence in NZ, there is the hope that cancer rates, especially cervical cancer, will decrease in the future. As there is a long period of time from getting HPV to it developing into cancer, the vaccines effects on HPV-related cancers will not be seen immediately (Mariani et al., 2015). In the future research will be conducted regarding the impact of the HPV vaccine on HPV-related cancers, and nurses may be involved in this.
Knowledge, or lack thereof, is a major theme that is highlighted from this literature. Lack of knowledge can have many implications when it comes to making decisions. If someone is given little information or misinformation on a subject, it greatly impedes their ability to make an educated informed decision on it (Rose et al., 2012). If parents are not given appropriate information, it will impact their decision to consent to the vaccination. As the vaccination is proven to be effective by the CDC, there should really be more support from parents wanting to protect their children from HPV and the cancers that could result from infection (Centers for Disease Control and Prevention, 2013). Vaccination rates for New Zealand infants are high, and generally people are receptive to these vaccines, so why not for the HPV vaccine too? Inadequate knowledge, whether it is the parents or guardians, teachers, staff, or girls themselves needs to be addressed. This has been shown in this literature review to be one of the predictors for parents choosing not to vaccinate their daughters. This leads to questions about how the knowledge and education levels about the HPV vaccine can be increased, and how nurses can be a part of this.
As the vaccine is mainly given through a school based program in NZ, there is the ability to educate girls about vaccine through the school itself (Rose et al., 2012). Sessions during class time that are conducted by a nurse or other appropriate persons are a good way to give information, and also gauge the levels of understanding the girls have. These sessions could be a good way to answer any questions, and also ask questions. Dispelling myths about HPV leading to sexual risk-taking behaviour and HPV only being needed for girls who are sexually active, can be done through education and teaching sessions as well. Resources and pamphlets are currently given to girls to read themselves and also take home to parents (Litmus, 2011). While these contain all relevant information, this does not mean they are read, and they may get lost in the transit from school to home. So it is important parents actually receive all information and consent forms. It was shown that a majority of school staff have a lack of knowledge of HPV and the HPV vaccine, and would like to know more (Rose et al., 2011). As parents may inquire about the vaccine with teachers or school staff, it may be necessary to have a teaching session for school staff by a nurse. This means that staff would have an understanding of the topic, and have appropriate responses to be able to give parents and girls.
As discussed in the literature review, intent to vaccinate was associated with parents having the view that the vaccine was effective and also the view that HPV was a severe infection that could lead to cancers (Rose et al., 2012). Therefore, a recommendation would be to review the way parents are informed about the vaccine, and alter the existing information to ensure it focuses on the vaccines effectiveness and information about how serious HPV can be. Nurses can help with this by having accurate and up to date information to give girls and their parents, either through a doctor’s practice, or through the school. Nurse led information sessions could be used to increase awareness and knowledge which may help increase the uptake of the vaccine.
The Ministry of Health has reported HPV’s links to cancers in NZ. The Gardasil vaccine is licenced and available in NZ, with its effects already being seen in the decrease of genital warts, but its effects on cancer will not be known until the future. Uptake of the vaccine is increasing, though it is not near the levels we have for our childhood vaccinations. Many factors influence a person’s decision to consent to their daughter getting the HPV vaccine, or a young woman deciding for herself. Knowledge, or lack thereof, is highlighted to being a main predictor to intent to vaccinate. There is a lot of misinformation that goes with the vaccine, so it is important that girls, their parents, and school staff are given accurate, up to date information. Nurses involved with the process through schools should be sure to give appropriate education to stop misinformation, by focusing on areas that have been shown to be a predictor of intent to vaccinate. These are: perceived effectiveness, safety, believing HPV to be a serious virus that can lead to cancers, and knowing that receiving the HPV vaccine has no links to increasing sexual risk-taking in young girls. It is hoped that by increasing knowledge about HPV and the HPV vaccine, uptake levels will be increased and girls in NZ will be protected from potential life threatening diseases in the future.
Centers for Disease Control and Prevention. (2013). Human papillomavirus vaccination coverage among adolescent girls, 2007-2012, and post license vaccine safety monitoring, 2006-2013- United States. Atlanta, GA: Author.
Hilton, S., & Smith, S. (2011). “I thought cancer was one of those random things. I didn’t know cancer could be caught…”: Adolescent girls’ understandings and experiences of the HPV programme in the UK. Vaccine, 29, 4409-4415.
La Torre, G., De Vitto, E., Ficarra, m. G., Firenze, A., Gregorio, P., & Boccia, A. (2013). Is there a lack of information on HPV vaccination given by health professionals to young women? Vaccine, 31, 4710-4713.
Litmus. (2011). HPV Immunisation Programme Implementation Evaluation Volume 1: Final Report. Wellington, New Zealand: Author.
Mariani, L., Vici, P., Suligoi, B., Checcucci-Lisi, G., & Drury, R. (2015). Early direct and indirect impact of quadrivalent HPV (4HPV) vaccine on genital warts: A systematic review. Advances in Therapy, 32, 10-30.
Markowitz, L. E., Hariri, S., Lin, C., Dunne, E. F., Steinau, M., McQuillan, G., & Unger, E. R. (2013). Reduction in human papillomavirus (HPV) prevalence among young women following HPV vaccine introduction in the United States, national health and nutrition examination surveys, 22003-2010. Journal of Infectious Diseases, 92, 1-9.
Ministry of Health. (2013a, October 2). About HPV. Retrieved from the Ministry of Health website: http://www.health.govt.nz
Ministry of Health. (2013b). HPV vaccine for cervical cancer: Information for girls, young women and their families [Pamphlet]. Wellington, New Zealand: Author.
Ministry of Health. (2013c, October 2). Having the HPV vaccine. Retrieved from the Ministry of Health website: http://www.health.co.nz
Ministry of Health. (2014a). HPV immunisation coverage by ethnicity, vaccination and eligible birth cohort- All DHBs. Wellington, New Zealand: Author.
Ministry of Health. (2014b). Immunisation Handbook. Wellington, New Zealand: Author.
Ministry of Health. (2015). Comparison of dose 3 HPV coverage between 2014 and 2015. Wellington, New Zealand: Author.
Ministry of Health. (2016). National and DHB immunisation data. Retrieved from the Ministry of Health website: http://www/health.govt.nz
Rose, S. B., Lanumata, T., & Lawton, B. A. (2011). Promoting uptake of the HPV vaccine: The knowledge and views of school staff. Journal of School Health, 81, 680-687.
Rose, S. B., Lawton, B. A., Lanumata, T. S., Hibma, M., & Baker, M. G. (2012). Predictors of intent to vaccinate against HPV/ cervical cancer: A multi-ethnic survey of 769 parents in New Zealand. The New Zealand Medical Journal, 125, 51-62.
Sopracordevole, F., Cigolot, F., Mancioli, F., Agarossi, A., Boselli, F., & Ciavattini, A. (2013). Knowledge of HPV infection and vaccination among vaccinated and unvaccinated teenaged girls. International Journal of Gynaecology and Obstetrics, 122, 48-51.
Whitehead, D. (2013). In Z. Schneider, & D. Whitehead (Eds.). Nursing and midwifery research methods and appraisal for evidence based practice (4th ed.). (pp.35-56). Sydney, Australia: Elsevier.