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The cervical cancer vaccination programme: improving awareness

GlaxoSmithKline conducted a survey examining the attitudes and behaviours of 16-18-year-old girls, who are not part of the education system, around their general health, and specifically cervical cancer and vaccination. Nurses and GPs also took part, answering questions about their role in practice. The results illuminated some vital issues …

Around 2,800 women are diagnosed with cervical cancer in the UK each year. Overall, two out of every 100 cancers diagnosed in women are cervical cancers and it is the second most common cancer in women under 35 years old.1

Primary care nurses hold a key position in the fight against cervical cancer – promoting knowledge about the disease, as well as vaccination, is vitally important.

Awareness of the causes of cervical cancer
The survey revealed an extremely low level of awareness of the causes of cervical cancer in this group of girls. When asked what they believed to be the cause, only 15% thought it was to do with a virus, infection or bacteria and just 6% understood it to be the human papillomavirus (HPV). And even when prompted by a question asking if they knew if HPV was the cause, this figure increased to just 19%.

Awareness of risk
While 71% of the girls questioned were aware of a cervical cancer vaccine, it seems that few understood who was most at risk (see Figure 1).

[[Fig 1 HPV]]

When asked if they believed they were personally at risk of cervical cancer, just 8% said they "strongly agreed" this to be true. However, after being presented with some core information about the disease (ie, its impact, how it is caused/transmitted by a common virus and how it can be prevented), 26% subsequently agreed strongly that they were at risk. For girls who had not already received vaccination, the perception of risk changed even more dramatically, from 10% before the core information to 38% strongly agreeing they were at risk of cervical cancer after the information. The survey therefore highlights the value and importance of even basic education of cervical cancer to this group.

What makes this low level of risk awareness even more surprising is that the research was conducted in late January, at which time the TV personality Jade Goody had been diagnosed with cervical cancer, which attracted much media coverage. Yet even with this prominent story, there was a low perceived risk of cervical cancer in this group of girls.

Practice nurses therefore clearly have a role to play in highlighting the risk of cervical cancer and the means of its prevention. And indeed the research points to a need for more communication and interaction between healthcare professionals and this group – when it comes to guidance on healthcare, 87% of 16-year-old girls agreed that they would rather be told what to do to look after their health than make their own decisions.

The role and influence of GPs and nurses
The survey strongly indicates that GPs and healthcare professionals seriously underestimate their role and their influence on vaccine uptake amongst this group of girls – 73% of GPs and 83% of nurses believed that the girls' friends would be the strongest influence in the girls' decision to be vaccinated.

However, when it comes to seeking further advice about the decision to receive the vaccination, 70% of the girls strongly referenced their GP – ahead of their mother, with just 16% citing their friends as an influence (see Figure 2). This suggests a real disconnect between the role that healthcare professionals believe they do play, and the significant influence they actually have in improving vaccination uptake.

[[Fig 2 HPV]]

On the basis of this research, practice nurses would do well to raise awareness of their and their GPs' critical importance during the decision-making process, and not to make assumptions about whom this group of girls will refer to for advice. The girls clearly have strong expectations around healthcare professionals' role in providing advice on cervical vaccination (particularly among 17 and 18-year-olds).

Furthermore, when asked, "Who do you think is covered by the vaccination programme?", a total of 43% of GPs were not aware that all 12–18-year-old girls were being offered the vaccine. In addition to this perhaps surprising statistic, 53% of GPs did not believe that 16–18-year-olds outside of education would be contacted via individual GP surgeries. In contrast, 79% of nurses knew that all 12-18 year old girls were being offered the vaccine.

Among the girls, there was a split in their understanding of whether they would be contacted by the surgery (44%) or if they should request the vaccine themselves (36%). It is clear that receiving information on cervical cancer encourages proactivity among girls to request vaccination.

With regard to accessing such information, girls have key access points, principally comprising core secondary research channels, such as the internet, newspapers and TV (where they have sourced their existing vaccine knowledge). The girls' mothers play a supportive role in initial information gathering and discussions, but the healthcare professional has the greatest influence on decisions about vaccination, and girls expect to have direct contact made with them about the vaccine.

Girls want to hear about vaccination through direct contact from the health professional, and the largest group (47%) said they would prefer a letter from the surgery. They also expect reminder letters.

However, while 75% of the GPs surveyed recognise that personal invites are the most effective way to communicate with girls, this does not appear to translate to their practice, as less than half of respondents (44%) had actually carried this out. Health professionals said they would be inclined to contact patients by letter two to three times to follow-up nonattendees.

So despite a significant proportion of GPs claiming they are likely to contact this group proactively, some still appear more likely to take a reactive approach and wait until the girls next come in.

There was a further discrepancy in the nature of the information sought by this group. Girls said they would respond best to warnings about the effects of cervical cancer, stating that statistics about deaths from the disease would make them more likely to have the vaccine if it was offered. In contrast, 71% of GPs and 74% of nurses believed that girls would respond most to the statement, "The vaccine is available to offer protection against cancer-causing types of HPV". As a group, the 16-year-old girls answered differently, and most (71%) wanted reassurance of safety and tolerability of the vaccine.

"Be proactive"
Responding to the survey results, Dr George Kassianos, a Berkshire GP and the immunisation spokesman for the Royal College of GPs, said: "I am pleased that GPs and practice nurses are the health professionals girls would go to for information on HPV vaccination."

However, he issued a note of caution over both GPs' awareness of who was being offered the vaccine and the girls' understanding of whether they would be contacted by their surgery. "The results among GPs highlight the fact that the responsibility for vaccination was not placed with them," Dr Kassianos said. "The same is reflected in the girls' opinion as to which vaccination provider will call them. A degree of confusion is apparent."

Professor Peter Stern at Manchester University feels that education is key to getting the message to this hard-to-reach group. He says: "Given the results of this survey, it is apparent that GPs and other relevant healthcare professionals need to be adequately educated on HPV-associated cervical cancer and the benefits of vaccination, thus enabling them to be proactive in engaging with women who are not covered by the school-based HPV vaccination programme. This is likely to be an important mechanism for increasing the coverage of women protected against the most important risk factors associated with cervical cancer."

Despite the impact of Jade Goody's very public battle with the disease, 16–18 year-old girls outside the education system still lack awareness of the causes and risks of cervical cancer.

Practice nurses and GPs have a vital role to play in communicating with this group. They should not underestimate their strong influence on vaccination uptake, as they play a critical and expected cog in the wheel of vaccination for these girls.

Primary care health professionals should be reminded that they are needed specifically to tackle this group, and not assume that these girls will be contacted or advised about vaccination by other means. Communication from GP surgeries, via letters, is not only expected by many of these girls, but is the most effective way to improve awareness of cervical cancer and maximise vaccine uptake.

Breakdown of respondents

• 139 16-18-year-old girls
• Not currently at school or college (full/part time) for more than two days a week
• Not had the HPV vaccine
• Via computer-aided web interviews

Healthcare professionals
• 100 GPs
• 95 nurses
• Are, or will be, involved in the vaccination programme for cervical cancer in the UK
• Via computer-aided web interviews

Key themes
• Low awareness of the cause of cervical cancer and personal risk from cervical cancer by 16-18-year-old girls
• 71% of girls had heard about cervical cancer vaccination but in the qualitative market research this was seen as a school programme for 12-13-year-olds
• Mothers play a key role in providing healthcare advice
• 43% of GPs were unaware that all 12-18-year-old girls were being offered the vaccine
• Girls expect HCPs to contact them directly concerning vaccination

1. Cancer Research UK. Cervical cancer statistics and outlook. London: Cancer Research UK; 2008.

Survey reference:
May 2009.