In this study of drivers and barriers to young women's choices about HPV vaccination, a literature review, a telephone interview-based survey and interviews with focus groups were combined methodologically. This triangulation of methods was used to ensure the validity and reliability of the study in the sense that it built upon existing knowledge, it sought to answer the research questions quantitatively by means of the survey and qualitatively to obtain an in-depth understanding of women's considerations.
The telephone survey provided quantitative data about the women accepting and rejecting HPV vaccination, including how many of those who wished to be vaccinated actually started the vaccination series and information about the most important factors influencing women's acceptance or rejection. The strength of focus groups lies in the insights they provide into the social forces acting on individual understandings of the area of interest. Interviews with focus groups in this study have produced a multi-faceted view of the ways in which Danish women's considerations about HPV vaccination relate to broader socio-cultural perceptions of cancer, sexuality and norms of equal access to health care. However, the social control that characterise group interviews mean that focus groups are less suitable for producing data about individual lives or narratives; for example, atypical individual understandings may be under-reported in focus groups .
This is one of the first studies to be conducted after the quadrivalent HPV vaccine became readily available in Denmark. It sheds light on the relationship between intention and action and the balance of factors that can encourage or hinder the translation of the intention to be vaccinated into the action of initiating vaccination in this specific socio-cultural context. While we believe that the many of these results are likely to be relevant and applicable to other societies, this thorough analysis of what is at stake in Denmark implies that they may not all be directly transferable to other countries. Perceptions of illnesses and preventive measures are always related to the specific socio-cultural context and health care system - and in this case also the particular information campaign. Whether the results of this study can be transferred to other societies thus remains to be shown.
This survey showed that most young Danish women have heard of vaccination against cervical cancer, but nearly one in five has not yet decided whether they want to be vaccinated. More than half of the women interviewed by telephone said they wanted to be vaccinated, but only half of these had actually started or completed the vaccination series. Since earlier studies found in the literature review have pointed to a very high acceptance rate, internationally and in Denmark, this suggests that the difference between intention and action can be considerable. Approximately one third of the women interviewed by telephone rejected HPV vaccination, but the focus groups suggested that this picture could change, provided that the barriers to vaccination were addressed.
This study did not show any opposition to the HPV vaccine as such, and participants in the qualitative study all had positive views on vaccination against cervical cancer. This also mirrors the high level of vaccine acceptance reported in earlier studies. Our participants mostly considered HPV vaccination as a means to prevent cervical cancer, unsurprisingly, since this has been the focus of the Danish information strategy. The focus groups revealed that the actual risk of acquiring cervical cancer was not considered. However, as suggested by other studies [21, 24, 40], our results show that women who have previously and knowingly been exposed to HPV-related diseases, or who know of people who have had HPV-related diseases or cancer, tend to be more accepting of vaccination.
Knowledge about genital warts was very limited among the focus group participants. This finding is supported by a recent study in which only 0.7% of Danish women assigned HPV as the cause of genital warts . Thus this factor was not part of the women's consideration about HPV vaccination, although the fact that the vaccine could prevent 90% of cases of genital warts was seen as an additional benefit. Other studies have suggested that the information that the quadrivalent vaccine can prevent genital warts considerably increases men's acceptance of HPV vaccination , and our qualitative study indicates that the same effect might be observed for women.
Attitudes to the fact that HPV is transmitted sexually are highly dependent on the prevalent sexual morals in a society and need further investigation. In contrast to the results of some USA-based studies [11, 13, 16, 19–21], for example, Danish men and women do not consider the mode of transmission of HPV as a barrier to HPV vaccination. On the contrary, they found that the mode of transmission increased the relevance of HPV vaccination of both sexes . The present study also suggests that Danish women do not regard sexual abstinence before marriage as a realistic means of prevention of HPV infection.
The qualitative study confirmed earlier reports that Danish women's knowledge about HPV, cervical dysplasia and the properties of the HPV vaccine is generally poor. For example, in one study only 1.2% of Danish women were able to name HPV as the cause of cervical cancer . Our study reveals that most focus group participants were under the impression that HPV vaccination provides full protection against cervical cancer, if given before the start of sexual activity. It is important that this misconception be investigated further since, although it may promote the uptake of vaccination, it may also encourage a false sense of security, e.g. some focus group participants indicated that they would be less concerned by the risk of HPV infection after HPV vaccination, especially if they had concurrently received a negative smear-test result. This highlights the danger that HPV vaccination might reduce uptake of other preventive measures, such as use of condoms and participation in the cervical cancer-screening programmes, which should ensure the maximal public health benefit for HPV vaccination.
Most of the focus group participants who had rejected HPV vaccination said they would actually like to be vaccinated if they could be convinced of the benefits. The most important factors influencing rejection were uncertainty or ignorance of the benefits of vaccination after the onset of sexual activity and the cost, which many regarded as very high. This was a confirmation of the results of the Danish HTA showing that young women were not likely not be vaccinated if they were to pay for it themselves. Our qualitative study shows that the lack of knowledge was less important when the vaccine was paid for by someone else, but became a decisive factor when the young woman had to pay herself.
We report that parental advice and financial support is very important to young women's acceptance of HPV vaccination. Proactive mothers, in particular, had great power to persuade their daughters to take active steps towards vaccination. The survey showed that acceptance of vaccination was associated with a higher level of education of the parents, although it is impossible to say whether the choice was influenced by the parents' educational level or by the potential higher income. GPs tended not to initiate talks with the young women about HPV vaccination, but when they did, or were consulted for this reason, they could also significantly influence the woman's choice. In contrast, women in the survey whose primary source of information was the media tended to think that HPV vaccination was not relevant to them, that they were insufficiently informed and consequently more frequently rejected vaccination.
The high coverage of the free HPV-vaccination programme for girls aged 12-15 years in Denmark supports the finding that the cost is very important to women's acceptance of vaccination. The focus group participants in our study had great confidence in the Danish health authorities and inclusion of HPV vaccination in this programme was regarded as approval of the safety and effectiveness of the vaccine. Conversely, they considered the decision not to include or inform women above the age of 15 years as an indication that this vaccine was not medically recommended for older girls or women. Our study shows that the fact that HPV vaccination is optional for women over 15 years old raises questions in it self and provokes uncertainty that can result in rejection, even when these women or their parents are able to afford vaccination. As other studies have shown, Danish women have a strong expectation that their GP will inform them of any necessary preventive health care measures, such as HPV vaccination . In light of the relatively high cost of the vaccine, medical authorities and health-care professionals must disseminate clear recommendations and information about HPV vaccination targeted to young women who are already sexually active if such women, or their parents, are to be convinced of the benefits of vaccination and be willing to pay.