Vaccine 31 (2013) 1051–1056

Contents lists available at SciVerse ScienceDirect

Vaccine
journal homepage: www.elsevier.com/locate/vaccine

Knowledge and awareness of HPV and the HPV vaccine among young women in
the first routinely vaccinated cohort in England
Harriet L. Bowyer a , Laura A.V. Marlow a , Sam Hibbitts b , Kevin G. Pollock c , Jo Waller a,∗
a
Cancer Research UK Health Behaviour Research Centre, Research Department of Epidemiology and Public Health, UCL, Gower Street, London, WC1E 6BT, United Kingdom
b
HPV Research Group, Institute of Cancer and Genetics, School of Medicine, Cardiff University, Cardiff, CF14 4XN, United Kingdom
c
Vaccine Preventable Diseases, NHS National Services Scotland, Health Protection Scotland, Cadogan Street, Glasgow, G2 6QE, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: A national school-based human papillomavirus (HPV) vaccination programme has been available for
Received 4 October 2012 12–13 year old females in the UK since 2008, offering protection against HPV types 16 and 18, which are
Received in revised form responsible for the majority of cervical cancer. Little is known about HPV knowledge in girls who have
11 December 2012
been offered the vaccine. Girls offered the school-based vaccine in the first routine cohort (n = 1033) were
Accepted 14 December 2012
recruited from 13 schools in London three years post-vaccination. Participants completed a questionnaire
Available online 28 December 2012
about HPV awareness, knowledge about HPV and the vaccine, and demographic characteristics includ-
ing vaccine status. About a fifth of the girls reported they were unaware of the HPV infection. Among
Keywords:
HPV infection
those who reported being aware of HPV (n = 759) knowledge was relatively low. Approximately half of
Knowledge the participants knew that HPV infection causes cervical cancer, condoms can reduce the risk of trans-
Adolescents mission and that cervical screening is needed regardless of vaccination status. These results are helpful
Vaccination in benchmarking HPV-related knowledge in vaccinated girls and could be used in the development of
Cervical cancer appropriate educational messages to accompany the first cervical screening invitation in this cohort in
the future.
© 2012 Elsevier Ltd. All rights reserved.

1. Introduction adult women surveyed were able to recognise HPV infection as a

In September 2008, a free national programme was introduced
in the UK offering 12–13 year old females a bivalent vaccination that
protects against the two high-risk types of human papillomavirus
(HPV) responsible for approximately 70% of cervical cancers [1].
Prior to vaccination all eligible girls are provided with an informa-
tion leaflet from the Department of Health, sent to their homes by
post. The leaflet includes information about the link between HPV
and cervical cancer, the sexually transmitted nature of HPV, the
need for three doses of the vaccine and the need to attend cervi-
cal screening in the future [2]. Most girls in the first routine cohort
were offered the vaccine at school (94.2%) within the UK [3]. Uptake
rates have been relatively high, with 84% of girls offered the vaccine
receiving all three doses in 2010/2011 in England [4] and similar
coverage in Scotland and Wales [5,6].
Prior to the introduction of HPV vaccination programmes,
awareness of HPV and its relationship with cervical cancer was low
in a variety of population groups, both in the UK [7–11] and else-
where [12]. Recently published data from the UK showed that a
year after the start of the programme, fewer than half (46%) of the
∗ Corresponding author. Tel.: +44 0 20 7679 5958; fax: +44 0 20 7679 8354.
E-mail address: j.waller@ucl.ac.uk (J. Waller).
risk factor for cervical cancer development [13]. Studies assessing
HPV knowledge in young females have generally focused on knowl-
edge prior to the introduction of the HPV vaccine [14], but it is also
important to assess the knowledge of those who have been involved
in the vaccination programme, as this could potentially have an
impact on future behaviours relating to sexual health and cervical
screening attendance. It has been suggested that HPV vaccination
could provide a ‘teachable moment’ for parents to discuss sex and
sexual health with their adolescent daughters [15,16]. Equally, it
could provide an opportunity to inform girls about cervical can-
cer and the recommendation to attend for screening when they
are invited (currently at 25 years in England; 20 years in Scotland
and Wales). With the time delay between HPV vaccination (12–13
years) and cervical screening attendance (20–25 years) it will be
important to reiterate these messages closer to the time of the first
screening invitation.
Little is known about HPV knowledge in girls who have been
offered the vaccine. A small body of qualitative research focusing on
vaccinated cohorts suggests that HPV knowledge is generally low.
These studies suggest that girls know little about how the human
papillomavirus is transmitted [17], how to reduce the risk of HPV
infection [18], or about the link between HPV and cervical cancer
[17,18]. Furthermore, girls are unclear about the level or duration
of protection the HPV vaccine offers [17–19] and lack knowledge

0264-410X/$ – see front matter © 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.vaccine.2012.12.038
1052 H.L. Bowyer et al. / Vaccine 31 (2013) 1051–1056
about the need for future cervical screening [17]. In one study
involving 87 girls, just over half were aware of cervical screening
and the need to attend in the future [18]. While these qualitative
studies have helped to map the range of girls’ knowledge after the
implementation of HPV vaccination programmes, larger quantita-
tive studies are needed in order to ascertain knowledge within a
representative sample. Previous studies in the US have shown that
vaccinated and unvaccinated girls have similar levels of knowledge
about HPV and the HPV vaccine [20,21]. Licht et al. [20] found that
regardless of vaccine status, respondents lacked knowledge about
the link between HPV and genital warts, HPV transmission and the
fact that HPV infection is as common in men as in women. The only
statistically significant difference in knowledge by vaccine status
was a greater awareness in those individuals who had received at
least one dose of the HPV vaccine, that HPV causes genital warts.
Caskey et al. [21] found that vaccinated respondents were more
likely to know that the HPV vaccine protects against cervical can-
cer, and that women who receive the HPV vaccine should continue
using condoms during sexual intercourse.
This study aimed to extend this research to the UK, using quan-
titative methods to examine knowledge about HPV and the HPV
vaccine, in girls based in London, England, three years after the
introduction of routine school-based vaccination.
2. Materials and methods
In September 2011, young women in school Year 11 (aged 15–16
years) were recruited from 13 schools in London, England. These
girls were part of the first cohort to have been offered the HPV vac-
cine in the NHS school-based vaccination programme in 2008–9. A
sampling frame was created using level of Free School Meal Eli-
gibility (FSME)1 and General Certificate in Secondary Education
(GCSE) attainment as indicators of socio-economic status (SES).
Schools were categorised as being above or below the national
average on each of these metrics (23% FSME [23] and 53% GCSE
(pupils attaining 5 A*–C grades including English and Maths [24])).
All government-funded (state) schools with female pupils and
reported HPV uptake within 10% of the national average [3] (n = 89)
were entered into the sampling frame.2 Schools in each cell of the
sampling frame were selected at random and contacted until the
target sample of 1000 participants was reached. Out of 89 schools,
19 (21%) refused to participate (primarily for reasons related to
scheduling difficulties) and 13 were included. The schools included
in the sample did not differ from the rest of those in the samp-
ling frame in terms of HPV uptake (2 (1,89) = 1.19, p = .276), FSME
(2 (1,89) = 3.63, p = .057) or GCSE attainment (2 (1,89) = 1.19,
p = .276).
One week before the study took place, parents of Year 11 girls
received an information sheet about the study, which included an
opt-out form; those that did not return the opt-out form to the
school implied consent.
Researchers visited the schools on a given day and all girls in
attendance were invited to complete the questionnaire (see Sup-
plement 1). In each classroom a researcher explained the purposes
and procedures of the study and all participants were given the
opportunity to read through an information sheet before comple-
ting the questionnaire. The questionnaire was then distributed to
all participants, with consent inferred from completion of the ques-
tionnaire. The questionnaires were completed in silence and upon
1
Children are eligible for free school meals if their parents are entitled to means-
tested welfare benefits from the UK government [22].
2
School-level data on uptake of HPV vaccine were only available for 162 out of
348 mixed/girls’ schools in London as Primary Care Trusts vary in whether they can
provide this information.
completion all participants received a debriefing sheet containing
further information about HPV.
Participants were asked about their date of birth, ethnicity and
religion. Household income was indexed by self-reported FSME
with individuals classified as ‘eligible’ or ‘not eligible’ for free school
meals. Participants’ awareness of HPV was assessed using the ques-
tion ‘Before today, had you heard of HPV?’; this question has been
used previously [25]. After a brief description of the vaccine, vac-
cine status was assessed by asking participants to tick a box that
best described them (response options: ‘I have had all 3 doses of the
HPV vaccine’; ‘I have had 1 or 2 doses of the HPV vaccine’; ‘I have
been offered the HPV vaccine but I haven’t had it’; ‘I have not been
offered the HPV vaccine’; ‘I don’t know’). Knowledge of HPV was
assessed in those who had heard of it using 21 statements about
HPV and the HPV vaccine and asking participants to rate them as
‘true’ or ‘false’ (there was also a ‘don’t know’ option). Items were re-
coded into responses that were ‘correct’, ‘incorrect’ or ‘don’t know’.
A total knowledge score was then derived for those with no more
than five out of 21 items missing (i.e. allowing for approximately
25% missing data) by summing the number of correct responses
(possible range 0–21). The knowledge measure has been subjected
to rigorous psychometric evaluation in population-based samples
[26]. The study was approved by the UCL research ethics committee
(ref: 0630/002).
2.1. Analysis
We used complex samples chi-square tests, clustering by school,
to examine demographic differences between girls who had heard
of HPV and girls who had not, and to examine demographic differ-
ences in HPV knowledge. Adjusting for correlation or clustering of
data within schools is needed to obtain unbiased tests of signifi-
cance. Analyses were performed using SPSS v20 [27].
3. Results
3.1. Sample characteristics
Over 98% of girls approached agreed to participate in the study
(n = 1033; see Fig. 1). Non-participation was either due to parental
(n = 5) or participant (n = 9) refusal to consent. Demographic charac-
teristics of the sample are shown in Table 1. All participants were 15
or 16 years old. Most were of White or Black ethnicity, were Chris-
tian or had no religious affiliation, and free school meal eligibility
was 27%, in line with national figures [23].
Individuals who had received at least one dose of the HPV
vaccine were coded as ‘vaccinated’ (n = 792/1033; 76.6%). This
included 71.2% who had received all three doses, and 5.4% who
had received 1–2 doses. A small number of girls reported that
they had not been offered the vaccine (n = 28). Of these, six indi-
cated in a subsequent open question that they had in fact refused
the vaccine, so these were coded as ‘unvaccinated’ along with 98
who responded that they had not been vaccinated (total ‘unvac-
cinated’ = 10.1% (104/1033)). Twenty-two girls who reported not
having been offered the vaccine,3 100 girls who did not know their
vaccine status and 15 girls with missing data (totalling n = 137)
were excluded from analyses of vaccination status.
3
We excluded these respondents as their answers suggested that they were either
not living in the UK at the time the vaccine was offered, or that their responses were
unreliable – all 12-13 year old girls in England should have been offered the vaccine
in 2008.
 H.L. Bowyer et al. / Vaccine 31 (2013) 1051–1056 1053

Offered quesonnaire
(n=1047)

Refused to
parcipate
(parent=5;
parcipant=9)

Completed
quesonnaire (n=1033)

Missing data for

HPV awareness
(n=8)

Awareness analysis
(n=1025)

Aware of HPV (n=819) Unaware of HPV

(n=206)

Missing data for Excluded: >5

knowledge missing items on
items (n=50-66) knowledge
measure (n=60)

Knowledge item Knowledge score

analysis (n=753-769) analysis (n=759)

Fig. 1. Recruitment and sample size for each analysis.

Table 1
Chi-square associations (clustering by school) between demographic factors and awareness of HPV (n = 1025a ).

HPV aware n (row %) HPV unaware n (row %) 2 clustering by school (p-value)

All (n = 1025) 819 (80.0) 206 (20.0)

Age (Mean, SD, t-test) (n = 993) 15.8 (0.3) 15.8 (0.3) 163.21 (.691)

Ethnicity (n = 1015) 7.53 (.247)

White (n = 443) 351 (79.2) 92 (20.8)
Black (n = 244) 201 (82.4) 43 (17.6)
Asian (n = 193) 162 (83.9) 31 (16.1)
Other (n = 135) 98 (72.6) 37 (27.4)
Missing (n = 10) 7 (70.0) 3 (30.0)

Religion (n = 1022) 3.09 (.439)

Christian (n = 478) 388 (81.2) 90 (18.8)
None (n = 277) 212 (76.5) 65 (23.5)
Muslim (n = 199) 163 (81.9) 36 (18.1)
Other (n = 68) 53 (77.9) 15 (22.1)
Missing (n = 3) 3 (100.0) –

Self-reported FSMEb (n = 894) 0.13 (.780)

No (n = 616) 490 (79.5) 126 (20.5)
Yes (n = 278) 224 (80.6) 54 (19.4)
Missing (n = 131) 105 (80.2) 26 (19.8)

Vaccine status (≥1 dose) (n = 890) 12.26 (.017)

Vaccinated (n = 787) 683 (86.8) 104 (13.2)
Unvaccinated (n = 103) 76 (73.8) 27 (26.2)
Missing (n = 135) 60 (44.4) 75 (55.6)
a
Missing data means that the n varies between analyses.
b
Free School Meal Eligibility.
1054 H.L. Bowyer et al. / Vaccine 31 (2013) 1051–1056

Table 2
Responses to knowledge items from sub-sample who had heard of HPV (n = 753–769)a .

Correct na (%) Incorrect na (%) Do not know na (%)

HPV knowledge items

HPV can be passed on during sex 538 (70.3) 36 (4.7) 191 (25.0)
Having many sexual partners increases the risk of getting HPV 480 (63.1) 40 (5.3) 241 (31.7)
Using condoms reduces the risk of getting HPV 440 (57.6) 55 (7.2) 269 (35.2)
HPV can be passed on by genital skin-to-skin contact 423 (55.4) 97 (12.7) 243 (31.8)
HPV can cause cervical cancer 404 (53.1) 46 (6.0) 311 (40.9)
A person could have HPV for many years without knowing it 396 (52.4) 29 (3.8) 331 (43.8)
HPV is rare (F) 269 (35.0) 90 (11.7) 410 (53.3)
There are many types of HPV 238 (31.3) 70 (9.2) 452 (59.5)
Having sex at an early age increases the risk of getting HPV 227 (29.9) 136 (17.9) 397 (52.2)
HPV can be cured with antibiotics (F) 224 (29.6) 84 (11.1) 449 (59.3)
Men cannot get HPV (F) 209 (27.5) 201 (26.5) 349 (46.0)
HPV always has visible signs or symptoms (F) 200 (26.1) 144 (18.8) 423 (55.1)
HPV can cause genital warts 177 (23.2) 68 (8.9) 517 (67.8)
HPV can cause HIV/AIDs (F) 142 (18.7) 170 (22.4) 448 (58.9)
Most sexually active people will get HPV at some point in their lives 132 (17.5) 202 (26.7) 422 (55.8)
HPV usually does not need any treatment 29 (3.8) 449 (59.0) 283 (37.2)

HPV vaccine knowledge items

HPV vaccines require three doses 257 (69.8) 20 (2.6) 208 (27.5)
Girls who have had the HPV vaccine do not need cervical screening (a smear or 399 (52.7) 41 (5.4) 317 (41.9)
Pap test) when they are older (F)
The HPV vaccine offers protection against most cervical cancers 354 (46.9) 42 (5.6) 359 (47.5)
Someone who has had an HPV vaccine cannot develop cervical cancer (F) 269 (35.7) 97 (12.9) 387 (51.4)
The HPV vaccine is most effective if given to people who have never had sex 236 (31.3) 97 (12.8) 422 (55.9)

F = Correct answer is ‘false’. For all other items, correct answer is ‘true’.
a
n varies slightly between items because of missing data.

3.2. Awareness of HPV
Eight girls had missing data for the question on HPV aware-
ness, leaving a sample of 1025 for analysis. Overall, 819 (80%)
respondents had heard of HPV, while 20% (n = 206) had not (see
Fig. 1). There were no statistically significant differences between
those who had heard of HPV and those who had not in terms of
ethnicity (2 (3,1015) = 7.53, p = .247), religion (2 (3,1022) = 3.09,
p = .439) or self-reported FSME (2 (1,894) = 0.13, p = .780). How-
ever, vaccinated participants were statistically significantly more
likely to have heard of HPV than unvaccinated participants (2
(1,890) = 12.26, p = .017).
3.3. HPV knowledge
Of the 819 participants who were aware of HPV, between 753
and 769 responded to each of the 21 items assessing knowledge
about HPV and the vaccine (see Table 2). Only three items were
answered correctly by over 60% of respondents – that HPV can
be passed on during sex (70.3%), that having many sexual part-
ners increases the risk of getting HPV (63.1%) and that the vaccine
requires three doses (69.8%). For nine of the items, the most fre-
quent response was ‘don’t know’. Only half (52.7%) knew that it is
not true that girls who have been vaccinated will not need screening
in the future.
A total knowledge score was calculated for 759 participants
with complete data for at least 16 out of 21 items on the knowl-
edge measure (i.e. <25% missing data). The mean total score
(pro-rated for those with missing data) was 8.30 (SD = 4.77) out
of a possible score of 21. Participants were divided into ‘high’
and ‘low’ knowledge groups using a median split. A total of 430
(56.7%) were classified as having low knowledge of HPV (0–9 cor-
rect responses) and 329 (43.3%) were classified as having high
knowledge (10–20 correct responses). There were no statisti-
cally significant differences between those with high and those
with low HPV knowledge in terms of ethnicity (2 (3,755) = 7.53,
p = .705), religion (2 (3,756) = 1.24, p = .690), self-reported FSME
(2 (1,662) = 0.11, p = .752), or vaccine status (2 (1,708) = 0.001,
p = .974)(see Table 3).
4. Discussion
This study is the first, to our knowledge, to use quantitative
methods to measure awareness and knowledge of HPV in a cohort
of girls who have been offered the HPV vaccine in the UK. Three
years after being offered the HPV vaccine in school as part of the
national programme in England, girls in our sample, 77% of whom
reported having received at least one vaccine dose, demonstrated
low HPV knowledge. A fifth of our respondents reported that they
had not heard of HPV, which may reflect the fact that the vaccine has
been widely publicised as ‘the cervical cancer vaccine’ rather than
the HPV vaccine, in the British media [28]. Although HPV and its
link with cervical cancer development are described in the Depart-
ment of Health information materials provided prior to vaccination,
the focus is on cervical cancer prevention [2]. When we asked girls
who had heard of HPV to respond to true/false statements about
HPV and the vaccine, the mean number of correct responses was 8
out of 21. This suggests that our sample overall had low levels of
knowledge about HPV and the HPV vaccine, supporting previous
studies assessing HPV knowledge among adult women in the UK
[7–11].
Our findings are consistent with previous qualitative and quan-
titative work demonstrating confusion about HPV infection and
the HPV vaccine, uncertainty about protection offered and lack of
awareness about the need for future cervical screening [17–19].
Information covering these areas was provided in a leaflet pub-
lished by the Department of Health [2], but it seems that three years
on, girls had retained relatively little of the detail. There is some lit-
erature identifying problems with information provision; evidence
from the US suggests that the information physicians provide about
HPV and the vaccine can be limited [29], and research conducted
in Belgium found that patients seek HPV-related information on
the internet, even after speaking to their health care provider [30].
In the school-based programme in the UK, information provision
relies primarily on a written leaflet rather than interactions with
 H.L. Bowyer et al. / Vaccine 31 (2013) 1051–1056
Table 3
Chi-square associations (clustering by school) between demographic factors and HPV knowledge (n = 759)a .
n (row %) with low knowledge
All (n = 759) 430 (56.7)
Ethnicity (n = 755)
White 191 (57.2)
Black 104 (58.1)
Asian 79 (52.0)
Other 53 (58.9)
Religion (n = 756)
Christian 202 (56.4)
None 115 (57.5)
Muslim 87 (58.8)
Other 25 (50.0)
Self-reported FSMEb (n = 662)
No 254 (55.5)
Yes 116 (56.9)
Vaccine status (n = 708)
Vaccinated 349 (55.0)
Unvaccinated 40 (54.8)
a
Missing data means that the n varies between analyses.
b
Free School Meal Eligibility.
health professionals, and little is known about what nurses deliv-
ering the vaccine tell girls as they are being vaccinated.
It seems surprising, nevertheless, that only half of the respon-
dents were aware that HPV can cause cervical cancer. It is important
that adolescents understand why they are being offered the HPV
vaccine to ensure uptake remains high; research into HPV-related
information provision and communication in the UK would help
assess whether more effective communication prior to, and at the
point at which the vaccine is offered is necessary. Only half of the
respondents were aware that cervical screening is still necessary
following vaccination. Cervical screening in England is not offered
until 25 years of age and so it may be premature to offer school-
aged children information on cervical screening. However, it does
highlight that healthcare providers should be aware of the need to
communicate effectively regarding HPV infection, the HPV vaccine
and cervical screening with young women as they approach the
screening age. It was encouraging to see that almost a quarter of
girls knew that HPV infection could cause genital warts, although
our participants had been offered the bivalent vaccine, which does
not protect against genital warts. Encouraging schools to discuss
HPV infection, the HPV vaccine and cervical cancer within personal,
social, health and economic (PHSE) education lessons might be a
way to integrate knowledge about HPV into broader health-related
issues.
The study benefited from a large sample size including girls from
a range of ethnic and socioeconomic backgrounds, and the use of a
validated measure of HPV knowledge. However the study is limited
in that it was carried out in London and so the generalizability of
the results to other parts of England or the UK is uncertain. We
used self-report to measure vaccine status, which limits the reli-
ability of the measure and our definition of vaccine status focused
on initiation rather than completion of the three-dose course. The
large amount of missing data suggests that recalling vaccination
after three years is problematic for some adolescents. Lastly, there
was a large amount of missing data for free school meal eligibility
(our marker of SES), which may have impacted the results.
5. Conclusions
Despite having been offered the HPV vaccine three years pre-
viously as part of the national HPV vaccination programme in
England, a significant proportion of girls in this study reported
being unaware of HPV. Those who were aware of HPV had low
1055
n (row %) with high knowledge 2 (p-value)
329 (43.3)
1.73 (.705)
143 (42.8)
75 (41.9)
73 (48.0)
37 (41.1)
1.24 (.690)
156 (43.6)
85 (42.5)
61 (41.2)
25 (50.0)
0.11 (.752)
204 (44.5)
88 (43.1)
0.01 (.974)
286 (45.0)
33 (45.2)
knowledge about the virus, the vaccine and the need for future
screening. Our study provides a benchmark of knowledge about
HPV and its relationship with cervical cancer development in a vac-
cinated cohort, which could be used in developing health education
materials to support future uptake of the routine cervical screening
programme.
Acknowledgements
This work was carried out as part of a Cancer Research UK project
grant (A13254, PI Professor John Edmunds). We are grateful to the
schools that worked with us to facilitate data collection and the
girls who took part in the study.
Conflict of interest: All authors declare no conflict of interest that
may have influenced this work.
Author contributions: JW conceived of the study. HB and JW col-
lected the data for the study. HB, LM and JW contributed to the
analyses of the study and all authors contributed to the interpreta-
tion of results and the writing of this paper and have approved the
final draft.
Appendix A. Supplementary data
Supplementary data associated with this article can be
found, in the online version, at http://dx.doi.org/10.1016/j.vaccine.
2012.12.038.
References
[1] Cuzick J, Castanon A, Sasieni P. Predicted impact of vaccination against human
papillomavirus 16/18 on cancer incidence and cervical abnormalities in women
aged 20–29 in the UK. Br J Cancer 2010;102(5 (March)):933–9.
[2] Department of Health. Your guide to the HPV vaccination. http://www.dh.
gov.uk/prod consum dh/groups/dh digitalassets/documents/digitalasset/dh
124484.pdf (accessed: 13.11.2012).
[3] Department of Health. Annual HPV vaccine uptake in England: 2008/2009.
http://www.dh.gov.uk/prod consum dh/groups/dh digitalassets/@dh/@en/
@ps/documents/digitalasset/dh 111676.pdf (accessed: 22.04.2012).
[4] Department of Health. Annual HPV vaccine coverage in England in 2010/2011.
https://www.wp.dh.gov.uk/immunisation/files/2012/03/120319 HPV
UptakeReport2010-11-revised acc.pdf (accessed: 22.04.2012).
[5] Information Services Division. HPV immunisation uptake statistics. http://
www.isdscotland.org/Health-Topics/Child-Health/Publications/2012-09-25/
2012-09-25-HPV-Uptake-Report.pdf?22234743834 (accessed: 27.09.2012).
[6] Public Health Wales Vaccine Preventable Disease Programme. Vac-
cine uptake in children in Wales. http://www2.nphs.wales.nhs.uk:8080/
VaccinationsImmunisationProgsDocs.nsf/3dc04669c9e1eaa880257062003b24
1056 H.L. Bowyer et al. / Vaccine 31 (2013) 1051–1056
6b/ed0ea73f2e3beb6280257a2200519f55/$FILE/Cover2011-2012.pdf
(accessed: 1.09.2012).
[7] Waller J, McCaffery K, Forrest S, Szarewski A, Cadman L, Wardle J. Awareness
of human papillomavirus among women attending a well woman clinic. Sex
Transm Infect 2003;79(4 (August)):320–2.
[8] Waller J, McCaffery K, Wardle J. Beliefs about the risk factors for cervical cancer
in a British population sample. Prev Med 2004;38(6 (June)):745–53.
[9] Marlow LAV, Waller J, Wardle J. Public awareness that HPV is a risk factor for
cervical cancer. Br J Cancer 2007;97(5 (August)):691–4.
[10] Pitts M, Clarke T. Human papillomavirus infections and risks of cervical cancer:
what do women know? Health Educ Res 2002;17(6 (December)):706–14.
[11] Goldsmith MR, Bankhead CR, Kehoe ST, Marsh G, Austoker J. Information and
cervical screening: a qualitative study of women’s awareness, understanding
and information needs about HPV. J Med Screen 2007;14(1):29–33.
[12] Klug SJ, Hukelmann M, Blettner M. Knowledge about infection with human
papillomavirus: a systematic review. Prev Med 2008;46(2 (February)):87–98.
[13] Low EL, Simon AE, Lyons J, Romney-Alexander D, Waller J. What do British
women know about cervical cancer symptoms and risk factors? Eur J Cancer
2012;48(16 (November)):3001–8.
[14] Brewer NT, Fazekas KI. Predictors of HPV vaccine acceptability: a theory-
informed, systematic review. Prev Med 2007;45(2–3 (August)):107–14.
[15] McRee AL, Gottlieb SL, Reiter PL, Dittus PJ, Tucker HC, Brewer NT. Human
papillomavirus vaccine discussions: an opportunity for mothers to talk with
their daughters about sexual health. Sex Transm Dis 2012;39(5 (May)):
394–401.
[16] Askelson NM, Campo S, Smith S, Lowe JB, Dennis LK, Andsager J. The birds, the
bees, and the HPVs: what drives mothers’ intentions to use the HPV vaccina-
tion as a chance to talk about sex? J Pediatr Health Care 2011;25(3 (May)):
162–70.
[17] Robbins SCC, Bernard D, McCaffery K, Brotherton J, Garland S, Skinner SR. Is can-
cer contagious? Australian adolescent girls and their parents: making the most
of limited information about HPV and HPV vaccination. Vaccine 2010;28(19
(April)):3398–408.
[18] Hilton S, Smith E. 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 2011;29(26 (June)):4409–15.
[19] Henderson L, Clements A, Damery S, Wilkinson C, Austoker J, Wilson S. ‘A false
sense of security’? Understanding the role of the HPV vaccine on future cervical
screening behaviour: a qualitative study of UK parents and girls of vaccination
age. J Med Screen 2011;18(1):41–5.
[20] Licht AS, Murphy JM, Hyland AJ, Fix BV, Hawk LW, Mahoney MC. Is use of
the human papillomavirus vaccine among female college students related
to human papillomavirus knowledge and risk perception? Sex Transm Infect
2010;86(1 (February)):74–8.
[21] Caskey R, Lindau ST, Alexander GC. Knowledge and early adoption of the HPV
vaccine among girls and young women: results of a national survey. J Adolesc
Health 2009;45(5 (November)):453–62.
[22] Department for Education. Free school meals eligibility criteria. http://www.
education.gov.uk/schools/pupilsupport/pastoralcare/a00202841/fsmcriteria
(accessed: 5.11.2012).
[23] The Poverty Site. Concentrations of poor children. http://www.poverty.org.uk/
19/index.shtml#def (accessed: 27.07.2012).
[24] The Telegraph. 2010 KS4 school league tables. http://schools.tmg.daltonfirth.
co.uk/results/ks4/2010/by/REGCODE.LEA (accessed: 27.07.2012).
[25] Jain N, Euler GL, Shefer A, Lu P, Yankey D, Markowitz L. Human papillo-
mavirus (HPV) awareness and vaccination initiation among women in the
United States, National Immunization Survey-Adult 2007. Prev Med 2009;48(5
(May)):426–31.
[26] Waller J, Ostini R, Marlow LA, McCaffery K, Zimet G. Validation of a measure
of knowledge about human papillomavirus (HPV) using item response theory
and classical test theory. Prev Med 2012;(November).
[27] IBM. SPSS Statistics for Windows (version 20.0) [Computer Program] IBM
Corp. Armonk, NY. Available from: http://www-01.ibm.com/software/uk/
analytics/spss/. 2011
[28] BBC. Q&A: the cervical cancer vaccine. http://news.bbc.co.uk/1/hi/health/
6223000.stm (accessed: 13.11.2012).
[29] Goff SL, Mazor KM, Gagne SJ, Corey KC, Blake DR. Vaccine counseling: a con-
tent analysis of patient-physician discussions regarding human papilloma virus
vaccine. Vaccine 2011;29(43 (October)):7343–9.
[30] Verhoeven V, Baay MF, Baay PE, Lardon F, Van RP, Vermorken JB. Everything
you always wanted to know about HPV (but could not ask your doctor). Patient
Educ Couns 2010;81 (October)(1):101–5.