Does HPV vaccination affect women's attitudes to cervical cancer screening and safe sexual behaviour?
Highlights
► We assessed the attitudes of HPV vaccine recipients and non-recipients. ► Vaccinated women held more positive attitudes to practicing safe sexual behaviour. ► Knowledge of cervical screening guidelines was extremely poor.
Introduction
The Human Papillomavirus (HPV) vaccine inoculates against the strains of HPV that cause 70% of cases of cervical cancer. HPV vaccination followed by regular cervical cancer screening is estimated to reduce lifetime risk of cervical cancer by 94% [1], highlighting that it is the combination of vaccination and screening that provides the best protection against this disease. In 2007, Australia was the first country to introduce a quadrivalent prophylactic HPV vaccine, Gardasil®, providing a unique opportunity to monitor the impact of vaccination on cervical screening rates. It is recommended that Australian women are screened every two years, starting when they turn 18, or two years after they first have sexual intercourse, whichever comes later. Although this guideline does not differ for women vaccinated with Gardasil®, between 1996 and 2008 rates of screening in Australia steadily declined, with the most prominent decrease evident amongst women aged 20–25 years old [2]. This age group has the lowest uptake (45%) of cervical screening in Australia [3] despite having the highest detection rates of cervical abnormalities [4]. It is therefore important to determine reasons for the decline in screening, and ensure it is not related to HPV vaccination.
There is a paucity of research regarding the impact of HPV vaccination on the uptake of screening, as the literature has predominantly focussed on factors influencing uptake of the vaccine [5], [6], [7]. The existing Australian research indicates that for a small but important proportion of women, cervical screening is of low priority after vaccination. In a recent qualitative study, the majority of girls aged 12–16 interviewed believed they were fully protected against cervical cancer after receiving the vaccine [8]. Another quantitative study utilising a sample of 159 unvaccinated female university students aged between 18 and 27 found that 19% viewed screening as being of low importance following vaccination [6]. The main limitation of research to date is the lack of direct comparison between vaccinated and unvaccinated women, to determine whether potential complacency towards screening is related to vaccination status.
It is currently unclear whether vaccinated young women are aware of screening guidelines and the continued need to screen. Qualitative studies using focus groups identified that young girls had poor knowledge of specific guidelines for screening commencement and frequency following HPV vaccination [8], [9], [10]. However, these studies assessed girls who would not require screening for several years.
International research has offered more insight into the impact of vaccination on health protective behaviour. In line with Australian findings of Cooper Robbins et al., two UK qualitative studies also identified low awareness that cervical screening is necessary following vaccination, as many girls believed the vaccination offered full protection against cervical cancer [9], [10]. To date, only one quantitative study compared rates of screening of vaccinated and unvaccinated women. This study assessed post-vaccination behaviour in a population based telephone survey of 760 German women aged between 14 and 65 [11]. Contrary to the aforementioned findings, Kuitto and colleagues found that vaccination uptake was positively correlated with participation in cervical screening, suggesting that women choosing to receive the vaccine had a positive attitude to preventative health that may promote uptake of cervical screening. However, 77% of the German participants were aged 27 and older, and therefore were not in the age bracket of interest (20–24 years) of recently vaccinated women via the school based vaccination programme and those for which rates of screening in Australia have been dropping.
More so than complacency to cervical screening, HPV vaccine literature has highlighted parents’ fears that vaccinated girls may engage in more risky sexual behaviour, such as earlier sexual debut, and an increase in unprotected sex and number of partners [12], [13], [14]. However, to date, only one study has directly assessed the potential impact of HPV vaccination on sexual behaviour. This study utilised a sample of unvaccinated adolescents and identified that a small but important proportion of teenage girls (20%) reported that they would be less concerned about protecting their sexual health after HPV vaccination [13].
The current study was designed to address limitations from previous research by utilising a sample of women aged between 18 and 30 in order to:
- 1.
Investigate whether women who have received the HPV vaccine report
- (a)
lower perceived vulnerability to cervical cancer
- (b)
less motivation to undergo regular cervical screening
- (c)
lower uptake of cervical screening and increased likelihood of engaging in unprotected sexual behaviour, compared to women who have not been vaccinated.
- (a)
- 2.
Assess levels of knowledge about cervical screening guidelines among vaccinated and non-vaccinated women.
To our knowledge, this is the first quantitative study to directly compare vaccinated and unvaccinated women's intentions to participate in cervical screening and attitudes to sexual behaviour.
Section snippets
Participants
Participants were female students (18–30 years) enrolled in the Psychology course at the University of Sydney, recruited via an online advertisement. All 1304 female students in the first year Psychology cohort were exposed to the advertisement. The vaccinated group included women who had received at least one dose of the HPV vaccine, and the unvaccinated group involved women who had not received any dose. Of 212 students initially recruited (16% of the eligible cohort), 19 did not complete the
Results
Table 1 provides an overview of the sample demographic characteristics. The mean age of participants was 19 (range 18–30). Over half of the sample (54%) identified as Australian, with the next most common ethnicity being North-East Asian (15%). More than a third of participants (40%) were Christian, and the same proportion reported being non-religious. Just over half of participants (55%) reported being sexually active, although only 32% had been sexually active for two years or more (i.e.
Discussion
Although the HPV vaccine has the potential to reduce the prevalence of cervical cancer, it is important to ensure that vaccination does not have detrimental effects on cervical screening and other health behaviours. In this educated sample, vaccinated women did not differ significantly from unvaccinated women on levels of perceived vulnerability to cervical cancer, intention to undergo cervical screening, uptake of cervical screening or likelihood of engaging in safe sexual behaviour.
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