Table 1 Evidence for key behavioural determinants that the EDUCATE package is trying to address

Lower HPV vaccination uptake among young people from BAME & more deprived backgrounds

1. Low levels of understanding about the HPV vaccine among some young people

Patel H, Jeve Y, Sherman S, Moss E. Knowledge of human papillomavirus and the human papillomavirus vaccine in European adolescents: a systematic review. Sexually transmitted infections. 2016 Sep 1;92(6):474–9

Overall European adolescents had poor understanding of basic HPV and HPV vaccine knowledge

Female adolescents are more likely to have heard of HPV and the HPV vaccine compared to males

Age, higher education, and a positive vaccination status were also associated with increased awareness

Prue G, Shapiro G, Maybin R, et al. Knowledge and acceptance of human papillomavirus (HPV) and HPV vaccination in adolescent boys worldwide: a systematic review. J Cancer Policy 2016;10:1–15

Globally adolescent males have poor knowledge of HPV and HPV vaccination

Adolescent male knowledge of HPV is lower than their female peers

Fisher H, Evans K, Ferrie J, Yates J, Roderick M & Audrey S. Young women’s autonomy and information needs in the schools-based HPV vaccination programme: A qualitative study. BMC Public Health 2020; https://doi.org/10.1186/s12889-020-09815-x

Reliance on leaflets to communicate information led to unmet information needs for young women and their families

Almost all study participants were supportive of increasing provision of age-appropriate information for young women about the HPV vaccine. Face-to-face methods of communication were favoured

Batista Ferrer H, Trotter CL, Hickman M, et al. Barriers and facilitators to uptake of the school-based HPV vaccination programme in an ethnically diverse group of young women. J Public Health 2016;38:569–77

A few of the unvaccinated young women said they had not heard about the HPV vaccine in the school setting

Literacy and language difficulties undermine informed consent and may prevent vaccination

Davies C, Skinner SR, Stoney T, et al. ‘Is it like one of those infectious kind of things?’ The importance of educating young people about HPV and HPV vaccination at school. Sex Educ 2017;17:256–75

Many young people have limited or no understanding of the vaccines they receive, including the HPV vaccine, or the diseases they are intended to prevent

2. Reluctance to be vaccinated among young people because of fear of receiving the vaccine

Fisher H, Evans K, Ferrie J, Yates J, Roderick M & Audrey S. Young women’s autonomy and information needs in the schools-based HPV vaccination programme: A qualitative study. BMC Public Health 2020; https://doi.org/10.1186/s12889-020-09815-x

If young people are allowed to consent, some may be more likely to refuse because of fear related to being vaccinated

Lack of priority or reluctance to receiving the HPV vaccine meant that young women could intercept the consent process, because they forgot about or misplaced the parental consent form

Bernard D, Cooper Robbins S, McCaffery K, Scott C & Skinner S. The domino effect: adolescent girls' response to human papillomavirus vaccination. Med J Aust. 2011. 194(2011), pp.297–300

Fear of HPV vaccination was a near universal experience among adolescents in the school setting and was often associated with significant distress that had an adverse impact on the vaccination process

Sotiriadis, A., Dagklis, T., Siamanta, V., Chatzigeorgiou, K., Agorastos, T., & LYSISTRATA Study Group. Increasing fear of adverse effects drops intention to vaccinate after the introduction of prophylactic HPV vaccine. Archives of Gynecology and Obstetrics. 2012: 285(6), 1719–1724

The proportion of women rejecting vaccination for safety concerns increased significantly after the introduction of the vaccine, coinciding with isolated cases of negative publicity and highlighting the potential of misinformation by the media

Chantler, T., Letley, L., Paterson, P., Yarwood, J., Saliba, V., & Mounier-Jack, S. (2019). Optimising informed consent in school-based adolescent vaccination programmes in England: a multiple methods analysis. Vaccine, 37(36), 5218–5224

In situations where an adolescent did not want to be immunised, nurses would ‘go with the young person’ even if parents had provided consent. In cases where it was evident that the student was fearful, they would book a clinic appointment

3. Lack of autonomy in decision-making & consent procedures by young people

Batista Ferrer H, Trotter CL, Hickman M, et al. Barriers and facilitators to uptake of the school-based HPV vaccination programme in an ethnically diverse group of young women. J Public Health 2016;38:569–77

The majority of vaccinated young women indicated that decisions were made by their parents, or with other adults, irrespective of their own perspective

However, the accounts of two young women implied that they had been instrumental in ensuring that they had received the HPV vaccine after missing vaccination in the school setting

Fisher H, Evans K, Ferrie J, Yates J, Roderick M & Audrey S. Young women’s autonomy and information needs in the schools-based HPV vaccination programme: A qualitative study. BMC Public Health 2020; https://doi.org/10.1186/s12889-020-09815-x

Where parental consent, either through paper-based consent forms or verbally, had been obtained, it was rare for young women to exercise autonomy and refuse the vaccination during the session

Perceptions of adults as the decision-makers and targets for information, undermined opportunities for young women to be fully informed about the HPV vaccine and be involved in decisions affecting their health

Paterson, P., Mounier-Jack, S., Saliba, V., Yarwood, J., White, J., Ramsay, M., & Chantler, T. Strengthening HPV vaccination delivery: findings from a qualitative service evaluation of the adolescent girls’ HPV vaccination programme in England. Journal of Public Health. 2019

Non-returned consent forms may not have been given to parents

Students would sometimes turn up to immunisation sessions without a completed consent form

Chantler, T., Letley, L., Paterson, P., Yarwood, J., Saliba, V., & Mounier-Jack, S. (2019). Optimising informed consent in school-based adolescent vaccination programmes in England: a multiple methods analysis. Vaccine, 37(36), 5218–5224

The majority of parents (70%) said that they automatically (on receipt of the consent form) consented for their child to be immunised, with only a third of young people being involved in this decision-making