Acceptability of human papillomavirus vaccination among Chinese women: concerns and implications

Transcription

1 DOI: /j x Gynaecological oncology Acceptability of human papillomavirus vaccination among Chinese women: concerns and implications TTC Kwan, a KKL Chan, a AMW Yip, a KF Tam, a ANY Cheung, b SST Lo, c PWH Lee, d HYS Ngan a a Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology and b Department of Pathology, The University of Hong Kong, Hong Kong, China c The Family Planning Association of Hong Kong, Hong Kong, China d Division of Clinical Health Psychology, Department of Psychiatry, The University of Hong Kong, Hong Kong, China Correspondence: Dr HYS Ngan, Department of Obstetrics and Gynaecology, 6/F, Professorial Block, Queen Mary Hospital, Pokfulam, Hong Kong, China. hysngan@hkusua.hku.hk Accepted 15 September Objective To explore Chinese women s perceptions of human papillomavirus (HPV) vaccination and their intention to be vaccinated. Design A cross-sectional community-based survey study. Setting Thirteen community women s health centres of The Family Planning Association of Hong Kong. Sample A total of 1450 ethnic Chinese women aged 18 or above who attended the health centres. Methods Participants completed a written consent and an anonymous questionnaire onsite. Main outcome measures Knowledge and beliefs about HPV and HPV vaccination against cervical cancer and participants own intention to be vaccinated. Results About 38% of the participants (n = 527) had heard of HPV and 50% (n = 697) had heard of vaccination against cervical cancer. HPV infection was perceived to be stigmatising and detrimental to intimate, family and social relationships. Despite misconceptions and a grossly inadequate knowledge about HPV and HPV vaccination, 88% of the participants (n = 1219) indicated that they would likely be vaccinated. Majority of the participants believed that sexually experienced women should be vaccinated, while 27% opposed vaccinating sexually naive women. Younger age women who perceived a disruptive impact of HPV infection on intimate relationship and their partners approval were significantly associated with a positive intention to be HPV vaccinated. Conclusions The easy acceptability of HPV vaccination among the mostly sexually experienced Chinese participants and their knowledge deficit on the subject may implicate potential misuse of the vaccines and a false sense of security against cervical cancer. There is a dire need for culturally sensitive and tailored education for the public, women of different ages and their partners about HPV and HPV vaccination. Emphasis must be placed on the prophylactic nature of the current vaccines, the uncertain effects when given to sexually experienced women, the importance of adolescent vaccination and the need for continued cervical screening whether vaccinated or not. Keywords Beliefs, cervical cancer, Chinese women, HPV vaccination, knowledge. Please cite this paper as: Kwan T, Chan K, Yip A, Tam K, Cheung A, Lo S, Lee P, Ngan H. Acceptability of human papillomavirus vaccination among Chinese women: concerns and implications. BJOG 2009;116: Introduction Human papillomavirus (HPV) vaccination has generated hope for substantially lowering the incidence of cervical cancer. To achieve success in preventing cervical cancer, public acceptance of HPV vaccination and active participation of the target population are crucial. Past studies showed that HPV vaccination acceptability was generally positive among young women, parents and physicians. 1 4 However, most of the studies were conducted in the west on non-asian populations. Findings of these studies may have limited generalisability to Asians with diverse cultural beliefs, religious practice and family and social norms that are distinctively different from western societies. These differences may have contributed to the comparatively low cervical screening rate among Asian women in western countries as well as the disproportionately heavy disease burden of cervical cancer in Asia. 5,6 Yet, studies on the perceptions and acceptability of HPV vaccination among Asians, particularly those residing in Asia, were scarce and therefore much needed given the potential of this new ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology 501

2 Kwan et al. measure in drastically reducing the burden of cervical cancer in this region. In Hong Kong, the age-standardised incidence rate of cervical cancer was 7.8 per women in 2005, which was comparatively low in Asia but remained higher than other western countries. 5,7,8 Opportunistic cervical cancer screening had been in operation for the past few decades and a government initiated recall programme was started in 2004 to promote cervical screening. Screening is offered by both the public and private sectors on a fee-for-service basis and costs vary among care providers. In a government population household survey, women reported an ever-screened rate of 42%, which was low in comparison with many developed countries. 7,9,10 Age, screening costs, cultural norm of modesty and practitioner characteristics influenced Chinese women s participation in screening. 11,12 HPV vaccination has been made available since The quadrivalent and bivalent HPV vaccines have been licensed for use in female patients aged 9 26 and years, respectively. Locally, HPV vaccination is an individual choice for one s own benefit and the cost of vaccination is borne solely by the vaccine recipients. Promotion of HPV vaccination has been mainly through the media organised by the pharmaceutical industry with a primary focus on cervical cancer prevention. The objectives of this study were to assess Hong Kong Chinese women s knowledge and beliefs about HPV and HPV vaccination against cervical cancer and their intention to be vaccinated at this initial stage of introduction. Findings of the study would help to identify areas of concerns and needs regarding HPV vaccination among Chinese and other Asian populations that share similar oriental cultural heritage. Methods Participants and recruitment Ethnic Chinese women aged 18 years or above serviced by the Hong Kong Family Planning Association during the period of February to November 2007 were recruited. The recruitment sites included five birth control clinics, five women s clubs and three youth health centres distributed in locations throughout Hong Kong. All eligible women were given an information sheet containing details of the study by the centre staff. Participants were asked to complete a consent form and an anonymous questionnaire on site. Drop-in boxes were placed at each recruitment site to collect the completed consents and questionnaires. Institutional Review Board (IRB) approval from the Joint Board of Ethics of the University of Hong Kong/Hospital Authority Hong Kong West Cluster was obtained before commencement of the study. Questionnaire The questionnaire used in the study was developed by our research team based on findings from an earlier focus group study that had been published elsewhere. 13 The 13-page questionnaire was designed to collect data on women s knowledge, beliefs and health practice in six areas: (1) cervical cancer, (2) cervical cancer screening, (3) HPV infection, (4) HPV vaccination against cervical cancer, (5) sexual practice and (6) health status and demographics. Before this study, the questionnaire was tested in a pilot study with a convenient sample of healthy women. The participants were asked to complete the questionnaire twice at a 2-week interval. Test retest reliability was good for individual sections of the questionnaire (Spearman Brown coefficients ranged from to 0.966) and acceptable for the section measuring vaccination knowledge (Spearman Brown coefficient = 0.697). Past studies demonstrated that public awareness of HPV was low and the causal link between HPV infection and cervical cancer was poorly understood. 14,15 Our focus group study noted that local participants had no awareness of HPV and held a generally negative attitude towards vaccination against sexually transmitted diseases. 13 Since the current study s focus was primarily on cervical cancer prevention, we used the phrase vaccination against cervical cancer throughout the questionnaire to draw participants attention to this aspect of HPV vaccination, to reduce confusion and to enhance participants understanding of the questions. Knowledge measures In two separate sections, participants were asked (1) if they had heard of HPV and (2) if they had heard of vaccination against cervical cancer. Those who answered yes to (1) or (2) were directed to answer six HPV knowledge items and three vaccination knowledge items, respectively, each with choices of true/false/don t know (Figures 1 and 2). For questions on HPV knowledge, each correct answer received 1 score and each incorrect or don t know answer received 0 score. The sum of the items was obtained (possible score range of 0 to 6), with higher score indicating more knowledge. Facts about HPV and vaccination against cervical cancer (Box 1) were given on the questionnaire after the knowledge questions but before participants were asked to indicate their beliefs and intention to be vaccinated to ensure that participants had basic knowledge on the topics. Belief measures Participants were asked to imagine their partners likely responses in these two situations: (1) if participant was HPV infected (five items) and (2) if participant was to be vaccinated against cervical cancer (two items). There were five items asking if participants agreed with vaccinating the following groups of women: all women, all normal healthconscious women, sexually active women, women with multiple sexual partners and sexually naive women or girls. 502 ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology

3 Acceptability of HPV vaccination among Chinese women 100 Percentage a b c d e f Individual question on knowledge about HPV* Answered 'don't know' Answered incorrectly Answered correctly Figure 1. Frequency (%) data on knowledge of participants who had heard of HPV (n = 527). *Questions with true/false/don t know choices (T, true is the correct answer; F, false is the correct answer). a: a person may be infected with HPV, but not know it, (T); b: use of condom can totally prevent HPV, (F); c: HPV can be sexually transmitted, (T); d: only certain types of HPV cause cervical cancer, (T); e: Pap smear can detect if the body has the virus or not, (F); f: HPV can be cleared by treatment, (F). Measure of intention to be vaccinated Intention was measured by a single item: Vaccination against cervical cancer is now available, how likely is it that you will take the vaccine? (6-point Likert scale ranging from highly likely to highly unlikely) For analysis purpose, the responses were recoded as a dichotomous likely/unlikely variable in that a likely response indicated a positive intention to be vaccinated. Demographic measures Information on sociodemographic status, past sexual history, past cervical screening practice and smoking status was collected. Statistical analyses Descriptives of all variables were computed. Student s t test was used to compare the knowledge level of those who were likely to be vaccinated and those who were not. Logistic regression was applied to obtain the crude odds ratios of all demographic, belief and HPV knowledge variables in association with a positive intention to be vaccinated. Adjusted odds ratios of belief and HPV knowledge variables were subsequently obtained by adjusting for statistically significant demographic variables. Data analysis was performed using SPSS version P < 0.05 was considered statistically significant. Percentage i ii iii Individual question on knowledge about vaccination against cervical cancer* Answered 'don't know' Answered incorrectly Answered correctly Figure 2. Frequency (%) data on knowledge of participants who had heard of vaccination against cervical cancer (n = 697). *Questions with true/false/don t know choices (T, true is the correct answer; F, false is the correct answer). i: vaccination is a way to prevent cervical cancer, (T); ii: after vaccination, regular cervical cancer screening is not necessary, (F); iii: vaccination is 100% effective for preventing cervical cancer, (F). Box 1. Information about HPV and vaccination against cervical cancer given in the questionnaire Facts about HPV HPV are a group of viruses. Different HPV strains, through different transmission modes, cause different diseases such as genital warts and skin warts Some HPVs are called high-risk HPV because they are known to cause cervical cancer. These high-risk HPVs are mostly transmitted sexually Men or women may be infected with HPV, but not know it Facts about vaccination for cervical cancer prevention Vaccination helps raise the body s defence to fight against certain diseases, for example, vaccination against measles during infancy Vaccination against cervical cancer is now available. The vaccines help raise the body s defence against high-risk HPV, through which the risk of cervical cancer is decreased The current vaccines are 70% effective for preventing cervical cancer These are prophylactic vaccines; they should be given before high-risk HPV infection takes place ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology 503

4 Kwan et al. Results Table 1. Demographic characteristics of participants (n = 1450) Age (years) (36) (46) 50 and above 253 (17) Marital status Single 492 (34) Married/cohabited 884 (61) Divorced/separated/widowed 72 (5) Education Nil/primary 219 (15) Secondary/post-secondary 870 (60) College/university 360 (25) Monthly family income (Hong Kong dollars*) 10,000 and below 407 (30) 10,001 16, (29) 16,001 30, (26) 30,001 and above 195 (15) Ever had sex before Yes 1251 (88) No 171 (12) Age of first sex (years) 15 and below 35 (3) (42) (36) 26 and above 229 (19) Number of lifetime sexual partners (63) (16) (10) 4 and above 125 (11) Past cervical cancer screening Yes 1007 (72) No 397 (28) Smoking status Never smoke 1142 (84) Ex-smoker 121 (9) Current smoker 93 (7) *1 GBP HKD. A total of 1450 women participated in the study and the response rate was 84%. Most of the participants were below 50 years of age with secondary school education and sexually experienced monogamous women who had attended cervical screening before. Among the 397 never-screened women, 57% were sexually experienced, of whom 27% were over 30 years old. Participant characteristics are presented in Table 1. There were 527 women (38%) who indicated that they had heard of HPV and answered the six HPV knowledge questions (sum score: median = 2, mean = 2.46 [SD = 1.43]). Only about half of these women were aware of the sexually transmitted nature of the virus. About one-third knew that only certain HPV types caused cervical cancer. Many participants, however, mistakenly thought that HPV could be detected by Pap smear or cleared by treatment. There was no significant difference in the mean score of HPV knowledge (P = 0.821) between the likely and unlikely to be vaccinated groups. Of the 697 participants (50%) who had heard of vaccination against cervical cancer, 28% were not sure if the vaccines were 100% effective against cervical cancer and 6% erroneously thought so. With respect to the need for cervical screening after vaccination, 4% thought it unnecessary and 12% did not know. Frequency data on knowledge about HPV and vaccination are listed in Figures 1 and 2. Participants beliefs about HPV and vaccination against cervical cancer and their intention to be vaccinated are presented in Table 2. Nearly half of the participants perceived an adverse impact on their relationships with partner, family or friends if they were HPV infected. For 42% of the participants, the impact was considered serious enough to end their intimate relationship and 65% suspected that their current partner would likely be the cause of the infection. Majority of the participants believed that sexually active women or women with multiple sexual partners should be HPV vaccinated. Indeed, 80% thought that all women should be vaccinated. However, 27% of the participants did not agree with vaccinating sexually naive women. Most participants believed that their partners would approve of vaccination. Among the 1385 women who responded to the question on vaccination intention, 88% indicated a positive intention to be vaccinated against cervical cancer. Odds ratios of demographics, belief and HPV knowledge variables associated with a positive intention to be vaccinated are listed in Tables 3 and 4. Factors that were associated with a positive intention to be vaccinated included: below 50 years of age, age of sexual onset between 16 and 20 years, the belief that HPV infection might bring an end to intimate relationship and perceived family s and partner s approval of vaccination. Conversely, participants whose family income was over HK$30,000 or whose partner would disapprove of vaccination were significantly less likely to be vaccinated. Discussion For most of the participants, HPV was either unheard of or little known. The knowledge deficiency was consistent with past findings except that most of the other studies were conducted before the introduction of the HPV vaccines, whereas our participants had likely been exposed to promotional messages about the vaccines as shown by their greater awareness of cervical cancer vaccination However, awareness does not ensure actual knowledge. The findings that the majority of the participants agreed with vaccinating all women, sexually active women or women with multiple sexual partners 504 ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology

5 Acceptability of HPV vaccination among Chinese women Table 2. Participants beliefs about HPV and vaccination against cervical cancer and their intention to be vaccinated Disagree, Somewhat disagree, Somewhat agree, Agree, Who should be vaccinated against cervical cancer? All women 171 (13) 113 (8) 214 (16) 868 (64) Normal health-conscious women 174 (13) 75 (6) 204 (15) 908 (67) Sexually active women 128 (9) 57 (4) 176 (13) 994 (73) Women with multiple sexual partners 137 (10) 45 (3) 126 (9) 1043 (77) Women or girls who have never had sex 226 (17) 138 (10) 279 (21) 709 (52) Likely, Unlikely, If you are HPV infected The infection is likely from your current partner 801 (65) 433 (35) The relationship with your partner will end 493 (42) 668 (58) Partner will suspect you of infidelity 616 (50) 608 (50) Family will suspect you of sexual impropriety 672 (49) 702 (51) Friends will keep a distance from you 630 (46) 739 (54) Approve, Disapprove, No response, If you are to be vaccinated against cervical cancer Your partner s response 1097 (87) 55 (4) 104 (8) Your family s response 1021 (74) 133 (10) 219 (16) How likely is it that you will be vaccinated against cervical cancer? Very unlikely 21 (2) Unlikely 74 (5) Somewhat unlikely 71 (5) Somewhat likely 501 (36) Likely 501 (36) Very likely 217 (16) while about one-third of them opposed vaccinating sexually naive women reflected a general lack of understanding of the mechanism through which HPV vaccination may prevent cervical cancer. Current efforts to educate the public about HPV vaccination at this stage of its introduction are clearly inadequate. Although brief information had been provided in the questionnaire, the complex HPV cervical cancer relationship might remain difficult for participants to comprehend. After HPV-related information was given, a hypothetical HPV infection was perceived by many participants as stigmatising and detrimental to intimate, family and social relationships. The negative psychosocial impact of HPV infection has been reported in other studies and was associated with its perceived sexually transmitted nature. 17,18 It is possible that the repercussion of HPV infection will be intensified in Chinese or Asian communities where traditional oriental values dictate that women should be modest and chaste. Despite increasing sexual openness in the younger generation, lifelong monogamy is still highly valued and practiced by many as reflected by the large proportion of monogamous women in our study. 19,20 A positive diagnosis of the sexually transmitted HPV carries negative moral connotations. 18,21 A frequently asked question about HPV related to how and from whom one might get the virus. 22 This is a critical question faced by monogamous women and may create a potential crisis for their current relationship for there is no previous relationship to which the infection can be attributed. Thus, over half of the participants blamed their current partners. The fear of being stigmatised may prompt HPV-infected women to conceal their diagnosis and for those not infected, to avoid any occasions that may associate them with a sexually transmitted disease, including taking preventive action against it. 13 Comparatively speaking, young and middle-aged women and women who perceived a disruptive impact of HPV ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology 505

6 Kwan et al. Table 3. Associations between demographic variables of participants and a positive intention to be vaccinated against cervical cancer Unlikely to be vaccinated Likely to be vaccinated n (% within category) n (% within category) Odds ratio (95% CI) P Age (years), (9) 468 (91) 2.88 ( ), (11) 570 (89) 2.11 ( ), and above 49 (21) 181 (79) 1.00 Marital status Single 48 (10) 432 (90) 1.00 Married/cohabited 107 (13) 731 (87) 0.76 ( ) Divorced/separated/widowed 11 (17) 54 (83) 0.55 ( ) Education Nil/primary 30 (16) 162 (84) 1.00 Secondary/post-secondary 89 (10) 748 (90) 1.56 ( ) College/university 47 (13) 309 (87) 1.22 ( ) Monthly family income (Hong Kong dollars*) ,000 and below 36 (9) 347 (91) ,001 16, (12) 336 (88) 0.74 ( ) ,001 30, (11) 304 (89) 0.85 ( ) ,001 and above 34 (18) 159 (82) 0.49 ( ) Ever had sex before Yes 143 (12) 1066 (88) 1.16 ( ) No 23 (13) 148 (87) 1.00 Age of first sex (years) and below 1 (3) 34 (97) 6.41 ( ) (9) 452 (92) 2.03 ( ) (15) 355 (85) 1.10 ( ) and above 36 (16) 191 (84) 1.00 Number of lifetime sexual partners (14) 638 (86) (11) 162 (89) 1.28 ( ) (6) 117 (94) 2.65 ( ) and above 11 (9) 113 (91) 1.63 ( ) Past cervical cancer screening Yes 127 (13) 841 (87) 0.70 ( ) No 37 (9) 351 (91) 1.00 Smoking status Never smoke 144 (13) 981 (87) 1.00 Ex-smoker 13 (11) 108 (89) 1.22 ( ) Current smoker 4 (4) 88 (96) 3.23 ( ) *1 GBP HKD. infection on current intimate relationship were more likely to be vaccinated. In addition, perceived social norms, in particular responses of partner and family towards vaccination had a strong influence over participants intention to be vaccinated. Similar findings on the importance of significant others had been reported locally and from other countries on HPV vaccination or cervical screening Irrespective of sociodemographic background, past sexual experience, cervical screening history and level of knowledge about HPV, an overwhelming majority of all participants favoured vaccination against cervical cancer for themselves. The high acceptability might be related to the public awareness of cervical cancer as a common disease among sexually experienced women in consequence to the widespread media campaign promoting cervical screening. Sharing similar age and sexual characteristics, it is plausible that the participants viewed vaccination against cervical cancer of direct personal relevance to them. In addition, the concept of vaccination is well rooted and generally accepted by people in Hong Kong owing to the long-established population-based childhood immunisation programme. In a focus group study, Chinese mothers indicated that they and their children were used to receiving all 506 ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology

7 Acceptability of HPV vaccination among Chinese women Table 4. Associations between belief and knowledge variables and a positive intention to be vaccinated against cervical cancer with and without adjustment Unlikely to be vaccinated Likely to be vaccinated n (% within category) n (% within category) Unadjusted odds ratio (95% CI) P Adjusted odds ratio (95% CI)* P If you are HPV infected Infection is likely from your current partner Unlikely 56 (13) 368 (87) Likely 81 (10) 705 (90) 1.32 ( ) ( ) Relationship with your partner will end Unlikely 80 (12) 576 (88) Likely 44 (9) 443 (91) 1.40 ( ) ( ) Partner will suspect you of infidelity Unlikely 76 (13) 518 (87) Likely 57 (9) 548 (91) 1.41 ( ) ( ) Family will suspect you of sexual impropriety Unlikely 90 (13) 600 (87) Likely 73 (11) 589 (89) 1.21 ( ) ( ) Friends will keep a distance from you Unlikely 82 (11) 645 (89) Likely 80 (13) 541 (87) 0.86 ( ) ( ) If you are to be vaccinated,,0.001,0.001 your partner s response Disapprove 26 (48) 28 (52) 0.31 ( ) ( ) Approve 84 (8) 1010 (92) 3.41 ( ), ( ) No response 23 (22) 81 (78) If you are to be vaccinated, your family s response,0.001,0.001 Disapprove 33 (25) 100 (75) 1.20 ( ) ( ) Approve 69 (7) 949 (93) 5.43 ( ), ( ),0.001 No response 62 (28) 157 (72) HPV knowledge 1.02 ( ) ( ) *Adjusted for age, income and age of sexual onset. sorts of vaccines without knowing the detailed reasons. Women were willing to accept a vaccine as long as it was endorsed by the medical professional and that disease prevention was the purpose. 13 In weighing the costs and benefits of cervical cancer vaccination, monetary cost aside, women may deem vaccination a relatively small cost compared with the highly valued benefit of protection against a potentially life-threatening disease. The apparent easy acceptability of HPV vaccination among our mostly sexually experienced participants, especially among those who should be but have not been screened, raises concerns given their grossly inadequate knowledge and misconceptions about HPV and the HPV vaccines. On the one hand, vaccinating young adolescent girls may be delayed as a result of a lack of parental perceived need, thus compromising the effectiveness of HPV vaccination. On the other hand, the benefits of vaccinating older sexually experienced women are uncertain and vary depending on individual sexual practice and past HPV exposure. While prevaccination HPV testing is not recommended, 28 the real life effect of vaccinating older sexually active women is difficult to estimate. 29,30 If these women choose to be HPV vaccinated expecting vaccination to offer the same full protection for them as for young adolescent girls, it may lead to a false sense of security and a lowered vigilance against HPV and cervical cancer. In the long run, harm and litigation are possible when women are HPV vaccinated without a good understanding of the kind and level of protection they may possibly get. Implications There is a dire need for carefully worked out, tailored and targeted education on HPV and HPV vaccination for the Chinese community. The prophylactic nature of the HPV vaccines, the need for continued cervical screening for ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology 507

8 Kwan et al. sexually experienced women with or without HPV vaccination and the importance of vaccinating young adolescent girls need to be explicitly stated. 29,31 Stressing the need for continued screening is vital to prevent women from mistaking HPV vaccination as a substitute for cervical screening, as reflected by our never-screened participants enthusiasm towards vaccination. The emphasis on adolescent vaccination is crucial in settings like Hong Kong where the vaccines are fully paid by the recipients. To be HPV vaccinated, local adolescents rely on the financial support from their parents. This support will not be granted if parents do not see their children s need to be vaccinated against a disease perceived to be of little relevance to the adolescents. In view of this, healthcare professionals may need to take a proactive role to educate parents about the rationale of adolescent HPV vaccination. Past studies noted that medical professionals endorsement enhanced HPV vaccine acceptance among parents. 4,32 The national recommendations for HPV vaccination vary among countries and the targeted age ranges from 9 to 26 years. 30 Currently, there are no clinical contraindications against vaccinating women older than the recommended age. 30,31,33 The bivalent HPV vaccine has been licensed for use on women up to 45 years of age in Australia 29 and other countries may also follow. Medical professionals will likely encounter enquiries or requests from older sexually experienced women who want HPV vaccination for themselves even when they have to pay for it. It is important that medical professionals are kept up to date with the latest advances in HPV vaccination to meet their clients needs. Potential vaccine recipients should be made aware of the uncertain benefits and limitations of HPV vaccination on older sexually experienced women for them to make an informed choice. Individual client counselling may be preferred as age, health history and sexual practice will influence the likely benefit of HPV vaccination for each woman. Given the importance of normative reference on vaccination intention, educational intervention may also involve the partners of women who will be vaccinated or who are interested in being vaccinated. A fundamental problem with HPV is that it is perceived to be linked to culpable behaviour, leaving room for responsibility attribution and moral stigmatisation. This is highly likely in the relatively conservative and predominantly monogamous Chinese and Asian societies. Our findings showed Chinese women s perceived serious consequences of HPV infection. Similarly, accepting HPV vaccination for the prevention of a sexually transmitted infection (STI) may elicit suspicion or mistrust from others who think that there is no need for it if one is sexually proper. Therefore, it is possible that in public educational campaign, explicitly emphasising the sex-related aspect of HPV, cervical cancer and HPV vaccination may aggravate the stigma associated with HPV infection and possibly with cervical cancer and deter the uptake of HPV vaccination. Thus, clinical information, especially about the virus s origin and transmission and the purpose of HPV vaccination needs to be suitably framed and presented with discretion and cultural sensitivity. The challenge of HPV education lies in carefully balancing the dissemination of adequate and clinically accurate information with what is acceptable and what will likely backfire within the culture, and in fostering preventive behaviour without stigmatisation. HPV vaccination programmes will need to be very cleverly constructed and very persuasive if vaccination is going to be effective. Simply offering HPV vaccination is not enough as the public needs to be encouraged and persuaded about its use. On a macro level, cultural and religious barriers contribute to the high cervical cancer burden in many Asian countries. These barriers, coupled with poor scientific knowledge about cervical cancer and HPV, may pose difficulties for introducing HPV vaccination in these countries. The findings of our study exemplified these issues. Haphazard efforts to promote HPV vaccination will not be enough to overcome these difficulties. Governmental support of HPV vaccination programme on a population scale is much needed. Study strengths and limitations To our knowledge, this is the first large-scale study on Chinese women s perceptions of HPV and acceptability of HPV vaccination against cervical cancer. Our findings are limited by the study s cross-sectional design in that causal inferences cannot be made. In addition, study participants were recruited from the local women s health centres and most of them had attended cervical screening before which might be an indication of their willingness to participate in preventive health care. Women who do not share the same interest may have different perceptions about HPV vaccination. Yet, it is also likely that these nonscreened women will have even less knowledge about the subject. Nevertheless, findings of this study enriched our understanding of Chinese women s perceptions towards HPV vaccination and identified areas of caution and needs in its promotion especially in an opportunistic setting. Conclusion The majority of the mostly sexually experienced Chinese women in this study welcomed vaccination against cervical cancer and expressed an intention to be vaccinated themselves. Comparatively speaking, participants who were younger, who perceived a serious disruptive impact of HPV infection on intimate relationship or whose family or partner approved of HPV vaccination were more likely to be vaccinated. However, the easy acceptability was accompanied by misconceptions and a grossly inadequate knowledge about HPV and HPV vaccination, which may lead to a false sense of security against cervical cancer and compromised vaccine 508 ª 2009 The Authors Journal compilation ª RCOG 2009 BJOG An International Journal of Obstetrics and Gynaecology

9 Acceptability of HPV vaccination among Chinese women effectiveness as a result of delaying vaccinating adolescent girls. Culturally sensitive educational intervention is much needed and should be tailored to meet the specific information needs of the general public and women of different ages. Emphasis may be placed particularly on the prophylactic nature of the HPV vaccines, the optimal candidates for vaccination and the uncertain effects if given to older sexually experienced women. Disclosure of interests The authors declare that there are no conflicts of interest. Contribution to authorship All authors meet the criteria of authorship by contributing substantially to the design and implementation of the project, drafting and revising the manuscript and the approval of the final manuscript. Details of ethics approval IRB approval from the Joint Board of Ethics of the University of Hong Kong/Hospital Authority Hong Kong West Cluster was obtained before commencement of the study (IRB reference number: UW T/1358; date of approval: 16 October 2006). Funding This study was jointly funded by The Wong Check She Charitable Foundation and The Research Fund from the Department of Obstetrics and Gynaecology, The University of Hong Kong. Acknowledgments We thank The Family Planning Association of Hong Kong for their assistance in participant recruitment and Dr Daniel SY Ho for his invaluable advice. This study was jointly funded by The Wong Check She Charitable Foundation and The Research Fund from the Department of Obstetrics and Gynaecology, The University of Hong Kong. This project constituted part of the first author s master study at The University of Hong Kong. j References 1 Brabin L, Roberts SA, Farzaneh F, Kitchener HC. 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