1. JULY JOGC JUILLET 2010 l 679
GYNAECOLOGY
GYNAECOLOGY
The Acceptability of HPV Vaccination
Among Women Attending the University
of Saskatchewan Student Health Services
Christopher Giede, MD, FRCSC,1
Laura Lee McFadden, MD,2
Pam Komonoski, RN,3
Anita Agrawal, MD, MBBS, FRCSC,1
Ardelle Stauffer, MD,1
Roger Pierson, MS, PhD, FEAS, FCAHS1
1
Department of Obstetrics, Gynecology and Reproductive Sciences, University of Saskatchewan, Saskatoon SK
2
Department of Academic Family Medicine, University of Saskatchewan, Saskatoon SK
3
Student Health Centre, University of Saskatchewan, Saskatoon SK
Abstract
Objective: Women attending the University of Saskatchewan
Student Health Services are being offered human papillomavirus
(HPV) vaccination but are not filling their prescriptions. We sought
to identify gaps in knowledge of the link between HPV infection,
cervical dysplasia, and cervical cancer among women attending
the Student Health Services, and to identify barriers to HPV
vaccination among this cohort of women.
Methods: Women attending the University of Saskatchewan
Student Health Services for any reason were invited to complete
an 18-question survey. The survey included questions regarding
knowledge of the purpose of Pap smears, the role of HPV
infection in cervical dysplasia and cancer, and HPV vaccination.
The questions were designed to elicit both quantitative and
qualitative data. Data analysis included basic descriptive analysis
and summarization of qualitative data.
Results: Four hundred surveys were distributed, and 371 (91%)
were returned. Eighty-two percent of participants were aware of
the HPV vaccine, and 40% ranked their knowledge of HPV as
good or very good; however, only 6% correctly answered questions
about methods of preventing HPV infection. Participants identified
cost (62%), concerns over adverse effects (43%), and lack of
knowledge (36%) as barriers to undergoing vaccination. Comments
about the HPV vaccine reflected frustration with cost and concerns
about adverse effects. When participants were asked if they would
undergo vaccination if it were free, 60% responded “yes,” 31%
responded “maybe,” and 8% responded “no.”
Conclusion: The young women in our survey had significant gaps in
knowledge of HPV infection and prevention, and educational
programs must be structured to address these deficits. Institutions
promoting vaccination must deal with the barriers of cost and fear
of adverse effects.
Résumé
Objectif : Les femmes qui consultent les services de santé des
étudiants de l’Université de la Saskatchewan se voient offrir une
vaccination contre le virus du papillome humain (VPH), mais ne
donnent pas suite à leur ordonnance. Nous avons cherché à
identifier les lacunes en ce qui concerne les connaissances au
sujet du lien entre l’infection au VPH, la dysplasie cervicale et le
cancer du col utérin chez les femmes qui consultent les services
de santé des étudiants, ainsi qu’à identifier les obstacles à la
vaccination anti-VPH chez cette cohorte de femmes.
Méthodes : Les femmes qui ont consulté les services de santé des
étudiants de l’Université de la Saskatchewan pour quelque raison
que ce soit ont été invitées à remplir un sondage comptant
18 questions. Ce sondage comptait des questions au sujet des
connaissances sur l’objet des frottis de Pap, le rôle de l’infection
au VPH dans la dysplasie et le cancer du col utérin, et la vaccination
anti-VPH. Les questions étaient formulées de façon à permettre
l’obtention de données quantitatives et qualitatives. L’analyse des
données comptait une analyse descriptive de base et un résumé
des données qualitatives.
Résultats : Quatre cents sondages ont été distribués et 371 d’entre
eux (91 %) nous ont été retournés. Quatre-vingt-deux pour cent
des participantes avaient entendu parler du vaccin anti-VPH et
40 % estimaient que leurs connaissances au sujet du VPH étaient
bonnes ou très bonnes; cependant, seulement 6 % d’entre elles
ont répondu correctement aux questions portant sur les moyens
de prévenir l’infection au VPH. Les participantes ont identifié les
coûts (62 %), les préoccupations au sujet des effets indésirables
(43 %) et le manque de connaissances (36 %) comme étant des
obstacles à la vaccination. Les commentaires au sujet du vaccin
anti-VPH reflétaient une certaine frustration envers les coûts mis
en jeu et des préoccupations quant aux effets indésirables.
Lorsque nous avons demandé aux participantes si l’offre d’un
vaccin gratuit pouvait rendre la vaccination plus facile à accepter,
60 % ont répondu « oui »; 31 %, « peut-être »; et 8 %, « non ».
Conclusion : Dans le cadre de notre sondage, les connaissances
des jeunes femmes à l’égard de l’infection au VPH et de sa
prévention présentaient des lacunes significatives; les programmes
pédagogiques doivent donc être structurés de façon à redresser
cette situation. Les institutions faisant la promotion de la vaccination
doivent faire face aux obstacles que représentent les coûts et la
peur des effets indésirables.
J Obstet Gynaecol Can 2010:32(7):679–686
Key Words: Human papillomavirus, HPV, vaccine, acceptability,
barriers
Competing Interests: None declared
Received on October 31, 2009
Accepted on December 29, 2009

2. INTRODUCTION
Infection with human papillomavirus (HPV) has been
identified as the most significant factor in the development
of cervical cancer worldwide.1,2 In high-income countries,
the introduction of organized Pap smear screening programs
has led to a 50% to 80% reduction in cervical cancer rates.3
However, secondary prevention is costly.4 It is estimated
that three billion dollars are spent per year in the United
States on the treatment of HPV related disease.5
Two HPV vaccines targeting serotypes 16 and 18 have been
developed, leading to the possibility of primary prevention
of cervical cancer.6,7 The vaccines are currently indicated for
use in females aged nine to 26. In Canada, the Federal and
Provincial governments have been working together to
implement school-based HPV vaccination programs for
girls aged nine to 12 years.8,9 However, there are currently
no national plans for organized vaccination of other age groups.
The decision to fund vaccination of nine- to 12 year-old
females takes into consideration two important factors:
1. that maximum vaccine efficacy will be achieved by
vaccination prior to the onset of sexual activity, and
2. that the average age for onset of sexual activity is in the
mid- to late-teens.10 Such a policy is logical from a
public health perspective. However, on an individual
basis it leaves a large segment of the female population
having to decide for themselves whether or not HPV
vaccination is important and worth the cost.
Catch-up vaccination refers to “vaccination of females aged
13 to 26 who have not been previously vaccinated or who or
who have missed a vaccination.”10 Catch-up vaccination is
applicable to women who have not initiated sexual activity
as well as those who have. The prevalence of HPV infection
among this group of women ranges from 28% to 46% and
peaks at age 21.11–13 However, it is uncommon for women
to test positive for both HPV 16 and 18 DNA.14,15 Most
women in this group, including those who are sexually
active, will derive benefit from current vaccines. Therefore,
women in this vulnerable age group should not be
overlooked.
Since 2007, health care professionals at the University of
Saskatchewan Student Health Centre have engaged in an
effort to educate female students about the need for cervical
cancer screening and HPV vaccination. Catch-up vaccination
has been offered to women who have met the criteria for
vaccination at their request. However, initial enthusiasm
from students for vaccination has diminished, and very few
students currently request the vaccine. One hundred and
ten female students attended Pap smear clinics from
November 2007 to March 2008. Twenty-three students
requested a prescription for HPV vaccine, but only one of
those prescriptions was filled.
Acceptance of HPV vaccination is largely based on public
awareness of the importance of vaccination in general,
vaccine safety, and physician recommendations.16,17 Factors
that have had a negative effect on the acceptance of HPV
vaccine include cost.18,19 Financial support for women
requesting vaccination at the University of Saskatchewan
depends on individual health care plans. Many students
must pay $450 for the required series of three injections.
The objectives of our study were to assess the knowledge of
female students at University of Saskatchewan regarding
cervical dysplasia and HPV infection, and to determine
what factors were preventing acceptance of the HPV
vaccine. We hypothesized that multiple barriers such as
cost, fear of adverse effects, and lack of knowledge were
preventing women from undergoing HPV vaccination.
METHODS
An 18-item questionnaire was developed specifically for
this study. The questions were designed by a panel of five
individuals (two gynaecologic oncologists, one resident in
obstetrics and gynaecology, one family practitioner, and one
nurse practitioner). The last two individuals were practitioners
at the University Student Health Centre where the survey
was administered.
The questionnaire was designed to elicit both quantitative
and qualitative data (Appendix). Answers were provided in
list form for most questions and participants were asked to
circle the letter corresponding to their answer. Where
indicated, more than one answer was permitted. The
questionnaire was structured to gather information in the
following categories:
1. basic demographics;
2. attitudes regarding the importance of Pap smears and
self-assessment of knowledge regarding cervical
dysplasia, HPV, and vaccination;
3. actual knowledge regarding HPV infection and
prevention; and
4. barriers to vaccination. In addition, participants were
asked what they felt was the most important question
regarding HPV infection and whether they would
receive vaccine if it were free.
All women attending the Student Health Services for any
reason were invited to participate. Surveys were given to
potential participants as they registered for clinic appoint-
ments, with explanations from two volunteer public health
students. A letter describing the intent of the study, the
voluntary nature of participation, and assuring confidentiality
GYNAECOLOGY
680 l JULY JOGC JUILLET 2010

3. was attached to each survey. Participants understood that
consent was implicit when they completed and returned the
survey. Surveys were filled out while the participants were
waiting for their appointments. In addition, women attending
special Pap smear clinics at the Student Health Services and
a sexual health fair at the Aboriginal Students’ Centre were
invited to participate. Participants at the health fair were
able to fill out the surveys privately.
Completed surveys were returned in sealed envelopes and no
personal information was recorded. Following completion
of the survey, all participants were provided with an
information brochure prepared specifically for this study.
Distribution of 400 surveys was planned and completed.
Descriptive statistics and frequency of responses were
assessed using SPSS version 16 (SPSS Inc., Chicago, IL)
(quantitative data). Comments from participants were
examined for themes (qualitative data).
Ethics approval for the study was obtained from the University
of Saskatchewan Ethics Review Board.
RESULTS
Four hundred questionnaires were distributed and 371 (92.8%)
were returned over a two-month period (October and
November 2008). All returned questionnaires were filled
out completely and none were returned damaged. Most
questions had a response rate of greater than 98%, but the
question “What do you think the barriers are to your friends
having the vaccine?” had a 95% response rate, and the question
“If you think you do not need the vaccine, what is the
reason why?” had a 71% response rate.
Demographic data are summarized in Table 1. The average
age of the study cohort was 22 years (SD 3.7), and 61% were
university undergraduates. Forty-three percent of participants
had either one or no lifetime sex partners. Nine percent
gave a history of ever having a sexually transmitted infection
and 9% had had an abnormal Pap smear.
How participants ranked the importance of having yearly
Pap smears and how they perceived their knowledge of
cervical cancer screening and the role of HPV is shown in
Table 2. Knowledge of the purpose of having Pap smears
was ranked higher than knowledge of HPV. Eighty-three
percent of respondents stated they were aware of the
existence of an HPV vaccine prior to completing this
survey.
Few participants responded correctly when asked about
how HPV is spread and how it is prevented (Table 3).
Twenty-six percent chose the correct answers pertaining to
how HPV is infection is spread, and 6% chose the correct
answer regarding methods to prevent HPV infection.
The most commonly identified barriers to HPV vaccination
were:
1. cost (231/369; 62%),
2. concern over adverse effects (160/369; 43%), and
3. lack of knowledge (131/369; 36%) (Table 4).
Four percent of participants mentioned other barriers not
provided in our list of choices. When participants were
asked to identify why they did not need HPV vaccination,
264/371 (71%) responded. Of those respondents, 42%
stated that they did feel that they should receive the vaccine.
The most common reason given for not needing vaccination
was being in a monogamous relationship (32%). Eight percent
chose the regular use of condoms as a reason not to require
The Acceptability of HPV Vaccination Among Women Attending the University of Saskatchewan Student Health Services
JULY JOGC JUILLET 2010 l 681
Table 1. Demographic data
Median age (n = 368) 21 (SD 3.72)
%
Age distribution
< 20
20–23
24–26
> 26
27.8
35.8
25.3
10.5
Level of education
Completed high school
College undergraduate
University undergraduate
University graduate
8.4
10.5
61.2
19.9
Number of sexual partners (n = 371)
0
1
2–4
5–10
> 10
11.9
31.3
31.3
17.8
7.8
Frequency of Pap smears
Every year
Every 2 years
Every 3 years
Only when my doctor reminds me
Never
55.3
10.5
0.8
5.9
27.5
History of abnormal Pap smears
Yes
No
9
91
Smoking history
Yes
No
6.5
93.5
History of STD
Yes
No
9.2
90.8

4. vaccination. If offered the vaccine free, 60% of 368 respon-
dents stated that they would undergo vaccination, 31%
responded that they might, and 8% responded that they
would not undergo vaccination.
Participants provided 293 written responses. There were
97 comments associated with the question “What do you
think the barriers are to you receiving the vaccine?”;
20 comments associated with the question “What do you
think the barriers are to your friends receiving the HPV
vaccine?”; and 176 comments in response to “What is the
most important question you would like answered regarding
HPV infection?”
The following themes regarding barriers to having HPV
vaccination were identified:
1. lack of need (n = 31),
2. age-related effectiveness (n = 10),
3. concern over adverse effects (n = 9),
4. knowledge of vaccine effectiveness (n = 9),
5. vaccine effectiveness after having abnormal Pap
smears (n = 4), and
6. cost (n = 4).
Lack of need was identified as a theme that included the
following:
1. being in a monogamous relationship (n = 15),
2. not being sexually active (n = 16), and
3. already having had the vaccine (n = 5).
Fourteen of the 16 (88%) respondents describing themselves
as “not sexually active” had also identified themselves as
never having had a sexual partner. Parental views of vaccination
were mentioned in two comments. Several individuals
expressed concern over the promotion of the vaccine by
pharmaceutical companies.
The following themes were identified in the responses to
“What is the most important question you would like
answered in regards to HPV infection?”:
1. a desire for moreknowledgeregardingHPVinfection(n=66),
2. concerns regarding adverse effects of vaccination (n = 51),
3. questions regarding HPV vaccination other than
adverse effects (n = 41),
4. cost (n = 12),
5. age limitations of vaccination (n = 8), and
6. male vaccination (n = 6).
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682 l JULY JOGC JUILLET 2010
Table 2. Attitude towards Pap smears and participant’s
ranking of their knowledge regarding purpose of Pap
smears, cervical cancer, and HPV
%
Importance of yearly Pap smear
Very important
Important
Somewhat important
Not important
Don’t know
51.2
35.3
7.0
0.8
5.7
Perception of knowledge regarding purpose of
Pap smears and cervical cancer
Very good
Good
Fair
Poor
None
19.9
37.2
30.5
9.4
3.0
Perception of knowledge regarding HPV
Very good
Good
Fair
Poor
None
14.1
26.4
28.4
25.3
5.7
Aware of HPV vaccine prior to study
Yes
No
Maybe
82.7
10.0
7.0
Table 3. Participants’ knowledge regarding
acquisition and prevention of HPV infection
%
Methods by which one can become infected with HPV
Vaginal intercourse*
Anal intercourse*
Sexual touching*
Kissing
Toilet seats
All correct answers
98
70
40
5
5
26
Methods to prevent HPV infection
Avoidance of sexual intercourse*
Regular use
of condoms
HPV vaccination*
All of the above
Both correct answers
95.1
88.7
94.6
84.9
6.2
* Correct answers

5. Twelve comments were recorded regarding cost, including
one about the cost of vaccination not being covered by pro-
vincial health insurance.
DISCUSSION
The assumption that multiple barriers prevent women
attending our Student Health Services from undergoing
HPV vaccination was supported by the findings in this survey.
The primary barriers included cost, lack of knowledge, and
fear of adverse effects. Unexpected barriers identified by
our survey included the perception that vaccination is not
required in monogamous relationships or in relationships
where condoms are used regularly.
Cost was the barrier to HPV vaccination most often selected
by participants in our survey. Cost was also identified as a
barrier to HPV vaccination in two other Canadian
studies.17,19 A cost of $450 for a cancer preventive
intervention may be reasonable to individuals earning an
income, but is often unaffordable for students. In addition,
there appears to be an expectation that government
insurance should pay for such an important preventive
intervention. Such a view is not unique to Saskatchewan.
In a telephone survey conducted in Quebec, 91% of
respondents under the age of 25 stated they would undergo
HPV vaccination if it were publicly funded, but only 72%
would still elect to do so if they had to pay for it.19 In the
present study, only 60% of participants said they would
undergo vaccination if it were free. Our findings suggest
that more than just financial support is required to increase
vaccine uptake at our centre.
Our assessment of knowledge regarding cervical dysplasia,
HPV infection, and vaccination was limited. Nevertheless,
participants demonstrated significant gaps in knowledge
regarding HPV. Although most women who participated
were aware of the existence of an HPV vaccine, most
ranked their knowledge of HPV as fair or worse. Very few
correctly identified all the modes of HPV spread, and most
incorrectly chose condoms as a method of preventing HPV
infection. Lack of knowledge was a frequent choice among
the possible barriers to vaccination, and it was a common
theme when participants were asked what they felt was the
most important question to be answered regarding HPV.
The introduction of the first HPV vaccine in 2006 received
extensive media coverage.20 Multiple health organizations
developed educational material regarding HPV infection
and prevention and made this information available online.
The Society of Obstetricians and Gynaecologists of
Canada21, the British Columbia Cancer Agency,22 and
Health Canada23 all have web pages devoted to the topic.
Two HPV information brochures developed by the U of S
Student Health Services were made available in 2007 and
2008. We interpreted our findings to mean that this
information was not disseminated to those who need it the
most.
Vaccine safety is crucial to its acceptance by the public.16,24
In a survey of 259 college students in the United States,
74% said they would accept HPV vaccination in part
because they believed it to be safe.16 In contrast, concern
over vaccine safety was chosen as a barrier to vaccine accep-
tance by almost one half of the participants in our survey.
HPV vaccines have consistently been demonstrated to be
safe. Ongoing results from large vaccine trials are demon-
strating an excellent safety profile.25–28 In the United States,
the Centers for Disease Control and the Federal Drug
Administration have been closely monitoring adverse
effects potentially attributable to HPV vaccination through
the Vaccine Adverse Event Reporting System. To May 1,
2009, 24 million doses of vaccine had been distributed.
There were 13 758 reported adverse events, of which 7%
were considered serious,29 giving a serious adverse event
incidence of 0.004%. In spite of the evidence demonstrating
vaccine safety, media coverage of the HPV vaccine has been
The Acceptability of HPV Vaccination Among Women Attending the University of Saskatchewan Student Health Services
JULY JOGC JUILLET 2010 l 683
Table 4. Barriers to vaccination
%
Barriers for respondents (question 14) (n = 369)
Cost
Adverse effects
Lack of knowledge
Lack of need
No barriers
Other
62
43
36
12
8
11
Barriers for friends (question 15) (n = 362)
Cost
Adverse effects
Lack of knowledge
Lack of need
No barriers
Other
60
40
61
6
5
4
Reasons for not needing the vaccine (n = 264)
I do think I should receive the vaccine
I am not currently sexually active
I am in a monogamous relationship
We always use condoms
Other
42
23
32
8
1
Would receive vaccine for free (n = 368)
Yes
No
Maybe
60
8
31

6. fraught with controversy and has focused on reporting
adverse events.30,31
Low uptake of HPV vaccine may be due to a perception
that it is unnecessary. Monogamy, not being currently sexually
active, and regularly using condoms were all cited in our survey
as reasons why vaccination was not required. While the regular
use of condoms is promoted as a means of protection from
sexually transmitted illness, it does not guarantee the
prevention of HPV transmission; a meta analysis of 20 studies
on the ability of condoms to prevent HPV infection had
inconclusive results.32 A more recent prospective study of
82 female university students demonstrated a reduction in
rates of HPV infection when condoms were used regularly,
but not its elimination, (HPV incident infection was reduced
from 89.3 per 100 patient-years to 37.8 per 100 patient-
years).33 Regular condom use was described by almost 90% of
our participants as a means of preventing HPV infection.
Misinterpretation of the question pertaining to HPV pre-
vention may have contributed to this result. However, com-
ments pertaining to why participants felt they did not need
HPV vaccination also pointed to a belief that condom use
can prevent HPV infection. Regular condom use should not
be seen as a substitute for HPV vaccination in preventing
HPV infection. Educational programs must clarify this issue
and promote the regular use of condoms as a means of
reducing, but not eliminating, the risk of HPV infection.
More than one half of the participants in our survey felt that
they would not need HPV vaccination if they were either in
a monogamous relationship or not currently sexually active.
Unfortunately, neither of these states is guaranteed to prevent
HPV infection and cervical cancer. Individuals who have
had only one sexual partner are nevertheless potentially
exposed, through that partner, to an entire network of sexual
activity.34 Women initiating sexual activity with a male partner
have been found to have a one-year HPV incidence of 28.5%
and a three-year HPV incidence of 50%; the risk increases
proportional to the male partner’s sexual experience.35 Women
who have had only their husband as sexual partner have a
risk of developing cervical cancer that is directly related to
their husband’s number of sexual partners.36 In a case–control
study from India, women whose only sexual activity had
been with their husband had a relative risk of developing
cervical cancer of 6.9 (95% CI 2.3 to 20.7) if their husband
had had extramarital sexual activity both before and during
their marriage.37 Clearly, with the exception of ongoing
abstinence, a woman’s sexual practice cannot ensure
protection against HPV infection. Women declining HPV
vaccination must understand the significance of the
relationship between their risk of HPV acquisition and the
sexual experience of their lifetime male partners.
Our study had a number of limitations. Our questionnaire
may not have identified all barriers to HPV vaccination.
Providing participants with a list to choose from may have
resulted in an underestimation of the significance of barriers
not listed. In the United States, opposition to school-based
vaccination has been driven by parental concerns about the
sexuality of their adolescent children.38 It is possible that
more individuals in our survey would have selected religious
beliefs and/or parental opposition as barriers if these had
been among our listed choices.
Previous surveys on the acceptability of HPV vaccination
examined factors that could positively influence women’s
attitudes towards vaccination.16,17,39 A consistent finding
was the importance of physician recommendation. In contrast,
our survey was designed specifically to determine why
women were not filling prescriptions for the vaccine and
why there had been a drop off in prescription requests in
spite of extensive dissemination of information on HPV
vaccination. It is possible that at the time of our survey, an
increased public effort by anti-vaccine groups and negative
media coverage had contributed to concerns that outweighed
the recommendations of a health care professional. A recent
telephone survey in the United States pointed to an increase
in anti-vaccine group activity and public controversy over
the motives of the pharmaceutical industry as contributors
to poor vaccine uptake.37
Our study focused on potential barriers to catch-up
vaccination. The importance of catch-up vaccination cannot be
overstated. Current HPV vaccines target HPV 16 and 18,
the strains accountable for 70% of oncogenic HPV
infections.6,7 Vaccine efficacies against these strains are
greater than 90%.15,40–42 In addition, current vaccines provide
cross-protection against other oncogenic HPV strains.43
Catch-up vaccination is provided at the time in life when the
incidence of HPV infections is at its highest.11–13 Seventy
percent of individuals age 26 and under will still be HPV
naïve.10 For those who have already been exposed to one of
the two most common strains of oncogenic HPV, vaccines
will still provide protection from the other strain.10,14,15
Finally, the benefits of catch-up vaccination will be realized
much sooner than that of school-based vaccination.44
A plateau in the rate of significant cervical dysplasia in
women receiving vaccine was seen just 18 months after the
initiation of the quadrivalent HPV vaccine trial.27 This
equates to a decreased likelihood of requiring surgery that
could jeopardize fertility.45
Most individuals eligible for catch-up vaccination are
consenting adults, and if HPV vaccination is to be accepted
by this population it must be perceived as important.
In Australia, where catch-up vaccination has been publicly
funded since 2007, rates of vaccine uptake among 15- to
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684 l JULY JOGC JUILLET 2010

7. 26-year-olds was only been 58%.46 Insufficient knowledge,
dislike of injections and not believing in vaccination were
given by women as reasons for not undergoing vaccination.
Health care workers must be able to address these issues and
educate potential recipients about the benefits of vaccination.
CONCLUSION
We identified significant gaps in young women’s knowledge
regarding HPV infection, and prevention strategies must be
structured to address these gaps. Barriers such as cost and
fear of adverse effects must be addressed urgently if we
wish to vaccinate all of the eligible female population. Only
then can we maximize the potential for primary prevention
of cervical cancer.
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