https://orcid.org/0000-0002-2428-6707
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Abstract
High-risk strains of Human Papillomavirus (HPV) can lead to the development of a number of cancers including cervical, vulvar, penile, anal and oropharyngeal. HPV vaccination programmes offer the HPV vaccine to males and females 12–13 years old in schools throughout the UK. However, knowledge of HPV remains low in post-primary schools. The aim of this study is to capture 15–16 year old students’ perceptions regarding the current provision of HPV education, and whether providing HPV education to 15–16 year olds could influence their intention to be vaccinated and/or future sexual health decisions related to HPV. Between 5th November 2021 and 6th May 2022, seven focus groups were conducted with 34 students in post-primary schools in Northern Ireland, United Kingdom. The data was analysed using the COM-B behaviour model to explore the perceived facilitators and barriers impacting students’ ability to protect themselves from acquirement of HPV. Students perceived their knowledge of HPV to be poor and supported the addition of comprehensive mandatory HPV education at 15–16 years old when many of them were becoming sexually active. They identified barriers including lack of parental education, school ethos and religion and insufficient education regarding their legal rights to self-consent to HPV vaccination. Students felt that removal of these barriers would lead to safer sexual practices, increased awareness of the importance of HPV screening and increased HPV vaccination uptake. The recommendations provided by students need to be supported by the Education Authority in conjunction with the Department of Health in order to be successfully implemented into the post-primary school curriculum.
Citation: Flood T, Hughes CM, Wilson I, McLaughlin M (2024) Applying the COM-B behaviour model to understand factors which impact 15–16 year old students’ ability to protect themselves against acquirement of Human Papilloma virus (HPV) in Northern Ireland, UK. PLOS Glob Public Health 4(4): e0003100. https://doi.org/10.1371/journal.pgph.0003100
Editor: Siyan Yi, National University of Singapore, SINGAPORE
Received: August 11, 2023; Accepted: March 18, 2024; Published: April 17, 2024
Copyright: © 2024 Flood et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: Data collected from the small focus groups within this study contain vulnerable populations. The sharing of focus group excerpts would violate the agreement to which the participants consented. Data requests may be e-mailed to the NHS Research Ethics Committee quoting IRAS ID 287358 at surreyborders.rec@hra.nhs.uk.
Funding: This work was supported by a grant allocated to Terri Flood, one of the researchers involved in this study. The grant was provided by the College of Radiographers, UK, through the CoRIPs Research Grant fund, grant number 189. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. None of the authors received a salary from any funder.
Competing interests: The authors have declared that no competing interests exist.
1. Introduction
In the UK, the impact of sexually transmitted infections (STIs) remains greatest in young people aged from 15–24 years old [1]. By the end of 2022, many STIs had returned to the high levels reported in 2019 prior to the coronavirus (COVID-19) pandemic [1]. Genital warts are the most common viral STI diagnosed in the UK and are largely caused by human papillomavirus (HPV) [2]. As well as genital warts, high risk HPV strains can lead to the development of a number of cancers including cervical, vulvar, penile, anal and oropharyngeal through oral sex, anal sex or vaginal sex [3]. HPV, unlike other common STIs like gonorrhoea, chlamydia, and syphilis, can be prevented through administration of vaccines. HPV vaccination has been introduced into at least 111 countries globally as part of national immunisation programmes [4]. In 2008, the UK introduced HPV vaccination into a post-primary school-based immunisation programme for females aged 12–13 years old [5]; in 2019 the programme was extended to males, 12–13 years old [6]. Specialist public heath trust nurses called Immunisation Nurses (IMNs) deliver this immunisation programme in post-primary schools [7]. IMNs must have minimum education and training standards to qualify as an IMN in the UK [8], with many IMNs also having a post-graduate qualification in public health [9].
Since the introduction of the HPV immunisation programme, cervical cancer rates in the UK have fallen by 87% [10]. This has been partially attributed to high HPV vaccination uptake throughout the UK [10] pre-COVID-19, with 82–84% of females receiving at least one HPV vaccine in the 1st year of post-primary school in 2018–2019 academic school year in England, Scotland and Northern Ireland (84% in Wales in 2019–2020) [11–14]. Despite the majority of legal COVID-19 restrictions ending in March 2022 [15], uptake has remained lower for females than pre-COVID levels with 1st year 1st dose completion rates for the academic year 2021–2022 of 74.3% in NI [16], 69.6% in England [12] and 77.5% in Scotland [17]. Equivalent male uptake rates were even lower being 67.3% in Northern Ireland [16], 62.4% in England [12], 69.6% in Scotland [17]. Wales public data reported 2022–23 1st dose in 1st year uptake of 12.3% in Wales (all genders) increasing to 69.1% in year 2 of school (72.8% in girls and 65.6% in boys) [18]. This pattern aligns to the sharp declines observed in immunisation rates globally since the COVID-19 pandemic [19].
This decline in HPV vaccination uptake may be due to multiple complex factors [20]. At the beginning of the pandemic, the World Health Organisation (WHO) advised postponement of immunisation programmes to enable IMNs to focus on administration of COVID-19 vaccines [19]. This has created a backlog of immunisations placing additional workload pressures on IMN teams [21]. IMNs report that provision of education around HPV vaccines in the UK is sub-optimal due to the limited time provided for them to educate students and their guardians [18]. While difficult to establish at this early point in time, post-COVID, changes in parental attitudes to vaccination may be influencing HPV vaccination rates. Temsah et al.’s 2021 study [22] conducted in Saudi Arabia found that 45.3% of the population was vaccine hesitant compared to 20% reported in a similar pre-COVID 19 2019 study [23]. Concern about the COVID-19 vaccine may also prompt concern about other vaccines fuelled by unregulated and often misleading social media information [20]. Studies indicate that online negative HPV vaccine video content is more popular than positive video content [24–26]. A Gallup poll from 2022 reported that 38% of people now have no trust in news media, a record high, and are receiving their health information from social media platforms [19]. Given the recent drop in HPV vaccination rates throughout the UK and the issues related to the trustworthiness of information, it is essential to ensure that students and parents are receiving the correct information in order to make decisions regarding HPV.
Studies indicate that the average age of first sexual intercourse in many European countries and the UK is 15–17 years old [27–29] with a significant number of adolescents engaging in unprotected oral sex [30] at a younger age, prior to vaginal intercourse [31]. While adolescent females’ knowledge of HPV has improved since the introduction of the HPV vaccine in schools, adolescent knowledge of HPV in general, remains suboptimal [32–34]. A recent UK study reported that only 25% of university students were aware of the link between oropharyngeal cancer and HPV [33], despite the sharp rise of oropharyngeal cancer worldwide [33, 35], surpassing the rates of cervical cancer in the US [36]. In fact, young people often perceive themselves as having low risk for acquiring STIs compared to other population groups [37].
Northern Ireland has a unique divisive political history and remains a deeply religious society consisting of mainly Catholics (46%) and Protestants (44%) [38–40]. This religious division is reflected throughout Northern Ireland in geographical location, employment and even sporting activities [40]. The majority of schools are religiously segregated into Catholic schools or state schools, attended mainly by Protestants [40]. Less than five percent of the school population attend integrated schools (schools with no religious affiliation) [40]. Despite this division, both Catholic and Protestant churches agree on many aspects related to the morality of sex, stressing abstinence before marriage and instilling a sense of shame and denial, particularly in regard to same-sex relations [41, 42]. Consequently, Northern Ireland’s culture is often described as being ‘morally conservative toward sexuality, reproduction, and sexual health education’(p19) [43] in comparison to other areas of the UK. Strong religious backgrounds, like those typically seen in Northern Ireland, have been shown to influence condom use, sexual initiation and sexual acceptance [44–46]. Religion has also been shown to be associated with HPV uptake [46–48] with one recent study indicating that highly religious young adults demonstrate lower knowledge of HPV and have lower HPV vaccine uptake compared to less religious young adults [48]. Other factors that have been found to influence HPV vaccine uptake include socioeconomic background and gender [34, 49] with HPV vaccination uptake being generally lower in males compared to females and lower in less affluent populations [50].
Consequently, for this multitude of reasons, providing additional education at a later age (15–17 years old) could provide an opportunity for adolescents to understand their HPV vaccination status and the HPV strains they are protected against. This would also be an opportunity for students who are 16 years old or above and students deemed Gillick competent [14], to self-consent to the vaccine without the need for parental consent. A person under 16 years old can be considered Gillick competent in the UK if they demonstrate a clear understanding of the HPV vaccine and potential consequences of HPV vaccination [51]. In Northern Ireland, if deemed Gillick competent, a young person can legally consent to the HPV vaccine without parental consent [52].
HPV education, to improve knowledge in this age range, has typically been delivered by a professional with a nursing, healthcare or medical background [53]. In some parts of the UK, school nurses have acquired postgraduate qualifications in health promotion/public health and could potentially also be an option for delivery of this HPV education [54, 55]. However, school-based nurses are often part-time or non-existent in schools and there is considerable variety in practice throughout the four countries of the UK [54, 55]. In Northern Ireland, a Christian charity called ‘Love for Life’ also provides some relationship and sexuality education when requested by post-primary schools [56]. While ‘Love for Life’ has delivered education in over 75% of post-primary schools, facilitators are not specifically from healthcare backgrounds and therefore focus is more on promoting healthy relationships rather than health education [56].
This study aims to explore 15–16 year old students’ perceptions in Northern Ireland regarding whether providing HPV education at this age could influence their intention to be vaccinated and/or future sexual health decisions related to HPV. Students’ responses will be captured using Mitchie’s Behaviour Change Wheel (BCW) [57], which is a well-established theoretical framework and has been central to the design of numerous interventions related to sexual health including sexual counselling [58], condom use [59] and the use of sexual health services by university students [60]. The BCW framework incorporates the Capability, Opportunity, Motivation, Behaviour (COM-B) model which is a theoretical model for understanding behaviour [57]. The Theoretical Domains Framework (TDF), which can be thought of as an extension of the COM-B model, sub-divides each COM-B category further. Michie et al. [57] describes the 14 TDFs as ‘a synthesis of 128 explanatory constructs from 33 theories of behaviour change’ (p9). See Fig 1 for cohesion of COM-B model and TDF domains. This model suggests that students’ decisions about protecting themselves against HPV is influenced by their perception of their capability, opportunity and motivation. Utilisation of the COM-B model will help to identify potential barriers faced by students and enable the identification of practical measures to facilitate their decision-making regarding protection against acquirement of HPV.
2. Method
A qualitative approach utilising focus groups was the method chosen for this study as focus groups have been established as being an excellent way to elicit exploratory information ‘concerned with how people make meaning from their experiences in the world’ (p924) [61]. They are less time-consuming compared to one-to-one interviews and the interactions between participants in the group can generate an extensive amount of rich data [61, 62]. Studies indicate that teenagers prefer focus groups to individual interviews as they provide a more relaxed, less intimating environment, enabling their peers to be around them to offer additional support [63, 64].
Using the Department of Education’s list of 193 post-primary schools [65], stratified random sampling was chosen to ensure representation of schools of different religions, socioeconomic backgrounds and genders as these are all factors which have been found to influence HPV vaccine uptake [34, 47, 49, 66]. An online randomizer [67] was used to select a range of schools representing variation in religion, gender and socioeconomic backgrounds. Subsequently, the selected post-primary schools in Northern Ireland were contacted with the aim of conducting focus groups with diverse groups of students. Through e-mail contact, Head of Schools were asked to pass on details of the study to any teachers that they thought might have students who would be interested in participating in the study. Once the teacher made contact with the research team, a short information session was held either via Microsoft teams or face-to-face to provide the students with information about the study. Participant information sheets and consent forms were provided to students at this time. Contact information for the researchers was provided to enable teachers, parents or students to ask questions to the researchers prior to consenting to the study. Students were asked to co-sign the consent form with one of their guardians if they consented to be part of the study and return to their teacher one week after the information session. After consent, a Qualtrics link requesting demographic data, was distributed to the students by their teacher to complete prior to participation in the focus group. Students were eligible to participate in the face-to-face focus groups if they were a student in year 12 (15–17 years old) in a post-primary school in Northern Ireland. Consent was confirmed prior to each of the focus groups for participation in and recording of the focus group.
One of the researchers, who held a post-graduate Qualitative Practical Skills Workshop Certificate through Ulster University, facilitated all focus groups while a second postdoctoral researcher in the team, observed and took notes. All four researchers involved in this study identified as female. To optimize the dynamics in each focus group, the researchers aimed to include 4–8 participants per group [68]. Guest et al. (2017) [69] suggest that 4–6 focus groups are likely to yield 90% of all potentially arising themes and therefore the researchers aimed for this minimum number.
The format of the focus group involved the facilitator and students sitting together in a circle, with drinks and light snacks provided for the students. Teachers were not present for any of the focus group discussions. After initial introductions, a brief presentation was displayed on a screen, where the facilitator asked students to consider ten questions about HPV to provide them with context to the topic and enable them to reflect on their pre focus group HPV knowledge. Students were encouraged to provide answers to the questions posed if they felt comfortable doing so. A focus group guide (S1 Appendix) was used to ensure that all focus groups were as consistent as possible. The ‘observer’ researcher sat away from this main group and did not contribute to any discussion during the focus group but did ask questions of the group at the end if they had any questions. Focus groups were video-recorded with students’ consent. The use of video-recording over audio-taping focus group sessions is recommended to ensure that each participants’ responses can be identified and to enable extensive analysis of non-verbal cues [70].
Ethics statement
Ethical approval for this project was granted by the NHS Research Ethics Committee in September 2020 (ID:287358) as a separate part of this study involved focus groups with NHS employed nurses. Individual trust approval was required only for the interview of NHS nurses rather than post-primary school student focus groups. Written informed consent was obtained from the parent/guardian of each participant under 18 years of age.
3. Data analysis
Directed content analysis was used to conduct the initial coding and generation of themes. A more structured process compared to conventional content analysis guides this type of analysis [71]. Coding of the data involves using pre-determined codes, categories and themes based on existing models or theories [71]; in this case the COM-B model and TDF domains. NVivo 12 was used to organise the TDF domains into codes, COM-B sub-domains into Categories and the COM-B domains into overarching themes. See Fig 1 for full details.
The focus group guide was produced using the COM-B model and TDF domains to identify the facilitators and barriers that students faced regarding protecting themselves from acquirement of HPV. Ten of the 14 TDF domains were targeted in the design of the focus group guide. The four TDF domains not targeted were students’ personal goals, intentions, behavioural regulation and belief about capabilities regarding HPV to avoid the need for sensitive and personal questions within this focus group environment. Two of the researchers independently organised the data into the pre-determined codes, categories and themes to increase the rigour of the analysis. The two researchers then met and discussed differences in their coding until full agreement was reached.
4. Results
Between November 2021 and May 2022, 34 students (24 females; 10 males) from four post-primary schools in Northern Ireland participated in this study within seven focus groups. Each focus group contained between 2–7 students. Twenty-three students (67.6%) indicated that they were Catholic and eight students (23.5%) indicated that they were Protestant. Thirty-two out of thirty-four students (94.1%) described their ethnicity as White Northern Ireland. Seven students (20.6%) did not know if they had received the HPV vaccine. See full demographic details in Table 1.
All emerging themes from the focus groups aligned with the pre-determined categories and sub-domains. See Table 2 for frequency of coding in each TDF domain to highlight the most important TDF domains as recommended by Hsieh & Shannon (2005) [71].
4.1 Capability
Psychological capability captures the students’ perception of their ability to ‘engage in the necessary thought processes, comprehension and reasoning’ (p3) [73] in order to protect themselves from HPV and make decisions regarding HPV vaccination.
4.1.1 Knowledge.
All students indicated that their knowledge was insufficient regarding HPV and that this topic was not discussed in detail at school. Most students were not aware that HPV was an STI, though those who were currently taking biology were aware of HPV being a virus. The majority of students expressed that their education regarding STIs in general was inadequate. Some students in each focus group demonstrated awareness of the link between HPV and cervical cancer and had an awareness of cervical screening. However, none of the students were aware of the other types of cancers associated with HPV. Students demonstrated a particular lack of knowledge regarding the types of HPV-associated cancers that males could acquire, thinking of it as a ‘female issue’ rather than affecting all genders. The majority of students were unaware that the HPV vaccination was now being offered to boys.
Female students being educated in a female only Catholic school felt that some students are very misinformed about the HPV vaccine. Reflecting on when they received their vaccination, students from all schools indicated that they could not recall any meaningful discussions within the school with either teachers or with the IMNs prior to the HPV vaccination. They indicated that they received so many vaccinations that they were confused regarding which vaccines they had received. While male students in the focus groups were not offered the HPV vaccine, some were unaware of whether or not they had received it in school.
Students felt that by participating in the focus groups, they had acquired a lot of knowledge and felt more informed about HPV vaccination and transmission routes. All students were highly in favour of more HPV education. Students in all groups felt that, as 15–16 year olds, there was no information that should be off limits in HPV education and that they needed to know everything about HPV and other STIs. They felt that it was important that all forms of transmission be discussed openly including risks associated with oral, anal and vaginal sex. They wanted to understand preventative measures, symptoms of HPV and management of HPV or another STI.
Many female students (of both religions) indicated that not all students would understand medical terms like oral sex or anal sex. They felt that it was important that the facilitator used non-scientific terms that students might know alongside the correct scientific terminology. However, male students had mixed opinions regarding whether non-scientific terms should be used in this educational setting but agreed that by only using scientific terms, the conversation would also be more formalised. Males felt that using non-scientific terms would be unprofessional and reduce the importance of the topic.
All students felt that there would need to be restrictions on the detail provided to younger students and topics would need to be adapted to be age appropriate. All students expressed that revisiting and building on information regarding HPV and other STIs, was important to do each year from age 12 to 16 years old and would help to normalise sexual health topics, reducing associated stigma. See Table 3 for students’ comments regarding this aspect.
4.1.2 Memory, attention and decision processes.
All students felt that a short face-to-face education format was essential to deliver this HPV education to aid attention and memory. The majority of students indicated that a small group size of 6–10 would be ideal when receiving this education to optimise discussions with the facilitator. They felt that it should be organised so that students are with some friends or others that they know well. They felt that this environment would encourage a more open debate if there was disagreement within the group. However, they recognised that this number may not be practical to implement and therefore agreed that a class size (15–30 students) would also work well; especially their form class. They felt that there is trust already established within a form class setting, and that this would be a safe alternative environment. All students agreed that larger class sizes in assembly halls would not be appropriate.
Some students in a female only Catholic school expressed that they would not feel comfortable receiving this education with boys present, indicating that it would restrict their ability to ask questions. However, the majority of students in this female only Catholic school felt that splitting up genders was outdated and that students of all genders should be taught together. Ultimately, they felt that it was important that genders were not divided into groups as they needed to learn together. They agreed that the best option would be to have a mixed gender lesson but then have a short debrief session afterwards with separate gender groups.
Students from mixed gender schools felt that having the groups mixed was important and that they would not feel awkward with mixed genders. Student comments are summarised in Table 4.
All students liked the idea of a more informal approach like having a ‘chat’ rather than someone delivering powerpoint slides. The majority of students commented on the importance of interactive activities like quizzes, practical condom demonstrations, snappy statistics and groupwork activities to aid their learning. Students recalled external facilitators who did practical activities and indicated that they remembered most from these enjoyable interactive classes. The majority of students indicated that they would not read a leaflet if provided.
Female students discussed the use of personal stories through watching videos by young people affected by HPV as being very impacting and influencing and felt that incorporating this into the education would be effective. However, male students felt that, if using real life stories, facilitators need to take care not to make the details too scary or intimidating though they agreed that hearing about a young person’s experience might be helpful. Some male students also indicated that boys tend to ridicule the people talking on videos.
All students agreed that it would be important to have the opportunity to ask questions anonymously related to the taught educational content. Students described technology, like Slido polls, which are available to assist anonymity when asking questions during the face-to-face education. A phone chat option with the facilitator post-education was discussed but students were definitely not keen on using the phone but would consider texting a facilitator.
The majority of students liked the idea of following up the face-to-face HPV education with some form of dedicated ‘snappy’ social media area embedded in Instagram or Tiktok. Students indicated that they rarely click on links provided during class and therefore they would not recommend their use. Students talked about the NHS designing an app to supplement this education similar to the COVID-19 app. However, some students felt that most students would not bother with social media after the class was complete. Posting supplementary information on Google classroom was not perceived favourably as students felt that they ‘missed everything’ on that site. Some commented that not all students would want to see graphic images of tumours but agreed that components like this could be embedded into Instagram for students to choose to view if they wanted. See Table 5 for students’ comments regarding this aspect.
4.1.3 Psychological skills (Cognitive & Interpersonal).
Students in all groups discussed the difficulty in trying to educate 12-year-old students about HPV at the time of vaccination due to their lack of maturity and inability to comprehend sexual relationships. All students felt that younger students tend to giggle and laugh during these types of classes. Students also felt that hearing about cancer at that age, would be quite scary.
All students explained how the form provided at the time of vaccination was not a suitable format to use for children aged 12–13 years old. They suggested that alternative formats like a short presentation or posters, would be more appropriate for students at this time. While students in all groups agreed that the information would not be as relevant to them at that time, they all strongly expressed that they would have liked to hear the basic facts about what the vaccination was protecting them against when they received it.
Students expressed mixed opinions regarding the age where more comprehensive information should be provided to students e.g. specific transmission routes and sexual behaviours associated with transmission. Around half of the students agreed that year 12 (15–16 years old), was the right time to receive more comprehensive information about the various aspects of HPV. They were concerned that providing comprehensive detail to 14-year-old students would be too scary for them. One female student (from a non-Catholic mixed gender school) even indicated that they felt that providing information at this age would encourage students to become sexually active.
However, the other half of the students felt that providing comprehensive education to students at 14 years (year 11) would be a more suitable option. They indicated that while not many students were sexually active at 14 years old, some students were and they needed to be safeguarded. They felt that timing comprehensive education at 14 years old would ensure that when they became sexually active, they would have the information to protect themselves. They felt that the content could be the same as year 12, but the language adapted slightly for that age group. At this age, they felt that students would understand the importance of this information and want to engage in conversations about this topic.
Gender or religious denomination did not appear to be a factor influencing individual students’ opinions regarding this aspect of the HPV education. See Table 6 for students’ comments regarding this aspect.
All students agreed that at 16 years of age, they were mature enough to make their own decisions about receiving the HPV vaccination and should be able to self-consent if offered the vaccine in year 12. They felt that having to ask their parents at this age would compromise their privacy. Female students felt that 15 year olds were mature enough to make their own decisions though male students felt that some 15 year old students may not have the capacity to self-consent. While many students were aware that legislation may not enable 15 years olds to self-consent, they also discussed the lack of education provided to them regarding their legal rights.
All students agreed that at 15 years old, it would be important for students to be assessed for their understanding of the information through chatting to the IMN prior to self-consenting to a vaccine. The majority of students felt that 14 year old students would not have the capacity to self-consent and make their own decisions due to lack of maturity.
Some students (from both genders and from both religious backgrounds) indicated that they felt that it was important that their parents knew that they were being offered the education and opportunity to self-consent to the HPV vaccination. They felt that it was important to include their parents and discuss it with them even if the decision was ultimately up to them.
Students stressed that it would be important for there to be a gap between delivering the education and taking up the HPV vaccine to provide students with time to reflect and make their decision after the education. See Table 7 for students’ comments on this aspect.
4.2 Opportunity
This section captures students’ perspectives regarding all of the external factors which they feel have impacted their access to HPV education and/or HPV vaccination. Michie’s COM-B model describes opportunity as being related to social influence (culture) and/or physical environment [73].
4.2.1 Social influences.
Students from all focus groups discussed how their parent/guardian were the primary decision-makers regarding all of the vaccinations that they had received to date including the HPV vaccination. The role of their parents in this decision-making process was one of high importance when they were younger. However, students indicated that this resulted in them taking a very passive role in their vaccination choices in the past and admitted that they had not really even considered what the vaccinations were protecting them against.
Most students felt that their parents were very supportive of them learning about HPV but many students felt that parents of other adolescents may not be so supportive. Students added that they did not feel that their parents would necessarily be supportive of them being sexually active. Reasons discussed through the groups for potential lack of parental support included concerns regarding the safety of vaccinations and a perception that HPV education would promote promiscuity.
Students in all groups felt that parents may not always have the education needed to make informed decisions for their children. They stressed the importance of educating parents to ensure that they can make informed decisions for their children. They felt that parents considered HPV a female issue and therefore may not understand the importance of HPV vaccination for males.
Some students talked about their parents often making decisions based on their own life experiences. Influencing factors included having a family member with a HPV-related cancer, their parent’s age and their parent’s own experiences when they were at school.
Some students highlighted the challenges associated with teaching parents as there would be no option to mandate education for them. They felt that educating students now would ensure that parents are educated in the future. Most students felt that their parents found it difficult to talk to them about sexual health.
Of note, students from the male only Catholic school commented that if parental consent had not been required for the focus groups, a much greater number of students would have participated. See Table 8 for students’ comments regarding this aspect.
All students felt that HPV and other STIs are stigmatised both in the Northern Ireland media and the school setting and that this impacts their opportunities for STI education.
Both male and female students felt that their sexual health education was negatively impacted by being educated in a Catholic school. They also felt that parents and schools with a strong religious affiliation, particularly Catholic schools, would have objections to HPV education being taught in schools.
Students from the male only Catholic school felt that their parents would be ‘furious’ if detailed sexual health education was provided to them before they were 16 years old. Students attending Catholic schools felt that there was an expectation that they would abstain from sexual interactions and therefore would not need to know about aspects of HPV as a result. Religion was not raised as an issue by students attending non-Catholic schools. See students’ comments in Table 9.
4.2.2 Physical environment and resources.
All students felt that the school environment provided the best opportunity to receive all of their HPV education as it was convenient to all adolescents. All students indicated that HPV education and sexual health education is not prioritised throughout their existing school curriculum. They felt that HPV education should be an integrated component of a larger sexual health education programme and be aligned to teaching about other STIs. All students felt that HPV education should be a mandated component of the normal school curriculum. Students talked about the importance of a consistent approach within this mandated education in all post-primary schools in Northern Ireland regardless of religious affiliation or school ethos. One student, from an ethic minority, highlighted the importance of equality in sexual health education as they felt that some ethnicities do not openly talk about any sexual health related issues.
Students explained how HPV education and other sexual health topics could fit well into the Professional Development (PD) classes or replace some Careers classes throughout the curriculum. Male students felt very strongly that they should not lose ‘games’ time to attend these classes but that they should be built into the curriculum.
Some students had received relationship education through ‘Love for Life’, an external specialist provider. They described how these classes focused on relationships but also touched on STIs. They explained how ‘Love for Life’ built on these topics and increased their complexity each year to align with their development. However, they all agreed that the detail covered regarding STIs in these classes was insufficient. Some students suggested that ‘Love for Life’ could adapt their sessions to incorporate this type of detail. Students attending the female only Catholic school did not receive this education. See student’s comments in Table 10.
Students felt that, if students were re-educated in year 12 (age 15–16 years), then another opportunity would need to be provided within the school for HPV vaccination shortly after the education. They indicated that practical aspects would negatively affect students’ opportunity to get the vaccination outside of the school environment. This included inability to travel to their GP, lack of initiative to book an appointment with their GP and possibly having to converse with their parents regarding why they want the HPV vaccination. See students’ comments in Table 11.
4.3 Motivation
This section captures students’ perspectives regarding their motivation, which are the internal processes, which influence their decision making and behaviours [65]. Michie et al. (2011) [74] describe two types of motivation; reflective motivation and automatic motivation. Reflective motivation involves motivation due to reflection on past events while automatic motivation involves ‘our desires, impulses and inhibitions’ (p3) [65].
4.3.1 Reflective motivation.
4.3.1.1 Social role and Identity. All students felt that information about HPV and other STIs was very relevant to their lives and important to understand. They indicated that students generally were becoming sexually active at 15–16 years old, with a smaller number of students being sexually active at 14 years old.
Female students talked about how they were motivated by stories of celebrities who had HPV associated cancer. They talked about watching Jade Goody’s life with cervical cancer and felt that these types of TV programmes helped them to realise that this could happen to them, increasing their motivation to learn about HPV. Many students expressed hearing about HPV through social media platforms but were cautious regarding the large volume of misinformation on social media. Many of these students expressed a lack of trust in social media information related to this topic. They also highlighted negative media attention regarding cervical screening. Previous experiences of HPV-related cancer in their families also increased students’ motivation to want to receive HPV education and the HPV vaccinations. See Table 12 for students’ comments regarding this aspect.
4.3.1.2 Belief about consequences. All students felt that HPV education would help them to understand the consequences of acquiring HPV as, prior to the focus group, they were largely unaware of most of the consequences. Without any additional education, female students demonstrated a reasonable awareness of the importance of cervical screening in preventing cervical cancer. However, until these focus groups, students were largely unaware that males could also develop HPV associated cancers. Students indicated that even information gained from these focus group sessions increased their motivation to want to be vaccinated and protect themselves from possibly developing HPV-associated cancers.
Some students commented that educating them would ensure that they were able to make their own informed decisions about vaccinating their own children in the future. This was perceived as an important and positive consequence of this HPV education.
All students expressed that having more knowledge through additional HPV education, would encourage safer sexual behaviour. All students felt that further HPV education would positively influence their attendance at any future HPV screening being offered to them. Some female students (from the female only Catholic school) felt that, with student’s current level of education, many students would not attend screening when offered it in the future. They felt that some students who were vaccinated might feel that they were fully protected against HPV and not understand the importance of attending for screening.
Male students indicated that they would take the HPV vaccine if it was offered to them in school today. See student’s comments regarding this aspect in Table 13.
4.3.1.3 Optimism. The majority of students felt that barriers may arise when trying to implement HPV education into schools. The most frequently cited barrier was a lack of support from some parents, particularly those with strong religious backgrounds. Many students felt that schools would be resistant to mandating HPV education into the curriculum unless supported by legislation from the Education Authority.
However, students indicated that despite the barriers discussed, they could all be overcome to enable the introduction of this HPV education. See Table 14 for students’ comments regarding this aspect.
4.3.2 Automatic motivation.
4.3.2.1 Emotion. The majority of students indicated that talking about STIs like HPV can be embarrassing for them and for the facilitator of the education. Consequently, the majority of students felt that the facilitator delivering the education should be an expert in this field who is external to the school. They felt that having open discussions would be easier with a person that they did not know but who had a strong healthcare background. All students indicated that the immunisation nurses are aptly placed to provide this education and rated their expertise as being of high importance. They felt that students pay more attention to and are more motivated by an external visitor and take the class more seriously. Students talked about how embarrassed most teachers would be talking about this subject and felt that teachers would not have expertise in this area. Most students indicated that they would not feel comfortable asking questions to teachers.
Students discussed how the ‘Love for Life’ group could alternatively incorporate this aspect into their teaching as they appeared to have very good knowledge and were energetic and enthusiastic.
Some students indicated that while IMNs would be appropriate to delivery this education, so would some of their science teachers. Males from various schools indicated that the facilitator would need to be able to assert themselves to prevent disruptive behaviour. They felt that the facilitator would need to have some experience in dealing with teenagers in this environment to control the class.
While three of the four schools had school nurses, only students from one school felt that, with the right training, the school nurse would be an appropriate person to deliver this education. However, most students felt that school nurses did not possess the skills or knowledge.
Most students felt that 25–30 years old would be the perfect age for a facilitator, as they would have a greater understanding of the student’s social culture. However, all students felt that the age of the facilitator was not as important as other characteristics; students valued expertise, openness, passion and being non-judgemental as being the most important attributes of the external facilitator. Some students liked the idea of young health professional students teaching this material. See Table 15 for students’ comments regarding this aspect.
Female students from the female only Catholic school indicated that fear was a strong motivator driving their desire to be vaccinated and educated about HPV. Individual experiences had contributed to that fear including media coverage regarding errors in cervical screening in Ireland and also negative experiences of family members contracting HPV and developing cancer.
Some male students felt that some amount of fear needed to be generated by the HPV education in order to encourage all students to pay attention to the education. One student indicated that it should be ‘just below scaring for it to work’ (S30).
Some female students from the female only Catholic school, mentioned fear of needles and cervical screening as being possible negatively influencing factors in some students’ decisions regarding the HPV vaccination. See Table 16 for students’ comments regarding this aspect.
5. Discussion
This qualitative focus group study, informed by the COM-B model, explored students’ perceptions of the facilitators and barriers associated with protecting themselves from HPV acquirement.
5.1 Capability
Students indicated that they do not currently have adequate knowledge about any aspects of HPV to inform decision-making regarding acquirement of HPV, consistent with previous studies [75]. While students indicated that they had some awareness of HPV-associated cervical cancer, students perceived HPV as a female issue and were unaware of the male cancers associated with acquiring HPV. These findings are consistent with a recent study by Franca et al. (2022) [76], who surveyed university students in the US. From 862 students (570 female; 292 male), 70% were aware that HPV can cause cervical cancer, compared to only 34–39% being aware of HPV as a causative agent for oropharyngeal, penile or anal cancer. Another study carried out in the US [35] in a military base also reported higher awareness of HPV as a causative agent for cervical cancer but poor awareness of the link between HPV and oropharyngeal cancer. Given that 40%-90% of new oropharyngeal cancer cases are HPV-associated [77], this lack of knowledge is concerning.
All students were strongly supportive of the addition of HPV education in school for their age group (15–16 years old). They agreed that, at this age, they were mature enough to receive in-depth information regarding all aspects of HPV including transmission routes, protection against HPV and management of HPV. Students were divided on whether comprehensive information should be introduced at 14 year old. Those who promoted this education felt that this was very important as some students are sexually active at 14 years old and they feel that this is the right age to be informed prior to becoming sexually active. Those who supported comprehensive information at 15–16 years old were concerned that providing this information at 14 years old would be too scary. Interestingly, a recent study in the UK of 11,000 adolescents indicated that only 3.2% of 14 year olds had engaged in oral sex or full sexual intercourse [78]; this is in contrast to earlier studies which indicates that 20–30% of 14 years olds were engaging in higher risk sexual behaviours in previous decades [78, 79].
Several aspects regarding the format of the HPV education were considered important by students in order to optimise attention and improve memory of the education. One aspect discussed included whether non-scientific terminology should be used during this education to support and clarify sexual terms like oral sex. Males indicted that using non-scientific terminology would reduce the professionalism of the teaching while females felt that including non-scientific terminology would increase their understanding of the topics covered. Interestingly, this difference in female and male interpretation of sexual behaviour terms is not new and has been widely explored in previous publications [80, 81]. In the past, researchers have reported that males and females assign different meaning to sexual terminology with males generally knowing a greater range of non-scientific expressions related to sexual activity than females [80]. While gender differences between perceptions regarding sexual behaviour terminology may exist, the majority of students indicated that HPV education should be taught with students of all genders mixed together. While most students from the girls’ Catholic school felt that separating genders was antiquated, many of them indicated that they would still be embarrassed and reluctant to discuss sexual health with males present. This finding, in alignment with previous research, suggests that single gender schools may predispose students to experience mixed-gender anxiety, potentially having a negative effect on future social interactions with the opposite sex [82].
To optimise interaction and attainment of HPV information, all students indicated that small groups of 6–10 students would be ideal. While this may pose practical challenges, this thinking is very consistent with evidence, which supports group sizes of 5–10 for optimal interaction within the group [83]. While some researchers have indicated that familiarity in a focus group can lead to peer-pressure and under-disclosure [83], students in this study consistently felt that being in the same group as their friends for this education, would create a safe environment and provide them with the opportunity to express themselves freely.
Students felt that a variety of interactive teaching methods should be utilised in a short HPV education session to maximise participation and retention of information. Social constructivist theories stress the importance of interactive teaching and its effect on focusing students’ attention and increasing motivation [84]. While female students were in favour of the use of personal stories through videos to aid decision-making regarding HPV, males were less likely to view these videos as a learning tool and anticipated that males would not take the videos seriously and ridicule and disrespect the speaker in the video. Males in this study also indicated that the facilitator of the HPV education session should have teaching experience in order to ‘control’ the more immature males in the class. A recent study 2017 conducted in post-primary schools in Northern Ireland supported this finding [85], indicating that male stereotypes are constantly reinforced by educators and their peers contributing to boys becoming more disruptive than girls in class.
Students felt that they are competent at 16 years of age to make their own decisions about protecting themselves from HPV and should be able to self-consent to all vaccinations including HPV vaccinations. While students in this study expressed that they would want their parents to be involved in their HPV vaccination decision-making, they ultimately felt that they should make the decision. Mixed views were expressed regarding whether 15-year-old students would have the maturity to self-consent with males generally expressing that not all students would be mature at that age. Students desired more information regarding their legal rights to self-consent. They commented that inability to self-consent limits their participation in research. A systematic review by Fisher et al. (2019) [86] revealed that the main barrier to adolescent self-consent was fear from healthcare providers and teachers regarding parental response, even where students were deemed competent to make their own decisions. In parts of the UK, some healthcare professionals assess competency for vaccination using a Gillick consent tool [87, 88]; however, IMNs are often confused about the legal rights of students [7, 9, 89], similar to students in this study. It is important to note that students 16 years and above and Gillick competent students under 16 years old, can legally consent to the HPV vaccination without their parents’ consent in Northern Ireland [52].
5.1.1 Actions needed to increase capability to support behaviour change.
To enable students to make sexual health decisions to protect themselves from acquirement of HPV, more information needs to be provided to them in the form of additional school-based HPV education. This HPV education should highlight the various types of cancers associated with HPV acquirement, especially those associated with males.
Given the potential differences in gender perceptions of sexual behaviour, the HPV education should be approached sensitively in a professional manner with limited verbal use of non-scientific terminology but clear explanations provided of all terminology used. Understanding of content could be gaged through the use of an anonymised audience response system (ARS) during the HPV education [90]. ARSs have been shown to capture students’ attention and increase concentration and interactions [84, 90].
Introducing a range of teaching methods during the HPV education for this age group is important. In developing a HPV intervention, it is important that facilitators undergo gender equality, diversity and inclusion training and a minimum level of teacher training in order to optimise the teaching experience for all students.
Students, educators and nurses delivering HPV vaccines, need to have a strong knowledge of the rights of students to self-consent to HPV vaccination. This should be implemented into the HPV education provided for this age group. Gottvall et al. (2015) [91] suggest that a relational approach is needed to promote dialogue between all parties with special care for the relationships between students and their parents.
5.2 Opportunity
Students indicated that they have not been provided with sufficient social and physical opportunities to receive education regarding HPV and HPV vaccination.
They felt that, while parents were supportive of their learning, parents were often uneducated and made decisions related to HPV vaccination based on their experiences of social media platforms or relatives’ experiences. Consistent with these findings, a recent post-COVID-19 study found that two of the three strongest factors influencing whether a parent would make a change to vaccinate their child included the parents’ vaccination history and their perception of the child’s risk [92]. In a recent UK survey of 186 parents [93], only half of the parents had heard of HPV prior to completing the survey. Knowledge related to HPV-associated conditions in males was particularly low.
This finding of low parental HPV knowledge aligns with findings from other countries [94, 95]. However, Sherman & Nailer found that even providing brief information regarding HPV, persuaded the majority of parents of the importance of HPV vaccination in all genders [93]. Sherman & Nailer highlight an urgent need for public HPV education, particularly highlighting relevance to males, in order to facilitate educated decision-making. Students who were from single sex schools affiliated with the Catholic religion felt that their sexual health education was negatively impacted by this affiliation. This finding aligns with previous research findings that indicate that sexuality education in Catholic schools focuses on abstinence with little to no education regarding safe sexual practices and STIs [96, 97]. Consequently, students felt that HPV education should be a mandated component of a larger sexual health education programme to ensure that students from all religions, cultures and backgrounds are receiving this information in a consistent manner in post-primary school.
Studies from various countries indicate that young people with higher rates of religious attendance, have poorer sexual health knowledge [98, 99] with religious teachings often emphasising values like abstinence rather than teaching facts related to sexual health [37, 75, 100]. Schools inconsistently enlisted ‘Love for Life’ to provide some STI education and when this education was implemented consistently each year in a school, the students rated this highly though they indicated that the level of detail could be enhanced. While students found facilitation from staff from ‘Love for Life’ open and non-judgemental, ‘Love for Life’ is a Christian charity with their own principals including prioritising delaying sex [47] so their approach may reflect this aim.
Students felt that it was essential that HPV education at 15–16 years old should be followed with an opportunity to receive the HPV vaccine in school. They indicated that barriers to obtaining the HPV vaccine outside of school would include having to communicate with their parents about why they want the vaccine in order to get transport to their general practice. For most parents and their children, talking about topics related to sexuality creates anxiety and apprehension, especially if parents disapprove of their child’s sexual choices [101].
5.2.1 Actions needed to increase opportunity to support behaviour change.
Public campaigns are needed to highlight the potential impact of HPV, especially to males. Currently throughout the UK, parents are provided with HPV education in the form of a letter and standardised NHS information leaflet [102–105]. However, parental HPV education should be provided with a greater range of educational resources through the schools, with multilevel intervention approaches [106] combining social media platform resources [107, 108], interactional videos and other resources [92] grounded in behavioural theory [53]. This education should teach parents of the positive implications of parent-child communication regarding sexual health topics including more consistent contraceptive use [101]. HPV education should be implemented into a mandated sexual health programme in post-primary schools as part of the curriculum to ensure equal access to this education.
Churches in Northern Ireland, particularly of Catholic faith, need to be supported in deepening their understanding of the importance of HPV vaccination promotion in their communities, remaining faithful to the church’s vision but recognising the contemporary context of life today. The Education Authority in conjunction with the Department of Health could play an important role in implementing HPV vaccine promotion strategies within faith-based communities to promote safe and open dialogue for health communication messages to be disseminated in a familiar and trusted setting [109].
5.3 Motivation
Students were motivated to protect themselves against HPV as they recognised that they could be potentially at risk of acquiring HPV if they were becoming sexually active. They described being positively motivated by media celebrity stories but recognised that social media can provide misleading and sometimes negative views of HPV and cervical screening. The majority of students in this age group use multiple social media platforms like Instagram and Snapchat and these platforms are an important source of their news [110]. In a 2016 study, compared to 83% of adults, only 44% of teenagers agreed that they could tell the difference between fake and real news [111]. In the past, celebrities with a cancer diagnosis have influenced young people to attend health checks, research cancers in more depth and possibly even contributed to change in health policy [112].
Students expressed being motivated by fear, which was driven by social media and/or their own personal experiences of HPV associated cancers in their social circle. Some students felt that scaring students was necessary in the HPV education to motivate them, though these students indicated that scaring students 14 years or under would not be appropriate. Studies suggest that fear can be effective in increasing vaccination uptake [113, 114] but warn that fear appeal in public campaigns may be perceived by adolescents as controlling them into message conformity [114]. Some students expressed fear of needles as being a barrier to student motivation to receive the HPV vaccines though indicated that this was higher at 12–13 years old than at 15–16 years old.
Students felt that having more information about HPV would encourage safer sexual behaviour and encourage attendance at HPV screening offered to them in the future. The males in the group, none of which were vaccinated, indicated that they would take the HPV vaccine if offered to them in school. This is consistent with studies which show that even providing short and limited HPV education, can increase intention to be vaccinated [53].
Students expressed that student embarrassment could hinder communication during HPV education and emphasised the importance of the facilitator’s characteristics in order to create a motivational environment. Openness and being non-judgemental were deemed the most important characteristics of a facilitator for delivery of HPV education alongside expertise in this area. Many students felt that having younger, more socially current facilitators around 25–30 years old would be ideal though age was rated as being much less important that the openness and expertise of the facilitator. They felt that it would be less embarrassing to have this subject taught by a person that they did not know, external to the school. Students commonly report embarrassment, shame and judgement as barriers to conducting open discussions about sexual health matters [115, 116] and therefore this is an extremely important consideration in the development of any HPV education for this age group. Given this information, all students identified that the IMNs would be the most appropriate professionals to deliver this education alongside delivery of the vaccination, recognising their expertise in this area. Being external to the school, students felt that they would be able to retain anonymity making it easier for them to ask questions and participate in discussions on the topic. Only one group of students identified the school nurse as a potential facilitator of this education, despite three out of four schools involved having an allocated school nurse. Despite being highly qualified, both educators and parents often perceive the role of the school nurse to be purely administration of medication and first aid with little recognition for their potential role in health promotion [117, 118]. Therefore, given their cultural environment, it is logical that students would also undervalue the skill set of school nurses as was evident in the study. IMNS and school nurses both express a strong desire to be more directly involved in health promotion and indicate that, historically, they were provided with time and resources for this purpose [9, 55]. However, both IMNs and school nurses express a lack of support in terms of time and resources allocated currently to develop roles in these areas of health education [9, 55]. Students felt that, apart from some science teachers, teachers would not have the topic expertise to teach HPV education and that embarrassment would hinder open discussions with most of their teachers. This finding is consistent with teachers’ opinions as those with no specific post-graduation public health education, also expressed a lack of knowledge and desire to teach sexual health education [119, 120].
5.3.1 Actions needed to increase motivation to support behaviour change.
Open-minded and non-judgemental nurses, with a public health qualification and phlebotomy qualification, should provide HPV education as external partners through post-primary school in order to increase student motivation to engage in this education. Fake news social media platforms should be discussed with students along with providing standardised evidence-based teaching about HPV-associated issues. The introduction of celebrity personalities may positively influence motivation for protecting against HPV though studies suggest that for identification to occur, the two parties in a para-social relationship must share some characteristics [112]. Public campaigns should balance health promotion messages carefully and avoid overly strong fear appeal messages. From April 2022, the World Health Organisation (WHO) concluded that either one or two HPV injections only are needed for 15 year olds instead of the previously administered three injections [121]. This could benefit HPV uptake for those students to have a strong aversion to needles.
6. Strengths and limitations
One of the strengths of this study is the use of the COM-B model and TDF domains to identify the aspects which need to change to enable students to protect themselves against acquirement of HPV. The National Institute for Health and Care Excellence (NICE) supports the use of this model when designing sexual health interventions in the UK [122]. However, due to the nature of focus groups, only 10 of the 14 TDF domains were targeted so some additional information may potentially have been missed through using this format.
While the study includes students with different genders and religions, the majority of students in the four schools have a middle to higher socioeconomic background so views could vary in schools with a higher portion of students from lower socioeconomic backgrounds. Additionally, the study included a higher percentage of females compared to males, which may have impacted the findings.
It is likely that participating schools are already more supportive of the HPV vaccination programme than schools which decided not to participate in the study which may impact the results. Teachers also may have targeted students who spoke more articulately and were more mature than the average student in their class. Due to the lack of ethic diversity and unique religious history in Northern Ireland, the results may not be generalisable to students in the rest of the UK.
7. Conclusion
Students, 15–16 years old, felt that they were mature enough to self-consent to HPV vaccination and make decisions regarding their sexual health. However, they indicated that they lacked sufficient HPV education and education regarding their legal right to consent to vaccination, to empower them to make these decisions. They supported the introduction of mandatory age-appropriate HPV education in all post-primary school year groups to provide consistent HPV content and delivery. They indicated that face-to-face interactive HPV education could easily be incorporated into their curriculum and should be delivered by an external expertise who is open and approachable. Such changes would need to be supported by the Education Authority in conjunction with the Department of Health. Students felt that removal of these barriers would lead to safer sexual practices, increased awareness of the importance of HPV screening and increased HPV vaccination uptake.
Supporting information
S1 Appendix. Focus group questions asked to participants in alignment with the COM-B model and TDF domains.
https://doi.org/10.1371/journal.pgph.0003100.s001
(DOCX)
Acknowledgments
We would like to express our sincere gratitude to the teachers and students who organised and participated in this study.
References
- 1.
United Kingdom Health Security Agency [Internet]. London: GOV.UK; c2023 [cited 2024 Mar 07]. Sexually transmitted infections (STIs): annual data tables. https://www.gov.uk/government/statistics/sexually-transmitted-infections-stis-annual-data-tables/sexually-transmitted-infections-and-screening-for-chlamydia-in-england-2022-report
- 2.
Public Health England [Internet]. London: GOV.UK; c2007 [updated 2016; cited 2024 Mar 07]. Genital warts and human papillomavirus: guidance, data and analysis. https://www.gov.uk/government/collections/genital-warts-and-human-papillomavirus-hpv-guidance-data-and-analysis
- 3. Young D, Xiao CC, Murphy B, Moore M, Fakhry C, Day TA. Increase in head and neck cancer in younger patients due to human papillomavirus (HPV). Oral oncology. 2015 Aug 1;51 (8):727–30. pmid:26066977
- 4.
World Health Organisation [internet]. Switzerland: WHO.int; c2024 [cited 2024 Mar 07]. Sexually transmitted infections (STIs). https://www.who.int/news-room/fact-sheets/detail/sexually-transmitted-infections-(stis)
- 5.
Public Health Agency [Internet]. Belfast, Northern Ireland; c2017 [cited 2024 Mar 07]. Human papillomavirus(HPV) immunisation programme; Factsheet for healthcare professionals. https://www.publichealth.hscni.net/sites/default/files/HPV_factsheet_for_professionals_May_2017_0.pdf
- 6.
National Health Service [Internet]. United Kingdom: NHS.uk; c2023 [cited 2024 Mar 07]. HPV Vaccine Overview. https://www.nhs.uk/conditions/vaccinations/hpv-human-papillomavirus-vaccine/
- 7. Hilton S, Hunt K, Bedford H, Petticrew M. School nurses’ experiences of delivering the UK HPV vaccination programme in its first year. BMC infectious diseases. 2011 Dec;11 (1):1–9. pmid:21864404
- 8.
Public Health England [Internet]. London: GOV.UK; c2018 [cited 2024 Mar 07]. Guidance: Immunisation training standards for healthcare practitioners. https://www.gov.uk/government/publications/national-minimum-standards-and-core-curriculum-for-immunisation-training-for-registered-healthcare-practitioners
- 9. Flood T, McLaughlin M, Hughes CM, Wilson IM. Applying the COM-B behaviour model to understand factors which impact school immunisation nurses’ attitudes towards designing and delivering a HPV educational intervention in post-primary schools for 15–17 year old students in Northern Ireland, UK. Vaccine. 2023 Aug 31;41(38):5630–9.
- 10. Falcaro M, Castañon A, Ndlela B, Checchi M, Soldan K, Lopez-Bernal J, et al. The effects of the national HPV vaccination programme in England, UK, on cervical cancer and grade 3 cervical intraepithelial neoplasia incidence: a register-based observational study. The Lancet. 2021 Dec 4;398(10316):2084–92. pmid:34741816
- 11.
Public Health Agency [Internet]. Belfast, Northern Ireland; c2019 [cited 2024 Mar 07]. Annual HPV vaccine coverage in Northern Ireland: 2018–19. https://www.publichealth.hscni.net/sites/default/files/2019-11/2018-2019.pdf
- 12.
UK Health Security Agency [Internet]. London: GOV.UK; c2022 [cited 2024 Mar 07]. Human papillomavirus (HPV) vaccination coverage in adolescents in England: 2021 to 2022. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1126762/hpr1322-HPV2.pdf
- 13.
Public Health Scotland [Internet]. Edinburgh, Scotland; c2020 [cited 2024 Mar 07]. HPV immunisation statistics Scotland school year 2019/20. https://www.publichealthscotland.scot/publications/hpv-immunisation-statistics-scotland/hpv-immunisation-statistics-scotland-hpv-immunisation-statistics-scotland-school-year-201920/
- 14.
Jo’s Cervical Cancer Trust [Internet]. London, United Kingdom; c2021 [cited 2024 Mr 07]. Attitudes towards the HPV vaccine. https://www.jostrust.org.uk/professionals/hpv/attitudes-to-hpv-vaccine
- 15.
Office for National Statistics [Internet]. London: GOV.UK; c2022 [cited 2024 Mar 07]. How people spent their time after coronavirus restrictions were lifted, UK: March 2022. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/howpeoplespenttheirtimeaftercoronavirusrestrictionswerelifteduk/march2022
- 16.
Public Health Agency [Internet]. Belfast, Northern Ireland; c2022 [cited 2024 Mar 07]. Annual HPV vaccine coverage in Northern Ireland: 2021–2022. https://www.publichealth.hscni.net/sites/default/files/2022-11/website%202021-2022.pdf
- 17.
Public Health Scotland [Internet]. Edinburgh, Scotland; c2022 [cited 2024 Mar 07]. HPV immunisation statistics Scotland school year 2021/22. https://www.publichealthscotland.scot/publications/hpv-immunisation-statistics-scotland/hpv-immunisation-statistics-scotland-hpv-immunisation-statistics-scotland-school-year-202122/#:~:text=Coverage%20of%20the%20first%20dose,52.1%25%20in%202020%2F21
- 18.
Public Health Wales [Internet]. Cardiff, Wales; c2023 [cited 2024 Mar 07]. Vaccine Uptake in Children in Wales January to March 2023. https://phw.nhs.wales/topics/immunisation-and-vaccines/cover-national-childhood-immunisation-uptake-data/cover-archive-folder/quarterly-reports/cover-146-jan-to-march-2023/
- 19. Altman JD, Miner DS, Lee AA, Asay AE, Nielson BU, Rose AM, et al. Factors affecting vaccine attitudes influenced by the COVID-19 pandemic. Vaccines. 2023 Feb 23;11(3):516. pmid:36992100
- 20. Larson HJ, Gakidou E, Murray CJ. The vaccine-hesitant moment. New England Journal of Medicine. 2022 Jul 7;387(1):58–65. pmid:35767527
- 21.
Saunders T, Blackwell M. Associated Newspapers Limited [Internet]. London, United Kingdom; c2021 [cited 2024 Mar 07]. Covid vaccine: Shortage of school nurses slowing roll-out of jabs for 12 to 15-year-olds in England. https://inews.co.uk/news/covid-vaccine-12-to-15-year-olds-roll-out-england-shortage-school-nurses-1255154
- 22. Temsah MH, Alhuzaimi AN, Aljamaan F, Bahkali F, Al-Eyadhy A, Alrabiaah A, et al. Parental attitudes and hesitancy about COVID-19 vs. routine childhood vaccinations: a national survey. Frontiers in public health. 2021 Oct 13;9:752323. pmid:34722451
- 23. Alsubaie SS, Gosadi IM, Alsaadi BM, Albacker NB, Bawazir MA, Bin-Daud N, et al. Vaccine hesitancy among Saudi parents and its determinants: Result from the WHO SAGE working group on vaccine hesitancy survey tool. Saudi medical journal. 2019 Dec;40(12):1242.
- 24. Briones R, Nan X, Madden K, Waks L. When vaccines go viral: an analysis of HPV vaccine coverage on YouTube. Health communication. 2012 Jul 1;27(5):478–85. pmid:22029723
- 25. Ache KA, Wallace LS. Human papillomavirus vaccination coverage on YouTube. American journal of preventive medicine. 2008 Oct 1;35(4):389–92. pmid:18675530
- 26. Keelan J, Pavri-Garcia V, Tomlinson G, Wilson K. YouTube as a source of information on immunization: a content analysis. jama. 2007 Dec 5;298(21):2482–4. pmid:18056901
- 27.
The French Institute for Demographic Studies [Internet]. Paris, France; c2014 [cited 2024 Mar 10]. Age at first sexual intercourse in France. https://www.ined.fr/en/everything_about_population/demographic-facts-sheets/focus-on/age_first_sexual_intercourse/
- 28. Ramiro L, Windlin B, Reis M, Gabhainn SN, Jovic S, Matos MG, et al. Gendered trends in early and very early sex and condom use in 20 European countries from 2002 to 2010. The European Journal of Public Health. 2015 Mar 20;25(suppl_2):65–8. pmid:25805791
- 29.
Gottvall M. Introduction of School-Based HPV Vaccination in Sweden: Knowledge and Attitudes among Youth, Parents, and Staff [Internet] [PhD dissertation]. [Uppsala]: Acta Universitatis Upsaliensis; 2014. (Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine).
- 30. Holway GV, Hernandez SM. Oral sex and condom use in a US national sample of adolescents and young adults. Journal of Adolescent Health. 2018 Apr 1;62(4):402–10.
- 31. Bersamin MM, Walker S, Waiters ED, Fisher DA, Grube JW. Promising to wait: Virginity pledges and adolescent sexual behavior. Journal of Adolescent Health. 2005 May 1;36(5):428–36. pmid:15837347
- 32. Patel H, Jeve YB, Sherman SM, Moss EL. 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. pmid:26792088
- 33. Dodd RH, Freeman M, Dekaj F, Bamforth J, Miah A, Sasieni P, et al. Awareness of the link between human papillomavirus and oral cancer in UK university students. Preventive Medicine. 2021 Sep 1;150:106660. pmid:34081936
- 34. Loke AY, Kwan ML, Wong YT, Wong AK. The uptake of human papillomavirus vaccination and its associated factors among adolescents: a systematic review. Journal of primary care & community health. 2017 Oct;8(4):349–62. pmid:29161946
- 35. Williams MU, Carr MM, Goldenberg D. Public awareness of human papillomavirus as a causative factor for oropharyngeal cancer. Otolaryngology—Head and Neck Surgery. 2015 Jun;152(6):1029–34. pmid:25820579
- 36. Roman BR, Aragones A. Epidemiology and incidence of HPV‐related cancers of the head and neck. Journal of Surgical Oncology. 2021 Nov;124(6):920–2. pmid:34558067
- 37. Chanakira E, O’Cathain A, Goyder EC, Freeman JV. Factors perceived to influence risky sexual behaviours among university students in the United Kingdom: a qualitative telephone interview study. BMC public health. 2014 Dec;14(1):1–7. pmid:25300195
- 38. Hayes BC, Nagle J. Ethnonationalism and attitudes towards same-sex marriage and abortion in Northern Ireland. International Political Science Review. 2019 Sep;40(4):455–69.
- 39.
Cooley L. The Conversation [Internet]. London United Kingdom; c2022 [cited 2024 Mar 07]. Northern Ireland census shows more Catholics than Protestants–a political scientist on what this really mean. https://theconversation.com/northern-ireland-census-shows-more-catholics-than-protestants-a-political-scientist-on-what-this-really-means-191273
- 40.
Francis LJ, Penny G, Barnes P. Testing the ‘worlds apart’thesis: Catholic and Protestant schools in Northern Ireland. Young People’s Attitudes to Religious Diversity 2016 Jul 1 (pp. 170–185). Routledge.
- 41. Kerrigan K, Green G. “Ghosts From the Past”: The Re-Emergence of Internalized Religious Stigma Following Diagnosis of HIV Among Northern Irish Gay Men. Journal of Homosexuality. 2019 Apr 16;66(5):635–52. pmid:29336695
- 42. Huschke S, Schubotz D. Commercial sex, clients, and Christian morals: Paying for sex in Ireland. Sexualities. 2016 Oct;19(7):869–87.
- 43. Wilkinson DC. Gender and sexuality politics in post-conflict Northern Ireland: Policing patriarchy and heteronormativity through relationships and sexuality education. Sexuality Research and Social Policy. 2021:1–4.
- 44.
Phillips KM, Reay B. Sex before sexuality: A premodern history. Cambridge: Polity; 2011.
- 45. Benagiano G, Carrara S, Filippi V, Brosens I. Condoms, HIV and the roman catholic church. Reproductive BioMedicine Online. 2011 Jun 1;22(7):701–9. pmid:21507723
- 46. Kirkwood K. Catholic bioethical perspectives on Ontario’s HPV vaccination. Open Medicine. 2008;2(4):e111. pmid:21602954
- 47. Shelton RC, Snavely AC, De Jesus M, Othus MD, Allen JD. HPV vaccine decision-making and acceptance: does religion play a role?. Journal of religion and health. 2013 Dec 1;52(4):1120–30. pmid:22076049
- 48. Birmingham WC, Macintosh JL, Vaughn AA, Graff TC. Strength of belief: Religious commitment, knowledge, and HPV vaccination adherence. Psycho‐oncology. 2019 Jun;28(6):1227–33. pmid:30931539
- 49. Henry KA, Swiecki-Sikora AL, Stroup AM, Warner EL, Kepka D. Area-based socioeconomic factors and human papillomavirus (HPV) vaccination among teen boys in the United States. BMC public health. 2018 Dec 1;18(1):19.
- 50. Hofstetter AM, Rosenthal SL. Factors impacting HPV vaccination: lessons for health care professionals. Expert review of vaccines. 2014 Aug 1;13(8):1013–26. pmid:24965128
- 51.
National Health Service [Internet]. United Kingdom: NHS.uk; c2022 [cited 2024 Mar 07]. Children and young people; Consent to treatment. https://www.nhs.uk/conditions/consent-to-treatment/children/
- 52.
NI Direct [Internet]. Northern Ireland, United Kingdom; c2022 [cited 2024 Mar 11]. HPV vaccine for adolescents aged 12 to 13 years old. https://www.nidirect.gov.uk/articles/hpv-vaccine-adolescents-aged-12-13-years-old
- 53. Flood T, Wilson IM, Prue G, McLaughlin M, Hughes CM. Impact of school-based educational interventions in middle adolescent populations (15-17yrs) on human papillomavirus (HPV) vaccination uptake and perceptions/knowledge of HPV and its associated cancers: A systematic review. Preventive Medicine. 2020 Oct 1;139:106168. pmid:32603795
- 54.
DeBell D, Tomkins AS. Discovering the future of school nursing: the evidence base. London: Amicus/CPHVA; 2006.
- 55.
Love for Life [Internet]. Northern Ireland, United Kingdom; c2024 [cited 2024 Mar 11]. Inspiring Young People To Value Strong Healthy Relationships. https://www.loveforlife.org.uk/
- 56. Hoekstra BA, Young VL, Eley CV, Hawking MK, McNulty CA. School Nurses’ perspectives on the role of the school nurse in health education and health promotion in England: a qualitative study. BMC nursing. 2016 Dec;15(1):1–9.
- 57.
Michie S, Atkins L, West R. The behaviour change wheel. A guide to designing interventions. 1st ed. Great Britain: Silverback Publishing. 2014;1003:1010.
- 58. Mc Sharry J, Murphy PJ, Byrne M. Implementing international sexual counselling guidelines in hospital cardiac rehabilitation: development of the CHARMS intervention using the Behaviour Change Wheel. Implementation Science. 2016 Dec;11(1):1–1. pmid:27724957
- 59. Webster R, Michie S, Estcourt C, Gerressu M, Bailey JV, MenSS Trial Group. Increasing condom use in heterosexual men: development of a theory-based interactive digital intervention. Translational behavioral medicine. 2016 Sep 1;6(3):418–27.
- 60. Cassidy C, Bishop A, Steenbeek A, Langille D, Martin-Misener R, Curran J. Barriers and enablers to sexual health service use among university students: a qualitative descriptive study using the theoretical domains framework and COM-B model. BMC health services research. 2018 Dec;18(1):1–2.
- 61. Stalmeijer RE, McNaughton N, Van Mook WN. Using focus groups in medical education research: AMEE Guide No. 91. Medical teacher. 2014 Nov 1;36(11):923–39. pmid:25072306
- 62. Tausch AP, Menold N. Methodological aspects of focus groups in health research: results of qualitative interviews with focus group moderators. Global qualitative nursing research. 2016 Feb 29;3:2333393616630466. pmid:28462326
- 63. Punch S. Interviewing strategies with young people: the ‘secret box’, stimulus material and task‐based activities. Children & society. 2002 Jan;16(1):45–56.
- 64. Liamputtong P. Focus group methodology: Principle and practice. Focus Group Methodology. 2011:1–224.
- 65.
Department of Education [Internet]. Northern Ireland, United Kingdom; c2020 [cited 2024 Mar 11]. School enrolment–school level data 2019/20. https://www.education-ni.gov.uk/publications/school-enrolment-school-level-data-201920
- 66. Rolston B, Schubotz D, Simpson A. Sex education in Northern Ireland schools: a critical evaluation. Sex education. 2005 Aug 1;5(3):217–34.
- 67.
Random.org [Internet]. Dublin, Ireland; Randomness and Integrity Services Ltd; c2024 [cited 2024 Mar 11]. What’s this fuss about true randomness? www.random.org
- 68. Kitzinger J. Qualitative research: introducing focus groups. Bmj. 1995 Jul 29;311(7000):299–302.
- 69. Guest G, Namey E, McKenna K. How many focus groups are enough? Building an evidence base for nonprobability sample sizes. Field methods. 2017 Feb;29(1):3–22.
- 70.
Dorner DG, Gorman GE, Calvert PJ. Information needs analysis: Principles and practice in information organizations. Facet Publishing; 2014 Dec 31.
- 71. Hsieh HF, Shannon SE. Three approaches to qualitative content analysis. Qualitative health research. 2005 Nov;15(9):1277–88. pmid:16204405
- 72. De Leo A, Bayes S, Bloxsome D, Butt J. Exploring the usability of the COM-B model and Theoretical Domains Framework (TDF) to define the helpers of and hindrances to evidence-based practice in midwifery. Implementation Science Communications. 2021 Dec;2(1):1–8.
- 73. Willmott TJ, Pang B, Rundle-Thiele S. Capability, opportunity, and motivation: an across contexts empirical examination of the COM-B model. BMC Public Health. 2021 May 29;21(1):1014.
- 74. Michie S, Van Stralen MM, West R. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implementation science. 2011 Dec;6(1):1–2. pmid:21513547
- 75.
Mitchell A, Patrick K, Heywood W, Blackman P, Pitts M. National survey of Australian secondary students and sexual health 2013. Melbourne: Australian Research Centre in Sex Health and Society & La Trobe University. 2014 Apr.
- 76. Franca MC, Boyer VE, Gerend MA, Lee M, Whittington KD, McKinney SL, et al. College students’ awareness of the link between human papillomavirus (HPV) and HPV-associated cancers. Journal of Cancer Education. 2023 Apr;38(2):669–76. pmid:35459979
- 77. Parsel SM, Barton BM, Beatty S, Friedlander PL. Knowledge gaps among patients and providers in HPV-related oropharyngeal cancer: a systematic review. Otolaryngology–Head and Neck Surgery. 2020 May;162(5):612–21. pmid:32122242
- 78.
Walker R. [Internet]. London: University College London; c2019 [cited 2024 Mar 11]. How intimate are Generation Z young teenagers? 21st June 2019. https://www.ucl.ac.uk/news/2019/jun/how-intimate-are-generation-z-young-teenagers-0#:~:text=Fewer%20than%20one%20in%2030,to%20new%20UCL%2Dled%20research
- 79.
Judd T. The Independent [Internet]. London, United Kingdom; c2005 [cited 2024 Mar 11]. One fifth of girls are sexually active by 14. 24th March 2005. https://www.independent.co.uk/news/uk/this-britain/onefifth-of-girls-are-sexually-active-by-14-5350178.html
- 80. Bogart LM, Cecil H, Wagstaff DA, Pinkerton SD, Abramson PR. Is it “sex”?: College students’ interpretations of sexual behavior terminology. Journal of Sex Research. 2000 May 1;37(2):108–116
- 81. Chetia B. Slangs and Gender-A Sociolinguistic Perspective. International Journal of Technical Research and Applications. 2015;4:43–6.
- 82. Wong WI, Shi SY, Chen Z. Students from single-sex schools are more gender-salient and more anxious in mixed-gender situations: Results from high school and college samples. PloS one. 2018 Dec 7;13(12):e0208707. pmid:30532270
- 83. Cameron J. Focusing on the focus group. Qualitative research methods in human geography. 2005;2(8):116–32.
- 84. Abdel Meguid E, Collins M. Students’ perceptions of lecturing approaches: traditional versus interactive teaching. Advances in medical education and practice. 2017 Mar 17:229–41. pmid:28360541
- 85. Skipper Y, Fox C. Boys will be boys: Young people’s perceptions and experiences of gender within education. Pastoral Care in Education. 2022 Oct 2;40(4):391–409.
- 86. Fisher H, Harding S, Hickman M, Macleod J, Audrey S. Barriers and enablers to adolescent self-consent for vaccination: A mixed-methods evidence synthesis. Vaccine. 2019 Jan 14;37(3):417–29. pmid:30573357
- 87. Chantler T, Letley L, Paterson P, Yarwood J, Saliba V, Mounier-Jack S. Optimising informed consent in school-based adolescent vaccination programmes in England: a multiple methods analysis. Vaccine. 2019 Aug 23;37(36):5218–24. pmid:31351797
- 88. Audrey S, Farr M, Roderick M, Evans K, Fisher H. How acceptable is adolescent self-consent for the HPV vaccination: findings from a qualitative study in south-west England. Vaccine. 2020 Nov 3;38(47):7472–8. pmid:33041101
- 89. Batista Ferrer H, Trotter CL, Hickman M, Audrey S. Barriers and facilitators to uptake of the school-based HPV vaccination programme in an ethnically diverse group of young women. Journal of Public Health. 2016 Sep 1;38(3):569–77. pmid:26054910
- 90. Kay RH, LeSage A. Examining the benefits and challenges of using audience response systems: A review of the literature. Computers & Education. 2009 Nov 1;53(3):819–27.
- 91. Gottvall M, Tydén T, Larsson M, Stenhammar C, Höglund AT. Informed consent for HPV vaccination: a relational approach. Health Care Analysis. 2015 Mar;23:50–62. pmid:23275146
- 92. Goldman RD, McGregor S, Marneni SR, Katsuta T, Griffiths MA, Hall JE, et al. Willingness to vaccinate children against influenza after the coronavirus disease 2019 pandemic. The Journal of pediatrics. 2021 Jan 1;228:87–93. pmid:32771480
- 93. Sherman SM, Nailer E. Attitudes towards and knowledge about Human Papillomavirus (HPV) and the HPV vaccination in parents of teenage boys in the UK. PloS one. 2018 Apr 11;13(4):e0195801. pmid:29641563
- 94. Sitaresmi MN, Rozanti NM, Simangunsong LB, Wahab A. Improvement of Parent’s awareness, knowledge, perception, and acceptability of human papillomavirus vaccination after a structured-educational intervention. BMC public health. 2020 Dec;20(1):1–9.
- 95. Zhang SK, Pan XF, Wang SM, Yang CX, Gao XH, Wang ZZ, et al. Knowledge of human papillomavirus vaccination and related factors among parents of young adolescents: a nationwide survey in China. Annals of Epidemiology. 2015 Apr 1;25(4):231–5. pmid:25656922
- 96. Levand MA, Ross K. Sexuality education as a moral good: Catholic support for accurate, holistic sexuality information. Theology & Sexuality. 2021 Sep 2;27(2–3):169–87.
- 97. Bialystok L, Wright J. ‘Just Say No’: public dissent over sexuality education and the Canadian national imaginary. Discourse: Studies in the Cultural Politics of Education. 2019 May 4;40(3):343–57.
- 98. Coleman LM, Testa A. Sexual health knowledge, attitudes and behaviours: variations among a religiously diverse sample of young people in London, UK. Ethnicity and Health. 2008 Jan 1;13(1):55–72. pmid:18066738
- 99. Martin N, Baralt L, Garrido-Ortega C. What’s religion got to do with it? Exploring college students’ sexual and reproductive health knowledge and awareness of sexual and reproductive health services in relation to their gender and religiosity. Journal of religion and health. 2018 Oct;57:1856–75. pmid:28653265
- 100.
Luker K. When sex goes to school: Warring views on sex—and sex education—since the sixties. WW Norton & Company; 2007 Apr 17.
- 101. Ashcraft AM, Murray PJ. Talking to parents about adolescent sexuality. Pediatric Clinics. 2017 Apr 1;64(2):305–20. pmid:28292447
- 102.
United Kingdom Health Security Agency [Internet]. London: GOV.UK; c2023 [cited 2024 Mar 07]. HPV universal vaccination: leaflet. https://www.gov.uk/government/publications/hpv-vaccine-vaccination-guide-leaflet
- 103.
Health Protection Service [Internet]. Northern Ireland: Public Health Agency; c2023 [cited 2024 Mar 11]. The HPV vaccine: Questions and answers for parents of girls and boys aged 12–13. https://www.publichealth.hscni.net/publications/beating-cervical-cancer-hpv-vaccine-questions-and-answers-parents-girls-year-9-and-10-e
- 104.
Public Health Scotland [Internet]. Edinburgh, Scotland; c2023 [cited 2024 Mar 07]. About the HPV vaccine. https://publichealthscotland.scot/our-areas-of-work/immunisation-vaccine-and-preventable-disease/immunisations-by-vaccine/hpv-immunisations/about-the-hpv-vaccine/the-hpv-vaccine/#:~:text=The%20Gardasil%C2%AE9%20vaccine,%2C%20redness%20or%20mild%20itching
- 105.
Public Health Wales [Internet]. Cardiff, Wales; c2020 [cited 2024 Mar 07]. HPV Vaccination. Protect yourself from cancers caused by HPV. https://111.wales.nhs.uk/pdfs/ERUK%20HPV%20leaflet.pdf
- 106. Ma GX, Zhu L, Tan Y, Zhai S, Lin TR, Zambrano C, et al. A multilevel intervention to increase HPV vaccination among Asian American adolescents. Journal of community health. 2021 Jul 7:1–8. pmid:34232452
- 107. Shoup JA, Wagner NM, Kraus CR, Narwaney KJ, Goddard KS, Glanz JM. Development of an interactive social media tool for parents with concerns about vaccines. Health Education & Behavior. 2015 Jun;42(3):302–12. pmid:25413375
- 108. Daley MF, Narwaney KJ, Shoup JA, Wagner NM, Glanz JM. Addressing parents’ vaccine concerns: a randomized trial of a social media intervention. American journal of preventive medicine. 2018 Jul 1;55(1):44–54. pmid:29773490
- 109. Lahijani AY, King AR, Gullatte MM, Hennink M, Bednarczyk RA. HPV Vaccine Promotion: The church as an agent of change. Social science & medicine. 2021 Jan 1;268:113375.
- 110. Middaugh E. Teens, social media, and fake news. Unpacking fake news: An educator’s guide to navigating the media with students. 2019 Mar 8:42–58.
- 111.
Barthel, M., Mitchell, A. & Holcomb, J. Many Americans Believe Fake News Is Sowing Confusion, Pew Research Center’s Journalism Project. 2016.
- 112. Kosenko KA, Binder AR, Hurley R. Celebrity influence and identification: A test of the Angelina effect. Journal of Health Communication. 2016 Mar 3;21(3):318–26. pmid:26192626
- 113. Tannenbaum MB, Hepler J, Zimmerman RS, Saul L, Jacobs S, Wilson K, et al. Appealing to fear: A meta-analysis of fear appeal effectiveness and theories. Psychological bulletin. 2015 Nov;141(6):1178. pmid:26501228
- 114. Kim HJ, Shin W. The effects of message source and fear appeal on young adults’ response to Sexually Transmitted Disease (STD) messages in Singapore. Asian Journal of Communication. 2018 Mar 4;28(2):185–204.
- 115. Roberts AB, Oyun C, Batnasan E, Laing L. Exploring the social and cultural context of sexual health for young people in Mongolia: implications for health promotion. Social science & medicine. 2005 Apr 1;60(7):1487–98. pmid:15652682
- 116. Waling A, Farrugia A, Fraser S. Embarrassment, shame, and reassurance: Emotion and young people’s access to online sexual health information. Sexuality Research and Social Policy. 2022 Jan 10:1–3. pmid:35035599
- 117. Maughan E, Adams R. Educators’ and parents’ perception of what school nurses do: The influence of school nurse/student ratios. The Journal of School Nursing. 2011 Oct;27(5):355–63. pmid:21788399
- 118. Alexandropoulou M. The health promoting school and the school nurse: A content analysis of school staff’s views. British Journal of School Nursing. 2013 Apr;8(3):134–41.
- 119. Westwood J, Mullan B. Knowledge and attitudes of secondary school teachers regarding sexual health education in England. Sex education. 2007 May 1;7(2):143–59.
- 120. Clayton HB, Brener ND, Barrios LC, Jayne PE, Everett Jones S. Professional development on sexual health education is associated with coverage of sexual health topics. Pedagogy in Health Promotion. 2018 Jun;4(2):115–24.
- 121.
World Health Organisation [internet]. Switzerland: WHO.int; c2022 [cited 2024 Mar 07]. One dose Human Papilloma Virus (HPV) vaccine offers solid protection against cervical cancer. https://www.who.int/news/item/11-04-2022-one-dose-human-papillomavirus-(hpv)-vaccine-offers-solid-protection-against-cervical-cancer
- 122.
The National Institute for Health and Care Excellence [Internet]. London, United Kingdom; c2014 [cited 2024 Mar 11]. Behaviour change; Individual approaches. https://www.nice.org.uk/guidance/ph49/resources/behaviour-change-individual-approaches-pdf-1996366337989