The English schools-based human papillomavirus (HPV) vaccination programme began for young women in September 2008 and was not extended to young men in England until the 2019/2020 academic school year (Public Health England et al, 2019). High coverage in the programme for young women was achieved, but variations across local authorities were apparent (Public Health England, 2019). In southwest England, lower uptake by geographical area, ethnicity and educational setting has been shown (Fisher et al, 2013).
The World Health Organization (2014) defines ‘young people’ as those aged 10–24 years old. In the UK, the legal framework allows young people to be vaccinated without parental consent provided they demonstrate sufficient understanding of the nature and implications of treatment, often referred to as ‘Gillick competence’ (Gillick v West Norfolk and Wisbech Area Health Authority and Department of Health and Social Security, 1985). However, local policies tend to require parental consent for the HPV vaccine in the school setting, though this is a matter of preference, rather than a legal requirement, and this may act as a barrier to receipt of the vaccination for some young people (Batista-Ferrer et al, 2016; Fisher et al, 2019).
New consent procedures were developed and implemented from 2017 in two local authority areas in southwest England, with relatively lower uptake (Audrey et al, 2018). Previously, only young women with written parental consent were invited to attend the HPV vaccination session. The new procedures allowed all eligible young women to attend, irrespective of whether they had returned a parental consent form. The immunisation team sought verbal parental consent by telephone and, if parents could not be contacted, adolescent self-consent was considered.
In 2018, a mixed-methods evaluation of the new consent procedures was undertaken by the authors (Audrey et al, 2018). Statistical analyses showed uptake improved in one of the local authorities and barriers to vaccination were overcome for some young women whose families were less likely to respond to paper-based methods of consent (Fisher et al, 2020).
‘The new procedures allowed all eligible young women to attend, irrespective of whether they had returned a parental consent form.’
In the UK, adolescents are legally capable of self-consenting to the HPV vaccination, provided they understand the implications of doing so. However, local policies do not always reflect this, and oft en require parental consent
‘… local policies tend to require parental consent for the HPV vaccine in the school setting, though this is a matter of preference, rather than a legal requirement, and this may act as a barrier to receipt of the vaccination for some young people’
A further paper by the authors describing the quantitative findings of this mixed-methods study is under review and also found results that support these conclusions. Nationally, uptake of the HPV vaccine remained stable (87.1% versus 87.5%, P=0.36) between the pre-intervention and the post-intervention period. In the first local authority, uptake increased from 76.3% in the pre-intervention period to 82.5% in the post-intervention period (risk difference=6.2%, P=0.17), while in the matched local authorities, uptake reduced from 85.2% to 79.9% (risk difference=−5.3%, P=0.04), giving a difference-in-differences measure of effect as 11.5% (P=0.03). In the second local authority, there was no evidence of a change in uptake from the pre- to the post-intervention period (84.8% to 87.3% risk difference: 2.4%, P=0.32), no change in the matched local authorities (risk difference: 1.0%, P=0.93), and the overall difference-in-differences measure of effect was 1.5% (P=0.57).
This paper focuses on the qualitative research, examining the implementation of the new procedures and implications for schools-based adolescent vaccination programmes. The focus of this arm of the study was to explore participants' understanding of HPV and the vaccination programme, and their views and experiences of adolescent consent and its procedures.
Methods
Recruitment
The research was undertaken in two local authorities in southwest England where the new consent procedures have been implemented. School recruitment and data collection took place during the 2017/18 and 2018/19 programme years (before the programme was widened to include male students). Mainstream schools in which at least 12 female Year 8 students had not been vaccinated during the 2016/17 programme year were sent information packs about the study and invited to participate. The decision to select 12 students who had not been vaccinated was pragmatic, as it enabled a sufficient number of schools (n=15) with enough young women not returning consent forms (range: 12–35) to be invited to participate in the study. Alternative education providers in the two study areas were also invited to participate, including schools for young women with special educational needs and disabilities (SEND).
The only inclusion criteria for participants was that they could speak English, as all interviews were conducted in English.
Overall, four out of 15 eligible mainstream schools, and five out of 17 alternative educational settings consented to take part in the study. Vaccination sessions were observed in three mainstream schools. A total of 53 participants were interviewed:
- The immunisation programme manager and three immunisation nurses (who comprised the permanent team delivering the HPV vaccination programme)
- Three members of staff in mainstream schools
- A staff member from each of the five alternative educational settings
- A total of 22 parents (21 mothers and one father), of whom five had daughters participating in the study
- A total of 19 young women. Eight (aged 12–13 years) were recruited at school and experienced the new consent procedures, and 11 (aged 13–17 years) were recruited from community organisations.
Initial recruitment for interviews was through participating schools and, because recruitment of parents and young people proved difficult, was broadened to include parent support groups and youth projects. Depending on preference, young women and parents were interviewed separately, with their parent/daughter or with a peer/peers. The interviews were conducted by one researcher and took place within schools, community organisations, homes or workplaces.
Interviews were halted after data saturation was reached. Digitally recorded, semi-structured interviews were conducted with immunisation nurses, school staff, parents, and young women. Topic guides focused on:
- Participants' understanding of HPV and the associated vaccination programme
- Adolescent consent for healthcare
- Views of the new consent procedures
- Experiences of the new procedures in practice
- Implications for other schools-based adolescent vaccination programmes.
Qualitative analysis
All recordings were transcribed verbatim, checked for accuracy, and anonymised. Thematic analysis (Braun and Clarke, 2006) was undertaken using the framework approach (Ritchie and Lewis, 2013), with a logic model designed for the mixed-methods study. Both inductive and deductive approaches were used, focusing on the main research questions regarding participants views and experiences of the vaccination programme and adolescent consent while capturing additional issues as they emerged from the data. Coding of all transcripts was undertaken by one researcher, and a second researcher double-coded a subset of 12 transcripts to check for meaning, relevance and reliability, and agree the coding framework applied to the full set of transcripts. Sections of text relating to the process of implementing the new consent procedures were extracted into a primary chart. Streamlined charts were produced during the process of analysing and summarising the data, as key terms and phrases were retained and extraneous text removed. This process was checked by a second researcher, and interpretation of the findings was agreed within the research team. The results are presented in relation to the stages of the new consent procedures:
- School preparedness
- Written parental consent
- Telephone consent
- Self-consent
- Catch-up clinics and alternatives
- Alternative educational settings and additional needs.
Ethical approval
Required approvals for the research activities were provided by the University of Bristol's Faculty of Health Sciences Research Ethics Committee and the NHS Health Research Authority (references: 57621 and 18/HRA/0367). Participants aged 16 years or older gave written informed consent before participating in the study. For participants younger than 16 years, both written parental consent and young women's consent were obtained.
Results
Eight out of the 19 young women participating in the study were from minority ethnic groups. All the young women attended mainstream schools and had received the HPV vaccine: one self-consented, six were vaccinated following parental verbal consent, and 12 had returned a parental consent form (one of whom had signed the form herself).
School preparedness
The immunisation staff indicated that some schools were not fully prepared for inviting all eligible young women to the immunisation session, irrespective of whether they had a parental consent form.
‘‘Some of them [schools] have not read the information that we gave them, and emailed to them, and gave them hard copies of at every opportunity! They still swear blind that they didn't know what was happening [laughs]… the consents and what we're doing, and the fact that we need everybody down, we need to speak to everybody… I think it doesn't get read.’
(Immunisation nurse 3)
Written parental consent
Written parental consent was achieved in the majority of cases, but it was acknowledged that some parental consent forms would not be returned.
‘‘The vast majority of them [parental consent forms] will come back on or before the deadline and then, no matter how much chasing you do with a particular, with a very small group of students thankfully, you will still never get them all returned.’
(School staff 1, mainstream school 2)
A variety of reasons were proposed as to why parental consent forms were not returned, including that the form was signed but not returned, that the form is not given to parents, or that the parents refuse.
‘Lots of them will be that they did sign the form and it's not made its way back to us. Some will be that they haven't seen the form at all, it never even made its way home to mum, that she didn't see the form. And then obviously you do get the parent refusals. It does say on the form that, even if it's a ‘no’, please sign that it's a ‘no’ and send it back. So, lots of them will just not send it back at all… some are just genuinely busy mums that are like “Oh my goodness, it's sat on the kitchen worktop, I forgot” [laughs] so it's just hectic, busy lives and they didn't send it back in time.’
(Immunisation nurse 2)
It was recognised that some households find it more difficult than others to deal with paper-based consent.
‘I think the school should provide folders so you could keep all your stuff safe [be]cause some people don't have the money to buy folders like me.’
(Young woman 1, mainstream school 1)
‘That difficult-to-get parent could be a parent that's working three jobs around the week, do you know what I mean, to keep the food on that child's table, could be someone that's looking after a sick parent, you know.’
(School staff, mainstream school 10)
In some cases, young people deliberately avoided vaccination by not informing parents that the session was taking place.
‘It's maybe that the kid doesn't give their parents the letter ‘cos maybe they've skimmed it through, they decide that they don't want it and then they just don't give it to the parents.'
(Young woman 1, community group 6)
The new consent procedures, with additional options, were intended to overcome some of the barriers to vaccination caused by the lack of written parental consent.
Telephone consent
Because of their preference for gaining parental consent, the immunisation team attempted to make telephone contact with a parent before considering a young person's competence for self-consent.
‘Initially when we talked about self-consent there were lots of concerns. Certainly, as a team, that's why we suggested we do parental verbal consents as a step before going to self-consent.’
(Immunisation programme manager)
School staff, parents and students appeared satisfied with this arrangement, commenting that the school nurses were good at ensuring parents had consented before giving the vaccination.
‘Even though there is a self-consenting process, the school nurses are quite good at phoning the - they're very good at phoning the parents here, and also the girls would generally want to phone the parents as well.’
(School staff, mainstream school 10)
‘They were asking me on the phone that if I'm happy for her to have it. I said yes it's ok…because they said it's something that is not going to hurt them [laughs] [be]cause I'm just worried.’
(Parent 2, community group 5)
‘The school had to ring her [participant's mother] to make sure that she was giving her consent…Because she read the information and she signed it but then she didn't give it back to me so I couldn't get it back to school in time.’
(Young woman 2, mainstream school 1)
There were initial concerns that the process of telephoning parents would be time consuming. This was observed during one vaccination session and raised during interviews.
‘They gave my parents a call but there was a lot of people who were waiting for the parents because they either forgot or they didn't even give their parents the form. And some people just, it was a lot of people on that day and lots of them were like “Oh, I want to have it done” and there weren't enough adults around.’
(Young woman 2, mainstream school 9)
But the benefits of seeking and gaining telephone consent were often reported by participants to outweigh the drawbacks.
‘It's a lot of work and for those schools that you get 30, 40 plus consent forms not coming back in, and you've got all those young people with you and you're trying to make all these phone calls. Yes, it is frustrating but actually, the fact that they get a good percentage of those come back as positives, actually that's good because those young people wouldn't necessarily have got vaccinated otherwise.’
(Immunisation programme manager)
As the programme progressed, additional funds were allocated to support the process of gaining parental telephone consent.
‘I had a long conversation with our commissioners, and we did get a little bit of extra money to allow us, not huge, but to give us a bit more capacity so that we could do it [telephone parents].’
(Immunisation programme manager)
The immunisation team also realised parents were more likely to answer the telephone if their child was making the call.
‘Now quite often we will get the young people to phone their parents because they'll answer their child's mobile phone. If they have a mobile number that's unrecognisable most people don't tend to answer.’
(Immunisation programme manager)
Concerns about whether the person giving telephone consent was the parent were overcome by the nature and content of the conversation.
‘They normally talk to you about their child and like “Oh it's been such a heck of a week, I'm so sorry we haven't managed to do the form”, do you know what I mean? You normally get more of a feedback as to, you know, and you're also asking them about allergies and their medical history and things. So, if I did feel that it wasn't, and they didn't have an idea, then I obviously would be concerned in that situation, you know, ask more questions as to decipher that they were a parent or a legal guardian.’
(Immunisation programme manager)
Self-consent
Very few young women self-consented to the vaccine.
‘I have only probably done only two self-consents, two or three, not very many. I don't think we've done very many as a group of us to be honest.’
(Immunisation nurse 1)
The new consent procedures included asking the young women if they had discussed the vaccine with their parents and whether administering the vaccine without parental consent would cause difficulties at home.
‘I would have a little chat with the girl and find out whether her parents are aware of the day and aware of the form and whether they've seen it… they've had to have chatted to the child about them wanting to have the immunisation for me to be happy to self-consent them.’
(Immunisation nurse 1)
‘I think you should call home, that's what I did… my mum didn't answer, but I signed in a form or something to say if mum actually wanted you to have your vaccine, and my mum wanted, so I filled in some forms, answered some questions.’
(Young woman 1, mainstream school 1)
This requirement for young people to say they had discussed the HPV vaccine with their parents could act as a barrier to vaccination.
‘They hadn't shown the form to their parents so they didn't have a feeling as to whether parents would like them to have it or would not, and so in that case I just gave them the clinic letter and yes, talked to them about clinic options.’
(Immunisation nurse 1)
Assessing competence could also lead immunisation nurses to conclude that self-consent was not appropriate.
‘We talk through the leaflet with them, talk about what HPV is and we ask them a few questions afterwards, the form that we go through, ask them a few questions about what is the name of the illness we're trying to protect, what can happen if you do get HPV virus, how many doses will you have. If they can't answer, even though you've just gone through the information with them, we wouldn't take their self-consent.’
(Immunisation nurse 2)
Concerns about a young woman who self-consented to the HPV vaccination against her parents' wishes were raised by all members of the immunisation team.
‘We had a Year 8 child who presented to the clinic saying that she hadn't got the form and, because she'd forgotten it but really wanted to have the vaccination, could she still have the vaccination. So we went through everything. We tried phoning mum, we tried phoning dad, she tried phoning mum and dad, we couldn't get hold of them, she was very aware of what the vaccination was about, we talked to her about it and we felt she was able to give her consent so we went ahead and gave the vaccination on the basis of self-consent and then had a huge complaint from parents because actually they'd signed the form to say no, but the girl hadn't handed that in. So, it's difficult in that situation, but actually the girl was obviously very aware of what she, she'd obviously read the letter and knew that if the form wasn't returned she could then go ahead and have the vaccination.’
(Immunisation nurse 2)
Although this was perhaps the clearest example of a young woman self-consenting to her own healthcare provision, some of the broader implications of going against parents' wishes were highlighted.
‘She never came back for a second vaccine and I have checked that, and she didn't come back for a second, so she has got some protection, but she hasn't got full protection… That's why we always ask, the first question we ask when we're doing self-consent is do you feel by you having this vaccination it will, I can't remember the exact wording, but do you feel it will be detrimental to, has discussion taken place why no consent's been completed by the family, consider delaying the vaccine if this may lead to any disagreements in the family… We just have to be very mindful that we're the advocate for that young person be[cause] we want them to have it, if they really want to have it done, but we don't want to be causing them harm within that family and breaking those family relationships.’
(Immunisation programme manager)
‘There were initial concerns that the process of telephoning parents would be time consuming… But the benefits of seeking and gaining telephone consent were often reported by participants to outweigh the drawbacks’
The young woman correctly anticipated that, if she returned the form in which her parents declined the vaccination on her behalf, she would not receive the vaccine. Although the immunisation team were willing to telephone parents of students who had not returned a form at all, they did not try to contact parents of young women who wanted to be vaccinated but whose parents had indicated refusal on the form.
‘If we've got a no… then we take that as a no. I think if you start keep phoning parents too much, they see that as harassment… we would get a letter to the parents saying I appreciate you said no this time, here's some more information, if you change your mind here's the clinic dates, just give us a ring.’
(Immunisation programme manager)
In practice, adolescent self-consent became the responsibility of more experienced members of the immunisation team.
‘It isn't something that we tend to do in health very often, so it was quite a “Ooh not quite sure about this”…It is the substantive members of staff in the imms [immunisation] team that would do self-consents ‘cos I felt it was important to have a key group of staff that were aware of the procedures and how to do it.’
(Immunisation programme manager)
Self-consent was less common than the team had anticipated, and it was acknowledged that some young women continued to be disadvantaged by a system that relies on parental consent.
‘I had hoped going into it that it would help us get the more vulnerable girls that may not have the vaccine otherwise, unless we caught them in school, and that their parents haven't sent consent forms back and probably aren't going to take them to the doctor's surgery to have it done or bring them to a clinic. However often those vulnerable girls aren't deemed competent once we go through the assessment with them unfortunately. Not always, obviously, but on the whole. Or they haven't spoken to parents about it, they've got no idea whether mum wants them to have it done or not.’
(Immunisation nurse 2)
As the programme progressed, the immunisation team appeared more comfortable with the new consent procedures, but there was still some reluctance to highlight the option of self-consent.
‘Whether it would cause more problems because they think “Oh it doesn't matter if I haven't got my consent form because I can self-consent anyway” and then obviously we have the problems of not everyone is suitable to self-consent, or if you've not discussed it with parents then we are not going to take your self-consent. So, obviously I'm not for holding information back from them, but I don't know what we would gain from that information being pushed more to them… it opens up more cans of worms the more self-consent we do [laughs].’
(Immunisation nurse 2)
Catch-up clinics and alternatives
Young women who did not receive the vaccine at a school-based session were informed of other options.
‘It is letting the young people know that there are other options, or they can wait [un]til they're a little bit older, that they actually absolutely can go to their GP and have it done, if they want us to talk to parents we're more than happy to do that, if they want to come back to a clinic we run a variety of clinics.’
(Immunisation programme manager)
‘If she's a bit anxious that she doesn't want a vaccine in front of her friends at school, so parents will bring them to clinic where they can feel more relaxed, people aren't looking at them having it done. Some of them may well be that they didn't know about the session at school perhaps so, the route where we would normally do self-consent, but they haven't even spoken to parents about it, they would then bring them to clinic to have it done there. Or they were absent on the day of the school and it's not one of the schools that we're going back to perhaps and they would bring them to clinic.’
(Immunisation nurse 2)
However, the convenience of the schools-based system for many parents and young people contrasted with the need to make an appointment and attend a catch-up clinic.
‘We do find that parents, obviously if you give them the option [of a catch-up clinic], if they phone in and book an appointment, they'll turn up. The ones that you phone to say “Oh we noticed your child hasn't had this, we sent you, you know, I'm not sure whether you want to come to a clinic” and you kind of make that agreement over the phone, if people are going to DNA [did not attend] it tends to be the ones that you've phoned, not the ones that have made the effort to phone in…That's why it is better if we can go through the young people in schools [be]cause parents, if they're not going to engage, won't take them anywhere.’
(Immunisation programme manager)
Some schools-based ‘mop up’ sessions took place if a sufficient number of young women were unable to attend the main vaccination session.
‘If we had a school where the school had inadvertently booked a school trip and a number of them were on a school trip, which often happens, and they were say 20 young people that were due a vaccine yet weren't, then we would go back in and do a school-based session. And if there were other young people who were around at the time who for whatever reason didn't have a consent form or whatever, then they would be welcome to come to that session.’
(Immunisation programme manager)
Alternative educational settings and additional needs
School staff and parents highlighted the importance of close relationships between schools and the parents of young people with SEND.
‘We all work together to earn the trust and support of the parents, so we'd have a much, we'd have a good chance of speaking to the parents… There's one or two parents who never return anything and then it's just a chase them up job, but because again we're only working with eight students in our class it's not that big a job, so we have the capacity to do that and make sure it all happens.’
(School staff 1, alternative educational setting 1)
‘I always let the school know if I'm not available. Like if I'm on a course, I'll ring the school in the morning or the day before and say “Look, I'm not available tomorrow, but you can always get hold of my parents or my sister if you need anything”. So, I always let them know in advance if I'm not going to be available… and they are really good with having contact as well. Really, really good.’
(Parent 1, community group 4)
Parents, school staff, and the immunisation nurses themselves expressed concerns that nurses who are not based in the schools would be unfamiliar with the complex needs of some young people. Consequently, they would be unwilling or unable to vaccinate without parental consent.
‘I know they're not doing boys yet but my son who has autism probably wouldn't speak to you. He wouldn't. He would just look at you because he's electively mute so, if something is tricky, he just won't talk.’
(Parent 2, community group 4)
‘I think with the type of students we've got I don't think, you know, a nurse would want to make that decision. I don't know [laughs] but I think that would be putting quite a lot of pressure on them as well actually to judge capacity.’
(School staff 1, alternative educational setting 1)
‘The special schools that I've seen so far, none of the children I would have thought would have any idea about HPV and be able to talk back to me about it.’
(Immunisation nurse 1)
But it was recognised that not all young people with SEND were unable to take responsibility for decisions about their health.
‘I think you'd have to take it on an individual case because a lot of the children are really bright and switched on and know a lot about a lot of things and it's not saying they wouldn't understand but I think because the extra, the nature of their disability, I think you would have to be a bit more careful with consent.’
(School staff 1, alternative educational setting 1)
‘My biggest fear is having my agency taken away from me based on me being disabled and thus perceived as not being able to make a decision, but I can.’
(Young woman 2, community group 4)
There were other settings and circumstances that could prevent implementation of the vaccination programme. Some young people were registered with a school but attended an alternative setting for part of their timetable.
‘Their movement around is quite hard to keep track of. One of the schools we went into, we didn't even realise that actually they had further satellite units… they're on the roll at [name of pupil referral unit] but actually they're educated in satellite units which are more suitable for their needs.’
(Immunisation nurse 2)
There was uncertainty about uptake of the vaccine for young people educated at home.
‘We also send out the consent forms to children who are on home tuition. It's only once have we had a parent bring their child in, who's on home tuition. And I do, I wonder what the uptake is for them. I've no idea whether that parent or any other parent are then thinking “Right, I'm not going into school so therefore I'll take them to the GP”.’
(School staff 1, alternative educational setting 3)
The consent process for vaccinating young people in the care of the local authority, or living with a foster family, was also considered a barrier to uptake.
‘Their foster carers are not allowed to sign it, but actually the foster carer is there with them, talking to them about it. So actually, you know, it should be I think a joint decision, particularly as I say we've had so many problems getting hold of social workers. But we have got a policy in place for that for September so hopefully that might improve…Just that we let social workers know at the beginning of the academic year and get consent at the beginning of the year.’
(Immunisation nurse 3)
The issue of gender identity was raised in relation to one student, although this may be partially resolved (at least in relation to the HPV vaccine) when the programme is implemented irrespective of gender.
‘We haven't got any further than, you know, trying to speak with him and say even though he identifies, he still has all the - but it's really difficult isn't it, because he's going through - plus he suffers with anxiety anyway.’
(School staff 1, alternative educational setting 3)
Discussion
The results suggest the new consent processes for the HPV vaccination generally worked well. Some schools needed to be reminded that all eligible young women were invited to the vaccination session, irrespective of whether they had returned a form with parental consent, illustrating the importance of good communication between school staff and immunisation teams for schools-based vaccination programmes. But, once the new system became clear, there appeared to be broad agreement that the requirement for written parental consent was a barrier to some young women receiving the vaccine that could be overcome by adjusting the consent procedures.
Telephoning parents on the day of the vaccination session was viewed as an acceptable and effective way to reach parents and ascertain their wishes. There were initial concerns that the telephone consent process was time consuming, but additional funds were allocated to support the process and the expenditure was considered worthwhile. The immunisation team also realised that parents were more likely to answer the telephone if their daughter made the initial contact. Concerns about whether the person giving verbal consent was the child's parent could be overcome by the subsequent conversation between the immunisation nurse and parent.
With appropriate resources, targeted to schools known to have lower uptake and a poorer response to the requirement for written parental consent, telephone consent could be usefully implemented in different local authorities and across other schools-based adolescent vaccination programmes.
Adolescent self-consent was rare. This may be explained partially by the relative success of the immunisation team in gaining parental verbal consent, but other factors specific to the principle of adolescent self-consent were evident. The new procedures included asking young people whether they had discussed the vaccine with their parents and whether administering the vaccine without parental consent would cause difficulties at home. This could act as a barrier to vaccination but was considered important by the immunisation team. The example of a young woman, assessed as competent, who self-consented to the HPV vaccination against her parents' wishes was raised by all members of the team. It was perhaps the clearest example of a young woman making her own decision about whether to receive the vaccine, but it may have reinforced the strong preference amongst the immunisation nurses to clarify parental consent. A scoping review examining children's choice in healthcare found children and young people were capable of making decisions about their healthcare services, and were willing to do so, but the rhetoric of choice was not evident in practice (Coad and Shaw, 2008).
It has been argued that it may become more acceptable for young people to be involved in healthcare decision-making if strategies are employed to challenge the dominant view that children always need protection (Twycross, 2016). A ‘young person-centred’ approach to obtaining adolescent self-consent could support young people's rights to make decisions about their healthcare. This approach is routinely adopted in the UK for provision of contraception to young people under the age of 16 years old, both in healthcare and school settings. Nevertheless, the predominant view of the adults and young women interviewed was to seek some form of parental consent for the HPV vaccine administered to those aged 12–13 years. A young person-centred approach may be more acceptable for other vaccination programmes delivered to older adolescents, such as the tetanus, diptheria, pertussis (TDap) vaccine and meningitis (MenACWY) programmes, which are usually given to young people aged 14–15 years old.
‘Some schools needed to be reminded that all eligible young women were invited to the vaccination session, irrespective of whether they had returned a form with parental consent, illustrating the importance of good communication between school staff and immunisation teams’
For young women with SEND, the consent process relied upon close communication between school staff and parents. Despite some recognition that not all SEND children were unable to take responsibility for decisions about their health, there was concern about the ability of the immunisation nurses to assess a range of complex needs. Other young women whose access to the vaccine, or consent options, were unclear or problematic included those who were registered with a school but attended an alternative setting for part of their timetable, those educated at home, those in the care of the local authority or living with a foster family, and young people with gender dysphoria.
Vaccination uptake outside of the mainstream schools-based sessions is substantially lower than in other settings (Fisher et al, 2020). This is of concern as young people are often considered more vulnerable and may experience adverse outcomes across multiple health and social domains. This remains an under-researched area and greater understanding of barriers to uptake of the HPV vaccination programme for young women is needed to further improve access and address inequalities in uptake.
Limitations
These data relate to implementation of new consent procedures in southwest England and may be less applicable to schools-based vaccination programmes elsewhere. Recruitment of Year 8 students and parents proved difficult through schools, although the number of interviewees was increased by recruiting through community organisations. At the time of the research, the HPV vaccine was only being offered to young women and a male perspective is not included in this study.
Conclusions
Expanding consent procedures for the schools-based HPV vaccination programme to include parental telephone consent proved to be a successful and pragmatic adaptation that was broadly welcomed by the immunisation nurses, parents, and young women in the study. The requirement for young women to confirm that they had discussed vaccination with their parents and that vaccination would not cause difficulties at home meant adolescent self-consent was rare in this age group. Greater understanding of the barriers to uptake outside of the mainstream school-based sessions is needed to further address inequalities in uptake.