Quote this article as:
H Fisher et al. (December 2023). Supporting adolescents in providing consent within the English HPV vaccination programme. www.HPVWorld.com, 250

Three vaccines are available that protect against the high-risk HPV types that are responsible for the majority of HPV-related cancers. In England, adolescents are usually offered the HPV vaccine when they are aged 12-13 years old, as it is most effective if administered before sexual debut. Until recently, uptake of the schools-based HPV vaccination programme exceeded the 80% level required to have a significant impact on cervical cancer deaths¹.

The COVID-19 pandemic has caused disruptions to delivery of the vaccination programme, and national uptake figures remain below 70%². Supporting more adolescents to provide consent could help restore uptake of the HPV vaccination programme to pre-pandemic levels.

Legal framework for consent
In most countries, the legal framework for consent for medical treatments, including vaccination, requires parental or guardian permission for adolescents aged below 18 years³. In England, adolescents are legally able to override parental decisions if they are considered by trained healthcare professionals to be ‘Gillick competent’⁴. In the context of the English vaccination programme, situations arise where adolescents could provide consent themselves as adolescents routinely attend vaccination sessions held at their school without their parents.

Acceptability of adolescent self-consent procedures
Prior to the COVID-19 pandemic, adolescent self-consent occurred infrequently despite the existence of a supportive legal framework⁵. There is evidence of a strong presumption that parents should be responsible for making decisions affecting the health of their children.

This is reflected in the procedures within the English schools-based HPV vaccination programme, where electronic or paper version of information leaflets, together with forms requesting parental consent, are distributed to parents or carers. In some cases, adolescents are excluded from the consent process entirely and may not have an opportunity to consider information about the HPV vaccine^8,9.

The preferred age at which the HPV vaccination is administered, and variation in the perceived maturity of vaccine-eligible adolescents, could prevent endorsement of adolescent self-consent^6,7. Concern has been raised about the potential to harm relationships and trust between parents and school staff, and also within families^6,10.

Many adolescents indicate that decisions to have the HPV vaccine were made by their parents, or with other adults, irrespective of their own perspective¹⁰. Often adolescents were complicit with this and appeared to prefer or expect their parents to be responsible for providing consent⁸. In some cases, adolescents appeared to play a more instrumental role in whether they were vaccinated or not. This included intervening in the consent procedures (e.g. completing the form themselves)^6,8 or actively ensuring they were vaccinated after missing a session at school (e.g. by reminding their parents to take them to the general practice)¹⁰.

Addressing information needs to support adolescents’ decision making
Many adolescents may be limited in their ability to provide self-consent because of their own information needs, or limited understanding of the HPV vaccine and the diseases it is intended to prevent^8,11.

To help address adolescents’ information needs, we used co-production research methodologies and the ‘person-based approach’¹² to develop a lesson about the HPV vaccine¹³. The content, style and format were informed by the preferences of adolescents from disadvantaged backgrounds and stakeholders (e.g immunisation nurses, school staff, youth workers). The resources have been made available in the public domain (Figure 1), and include a PowerPoint presentation interspersed with short films, exercises, lesson plan and a guidance document for educators. 

The lesson is designed to be delivered prior to the vaccination session at school, giving adolescents the opportunity to find out about the HPV vaccine. Strategies to improve communication about the HPV vaccine may increase adolescents’ autonomy in consent procedures, clarify their rights and responsibilities in relation to health care services, and contribute to higher uptake of the HPV vaccination programme following disruptions caused by the COVID-19 pandemic.

CONFLICTS OF INTEREST
No conflicts of interest to declare.


References

1. Jit M, Choi YH, Edmunds WJ. Economic evaluation of human papillomavirus vaccination in the United Kingdom. BMJ. 2008. 337:a769. Available from: https://www.bmj.com/content/337/bmj.a769

2. UK Health Security Agency, Human papillomavirus (HPV) vaccine coverage estimates in England: 2021 to 2022. Available from: https://www.gov.uk/government/collections/vaccine-uptake#hpv-vaccine-uptake

3. World Health Organisation, Considerations regarding consent in vaccinating children and adolescents between 6 and 17 years old. 2014. Available from: https://www.who.int/publications/i/item/considerations-regarding-consent-in-vaccinating-children-and-adolescents-between-6-and-17-years-old

4. Gillick v West Norfolk and Wisbech Area Health Authority and Department of Health and Social Security. 1985: London: House of Lords. Available from: https://www.lawteacher.net/cases/gillick-v-west-norfolk.php

5. Fisher H, Evans K, Reynolds R, et al., Secondary analyses to test the impact on inequalities and uptake of the schools-based human papillomavirus (HPV) vaccination programme by stage of implementation of a new consent policy in the south-west of England. BMJ Open. 2021;11(7):e044980. Available from: https://doi.org/10.1136/bmjopen-2020-044980

6. Audrey S, Farr M, Roderick M, et al., How acceptable is adolescent self-consent for the HPV vaccination: qualitative findings from a process evaluation in south-west England. Vaccine. 2020;38(47):7472-8. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7604563/

7. Fisher H, Harding S, Hickman M, et al., Barriers and enablers to adolescent self-consent for vaccination: A mixed-methods evidence synthesis. Vaccine. 2019;37(3): 417-29. Available from: https://pubmed.ncbi.nlm.nih.gov/30573357/

8. Fisher H, Evans K, Ferrie J, et al., Young women’s autonomy and information needs in the schools-based HPV vaccination programme: A qualitative study. BMC Public Health. 2020;20(1):1680. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-020-09815-x

9. Chantler T, Pringle E, Bell S, et al., Does electronic consent improve the logistics and uptake of HPV vaccination in adolescent girls? A mixed-methods theory informed evaluation of a pilot intervention. BMJ Open. 2020;10(11):e038963. Available from: https://bmjopen.bmj.com/content/10/11/e038963

10. 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;38(3):569-577. Available from: https://pubmed.ncbi.nlm.nih.gov/26054910/

11. Davies C, Skinner SR, Stoney T. ‘Is it like one of those infectious kind of things?’ The importance of educating young people about HPV and HPV vaccination at school. Sex Education. 2017;17(3):256-275. Available from: https://www.tandfonline.com/doi/full/10.1080/14681811.2017.1300770

12. Yardley L, Morrison L, Bradbury K, Muller I. The person-based approach to intervention development: application to digital health-related behavior change interventions. J Med Internet Res. 2015;17(1):e30. Available from: https://www.jmir.org/2015/1/e30/

13. Fisher H, Chantler T, Finn A, et al. Development of an educational package for the universal human papillomavirus (HPV) vaccination programme: a co-production study with young people and key informants. Res Involv Engagem. 2022;8(1):16. Available from: https://researchinvolvement.biomedcentral.com/articles/10.1186/s40900-022-00349-7

14. Fisher H, Audrey S, Chantler T, et al. Towards successful implementation of public health research into practice: Experiences and lessons learned from EDUCATE. Public Health Pract (Oxf). 2023;6:100447. Available from: https://doi.org/10.1016/j.puhip.2023.100447



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