Culture, Health & Sexuality, 2013

Vol. 15, No. 9, 10711084, http://dx.doi.org/10.1080/13691058.2013.807518

Barriers to receiving human papillomavirus vaccination among female

students in a university in Hong Kong
Judy Yuen-man Siu*

David C. Lam Institute for East-West Studies, Hong Kong Baptist University, Hong Kong,
Hong Kong
(Received 12 October 2012; final version received 19 May 2013)

This paper investigates, using a qualitative approach, barriers to receiving Human

Papillomavirus (HPV) vaccine among female undergraduate students in a Hong Kong
university. By conducting individual semi-structured interviews with 35 young women
aged 19 to 23, seven intertwining perceptual, social and cultural, healthcare provider and
financial barriers were identified. These barriers included the perception as being low-
risk due to an absence of sexual contact, lack of confidence in the safety of the vaccine,
suspicion of parents concerning the intention to get vaccinated, lack of positive
discussion among peers, insufficient information from primary-care doctors, difficulty in
choosing a suitable HPV vaccine and cost of the vaccine. Future HPV-vaccination
promotion therefore not only needs to enhance risk perception and needs awareness of
young women, but also educate parents and correct their misconceptions. As primary
care doctors are the first line of contact with patients, providing more support to enhance
their knowledge of the HPV vaccine and to encourage their enthusiasm in providing
responsive disease-prevention education can motivate young women to get vaccinated.
Keywords: HPV vaccination; perceptions; barriers; female university students; Hong
Kong

Introduction
Cervical cancer is the second most common form of cancer in women worldwide (World
Health Organization 2012). In Hong Kong, it was the tenth most common cancer among
women in 2010 (Hong Kong Cancer Registry, Hospital Authority 2012). A total of 400
new cases were recorded in 2010, accounting for 3.2% of all new cancer cases in women
(Hong Kong Cancer Registry, Hospital Authority 2012). Cervical cancer was also the
ninth most common cause of female cancer deaths in 2010 in Hong Kong (Hong Kong
Cancer Registry, Hospital Authority 2012). In all, 146 women died of cervical cancer in
that year, accounting for 2.8% of female cancer registered deaths (Hong Kong Cancer
Registry, Hospital Authority 2012).
Genital infection by Human Papillomavirus (HPV) can cause cervical cancer (World
Health Organization 2012) and HPV-16 and 18 are documented as high-risk strains that
have been shown to be responsible for over 70% of cervical cancer cases (Lowy and
Schiller 2012; Waheed et al. 2012). Besides cervical cancer, HPV can also lead to cancers
in vulva, vagina, penis, anus and oropharynx, as well as genital warts (Centers for Disease
Control and Prevention 2012).
Receiving an HPV vaccination has been clinically recognised as an effective
preventive measure in decreasing the incidence of precursors of cervical cancer (Gersch,

*Email: judysiu@hkbu.edu.hk

q 2013 Taylor & Francis

1072 J.Y.-m. Siu

Gissmann, and Garcea 2011; Kane 2012; Widdice 2012). Many countries have
implemented HPV vaccination programmes for woman to reduce the disease burden
(Sander et al. 2012; Wamai et al. 2012). The vaccine has the best efficacy in women who
have not yet had sexual intercourse and is largely recommended to adolescent girls and
young adult women (Tiro et al. 2012).
In Hong Kong, HPV vaccination is recommended for women aged 9 to 45 years
(Youth HPV Prevention Program 2011). It is voluntary and not included in the compulsory
Hong Kong Childhood Immunisation Programme by the Department of Health (Family
Health Service, Department of Health The Government of the Hong Kong Special
Administrative Region 2006). Unlike other optional vaccines, such as the influenza
vaccine, no subsidies are provided by the government for HPV vaccination. Two types of
HPV vaccines, Gardasil w and Cervarix w, are registered in Hong Kong. A three-dose
course usually costs HK$2500 (equivalent to US$321) to HK$4000 (equivalent to
US$514). Primary and secondary school students have been able to enjoy a discounted rate
of $2000 (equivalent to US$256) for the whole course under the Youth HPV Prevention
Program, with the support of The Society of Physicians of Hong Kong together with The
Family Planning Association of Hong Kong, since 2011 (Youth HPV Prevention Program
2011). Students in tertiary education can usually enjoy a discounted rate at university
health service centres, although prices vary. In 2008, 768 women received an HPV vaccine
from The Family Planning Association of Hong Kong (Family Planning Association of
Hong Kong 2009) and around 5% of the target population was vaccinated in 2011 (Metro
Daily 2011).

Significance
University students are noted to be sexually active in western and certain Chinese
communities (Boccalini et al. 2012; Chiao et al. 2012; Rathfisch et al. 2012), but young
adults generally lack awareness of HPV vaccination as a preventive measure (Blumenthal
et al. 2012). Studies suggest that 75% of all sexually active people will be infected with
HPV at some point during their life after sexual debut (Centre for Health Protection 2008).
Therefore, university students are the targets of HPV vaccination promotion in most Hong
Kong universities health services. However, the coverage and acceptance of HPV
vaccination have not been satisfactory, neither in western countries (Ribassin-Majed,
Lounes, and Clemencon 2012; Tsui et al. 2013) nor in societies like Hong Kong (Family
Planning Association of Hong Kong 2009; Metro Daily 2011).
Although past studies have examined barriers to receiving HPV vaccination, most
have been conducted in non-Asian countries, with a paucity of Chinese-based studies.
Only a few studies have investigated Hong Kong female students attitudes toward
receiving HPV vaccination (Chan, Lam et al., 2011; Chan et al. 2009; Kwan et al. 2008;
Wong, Fong, and Chan 2009). Two of these are purely quantitative studies that only
provide an initial overview (Chan et al. 2009; Wong, Fong, and Chan 2009). Another two
are qualitative studies that provide a more in-depth understanding. The study population of
one of these studies comprised mostly secondary school girls aged 13 to 20 with low
autonomy in decision making regarding their health (Kwan et al. 2008). Their health
perceptions and preventive health behaviour are mostly under the influence of significant
others, such as parents. Another study focused on university female nursing students with
higher autonomy and independence in making health decisions. However, the sample may
not reflect the perceptions of young women lacking in professional health knowledge
(Chan, Lam et al., 2011). In view of this, the present study was conducted with female
 Culture, Health & Sexuality 1073

undergraduate students aged 19 to 23 years, who had received no professional health

training, to fill the gap in understanding.

Methods
Design and setting
A qualitative approach using in-depth individual semi-structured interviews was adopted.
A total of 35 female students studying undergraduate programmes in a Hong Kong
university were recruited by purposive sampling (Bernard 2002). The sampled university
is one of the eight public universities supported by the University Grants Committee in
Hong Kong, with over 20,000 undergraduate and postgraduate students. The majority of
students are Hong Kong Chinese. The university is a comprehensive research-intensive
university with eight faculties, including arts, business administration, education,
engineering, law, medicine, science and social sciences.

Data collection
A qualitative research approach using in-depth semi-structured interviews was adopted.
Interviews were conducted on a one-on-one basis. Participant sampling took place via a
health seminar organised by the university health service centre in September 2011. All
undergraduate students in the sampled university were the targets of this health seminar, and
450 female students attended. A simple questionnaire asked about the four inclusion criteria
(below), their willingness to participate, their academic discipline and contact methods.
Questionnaires, together with an information sheet outlining the nature and purpose of the
study, were distributed to 450 female students. Among the 432 questionnaires received, 408
students fulfilled the sampling criteria and agreed to participate in the semi-structured
interviews, and 35 participants were recruited. The participants were selected basing on their
study disciplines to ensure variety in participants study backgrounds.
The inclusion criteria of the participants were: (1) female undergraduate students,
excluding medical and health sciences students, (2) no experience of sexual intercourse,
(3) have not yet received an HPV vaccination and (4) Hong Kong Chinese by ethnicity. As
the HPV vaccine is mainly targeted at women who are not yet sexually active, and as this
study aimed at examining the barriers to receiving HPV vaccine among female university
undergraduate students in Hong Kong, only the Hong Kong Chinese female students who
reported no sexual experience and who had not yet received HPV vaccination were
sampled to examine perceived barriers.
Prior to the interviews, the 35 participants were informed about the purpose and nature
of the study via a participant information sheet that was written in their mother tongue.
Participants were given sufficient time to ask questions and seek clarification from the
author and written consent was obtained from each. All participants were assured of their
rights and freedom to withdraw from the study without prejudice. All interviews were
conducted in a private room in the sampled university and were audio-recorded with
participants consent. To protect participants anonymity, names were not mentioned in
the interviews. Likewise, all names used in this article are pseudonyms.
The study had research ethics approval from the Committee on the Use of Human and
Animal Subjects in Teaching and Research of Hong Kong Baptist University.
Interviews were conducted between September 2011 and January 2012, each
lasting from 1.5 to 2 hours. To compensate for the time contributed, each participant
was given a HK$100 supermarket cash coupon upon completion of the interviews.
1074 J.Y.-m. Siu

All interviews were conducted by the researcher to ensure consistency and quality
of interviews. An interview question guide developed by the researcher was used
throughout the interview process to guide the discussion and to ensure the interview was
focused and followed a clear direction. Demographic data, including participants age,
relationship status, discipline of studies, nature of part-time work, approximate monthly
income (individual and family) and doctor-seeking habits, was obtained at the end of the
interviews.
All data and field notes were stored in locked files and treated with strict
confidentiality. Only the researcher had access to the data and field notes. Each participant
was represented by a code in the data and interview transcripts to further protect their
privacy and confidentiality. The audio digital records of the interviews were destroyed
after the interviews had been transcribed.

Data analysis
Initial data analysis was conducted immediately during interviews to ascertain what was
known and what needed to be explored further (Green and Thorogood 2004, 219).
Interviews were transcribed verbatim within five days of each interview, and coding and
analysis were performed immediately. Thematic content analysis was used to identify
major themes within the data (Liamputtong and Ezzy 2005). Interview transcriptions were
segmented into meaning units and thereafter collapsed into categories and eventually
themes through the process of abstraction and constant comparison. Recurrent themes
were highlighted. Coding schemes were developed (Liamputtong and Ezzy 2005) using an
inductive approach (Bernard 2002). A code book was kept in which to transform the data
from interviews into categories to identify major themes (Bernard 2002). New thematic
codes emerging from data were added to the coding list and codes that did not fit were
discarded, so that the codes were grounded into the data.
The rigour of the study was examined in line with criteria set out by Lincoln and Guba
(1985). Credibility was established by performing a validity check with participants who
were asked to check the transcribed interviews to ensure the transcriptions were consistent
with their meanings (Green and Thorogood 2004). Direct interview quotations from the
participants were included so that their ideas were clearly represented. This process
established neutrality at the same time, since it ensured the findings were shaped by the
participants and not by researcher bias, motivation or interest. Reliability was established
by coding and recoding of the transcripts by the researcher to ensure the categories and
themes were clear and free of ambiguity and overlaps. To ensure accuracy of the
categories and themes, recoding was performed by the researcher one month after the first
coding was completed.

Results
Participants
All 35 participants were female Hong Kong Chinese undergraduate students aged between
19 and 23 years. All were eligible to participate in the HPV vaccination programme at the
university. Participants came from various disciplines, excepting health sciences and
medicine. All were unmarried, with 26 of them in a relationship. A total of 32 had a part-
time job. In all, 14 participants nominated a family doctor or familiar doctor as their
primary care provider. The remaining 21 did not have a stable primary care provider, and
doctor shopping (seeing multiple treatment providers) was common among them. None
 Culture, Health & Sexuality 1075

of the participants regarded the doctors in the university health service as their family
doctors or primary care providers, and none of them had ever used the university health
service for medical treatment. New student physical check-ups and having vaccinations
were the only purposes of their visits to the university health service.

Perceptual barriers
Perception as being low-risk due to an absence of sexual contact
Almost all the participants did not feel the need to be vaccinated. Sexual experience
shaped their risk perception. They perceived themselves as being very low-risk with
regard to cervical cancer due to their abstinence from sex. This participant shared a
common viewpoint:
I have no sexual experience, so I do not think I am at risk of getting cervical cancer. Cervical
cancer is caused by sexual intercourse. I think those who plan to have sex may find the vaccine
more useful. There is no need for me to get vaccinated if I do not have sex or get married in the
near future. (Amy, aged 22)
Participants perception as being low-risk and not having the need to receive HPV
vaccination was also closely related to how they perceived the HPV vaccine. All the
participants referred to the HPV vaccine as cervical cancer vaccine in the interviews. As
cervical cancer is widely perceived as a sex-induced cancer suffered exclusively by sexually
active women, most participants saw little need to be vaccinated due to their abstinence.
Citing a recent study conducted by The Society of Physicians of Hong Kong, HPV has
been reported in popular newspapers to exist in many public areas (such as the hand rails in
public transport and in shopping malls) (Metro Daily 2011; Oriental Daily 2011a), which
implied that one could suffer from HPV diseases without sexual contact. However, these
news reports aroused resentment in some participants instead of serving as an incentive for
them. As this participant commented:
I read that news report too. We all touch these public utilities. So what is the point of me
getting vaccinated as I may already have been infected? I think the news report is too
exaggerated. It just serves the greediness of doctors and pharmaceutical companies, and
creates consumption of this vaccine by inducing public panic. I still believe my risk of cervical
cancer is extremely low, as I do not have any sexual contacts. If it is really that easy for one to
get infected, then all people should already have been infected, and there is even no
justification for me to get vaccinated. (Beatrice, aged 23)

Lack of confidence in the safety of the vaccine

Worries over the safety of HPV vaccines were significant for half the participants. The
following participant shared a common worry:
Some negative side-effects have been reported. As the cervical cancer vaccine is quite new, I
would rather wait. New inventions always require improvement. Newer and better vaccines
may be invented after several years. It will never be too late for me to get vaccinated if I do not
have sex. (Cathy, aged 21)

Social and cultural barriers

Suspicion of parents concerning the intention to get vaccinated
More than half the participants experienced parents discouragement from receiving HPV
vaccination. Parents were suspicious about participants intention to receive HPV
1076 J.Y.-m. Siu

vaccination. This participant shared how her mother reacted after learning that she was
thinking about having the vaccination:
My mother was very shocked when I told her I was thinking about having the cervical cancer
vaccine. She kept nagging me that virginity is the most important property to be a good girl
before marriage. (Doris, aged 20)
The experience of this participant demonstrated that one of the major concerns of parents
was a worry over their daughters possible involvement in pre-marital sex. Participants
parents tended to perceive HPV vaccination as unnecessary if their daughters were not
going to have sex:
My mother was very anxious after learning that I wanted to have the cervical cancer vaccine.
She said only girls who want to do something bad [have sex] want to have such vaccination,
and there is no need for me to do so. My mother said it is important for good girls to protect
their virginity until they get married. The reaction of my mother was so strong that it made me
dare not mention it again. (Estella, aged 22)

Lack of positive discussion among peers

Peers can have significant influence over the adoption of health behaviours. There is an
absence of positive discussion about HPV vaccination among peers, as indicated by the
participants. Also, only a few of their peers had ever received an HPV vaccination.
Without positive discussion and motivation from peers, more than half the participants
were not motivated to receive the vaccination. The following participant shared the
importance to her of peer influence in receiving the vaccination:
My friends and I do not talk much about cervical cancer vaccines. I have asked my friends if
they were interested in receiving the vaccine, but none of them were interested. If they were
interested, then we could have accompanied each other to have the vaccine. I do not feel I want
to have the vaccine if none of my friends want to. (Flora, aged 19)
In some cases, peers negative comments about the vaccine served as a barrier. This
participant described how peers comments had scared her off from receiving HPV
vaccination:
Only one or two friends of mine have had the cervical cancer vaccine; they commented the
shot was particularly more painful than other vaccines. Also, one of my friends suffered from
fever, dizziness, extreme tiredness and a rash for some days just after the first dose, and she
dared not continue the remaining course, so I do not think about receiving the vaccine at this
moment. (Helen, aged 20)
Peers negative perceptions and responses over the intention of getting vaccinated also
served as a barrier for some participants. Such negative responses originated from cultural
views about sex:
One of my friends wanted to receive the cervical cancer vaccine and she asked her friends if
they also wanted to, but she was teased by her friends, laughing at her that her relationship
with her boyfriend had become so intimate. They teased her that she has to use her body to
keep her boyfriend. (Ivy, aged 21)

Healthcare provider barriers

Insufficient information from primary-care doctors
Insufficient information on HPV vaccines from primary-care doctors also served as a
barrier for participants. Half of them mentioned that their primary-care doctors only
 Culture, Health & Sexuality 1077

provided information in the form of promotional leaflets and posters. Participants

experienced difficulty in obtaining further detailed information and advice from their
primary-care doctors:
I asked my doctor about the cervical cancer vaccine, but what he told me was almost the same
as the content of the promotion leaflet. I asked further, but he just kept repeating the
information indicated on the leaflet, so I still cannot decide whether to receive the vaccination.
(Jenny, aged 22)
Another barrier encountered by participants was the non-enthusiasm of some primary-care
doctors in providing the vaccine information. Such experience was particularly prevalent
among participants who did not have a family doctor or a stable primary-care doctor. The
following participant, who was a doctor-shopper, shared:
The doctor was not enthusiastic about telling me about the cervical cancer vaccine, even
though I asked him. He just told me to look at the poster outside [in the waiting area] and thats
all. Also, he started to lose his patience when I asked more about the vaccine. Probably he had
many patients waiting outside, so he did not want to be bothered over just a vaccination.
(Karen, aged 23)

Difficulty in choosing a suitable HPV vaccine

Gardasilw and Cervarixw are the two HPV vaccines approved and offered in Hong Kong.
More than half the participants, however, did not know the difference between the two
vaccines. Therefore, they had difficulty choosing a suitable vaccine for themselves, which
served as a barrier for them:
I do not know which cervical cancer vaccine is better, so it is very difficult for me to choose.
I have been considering if I can have both vaccines but it seems no one will do such a
crazy thing. Therefore, may be it is better for me to wait until I have more information. (Lily,
aged 20)
Although the two vaccines led to participants confusion, in many cases the difficulty in
making a decision was linked to the insufficient information provided by primary-care
doctors:
My doctor could not tell which cervical cancer vaccine is better. He just said both vaccines
have different characteristics, and the virus coverage is different, so I have to decide myself. I
have no way of knowing which vaccine is better, so I chose to forget about the vaccination
until I have more information. (Nancy, aged 23)

Financial barriers
High cost of the vaccine
Although most participants had part-time jobs, the high cost of HPV vaccines was a major
barrier for almost all of them. The price of each dose offered by the university health
service centre of the sampled university was HK$850 (equivalent to US$109) during the
study period, which meant the participants had to pay HK$2550 for a full course
(equivalent to US$327). This was not affordable for every participant, since they had not
yet gained full financial independence. However, high cost alone was insufficient to
account for their low incentive. Rather, this factor in combination with other barriers
discouraged participants:
The vaccine is too expensive. It costs almost my whole monthly wages from my part-time job.
If I really have the need, I would not mind spending my wages on the vaccination. However, I
1078 J.Y.-m. Siu

am still unmarried so I do not think I have the need at this moment. Spending such a large
amount of money on a vaccine that is not useful for me at this moment is not worthwhile.
(Pinky, aged 21)
As many participants were still financially dependent on their parents, parental attitudes
and support were crucial to their motivation to be vaccinated. Participants would not
choose to be vaccinated if their parents were unsupportive:
My mother said there is no use for me to get vaccinated except if I want to do something
inappropriate [having sex]. As my mother discourages me to get vaccinated, I will not have it
because she will not pay for it or sponsor me. I just have one part-time job but the wages are
insufficient to pay for the vaccination. (Susan, aged 20)

Discussion
Cervical cancer has been commonly portrayed as a sex-induced cancer in Chinese
communities like Hong Kong (Hong Kong Cancer Fund 2012). As noted by Sontag
(2001), many diseases, including cancers, have attached negative metaphors, and cervical
cancer is no exception. In Hong Kong, cervical cancer is often portrayed as a disease
suffered exclusively by sexually active women, and being diagnosed this cancer can
symbolise a womans promiscuity, multiple sex partners and early sexual debut (Hong
Kong Cancer Fund 2012). However, such negative connotations alone did not motivate the
participants to have the vaccination. Several barriers combined to discourage them from
undertaking this preventive health behaviour. Besides participants perceptions of HPV
and HPV vaccines, their perception as being at low-risk, the influence of significant others
and peers, the attitudes of primary-care doctors, vaccine cost and social and cultural views
about sex all served as barriers to uptake.
Fear appeal is one of the commonly used communication strategies in health-
promotion programmes (Smerecnik and Ruiter 2010) and such an approach was adopted
by HPV-vaccination promotion in Hong Kong during the study period. Popular newspaper
reports cited the research findings by The Society of Physicians of Hong Kong,
highlighting public utilities as being a medium for HPV transmission and everyone being
at risk of being infected by the sexual cancer (Metro Daily 2011; Oriental Daily 2011a).
The HPV vaccination was promoted as an effective preventive measure and a one-page
vaccination-promotion advertisement was published on the same day in several
newspapers (Oriental Daily 2011b). However, fear appeal contributed little as an
incentive for the participants. Rather, they perceived these reports as exaggerated and
commercial, serving the profit-making desire of doctors and pharmaceutical companies.
The approach of fear appeal in health promotion, therefore, does not always guarantee the
expected preferable outcome. It may induce resentment among target clients, which serves
as an obstacle to the success of health-promotion programmes.
One of the most significant barriers was participants perception of being at low
personal risk due to abstinence from sex, which impacted their perceived need to receive
HPV vaccination. Sexual experience shaped the risk perception of the participants. The
findings of this study parallel other international literature, which demonstrates that young
people as a whole tend to have a lack of awareness of the personal risk of acquiring HPV
(Blumenthal et al. 2012). In addition, women without sexual experience have been shown
to be less likely to get vaccinated (Blodt et al. 2012). Being sexually active is associated
with womens higher-risk perceptions (Ayissi et al. 2012), and for those who are sexually
inactive it is deemed unnecessary for them to receive HPV vaccination (Kobetz et al.
2011; Kwan et al. 2009).
 Culture, Health & Sexuality 1079

Language can shape peoples cultural beliefs and ideologies (Duranti 2004) and the
participants low perceived needs of getting vaccinated could be influenced by their
language use. Participants often referred to the HPV vaccine as a cervical cancer vaccine
in interviews. As cervical cancer is suffered primarily by women who have sexual
intercourse, such labelling strengthens their perception of the interlocking relationship
among sexual activity, HPV and cervical cancer, thereby reinforcing participants belief
that they were not at risk. This served to discourage participants from receiving the
vaccination. A cervical cancer vaccine in participants terms, hence, was only needed by
women indulging in sexual intercourse.
In contrast to other international literature, which shows parents support for their
daughters to receive the HPV vaccine (Rose et al. 2012), the findings of this study
demonstrated that parents, in particular mothers, served as a notable barrier for the
participants. Although some previous studies have also noted that parents could serve as
a barrier, vaccine effectiveness, safety and side-effects were these parents major
concerns (Smith et al. 2011; Wamai et al. 2012). This is different from the concerns of
the participants parents, for whom worries about their daughters possible engagement
in pre-marital sex were profound. Young women have been shown to be heavily
influenced and regulated by their parents regarding perceptions of sexuality (Grant 2012;
Hyde et al. 2012). In this study, most participants mothers felt suspicious about the
intention to get vaccinated. This served to prevent the participants from receiving the
vaccination.
Mothers also played a prominent role in influencing participants vaccination
attitudes and behaviours not only perceptually, but also financially. Participants had very
low incentive to receive the vaccination if their parents did not provide the necessary
monetary support. In the future, HPV vaccination promotion should aim to educate
parents towards more positive values to it if it is to reach the wider adolescent population
in Hong Kong. Importantly, the international literature reveals that vaccinated women
often possess a more positive view towards practising safe sex (Mather, McCaffery, and
Juraskova 2012).
Past literature shows that sexual restraint reflects a societys social structure and
reinforces gender inequality (Froyum 2010). Such a good girl ideology could be
devastating for the promotion of HPV vaccines. Patriarchal values in relation to sexuality
prevail in Hong Kong (Yan et al. 2011) and virginity is an important cultural ideal for
unmarried women in Chinese communities. As demonstrated by participants, being a
good girl in the eyes of parents meant preserving her virginity until her marriage. As
the HPV vaccine is perceived as having the potential to violate this cultural value from the
viewpoint of participants parents, it is not surprising that parents are not supportive of
participants when they wish to have the vaccination. Gender inequality, in this case, also
symbolises restrictions on women to choose better health protection for themselves.
The cultural value of virginity as well as the perceived relationship between receiving
HPV vaccination and pre-marital sex was prevalent among the peers of the participants
as well. There was a lack of positive discussion on HPV vaccination between participants
and their peers. Negative discussion concerning vaccination side-effects, but also the
connection between receiving the vaccine and the intention to have pre-marital sex, caused
participants to be teased by their peers. Indeed, unfavourable perceptions about
vaccinating women without sexual activity are not uncommon in Hong Kong (Kwan et al.
2009). A survey conducted by the Hong Kong Sex Culture Society on 943 tertiary school
students in late-2006 showed that around 48% of tertiary students opposed pre-marital sex,
14% of them agreed with pre-marital sex only on the basis of a pending marriage and
1080 J.Y.-m. Siu

around 58% of the students felt that holding hands and kissing would be their most
intimate behaviour before marriage (The Sun 2007).
Hence, pre-marital sex is not yet widely accepted among young adults in Hong Kong,
which is in contrast to the sexual values among university students in other Chinese
societies (Chiao, Yi, and Ksobiech 2012). Under such social and cultural influences, the
peers of participants were not socialised to have a positive attitude towards HPV
vaccination. Lack of positive discussion among young adults impacts their perceived
needs, causing them to be demotivated concerning vaccination. Young people would
benefit from education to facilitate positive views on HPV vaccination, thereby enhancing
willingness to undergo HPV vaccination.
Recommendation from doctors is another significant incentive for women to receive
an HPV vaccination (Chan, Chan et al., 2011; Kobetz et al. 2011). Insufficient information
and support from primary-care doctors was another barrier for participants (Francois et al.
2011; Stocker et al. 2013). Primary-care doctors lack of enthusiasm in encouraging the
vaccination, as experienced by some participants, also demotivated them. As one of the
key roles of primary-care doctors is the provision of disease-prevention education and
healthcare-management advice to patients (Mercer et al. 2010), enhancing their
enthusiasm for promoting preventive health behaviour to patients would be helpful in
motivating vaccination behaviour.
Having a family doctor or a stable primary-care doctor was shown to better promote
HPV vaccination. Among the 14 participants with a family doctor or a regular primary-
care doctor, 9 had discussed HPV vaccination with their doctors, whereas only 3 of the
remaining 21 doctor-shopping participants had done the same. Future HPV-vaccination
promotion in collaboration with family doctors could thus stimulate better outcomes.
The high cost of HPV vaccines was another prominent barrier for the participants. This
finding is consistent with previous studies to some extent (Al-Naggar and Bobryshev
2011; Khoo et al. 2011). However, high cost was barely adequate to serve as a standalone
barrier for the participants, even though they had not yet obtained complete financial
independence. Rather, it connected with other barriers, as demonstrated above. Therefore,
merely offering discounts and lower vaccination cost may engender only limited results if
other barriers are not tackled.

Limitations
The sampled participants comprised only undergraduate female students aged 19 to 23
years at one university. Undergraduate female students in other universities and non-
college students were not included. In addition, those who had sexual intercourse
experience were excluded from the sampling. Future study concerning women in other age
groups and women with sexual experience could provide a more holistic picture to
understand the barriers to vaccination among women in Hong Kong.
Parents, and mothers in particular, were shown to be among the strongest barriers for
the participants. However, parents were not the focus of this study. Therefore, future study
should investigate the attitudes and perceptions of parents towards HPV vaccines. This
may allow an in-depth understanding of parents worries and concerns.
As this study investigated the barriers to receiving HPV vaccination among young
women, only female undergraduate students who had not received the vaccine during the
study period were sampled. Those students who had received the vaccination were
excluded from this study. Further investigation of women who have received the HPV
vaccination can provide insight into the incentives for receiving the vaccination. As
 Culture, Health & Sexuality 1081

incentives and barriers constitute different sides of the same coin, understanding the
incentives can provide supplementary information on this issue.

Conclusion
Promoting HPV vaccination to schoolgirls and young women is an important public health
measure in cervical cancer prevention. This paper demonstrates a number of interlinked
perceptual, social and cultural, healthcare provider and financial barriers preventing
participants from receiving the HPV vaccination. Future HPV-vaccination promotion
should aim at creating a favourable social environment so that young women are more
encouraged to undertake vaccination.

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Resume
Cet article explore les obstacles a la vaccination contre le papillomavirus humain (HPV) parmi des
etudiantes de premier cycle dans une universite de Hong-Kong. En conduisant des entretiens
individuels semi-structures avec 35 jeunes femmes agees de 19 a 23 ans, nous avons identifie sept
obstacles tous interconnectes - perceptuels, socio-culturels, lies aux prestataires de soins, et
financiers. Ces obstacles comprenaient la perception dun risque faible en raison de labsence de
rapports sexuels, le peu de confiance accordee au vaccin pour son innocuite, les soupcons des parents
1084 J.Y.-m. Siu

eveilles par lintention de leurs filles de se faire vacciner, labsence de discussion positive parmi les
pairs, linsuffisance de linformation fournie par les medecins des premiers soins, la difficulte a
choisir un vaccin approprie contre le HPV et le cout de ce dernier. Aussi les futurs efforts de
promotion du vaccin contre le HPV devront non seulement ameliorer la perception du risque et la
prise de conscience des besoins en information des jeunes femmes, mais aussi eduquer les parents et
corriger leurs perceptions erronees. Les medecins des premiers soins etant en premiere ligne face aux
patients, les soutenir afin quils ameliorent leurs connaissances sur le vaccin contre le HPV et
susciter leur enthousiasme pour assurer une education adaptee en ce qui concerne la prevention des
maladies peut avoir pour consequence la motivation des jeunes femmes a se faire vacciner.

Resumen
El presente artculo reporta los resultados de una investigacion de enfoque cualitativo que examino
las razones por las cuales las estudiantes de licenciatura de una universidad de Hong Kong son
renuentes a recibir la vacuna del virus del papiloma humano (vph). Tras realizar entrevistas
individuales y semiestructuradas a 35 mujeres jovenes, cuyas edades oscilan entre 19 y 23 anos, se
identificaron siete barreras entrelazadas, concernientes a lo perceptual, a lo social y a lo cultural, a la
provision de cuidados de salud y a lo financiero. Dichas barreras se establecieron a partir de la idea
de considerarse una persona de bajo riesgo por el hecho de no tener relaciones sexuales; por la falta
de confianza en la seguridad de la vacuna; por la sospecha de los padres respecto a las razones para
vacunarse; por la falta de dialogo positivo entre los pares; por la insuficiente difusion de informacion
de parte de los medicos de atencion primaria; por la dificultad de escoger la vacuna vph correcta; y
por el costo de la vacuna. En este sentido, cualquier campana que promueva la vacuna vph a futuro
tendra no solo que alertar sobre el riesgo y las necesidades entre las jovenes, sino tambien informar a
los padres para corregir sus ideas erroneas. Tomando en cuenta que los medicos de atencion primaria
constituyen el contacto principal con las pacientes, se les debe brindar mayor apoyo, con el fin de
aumentar sus conocimientos acerca de la vacuna vph e impulsar su compromiso a difundir
informacion sobre la prevencion de enfermedades. Ello puede motivar a mayor numero de mujeres
jovenes a vacunarse.
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