Knowledge of HPV infection and vaccination among vaccinated and unvaccinated teenaged girls

Factors influencing human papillomavirus vaccination uptake in European women and adolescents: A systematic review and meta-analysis

OBJECTIVE

Cervical Cancer (CC) lingers as a severe public health issue due to low vaccination coverage and poor screening addressability. Hence, this systematic review explored psychological factors influencing the Human Papilloma Virus (HPV) vaccination uptake in European women.

METHODS

As of September 2022, PubMed, EMBASE, Scopus, and Web of Science were systematically searched to include English studies assessing diverse factors influencing vaccination uptake in European women. Only studies comparing vaccinated with unvaccinated women were included. Quality assessment, publication attrition assessment, and sensitivity analyses were performed.

RESULTS

Eighteen studies were included, totaling a population of 18,611 participants. Results indicated that knowledge about HPV infection could positively influence vaccination rates with an Odds Ratio (OR) of 1.82 and a confidence interval (CI) between 1.27 and 2.61, showing statistical significance at a Z value of 3.24 with a p-value of 0.001. Neither knowledge about HPV vaccination (OR = 1.39, CI: 0.73-2.65, Z = 1.01, p = 0.31) nor knowledge about CC screening (OR = 1.05, CI: 0.55-1.98, Z = 0,14, p = 0.89) seem to affect vaccination rates. Regardless, intention to undertake CC screening (CCS) showed an OR = 1.68 in favor of the group intending to perform it, with a CI between 1.37 and 2.07, showing statistical significance at a Z = 4.94 and p = 0.00001. Other aspects affecting vaccination uptake were fear of side effects, insufficient information, and belief that chances of being infected are low.

CONCLUSIONS

Results demonstrated that diverse aspects could affect the vaccination intent, while personalized interventions focusing on population and country characteristics need to be assembled to mitigate vaccination coverage.

Beliefs about HPV vaccination and awareness of vaccination status: Gender differences among Northern Italy adolescents

Human papillomavirus (HPV) is one of the most frequent sexually transmitted infectious agents worldwide, and it is responsible for a significant burden of cancers. The aim of this study was to evaluate HPV knowledge and awareness in a sample of Northeastern Italian adolescents and parental support available to them, in order to highlight potential room for improvement towards optimal HPV vaccination adherence. Between April and May 2018 an observational questionnaire-based study was conducted in 1st year students of secondary upper schools in Udine (Italy). We quantitatively evaluated HPV knowledge, awareness and parental support level of male and female adolescents. The contribution of sociodemographic characteristics to HPV vaccination knowledge and uptake were explored using Chi-Square or Fisher test and multivariate logistic. Knowledge about HPV vaccine resulted to be mostly insufficient among enrolled adolescents, with a worrying proportion of them believing that HPV vaccine was expected to prevent HIV/AIDS. Awareness about their vaccination status was poor, and more than half of them were not involved in HPV vaccine uptake deliberation. Girls performed better than boys in relation to knowledge, awareness and engagement. Our results support the hypothesis that HPV vaccine knowledge and uptake can be affected by some gender bias. Improvements in adolescent health education and vaccination strategies are needed to engage and finally protect both genders from HPV.

An online survey on emotions, impact on everyday life, and educational needs of women with HPV positivity or abnormal Pap smear result

This study aimed to evaluate the emotional path, impact on everyday life, and adequacy of patient education throughout the diagnostic and therapeutic journey of women who received a positive human papillomavirus (HPV) test or Pap smear result.An online survey was designed to determine the demographic characteristics, dominant feelings throughout the diagnostic and therapeutic procedures, major lifestyle changes, impact on social life, and perceived adequacy of patient information in Italian women with a positive HPV test or abnormal cervical cytology result. In this study, the phases of the "patient's journey" included the initial test, waiting for colposcopy or biopsy, waiting for surgery, and follow-up.Anxiety, worry, and fear were the most frequently cited emotions during the initial tests and intervals between procedures. Anxiety and fear gradually decreased during the journey until surgery, and higher levels of optimism were observed postsurgery. The most frequently reported lifestyle changes were attempts to boost the immune system, increased precautions in sexual practices, and dietary changes. Social life is affected by changes in sexual and intimate relationships with partners. Women reported receiving insufficient patient education on the diagnosis and its implications, progression, management, personal care, and resolution.Significant attention should be given to the psychosocial aspects of the entire patient journey after receiving a positive HPV test or an abnormal Pap smear result. It is essential to establish a good rapport between patients and healthcare professionals, and to educate women regarding the condition by minimizing the gap between the perceived and desired adequacy of information.

Awareness of HPV and drivers of HPV vaccine uptake among university students: A quantitative, cross-sectional study

HPV vaccination is a milestone in primary prevention. However in Italy, vaccine coverage is still nowhere near the target of 95%. We investigated factors associated with inclination to get vaccinated in university students, as they are likely to have just assumed a central role in their healthcare decision-making. University students aged 18-25 were asked to fill in a questionnaire. The effect of socio-demographic and behavioural characteristics on HPV awareness was assessed with a logistic regression adjusting for age, gender, nationality, degree course, relationship, age at first intercourse, number of sexual partners, smoking, sexual orientation, past diagnosis of STDs and knowledge of people who had received HPV vaccine. A second regression adjusting also for information sources, awareness and knowledge investigated factors associated with inclination to receive vaccine. Nine thousand nine hundred and eighty-eight questionnaires were included (response rate 91.3%); awareness of HPV and vaccine was 83.3% and 69.9% respectively. Awareness (AOR: 3.3; 95% CI: 2.3-4.6) and a good knowledge positively affected acceptability, as well as a previous diagnosis of STDs and knowledge of vaccinated people. Healthcare workers (AOR: 1.6; 95% CI: 1.4-1.9) and family members (AOR: 1.7; 95% CI: 1.4-2.1) were the most influencing information sources, even if knowledge of vaccinated people was by far more persuasive (AOR: 2.7; 95% CI: 2.2-3.3). Only 12% of participants were acquainted with skin to skin HPV transmission, while 75% believed in a full effectiveness of condom; less than 22% associated HPV with cancer (other than cervical cancer). Efforts to increase awareness are likely to be worth considering that: awareness is the main determinant of vaccine acceptance; only 50% of individuals not interested in receiving vaccine were aware of it; males are much less aware (AOR: 0.09; 95% CI: 0.07-0.11). Moreover, this study spotlights some misconceptions around HPV and acknowledges a pivotal role of healthcare workers, family and peer influence.

HPV knowledge and vaccine acceptance among European adolescents and their parents: a systematic literature review

BACKGROUND

Since the introduction of HPV vaccines, several studies have been conducted in different countries to assess HPV knowledge and vaccine acceptance. The aim of this study was to perform a systematic literature review to summarize results and identify factors associated with HPV knowledge and vaccine acceptance in adolescents and their parents and to compile the measurement tools used in the published research studies performed in European countries where HPV is licensed.

METHODS

A systematic literature review was conducted for studies published between January 1st 2006 and December 31st 2017.

RESULTS

Seventy non-interventional studies performed in 16 European countries met the inclusion criteria. Thirty-eight of them reported data on HPV knowledge and 40 reported data on HPV vaccine acceptance. Further, 51.8% of adolescents (range 0% to 98.6%) and 64.4% of parents (range 1.7% to 99.3%) knew about HPV infection. Insufficient information and safety concerns were the main barriers to vaccination acceptance.

CONCLUSION

HPV knowledge and vaccine acceptance are still modest and vary widely between studies across EU countries. Coordinated efforts should be made to provide the relevant population with information for informed decision-making about HPV vaccination.

Human papilloma virus vaccination and attitudes towards contraception: a cross-sectional study

Objective: Human papilloma virus (HPV) vaccination may result in misconceptions that encourage young women to adopt risky contraceptive practices. The purpose of this article was to investigate whether HPV vaccination status was associated with choice of contraceptive method and adoption of risky sexual behaviour. Methods: Vaccinated and non-vaccinated visitors to a university department paediatric and adolescent gynaecology clinic were asked to anonymously fill in a survey comprising questions on sociodemographic characteristics, sexual history, opinions on contraception and attitudes towards contraception. Results: A total of 191 women were studied, 75 (39.3%) of whom had received the HPV vaccination and 116 (60.7%) of whom had not. The main contraceptive methods used in both groups were male condom (46%), emergency contraception (14%) and coitus interruptus (12%). The vaccinated group was less religious and had better educated mothers compared with the non-vaccinated group (relative risk [RR] 0.64; 95% confidence interval [CI] 0.45, 0.93; p = .016 vs RR 1.91; 95% CI 1.01, 3.63; p = .027, respectively). They also had an earlier sexual debut (RR 1.94; 95% CI 1.06, 3.55; p = .015), agreed that vaccination increased the safety of sex (RR 1.45; 95% CI 1.02, 2.05; p = .039) and considered the HPV vaccine a prerequisite to initiation of a sexual relationship (RR 1.87; 95% CI 1.34, 2.63; p < .001). Conclusion: HPV vaccination did not affect sexual behaviour, attitudes to condom use or choice of contraceptive method.

A Nationwide Study Comparing Knowledge and Beliefs about HPV among Female Students before and after HPV Vaccination

STUDY OBJECTIVE

To assess the knowledge and beliefs regarding human papillomavirus (HPV) and the HPV vaccine among girls before and after vaccination in the Malaysian HPV Immunisation Programme.

DESIGN

A nationwide longitudinal survey.

SETTING

Thirty-two randomly selected schools from 13 states and 3 federal territories in Malaysia from February to March 2013, and October to November 2013.

PARTICIPANTS

Form One female students (13 years old).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Mean knowledge score of HPV infection.

RESULTS

A total of 2644 students responded to the prevaccination survey, of whom 2005 (70%) completed the postvaccination survey. The mean knowledge score was 2.72 (SD ± 2.20) of a maximum score of 10 in the prevaccination survey, which increased significantly to 3.33 (SD ± 1.73) after the 3 doses of HPV vaccine (P = .001). Many answered incorrectly that, "Only girls can get HPV infection" (91.5%, n = 1841 prevaccination vs 96.1%, n = 1927 postvaccination), and only a few were aware that, "Vaccinating boys helps to protect girls against HPV infection" (11.4%, n = 229 for prevaccination vs 10.2%, n = 206 for postvaccination). The mean knowledge score was significantly higher postvaccination among higher-income families and those with parents of a higher occupational status. Regarding beliefs about the HPV vaccine, 89.4% in the prevaccination survey held the view that they would not get a HPV infection, and the percentage remained similar in the postvaccination survey. Perceived severity of HPV infection also remained low in the pre- and postintervention groups. Only 21.5% reported receiving health information about HPV along with the provision of the HPV vaccine; those who received health information showed higher levels of knowledge.

CONCLUSION

Findings revealed a general lack of knowledge and erroneous beliefs about HPV and the HPV vaccine even after receiving vaccination. This suggests that imparting accurate knowledge about HPV along with vaccine administration is essential. Specifically, girls from lower socioeconomic groups should be a target of educational intervention.

Vaccination perspectives among adolescents and their desired role in the decision-making process

Background: To assess the knowledge and attitudes of middle school students toward vaccination, we measured their understanding of vaccine safety and effectiveness, expectations for communication with heath care providers, and their desired role in the vaccination decision-making process. Methods: A cross-sectional, self-administered survey was conducted among seventh and eighth grade students in a middle school in Upstate New York. Bivariate analyses were conducted to identify differences in perspective by gender, grade, and attitudes toward vaccination. Results: Of 346 students attending class, 336 (97.1%) participated. The majority of respondents were White (71.3%) and 11 to 13 years of age (78.2%). Boys were significantly more likely than girls to perceive vaccines to be very safe (48.4% vs 30.2%, p < 0.01) and very effective (49.7% vs 29.0%, p < 0.01). Approximately one-third of adolescents reported having a say in the decision to be vaccinated and a quarter of students expressed a desire for specific information about vaccines. Conclusions: This study found that young adolescents in a nonurban area of Upstate New York were generally marginalized in the vaccine decision-making process yet third of them indicated an interest in how vaccines work and a desire to participate in healthcare decisions. Interventions to improve vaccine uptake among adolescents should capitalize on this desire to understand vaccine safety, effectiveness and mechanism of action.

Urban-Rural Inequities in the Parental Attitudes and Beliefs Towards Human Papillomavirus Infection, Cervical Cancer, and Human Papillomavirus Vaccine in Mysore, India

STUDY OBJECTIVE

The aim of this study was to compare the parental attitudes and beliefs about human papillomavirus (HPV), cervical cancer, and HPV vaccine between urban and rural areas, India.

DESIGN

Cross-sectional.

SETTING

Mysore, India.

PARTICIPANTS

Parents of school-going adolescent girls.

INTERVENTIONS

Parents completed a self-administered questionnaire.

MAIN OUTCOME MEASURES

Attitudes and beliefs about HPV, cervical cancer, and HPV vaccine.

RESULTS

A total of 1609 parents from urban (n = 778) and rural (n = 831) areas participated in this study. Most of the parents had never heard about HPV (73.6%), did not know that their daughters could get an HPV infection (62.7%) or cervical cancer (64.1%) in the future, and believed that HPV vaccine was not effective (67.1%). Parents living in the urban area were more likely to believe that HPV infection (adjusted odds ratio [aOR], 2.69; 95% confidence interval [CI], 1.43-5.06) and cervical cancer (aOR, 2.68; 95% CI, 1.83-3.91) could cause serious health problems than those living in the rural area. The odds of agreeing that HPV vaccination will make girls sexually active was lower among urban than rural parents (aOR, 0.55; 95% CI, 0.33-0.94). There was no significant difference among parents in the urban and rural areas in their beliefs about susceptibility of their daughter to HPV infection or cervical cancer, and beliefs about the safety and ability of HPV vaccine to protect against cervical cancer.

CONCLUSION

Rural parents might be reluctant to recommend behaviors that can help prevent HPV infection and cervical cancer such as HPV vaccination for their daughters.

Changes in (risk) behavior and HPV knowledge among Dutch girls eligible for HPV vaccination: an observational cohort study

Background

Implementation of human papillomavirus (HPV) vaccination raised concerns that vaccination could lead to riskier sexual behavior. This study explored how possible differences in sexual behavior and HPV knowledge developed over time between HPV-vaccinated and unvaccinated girls.

Methods

A random sample of 19,939 girls (16–17 year olds) eligible for the catch-up HPV vaccination campaign in the Netherlands was invited for a longitudinal study with questionnaires every 6 months over a two-year follow-up period. Possible differences over time between vaccinated and unvaccinated participants were studied using generalized equations estimation (GEE).

Results

A total of 2989 girls participated in round one, of which 1574 participated (52.7%) in the final 5th round. Vaccinated girls were more likely to live in more urban areas (OR 1.28, 95%CI 1.10–1.47) and to use alcohol (OR 1.46, 95%CI 1.24–1.70) and contraceptives (OR 1.69, 95%CI 1.45–1.97). Vaccinated and unvaccinated girls showed comparable knowledge on HPV, HPV vaccination, and transmission. Vaccinated girls were more likely to be sexually active (OR 1.19, 95%CI 1.02–1.39), and this difference increased over time (OR for interaction 1.06, 95%CI 1.00–1.12). However, they had a slightly lower number of lifetime sexual partners (mean difference − 0.20, 95%CI -0.41-0.00). Vaccinated girls were less likely to use a condom with a steady partner (aOR 0.71, 95%CI 0.56–0.89). However, the difference between vaccinated and unvaccinated girls with regard to condom use with casual or steady partner(s) did not significantly change over time.

Conclusion

Overall, we did not find indications that vaccination influenced sexual behavior in girls during 2 years of follow-up. The few differences found may be related to existing disparities in the socio-demographic characteristics of the young population pointing to the importance and improvement of education with regard to safe sex practices. Our findings do not suggest that vaccination status is associated with changes in sexual risk behavior and thus it is unlikely that this might influence the effectiveness of the vaccination program.

Development and testing of the questionnaire CEC-61: Knowledge about cervical cancer in Chilean adolescents

Despite a clear association between human papillomavirus and cervical cancer, knowledge in adolescent populations regarding the disease and methods for its detection and prevention is deficient. The aim of this study was to develop and test a new questionnaire concerning knowledge on cervical cancer. An instrument was developed and validated to measure knowledge in 226 Chilean adolescents between April and June 2011. Content validity, construct validity, and reliability analysis of the instrument were performed. The new, validated instrument, called CEC-61 (Conocimientos en Cancer Cérvicouterino-61 items/Knowledge in Cervical Cancer-61 items), contains nine factors and 61 items. The new questionnaire explained 81% of the variance with a reliability of 0.96. The assessment of knowledge with a valid and reliable instrument is the first step in creating interventions for a population and to encourage appropriate preventive behavior. CEC-61 is highly reliable and has a clear factorial structure to evaluate knowledge in nine domains related to cervical cancer disease, cervical cancer risk, papilloma virus infection, the Papanicolaou test, and the papilloma virus vaccine.

Nationwide Survey of Knowledge and Health Beliefs regarding Human Papillomavirus among HPV-Vaccinated Female Students in Malaysia

The National HPV Immunization Programme, which offers free human papillomavirus (HPV) vaccines to teenaged female students, was launched in Malaysia in 2010. HPV vaccination paired with adequate knowledge about HPV infection provides the best protection against cervical cancer. To identify the level of knowledge and the health beliefs towards HPV and the HPV vaccine among HPV-vaccinated female students in Malaysia. A nationwide cross-sectional survey among 14 years old female students who had received three doses of the HPV vaccine was conducted in 32 randomly selected schools from 13 states and 3 federal territories in Malaysia between February 2013 and April 2013. Among 2482 respondents, knowledge about HPV infection and the HPV vaccine was extremely poor. The mean total knowledge score was only 3.56 (SD ± 1.76), out of a possible score of 10. The majority of respondents were unaware that vaccinating boys with HPV can help protect girls against HPV infection (91.6%), HPV cannot be cured (81.6%) and that HPV is a sexually transmitted infection (70.3%). Most of the respondents had the misconception that only females get HPV (95.1%), and that the HPV vaccine eliminates the need for Pap smear tests (68.3%). Most respondents (91.6%) believed that they would not get an HPV infection. Almost half of the respondents (42.9%) held the misconception that HPV infection could not lead to serious illness. Findings revealed poor knowledge about both HPV and the HPV vaccine, low perceived susceptibility to HPV infection and misinformation about HPV infection among HPV-vaccinated girls. Therefore, it is essential to increase the knowledge and awareness of health risks regarding HPV infection among teenaged girls who have received the HPV vaccine.

Human Papillomavirus Vaccination and Sexual Disinhibition in Females: A Systematic Review

CONTEXT

Some parents believe human papillomavirus (HPV) vaccination increases the chance of risky sexual behaviors among adolescents. This review summarizes the evidence available on adolescent girls and women engaging in risky sexual activity following HPV vaccination.

EVIDENCE ACQUISITION

Systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was conducted in 2014 and updated in 2015. Literature was searched for articles published between 2004 and 2015 in MEDLINE, PsycInfo, CINAHL, Cochrane Database, Web of Science, and EMBASE without language limits. Studies were screened according to predefined inclusion and exclusion criteria. Methodologic quality of the included articles was assessed.

EVIDENCE SYNTHESIS

The search resulted in 21 articles to be included in the review, with 527,475 participants. Included studies were conducted in 12 different countries using experimental and observational study designs. The review included data on girls aged as young as 11 years to women aged 40 years. Studies measured changes in sexual behaviors using a variety of outcomes, including age at sexual debut; risky sexual behaviors; use of condoms and contraception; and clinical indicators such as rates of sexually transmitted infections, HIV, and pregnancy terminations. Available data showed either no association between vaccination status and the outcomes of interest or a positive association between safer sexual behaviors, such as condom use and receipt of HPV vaccination. Methodologic quality of all but one study was moderate or weak.

CONCLUSIONS

This review did not find sufficient evidence to support compensatory sexual risk behaviors following HPV vaccination among adolescent girls or women.

Determination of knowledge levels, attitude and behaviors of female university students concerning cervical cancer, human papiloma virus and its vaccine

BACKGROUND

The purpose of the study is to investigate knowledge, attitudes and behaviours concerning cervical cancer, HPV and HPV vaccine of female students studying at a university in a health related department and explore variables affecting taking the vaccine.

METHODS

The research group consists of female students attending a health related department in Balıkesir University. The data of this cross-sectional research was collected via surveys.

RESULTS

The average total knowledge score of the students concerning risks, symptoms and screening methods of cervical cancer and HPV vaccines was 14.15 ± 6.7. The HPV knowledge score of the students attending the faculty of medicine was higher compared to the students attending other departments and their HPV vaccine knowledge score was higher compared to the students attending nursing and paramedics students. The HPV vaccine knowledge score of the students attending the department of midwifery was significantly higher compared to other students. Only 0.9 % of the students took the vaccine. One third of the students who did not take the vaccine did not know that the vaccine was available in our country. In terms of the department that they attended, the students with a higher total knowledge score compared to the average (OR:1.5) and students with history of cancer in their families (OR:1.6) were more likely to consider taking the vaccine.

CONCLUSIONS

Research group's knowledge on risk factors of cervical cancer, Pap smear test, symptoms and prevention ways of cancer, HPV and HPV vaccine was low.

Parental attitudes towards male human papillomavirus vaccination: a pan-European cross-sectional survey

Background

Human papillomavirus (HPV) is a common sexually transmitted virus that can lead to severe diseases in both women and men. Today, HPV vaccination is offered to females only across Europe. We aimed to examine parental attitudes to HPV vaccination of their sons given brief information about HPV in both genders.

Methods

A literature study on acceptability of male HPV vaccination was carried out to inform the construction of a study questionnaire. Following up on a Danish study from 2012, this questionnaire was applied in 1837 computer assisted interviews with parents of sons in the UK, Germany, France and Italy. In each country, the parents were representative in terms of geographical dispersion, city size and age of sons in the household. The applied questionnaires took the varying vaccination policies and delivery systems into account. The data were analysed pooled and for each country using significant statistical tests (chi-2) with a 95 % confidence interval.

Results

Approximately ¾ of parents in the UK, Germany and Italy were in favour of HPV vaccination of their sons. In France, this applied to 49 % of respondents. Favourable parents wanted to protect their sons from disease and found gender equality important. Parents in doubt about male HPV vaccination needed more information about HPV diseases in men and male HPV vaccination; Rejecting parents were generally sceptical of vaccines and feared vaccination side-effects. Parents in countries with active vaccination policies (UK and Italy) tended to trust the importance of national vaccination programmes. Parents in countries with passive vaccination strategies (Germany and France) had greater need for information from health care professionals (HCP) and public health authorities.

Conclusion

Given brief information about HPV in both genders, parental acceptance of HPV vaccination of sons is as high as acceptance levels for girls. All parents should be informed about HPV to make informed decisions about HPV vaccination for their children. There is a need for joint efforts from public health authorities and HCPs to provide parents with such information.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-015-1863-6) contains supplementary material, which is available to authorized users.

Exploring reasons for non-vaccination against human papillomavirus in Italy

Background

In Italy, free-of-charge HPV vaccination is offered to 11-year-old girls since 2007. The National Immunization Plan established the target coverage at a minimum of 70%; it should increase to 95% within 3-year time frame. In 2012, four year after the introduction of HPV vaccination, coverage was stable at 69%. We conducted a national cross-sectional study to explore barriers to vaccination in Italy.

Methods

Vaccination services selected, through the immunization registries, a sample of unvaccinated girls born in 1997 or 1998 and posted to their families a 23-items questionnaire inquiring barriers to vaccination, HPV knowledge, source of information on HPV, perception of risk of contracting HPV, advice from consulted health professionals on HPV vaccination.

Results

We analysed 1,738 questionnaires. Main barriers were fear of adverse events (reported by 80% of families), lack of trust in a new vaccine (76%), discordant information received by health professionals (65%) and scarce information on HPV vaccination (54%). Overall, 54% of families replied correctly to more than half of 10 questions exploring knowledge on HPV vaccination. Families with a high knowledge score were more likely to live in Northern and Central Italy, be Italian, have a high educational level, include a mother who attended cervical screening regularly and consult more information sources. Although paediatricians/general practitioners and gynaecologists were considered the most trusted source of information by 79% and 61% of respondents, they were consulted only by 49% and 31%. Among parents who discussed vaccination with a physician, 28% received discordant advices and 31% received the recommendation of accepting vaccination.

Conclusions

Fear of adverse events, discordance of information and advices from physicians, and scarce information were the more commonly reported barriers to HPV vaccination. Health professionals played a key role as information providers, thus they must be better trained to provide clear notions. Training needs to include the development of communication skills; transparent discussion about the pros and cons of vaccination may reduce fear of adverse events and increase trust in vaccination. The creation of a public health network around vaccination would allow sharing information and attitudes on vaccinations, so that homogeneous messages could reach the target population.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-014-0545-9) contains supplementary material, which is available to authorized users.