Open Access Highly Accessed Research article

Equity in human papilloma virus vaccination uptake?: sexual behaviour, knowledge and demographics in a cross-sectional study in (un)vaccinated girls in the Netherlands

Madelief Mollers12, Karin Lubbers3, Symen K Spoelstra3, Willibrord CM Weijmar-Schultz3, Toos Daemen4, Tjalke A Westra4, Marianne AB van der Sande15, Hans W Nijman3, Hester E de Melker1 and Adriana Tami46*

  • * Corresponding author: Adriana Tami

  • † Equal contributors

Author Affiliations

1 Epidemiology and Surveillance, Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands

2 Pathology, VU University Medical Center (VUmc), Amsterdam, The Netherlands

3 Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

4 Department of Medical Microbiology, Molecular Virology Section, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands

5 Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands

6 Department of Medical Microbiology, University Medical Center Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands

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BMC Public Health 2014, 14:288  doi:10.1186/1471-2458-14-288

Published: 28 March 2014



In the Netherlands, human papillomavirus (HPV) vaccination is part of a national program equally accessible for all girls invited for vaccination. To assess possible inequalities in vaccine uptake, we investigated differences between vaccinated and unvaccinated girls with regard to various characteristics, including education and ethnicity, (both associated with non-attendance to the national cervical screening program), sexual behaviour and knowledge of HPV.


In 2010, 19,939 nationwide randomly-selected 16–17 year-old girls (2009 vaccination campaign) were invited to fill out an online questionnaire. A knowledge scale score and multivariable analyses identified variables associated with vaccination status.


2989 (15%) of the selected girls participated (65% vaccinated, 35% unvaccinated). The participants were comparable with regard to education, ethnicity, most sexual risk behaviour and had similar knowledge scores on HPV transmission and vaccination. However, unvaccinated girls lived in more urbanised areas and were more likely to have a religious background. Irrespective of vaccination status, 81% of the girls were aware of the causal relationship between HPV and cervical cancer, but the awareness of the necessity of cervical screening despite being vaccinated was limited.


HPV vaccine uptake was not associated with knowledge of HPV and with factors that are known to be associated with non-attendance to the cervical cancer screening program in the Netherlands. Furthermore, most sexual behaviour was not related to vaccination status meaning that teenage unvaccinated girls were not at a disproportionally higher risk of being exposed to HPV. Routine HPV vaccination may reduce the social inequity of prevention of cervical cancer.

Monitoring; Human papilloma virus; Vaccination uptake; Sexual behaviour; Knowledge