By Jo Waller, on 26 April 2018
Lion Shahab, Jennifer A. McGowan, Jo Waller, Samuel G. Smith
Approximately one third to one half of cancer diagnoses are preventable by changes to lifestyle behaviours. In Europe, at least 1.1 million cancer cases per year could be prevented if people had healthier lifestyles. According to the latest (4th) European Code Against Cancer (ECAC), established cancer risk factors include active and passive smoking, alcohol consumption, being overweight or obese, being physically inactive, have a poor diet, being exposed to ultraviolet radiation (e.g. from the sun), and infection with human papillomavirus (HPV). However, many other unverified (‘mythical’) causes of cancer appear in tabloids and on social media. Recognising the difference between the real and the ‘mythical’ cancer causes can be difficult. Conflicting messages can make it harder for people who are trying to reduce their cancer risk to place their efforts into effective activities.
In a study published in the European Journal of Cancer, we report findings from the 2016 Attitudes and Beliefs About Cancer-UK Survey of 1,330 UK participants. The survey explored the public’s beliefs about actual cancer causes (smoking, alcohol consumption, low physical activity, low fruit and vegetable consumption, being overweight) and mythical causes of cancer. Awareness of actual causes of cancer was low, with participants on average on being able to identify half of the causes of cancer. More than a third (40%) of adults did not know that being overweight was associated with an increased cancer risk and the same number did not recognise sunburn as a cancer risk. Almost three in four adults (71%) did not know that HPV is associated with cancer. Being able to identify correct causes of cancer was related to the likelihood of participants not smoking, and eating five or more fruit and vegetables a day.
Participants could, on average, only identify 36% of mythical causes of cancer as incorrect. Of these, adults were most likely to believe that stress (43%), food additives (42%) and electromagnetic frequencies (35%) caused cancer. A quarter (26%) of participants believed that mobile phones could cause cancer. Interestingly, adults who endorsed the actual causes of cancer were also more likely to also believe in the mythical causes, suggesting a great level of confusion between the two.
If people are to make informed decisions about their lifestyle they need an accurate understanding of cancer risk factors. Our survey shows that there is a large degree of confusion among the general public regarding those risks. It seems that the numbers of people who believe in the unfounded causes of cancer has increased over the last decade. This could be linked to the way people now access information and the rise of so-called “fake news”. Looking for information from reputable websites like NHS Choices and Cancer Research UK is a good way to avoid this. Cancer Research UK even has a page presenting evidence to debunk some the myths, which could be a useful resource for people who are understandably confused.
When women are too busy for cervical screening or have had a bad experience, could HPV self-sampling be an appealing alternative?
By Laura Marlow, on 17 April 2018
By Kirsty Bennett and Laura Marlow
In the UK, women aged 25 to 64 are regularly invited for cervical screening (the ‘smear test’ or ‘Pap test’). While uptake of cervical screening is generally high, it has been declining in recent years, and in 2017 just over a quarter of women did not attend screening. Studies exploring screening non-attendance suggest a wide range of reasons that women do not go, including practical barriers such as difficulties arranging appointments, emotional barriers including embarrassment and fear of what the test might find and low perceived risk of cervical cancer.
One of our previous blogs described how most non-participants at screening are aware of screening and have made a decision about future attendance. The majority of these intend to go despite currently being overdue or unscreened, but some have made an active decision not to attend for screening in future. In our latest study, funded by Cancer Research UK as part of a larger project on cervical screening, we explored barriers to cervical screening among 426 women who had made an active decision not to attend in the future, and compared them with 117 women who intended to be screened in the future.
Participants were shown sixteen possible barriers which covered a variety of reasons why some women might not attend screening, and they were asked to choose the ones that applied to them. Women who had made an active decision not to be screened were more likely than the ‘intenders’ to say that screening wasn’t relevant to them because of their sexual behaviour (reported by 27%). Cervical cancer is caused by a sexually transmitted infection (HPV, or human papillomavirus – see below), so some women had decided not to go for screening because they were no longer sexually active, or had been in the same relationship for a long time. They also reported having more important things to worry about than screening (reported by 12%) and some said they had weighed up the risks and benefits and decided it was not worth getting screened (reported by 13%).
We went on to ask women about their interest in HPV self-sampling. HPV is a very common sexually transmitted infection and nearly all cases of cervical cancer are caused by this virus. It can take many years for an HPV infection to develop into cervical cancer so a woman’s current sexual behaviour does not necessarily reflect her current risk. Although it’s not offered by the NHS Cervical Screening Programme at the moment, HPV self-sampling allows women to collect a sample themselves, usually by using a vaginal swab. The sample is then sent to a laboratory and tested for HPV. Many of the women who had decided not to attend cervical screening (66%) indicated that they would be interested in self-sampling. Self-sampling seemed to be particularly appealing to women who reported a bad experience of screening in the past, and those who were too busy or embarrassed to attend. Shifting the perceived cost-benefit ratio for these women by offering HPV self-sampling might increase screening participation in this group. Studies in several countries have found that offering self-sampling to women who don’t attend for screening can be a very effective way of increasing participation. With the shift to HPV primary screening planned for 2019 in England, self-sampling may become a feasible option for some women.
Kirsty F Bennett KF, Waller J, Chorley AJ, Ferrer RA, Haddrell JB, Marlow LAV. Barriers to cervical screening and interest in self-sampling among women who actively decline screening. Journal of Medical Screening. Published online.
By Laura Marlow, on 21 March 2018
Every year around 28% of women who are eligible for cervical screening do not attend as recommended. Last year we blogged about a paper we had published exploring how these women can be divided into five broad sub-types; 1) unaware of screening, 2) unengaged with screening, 3) undecided about whether to go for screening, 4) decided not to go for screening and 5) decided to go but not yet gone. We also found some patterns in the way these different non-attender types are distributed across different groups of the population. For example, we found that women from ethnic minority groups were more likely to be unaware of screening and older women were more likely to have decided not to go. Understanding these patterns will help us to decide how interventions might be shaped differently for different types of non-attenders. For example, since women from ethnic minority groups are more likely to be unaware of cancer screening, targeted public health campaigns aimed at raising awareness within ethnic minority communities could be beneficial.
More recently, we have been delving a bit deeper and have tried to unpick some of the psychological and behavioural differences between the most common non-attender groups. Published in the journal Preventive Medicine this week, our new work shows some interesting findings. Most notably we showed that women who are unaware of screening tend to be more fatalistic, both about life in general and about cancer. They also have more negative beliefs about cancer outcomes. Women who had decided not to be screened frequently perceived themselves to be at lower risk of cervical cancer. And for women who were unengaged with screening, both more fatalistic beliefs and lower perceived risk were relevant. Health behaviours also varied between the different groups, with unaware women less likely to have seen a GP recently, and unengaged women less likely to seek out health information and more likely to actively avoid cancer information in the media.
This work will help us to identify the content of the messages that we might use for specific types of non-attenders. Interventions to raise awareness of screening should include messages that address fatalistic and negative beliefs about cancer. By contrast, information for women who have decided not to be screened may need to ensure they have an accurate knowledge of their risk of cervical cancer and that they understand the benefits of screening. This will help make sure women who decide not to take part are making an informed choice. Our next step it to outline what these interventions might look like – watch this space!
By Laura Marlow, on 19 February 2018
In the UK, women are invited for cervical screening (the ‘smear test’) between the ages of 25 and 64, and although uptake is high it has been falling for some years across all age groups (1). A number of studies have focused on improving uptake among younger women (2), but a recent BMJ article called for work to focus on the needs of ‘older’ women too, given that half of all cervical cancer deaths are in women over 50 (3). One particular issue for older women can be that screening becomes more painful following the menopause. Lower oestrogen levels can cause thinning and dryness of the vaginal walls and it’s estimated that half of all post-menopausal women have these symptoms. This can mean that inserting the speculum (the instrument used to open the vagina for examination) is particularly painful for some ‘older’ women. Dr Anita Lim at King’s College London has been awarded funding by Cancer Research UK to explore a different procedure for collecting samples without a speculum. Samples collected without the speculum would be tested for human papillomavirus (HPV) and women would only need to have further examination if they were found to be HPV positive.
Collaborating with Dr Lim, we led some exploratory work to assess the acceptability of this potential alternative (4). Published online last week in the Journal of Medical Screening, the work included focus groups and interviews with 38 women aged 50-64 who had a variety of cervical screening histories (‘up to date’, ‘overdue’ and ‘never been screened’). As expected, many of the women reported negative experiences of the speculum during cervical screening and found its insertion was sometimes painful, particularly after the menopause. Women were generally positive about the idea of screening without a speculum and thought it would be less invasive than the current procedure. However, some women were concerned that this method could be less accurate, because the swab might touch other areas and collect unwanted cells, and the sample-taker would not be able to clearly see the cervix without a speculum. Women said they would want sufficient information and reassurance, particularly about the effectiveness of non-speculum sampling compared to current cervical screening.
The findings from this study suggest that HPV testing on clinician-collected samples taken without a speculum could be an acceptable alternative to conventional cervical screening. It might be particularly useful for older women who have had difficulty with the speculum examination, potentially due to post-menopausal changes. Dr Lim will continue to explore the acceptability of introducing clinician-collected non-speculum sampling alongside assessing how well the test works, but preliminary work suggests introducing this procedure could improve screening uptake among 50-64 year-olds who have put off attending.
- Screening and Immunisations team. Cervical screening programme: England, 2016-17. Health and Social Care Information Centre, 2017, p. 1 – 76.
- Kitchener HC et al. A cluster randomised trial of strategies to increase cervical screening uptake at first invitation (STRATEGIC). Health Technol Assess 2016, 20(68):1-138.
- Sherman SM et al. Cervical cancer is not just a young woman’s disease. BMJ 2015, 350:h2729.
- Freeman et al. Acceptability of non-speculum clinician sampling for cervical screening in older women: A qualitative study. JMS, in press.
By Moritz P Herle, on 16 October 2017
by Nathalie Kliemann and Becca Beeken
Obesity is a growing public health concern. Individuals with obesity (Body Mass Index ≥30) are at increased risk for a range of diseases including cardiovascular diseases and a number of cancers. There is therefore a need to find effective ways to help individuals with obesity to lose weight. Evidence from recent studies suggests that brief interventions based on habit theory may be a novel approach. Interventions based on habit theory encourage people to repeat certain behaviours in a consistent context (in the same place or at the same time of day). This helps to make the behaviours more automatic (do them without really thinking about them) over time. These interventions also encourage people to set goals, plan when they will perform their behaviours, and monitor how they are getting on during the habit formation process. This can improve people’s ability to control their behaviours or their ability to ‘self-regulate’. Self-regulation refers to the ability to control behaviours, attention and thoughts to achieve a goal (e.g. avoid eating chocolate to lose weight).
Our research group at University College London developed a habit-based weight loss intervention, called 10 Top Tips (10TT), with the charities Cancer Research UK and Weight Concern. The 10TT are a set of everyday healthy eating and activity behaviours that are described in a leaflet alongside advice for turning the behaviours into habits. The leaflet recommends making specific plans, repeating the behaviours in a consistent context, and monitoring performance daily using a log book.
The leaflet was tested in a randomised controlled trial in primary care. Patients with obesity from 14 GPs across England were invited to take part. Those who consented were randomly allocated to 1 of 2 groups. Individuals in one group were given the 10TT by a practice nurse in an appointment at their GP surgery. The other groups were referred to the usual care offered by their GP. Initial results of this trial demonstrated that patients who received the 10TT intervention lost almost one kilo more than those receiving usual care. Furthermore, patients who received 10TT reported the behaviours had become more automatic over three months. This suggests that 10TT was more effective at establishing new habits by the end of the intervention period. In the present study, we aimed to understand the effect of 10TT on self-regulatory skills and whether changes in self-regulatory skills and automaticity explained why the intervention helped people to lose weight over three months.
In our latest research we found that over three months patients who were given 10TT reported greater increases in self-regulatory skills than those who received usual care. Changes in self-regulatory skills and automaticity over 3 months appeared to, at least partially, explain how the intervention helped people to lose weight. Participants who monitored their behaviours for longer, recorded their weight more often, and made more plans, experienced the greatest changes. This findings support the proposition that self-regulatory training and habit formation are important features of weight loss interventions.
We hope the results of our research will improve our understanding of how interventions based on habit theory work. These findings could guide the development of more effective habit-based weight loss interventions to help people to lose weight.
In future studies, we aim to explore whether the effects of the 10TT intervention can be enhanced through making it easier to use the log books (e.g. through digital self-monitoring via a mobile phone app). We are also interested in whether adding self-regulatory training to help people break existing habits (as well as forming new habits) would increase weight loss.
Article link: Kliemann N, Vickerstaff V, Croker H, Johnson F, Nazareth I, Beeken B. The role of self-regulatory skills and automaticity on the effectiveness of a brief weight loss habit-based intervention: secondary analysis of the 10 top tips randomised trial. International Journal of Behavioural Nutrition and Physical Activity. 2017, 14:119.
By Moritz P Herle, on 8 August 2017
by Anna Roberts
Over 14 million people are diagnosed with cancer worldwide each year, and this is expected to rise to 22 million over the next two decades. Thankfully, due to improvements in early diagnosis and treatment, the number of people who are surviving longer after cancer is also increasing.
However, many people diagnosed with cancer experience long-lasting and debilitating side effects (e.g. fatigue, pain, sleep difficulties, anxiety and depression), all of which can substantially reduce quality of life. Health behaviours, such as physical activity and diet could prolong survival, reduce the risk of cancer returning and have been shown to reduce many of these common side effects. However, it is many of these side effects which make physical activity more difficult to do following a cancer diagnosis, and the number of cancer survivors who meet the recommended 150 minutes of moderate-vigorous physical activity per week is lower than for people who have never had cancer. Therefore, there is a need for interventions which can help support cancer survivors’ to take part in physical activity following their diagnosis.
Digital interventions use technologies such as text messaging, email, mobile apps, social media, websites and patient portals can be used to support health behaviours such as physical activity and diet. Digital interventions have increased in popularity as they are easy to access, tend to cost less than face-to-face support and therefore have the ability to reach a large number of people. This is especially true given the ever increasing number of UK adults who access the internet and own a smartphone.
In the last few years, the number of studies which have looked at how effective these types of technologies are at improving cancer survivors’ physical activity participation and diet quality has rapidly increased. In our new study, we reviewed all of the published literature to see how effective digital technologies are at increasing physical activity or improving dietary quality among people diagnosed with cancer. We also looked at the effect of these types of interventions on body mass index (BMI) and other cancer-relevant outcomes measured in the studies, such as fatigue, sleep quality, anxiety and depression and quality of life.
15 studies were included in the review, all of which evaluated the effect of a digital technology on physical activity and five studies also evaluated the effect on dietary quality. By statistically combining the data from the studies (also known as a meta-analysis), we were able to estimate that digital technologies can increase cancer survivors’ moderate-vigorous physical activity by approximately 40 minutes per week. This technique also allowed us to show that digital technologies can significantly reduce BMI, however there was no evidence of an improvement in cancer survivors’ quality of life. While there was evidence for a reduction in fatigue, this was not large enough to be deemed statistically significant. Meta-analysis was not possible for all of the outcomes we were interested in (either due to the variation between studies in the way in which they were measured or because of the small number of studies which assessed these outcomes). Of the 5 studies which assessed the effect of digital interventions on diet, only 2 showed an improvement in dietary quality. There was no evidence of any improvement in anxiety or depression and while only 2 studies evaluated the effect on sleep quality, both showed a significant improvement in sleep outcomes.
However, as this is an emerging field of research, the quality of the included studies was varied. For instance, all of the studies asked participants to report their own physical activity participation using questionnaires. These types of questionnaires are notorious for overestimating actual physical activity levels. Furthermore, the length of follow-up in these studies was relatively short which makes it difficult to understand the longer-term impact of these types of interventions. There was also large variation between the studies in terms of the types of digital interventions, the types of cancer and the way in which the outcomes were measured. This makes it very difficult to ascertain what types of intervention are most effective, for which outcomes, among which groups of cancer survivors. While the results of this review show that the use of digital technologies in this context appears promising, we also call for larger, high-quality studies with objective measures of physical activity and longer follow-up periods.
Article link: Roberts AL, Fisher A, Smith L, Heinrich M, Potts HWW. Digital health behaviour change interventions targeting physical activity and diet in cancer survivors: a systematic review and meta-analysis. Journal of Cancer Survivorship, 2017.
By Laura Marlow, on 3 July 2017
Authors: Amanda Chorley, Laura Marlow, Jo Waller
One of our previous blogs discussed how rates of cervical screening (aka the smear test, or pap test) have been declining in the UK. Last year, screening uptake rates fell to 72.7%, meaning that over a quarter of women had not been screened as recommended (1). A better understanding of why women are not being screened is vital. If women are making informed decisions not to attend this is perfectly acceptable, but if women do not understand cervical screening or find it difficult to attend for other reasons (e.g. inconvenient appointment times), interventions to address this are important. Treating women who do not attend screening as a single group of “non-participants” means those with very different screening experiences and intentions are considered to be the same. Unsurprisingly this means that “one size fits all” interventions to increase screening participation do not have large effects, as they are unlikely to be suited to individual women’s differing needs.
In our latest study published in the European Journal of Cancer last week, we used the Precaution Adoption Process Model (PAPM)(2) to try and improve our understanding of the ways in which women who do not attend screening may differ. The PAPM is a model from behavioural science which states that before carrying out a health behaviour (in this case cervical screening), a person must move through a number of stages. A person must first be aware of the health behaviour and engaged with it before they can make a decision whether or not to carry it out. If they do decide to carry out the behaviour, they must then overcome any barriers which may be in the way of this (e.g. getting to the screening appointment). Importantly, the PAPM also includes the possibility for people to make an active decision to not participate in the behaviour. By classifying women according to the PAPM we hoped to identify what the most common type of screening non-participant is, and whether women within a particular group tend to have shared characteristics.
793 (27%) of the 3113 women we surveyed were either overdue for screening (including those who had never had a smear test) or said they did not plan to go for screening when next invited. Of these non-participating women, just over half said that they do intend to go. These women tended to be younger than women who were up to date with screening, and were more likely to be single and from less affluent backgrounds. Perhaps more surprisingly, given the fact that all should have received an invitation and leaflet about screening as part of the NHS programme, 28% of non-participating women said that they had never heard of cervical screening, smear or pap tests, even after being shown a photo of the procedure. These women were more likely to be younger and from ethnic minority and less affluent backgrounds, and to have English as a second language. Finally, 15% of non-participating women said that they had made a decision not to be screened in the future. These women tended to be older, and most had been screened before. As with the other two groups, they were also more likely to be from less affluent backgrounds.
The differences between these groups of non-participants show how important it is to consider the different reasons for non-participation. Changes such as more flexible clinic hours or text message reminders may help women who do want to go for screening but have found it hard to get around to it. However, for women who are unaware of cervical screening, more accessible information about the programme is a vital first step towards making an informed choice about whether to participate or not. As we found that unaware women were more likely to be from ethnic minority backgrounds and less likely to speak English as their first language, it may be helpful to provide information in more languages and through TV or radio advertisements rather than just using written materials. Choosing not to be screened is a legitimate choice, and one that needs to be respected by medical professionals. However, in order for women to make an informed choice it is important that they have access to relevant information, including the benefits, risks, and limitations of screening. For some of the women who have decided not to go in the future, it may be the case that they have sought out this information. For other women the decision not to go for further screening may be due to a previous bad experience.
Our survey goes some way to showing that there is not just one type of cervical screening non-participant, but different groups of women with different experiences, choices, and needs. In the future we hope to look further into these differences, both between and within the different groups described in this post.
1. Screening and Immunisations team ND. Cervical screening programme: England, 2015-16. Health and Social Care Information Centre, 2016, p. 1 – 76.
2. Weinstein N. The Precaution Adoption Process. Health Psychology. 1988; 7: 31.
By Moritz P Herle, on 23 May 2017
by Amanda Chorley and Jo Waller
Cancer screening programmes, such as breast, cervical, and bowel, are an important tool in the fight against cancer. Many people are aware of the value of early detection of cancer, which breast screening and the Faecal Occult Blood test (FOBt) part of bowel screening offer, which allows for treatment at an earlier stage when it is more likely to be effective. But are people aware that cervical screening and bowel scope screening (also known as flexible sigmoidoscopy, or FS) primarily aim to prevent cancer by identifying and removing abnormalities which may progress into cancer at a later date? This is the question we looked to answer in our recently published paper1 in the Journal of Medical Screening.
As part of a larger survey on attitudes and behaviours surrounding cancer, we asked 1433 middle aged and older adults what they thought the main purpose of each of these screening programmes was. We found that while the majority of respondents were aware that breast screening (77.9%) and FOBt (73.2%) aimed to detect cancer early, only 17.6% knew that cervical screening primarily aimed to prevent cancer. For bowel scope screening the figure was only 13.8%. Overall only 13 people correctly identified the purpose of all four screening programmes, which is just under 1% of respondents.
We also looked at whether people had participated in each programme in the past to see whether that had any effect on awareness of the purpose of the programme. People who had been sent a test kit, and those who had completed and returned the kit were more likely to know that FOBt is designed to detect cancer early. For breast screening, only those having participated in screening were more likely to know that it was aimed at early detection. Having received an invitation did not seem to have an effect on knowledge of the purpose of the test.
However for both cervical screening and bowel scope screening neither those who had received an invitation nor those who had actually participated in the programme were any more likely to be aware of the preventive nature of the programme than respondents who hadn’t been invited or participated. This is despite the leaflets accompanying invitations clearly stating prevention as the main purpose.
On the one hand it is positive that public health messages on the importance of the early detection of cancer have been so effective, and that the majority of people recognise this to be the purpose of breast screening and FOBt. However, for people to make an informed choice about whether to participate in a screening programme they need an understanding about what the screening test aims to do, as well as any risks and benefits. Our survey suggests that this is not the case for cervical screening and bowel scope. As well as this lack of awareness being an issue for informed choice, it could also have consequences for how people engage with the screening programmes. People may end up avoiding screening tests if they are afraid they might be told they have cancer2, 3. Knowing that some programmes can prevent cancer by finding and removing abnormalities may help to reduce these fears. Other studies have shown that women invited to colposcopy after having an abnormal result from their smear test sometimes mistakenly believe they have cancer4, 5. A better awareness that cervical screening mainly looks for cell abnormalities which can be removed before they have a chance to turn into cancer may help in reducing stress and worry about the abnormal result.
If leaflets aren’t getting these messages across effectively, one of the priorities for the future will be finding different ways to communicate about cancer screening so that everyone understands what the tests are trying to do.
- Chorley AJ, Hirst Y, Vrinten C, Wagner Cv, Wardle J and Waller J. Public understanding of the purpose of cancer screening: A population-based survey. J Med Screen. 2017; 0: 0969141317699440.
- Vrinten C, Waller J, von Wagner C and Wardle J. Cancer fear: facilitator and deterrent to participation in colorectal cancer screening. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. 2015; 24: 400-5.
- Andersen MR, Smith R, Meischke H, Bowen D and Urban N. Breast cancer worry and mammography use by women with and without a family history in a population-based sample. Cancer epidemiology, biomarkers & prevention : a publication of the American Association for Cancer Research, cosponsored by the American Society of Preventive Oncology. 2003; 12: 314-20.
- Kavanagh AM and Broom DH. Women’s understanding of abnormal cervical smear test results: a qualitative interview study. BMJ (Clinical research ed). 1997; 314: 1388.
- Gray NM, Sharp L, Cotton SC, et al. Psychological effects of a low-grade abnormal cervical smear test result: anxiety and associated factors. British journal of cancer. 2006; 94: 1253-62.
By Lauren Rockliffe, on 16 March 2017
What is HPV?
Human papillomavirus, also known as HPV, is a common virus that affects the skin and moist areas that line the body, such as the cervix. It is spread by skin-to-skin contact and can be transmitted through sexual activity. Most people will come into contact with HPV at some point in their life, and in most cases the body will get rid of the virus on its own. However, in some cases the virus can cause cell changes which can increase the risk of some cancers, such as cervical cancer. There are over 100 different types of HPV, but two types in particular (types 16 and 18) cause 70% of cases.
In 2008 a vaccination was introduced which protects against these two types of HPV. It also protects against two other types of HPV that don’t cause cancer, but do cause genital warts. The vaccination is mainly given through schools to girls aged 12-13 (in school year 8). The vaccine is given in two separate injections.
Why was this study done?
Most girls get the vaccination but as we’ve written before, there are some girls who do not. Research has shown that girls from ethnic minority backgrounds are less likely to have the vaccination than White British girls. In our new study, published this week, we investigated why this might be the case.
What did we do?
We did thirty-three face-to-face interviews with parents from ethnic minority backgrounds, whose daughters both had and had not got the vaccine. We also did interviews with parents from White British backgrounds, whose daughters had not got the vaccine, so that we could see whether there were any differences between what parents from different ethnic backgrounds were saying. All but one of the people we interviewed were mothers.
What did we find?
Parents have concerns about the vaccine
Parents had concerns about side effects of the vaccine and its effectiveness, despite the vaccine being recognised as safe by the UK government and World Health Organisation. Some parents were worried that the benefits of having the vaccination might not outweigh the risks. Other parents worried that it might encourage girls to be more sexually active.
Other people’s opinions and experiences are important
Some parents’ vaccination decisions were affected by things they had heard from other people about the vaccination. A number of parents had got information from others about the vaccine and some parents had heard about girls who happened to become unwell after having the vaccine and whose parents thought this must have been caused by the vaccine.
Parents need more information
Many parents had not heard about the vaccine before their daughter was invited to have it. Some parents felt like they had not been provided with enough information about the vaccine and others chose to research it themselves.
Some parents prefer to protect their daughters using other methods
Although there isn’t any evidence that complementary medicines can prevent HPV, some parents preferred to use them instead of vaccination and some encouraged a healthy lifestyle to prevent illness. Others thought that better ways to prevent their daughter from getting an HPV infection would be to encourage them to have safe sex, to educate them about sex or for their daughters to not have sex before marriage. A few parents believed illness was caused by things outside their control, such as God.
Some parents don’t trust authorities
A number of parents believed that the introduction of the vaccine was driven by pharmaceutical companies wanting to make money. Some of these parents lacked faith in the government and why it had chosen to introduce the vaccine.
Emotions influence vaccination decisions
Some parents felt that they might regret the decision if they vaccinated, whilst others felt they might regret their decision if they did not.
What did we conclude?
In general, many of the things parents spoke to us about were said by parents from all different ethnic backgrounds. However, there were some issues that were only brought up by parents from ethnic minority backgrounds. These included preferring their daughters to wait until marriage before having sex and believing that cervical cancer is caused by things that are out of their control.
The results of this study suggest to us that any future attempts to try and increase uptake of the vaccination need to consider issues that are important to parents from ethnic minority backgrounds. It may be helpful to involve community group leaders and religious leaders when designing future interventions, to ensure that it is appropriate and well considered.
By Sarah Jackson, on 8 March 2017
Rises in obesity prevalence over recent decades have corresponded with increasing stigmatisation of, and discrimination against, individuals living with obesity. Weight stigma is often justified on the basis that it might encourage people to lose weight, but a growing evidence base indicates that experiences of weight-related stigmatisation may in fact encourage behaviours that promote obesity.
A few small studies have indicated that people who face weight stigma are more inclined to avoid physical activity, but none have been able to clearly establish what effect experiencing stigma has on actual exercise behaviour.
In a new study published today in BMJ Open we explored the relationship between weight discrimination and physical activity. The research involved 5,480 men and women aged 50 years and older taking part in the English Longitudinal Study of Ageing, a large population-based cohort of middle-aged and older adults living in England.
Overall, one in twenty people said they had been discriminated against because of their weight, ranging from lack of respect or courtesy to being threatened or harassed. Rates of weight discrimination varied considerably according to how overweight a person was, from 0.9% of people with a body mass index (BMI) in the overweight range (25-29.9) to 13.4% of people with obesity (BMI greater than 30).
Importantly, we found that people who had experienced weight-related discrimination had almost 60% higher odds of being inactive and 30% lower odds of engaging in moderate or vigorous exercise once a week than their peers.
Interestingly, a person’s BMI in itself did not affect the relationship between weight discrimination and exercise, indicating that people who experience weight-related discrimination are likely to be less physically active, regardless of their weight.
There could be several reasons for our findings. People who feel stigmatised may be more self-conscious about exercising in front of others for fear they will attract undesirable attention, leading to embarrassment or teasing. They may also begin to believe the negative stereotypes against themselves as lazy and worthless, leaving them wondering why they should bother trying to be active.
Given the substantial benefits of being physically active for both physical and mental health, interventions that aim to reduce weight bias at a population level – for example through schools, local communities or national campaigns – may have greater impact on health than those that encourage people to lose weight. A Health at Every Size approach may be helpful in encouraging people to develop and maintain healthy habits, including regular physical activity, for the sake of health and wellbeing as opposed to weight control.
Jackson SE, Steptoe A. Association between perceived weight discrimination and physical activity: a population-based study in English middle-aged and older adults. BMJ Open. 2017;7:e014592.