Overcoming the knowledge-behavior gap: The effect of evidence-based HPV vaccination leaflets on understanding, intention, and actual vaccination decision

Vaccine. 2014 Mar 10;32(12):1388-93. doi: 10.1016/j.vaccine.2013.12.038. Epub 2014 Jan 28.


Objective: Informed decision making requires transparent and evidence-based (=balanced) information on the potential benefit and harms of medical preventions. An analysis of German HPV vaccination leaflets revealed, however, that none met the standards of balanced risk communication.

Methods: We surveyed a sample of 225 girl-parent pairs in a before-after design on the effects of balanced and unbalanced risk communication on participants' knowledge about cervical cancer and the HPV vaccination, their perceived risk, their intention to have the vaccine, and their actual vaccination decision.

Results: The balanced leaflet increased the number of participants who were correctly informed about cervical cancer and the HPV vaccine by 33 to 66 absolute percentage points. In contrast, the unbalanced leaflet decreased the number of participants who were correctly informed about these facts by 0 to 18 absolute percentage points. Whereas the actual uptake of the HPV vaccination 14 months after the initial study did not differ between the two groups (22% balanced leaflet vs. 23% unbalanced leaflet; p=.93, r=.01), the originally stated intention to have the vaccine reliably predicted the actual vaccination decision for the balanced leaflet group only (concordance between intention and actual uptake: 97% in the balanced leaflet group, rs=.92, p=.00; 60% in the unbalanced leaflet group, rs=.37, p=.08).

Conclusion: In contrast to a unbalanced leaflet, a balanced leaflet increased people's knowledge of the HPV vaccination, improved perceived risk judgments, and led to an actual vaccination uptake, which first was robustly predicted by people's intention and second did not differ from the uptake in the unbalanced leaflet group. These findings suggest that balanced reporting about HPV vaccination increases informed decisions about whether to be vaccinated and does not undermine actual uptake.

Keywords: Absolute versus relative risk; Evidence-based health information; Gardasil; HPV vaccination; Informed decision making; Knowledge–behavior gap; Paternalistic decision making; Patient information; Risk communication; Risk perception in vaccination.

MeSH terms

  • Decision Making
  • Female
  • Germany
  • Health Knowledge, Attitudes, Practice*
  • Humans
  • Intention
  • Male
  • Papillomavirus Infections / prevention & control*
  • Papillomavirus Vaccines / therapeutic use*
  • Parents / psychology
  • Patient Education as Topic*
  • Surveys and Questionnaires
  • Uterine Cervical Neoplasms / prevention & control
  • Uterine Cervical Neoplasms / virology
  • Vaccination / psychology*


  • Papillomavirus Vaccines