Human papillomavirus vaccine uptake, predictors of vaccination, and self-reported barriers to vaccination

OBJECTIVE

To describe human papillomavirus (HPV) vaccine uptake, predictors of vaccination, and barriers to vaccination in young women.

METHODS

Participants were 13-26-year-old girls and women recruited from an urban, hospital-based clinic. Between June and December 2007, 6 months after they had completed a baseline survey, they were recontacted to assess receipt of at least one HPV vaccine dose and barriers to receiving the vaccine. We assessed whether demographic factors, gynecological history, and attitudes measured at baseline were associated with vaccination at follow-up using logistic regression.

RESULTS

Of the 262 women who completed the baseline study, 189 (72%) participated in this follow-up study. At follow-up, 68 of 189 (36%) had received >or=1 HPV vaccine dose. Factors measured at baseline that predicted vaccination 6 months later included insurance coverage for HPV vaccination (odds ratio [OR] 5.31, 95% confidence interval [CI] 1.61-17.49) and the belief that one's parents, partners, and clinicians endorsed HPV vaccination (OR 2.21, 95% CI 1.29-3.79); those with a history of an abnormal Pap test were less likely to have received the vaccine (OR 0.30, CI 0.10-0.92). Of the 121 who were unvaccinated, 54 (45%) had not returned to the clinic since the baseline study, 51 (42%) had returned but were not offered vaccine, and 15 (12%) had declined vaccination.

CONCLUSIONS

Interventions to increase HPV vaccination rates in women in the catch-up age group for vaccination should ensure that vaccine costs are covered, promote HPV vaccination as normative, and establish clinic-based systems to prevent missed opportunities for vaccination.

Predictors of HPV vaccine uptake among women aged 19-26: importance of a physician's recommendation

Among insured women, aged 19-26 years, those who discussed the HPV vaccine with their physician and received a recommendation were overwhelmingly more likely to be vaccinated. Student status and perception of the personal importance of vaccination were also predictive of vaccination. The strength of the physician's recommendation played a significant role in the decision to be vaccinated, resulting in a 4-fold greater likelihood of vaccination when women received a strong recommendation versus one that was not strong. Health care providers should be well-informed about HPV vaccination and recognize that the strength of their recommendation to patients will foster appropriate uptake.

Human papillomavirus vaccine acceptability among a national sample of adult women in the USA

Background: In the USA, the human papillomavirus (HPV) vaccine is currently licensed for 9–26-year-old females, but licensure for women over 26 years is being considered. The aim of the current study was to investigate the association of sociodemographic and health-related factors to HPV vaccine acceptability among adult women. Methods: The current study utilised a nationally representative sample of women (n = 1323) aged 27–55 living in the USA, with an oversampling of black and Latina women. A multiple item measure of HPV vaccine acceptability across varying cost and location-of-availability (clinic only v. any local pharmacy) conditions was the main outcome measure. General linear modelling was used to analyse the association of vaccine cost, location availability, and sociodemographic and health-related variables with vaccine acceptability. Results: Vaccine cost had the strongest association with acceptability [F (2, 1249) = 832.1; P < 0.0001]; however, factors such as religiosity, political views, a history of various negative sexual health outcomes and previous flu shot receipt were also associated with acceptability. Location availability had a statistically significant but modest effect, with a slight preference shown for health clinic availability. Conclusions: Adult women had generally high levels of HPV vaccine acceptability, but were greatly influenced by cost of the vaccine. Women who had experienced negative sexual health outcomes due to HPV-specific infection rated the vaccine as more acceptable, perhaps due to distress associated with those outcomes.

Enrolment of young adolescents in a microbicide acceptability study

BACKGROUND

Clinical trials of microbicides should include adolescent participants. There may be unique challenges including obtaining informed consent, meeting eligibility criteria and adherence to study demands. We report on our experience enrolling young adolescents in a microbicide surrogate acceptability study and the implication of our experience for other types of clinical trials.

METHODS

Adolescent females were enrolled in a microbicide surrogate acceptability study for 6 months which required parental consent. They were asked to use the product every time they had coitus. They had face-to-face interviews at intake, 3 and 6 months, and completed weekly phone diaries.

RESULTS

Of the 208 enrolled, 95 participants were between 14 and 17 years. Ten were pregnant at intake, and 15 did not have sex during the study. Of the remaining 70 adolescents, 46 (66%) used the product at least once during the 6-month period, and all but seven attended a face-to-face interview after intake.

CONCLUSIONS

It will be possible to include young adolescents in clinical studies, even if parental consent is required. However, there will be challenges, and researchers need to anticipate those challenges and reduce barriers to enrolling young adolescents.

Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians

BACKGROUND

The purpose of this study was to examine Texas physicians' recommendations for the quadrivalent human papillomavirus (HPV) vaccine in 11-to-12-year-old girls, intention to recommend HPV vaccines to 11-to-12-year-old boys, and attitudes about mandated HPV vaccination for 11-to-12-year-old girls.

MATERIALS AND METHODS

We conducted a cross-sectional, web-based survey of Texas physicians who provide direct patient care in family medicine, pediatrics, obstetrics/gynecology, and internal medicine in September 2008. The three outcome variables were: HPV vaccine recommendations to 11-to-12-year-old girls, likelihood of recommending the vaccine to 11-to-12-year-old boys, and agreement with mandated vaccination of 11-to-12-year-old girls. Univariate and logistic regression analyses were used to determine practice-related and attitudinal factors associated with each outcome.

RESULTS

Of the 1,122 respondents, 48.5% stated they always recommended HPV vaccines to girls, 68.4% were likely to recommend the vaccine to boys, and 41.7% agreed with mandated vaccination. In multivariate logistic regression models, variables independently associated with recommendation to 11-to-12-year-old girls included: percentage of patients with Medicaid [odds ratio (OR), 1.02; 95% confidence interval (95% CI), 1.01-1.03], academic versus nonacademic practice (OR, 2.11; 95% CI, 1.05-4.23), office procedures to maximize vaccination (OR, 1.25; 95% CI, 1.01-1.56), HPV knowledge (OR, 1.25; 95% CI, 1.04-1.49), valuing HPV vaccine information from both professional organizations (OR, 1.90; 95% CI, 1.15-3.16) and professional conferences (OR, 1.68; 95% CI, 1.10-2.57), belief in mandated HPV vaccination (OR, 5.38; 95% CI, 3.28-8.83), and barriers to vaccination (OR, 1.08; 95% CI, 1.00-1.16).

DISCUSSION

Half of the physicians in this study did not follow current recommendations for universal HPV vaccination of 11-to-12-year-old girls. Factors linked to vaccine recommendations may be targeted in educational or policy interventions.

Research on adolescents and microbicides: a review

Adolescents are an important target for microbicide research, as they are disproportionately affected by sexually transmitted infections and currently are underrepresented in the microbicide research literature. Furthermore, adolescents are psychosocially and biologically different from adults, and findings from adult research cannot be assumed to apply universally to adolescents. Adolescents, to date have rarely been included in clinical trials and acceptability research for microbicides, in part because their participation requires attention to unique developmental issues, including parental consent and confidentiality. Despite these challenges, adolescents should be included in microbicide clinical research. If adolescents are ultimately expected to use microbicides, it is essential that we understand the developmental, contextual, and relationship variables that may influence use and acceptability. Accordingly, the goal of this paper was to examine the issues affecting the inclusion of adolescents in microbicide clinical research as well as review the existing adolescent-specific microbicide research, which highlights the various factors that may influence use and acceptability. It is hoped that this review can provide guidance for future work with this important, specialized population.

Relationship context associated with microbicide-like product use

STUDY OBJECTIVE

Topical microbicides are being developed to provide an alternative method of prevention of HIV and sexually transmitted infections. Although topical microbicides would be a female-controlled method of prevention, their use is likely to be disclosed to partners. Thus, the characteristics of the partner relationship may play a role in their use. We sought to examine whether qualities of the relationship and of the partner were associated with using a microbicide-like product.

DESIGN

We studied 166 females (14 to 21 years of age) who were participating in a 6-month study of microbicide-like products (vaginal lubricants). They described partner relationships and characteristics of the partners.

RESULTS

Of the 166 participants, 118 used the product. In bivariate analyses, those whose relationships were longer, monogamous, more mutual, and more satisfying were more likely to use the product. Further, when sex occurred in the young women's or couples' homes, use also was more likely. There was no relationship between product use and whether the partner had a job or was in school or between the partners' levels of substance use. In a multivariable logistic regression with backwards elimination, only relationship satisfaction remained significant in the model.

CONCLUSION

Topical microbicides will be used within the context of a relationship, and characteristics of the relationship most likely will influence use. These findings suggest that special attention may have to be given to supporting use in high-risk relationships and that all interventions to enhance uptake should consider the relationship context.

Epidemiology and risk factors for human papillomavirus infection in a diverse sample of low-income young women

BACKGROUND

Two HPV vaccines prevent infection with HPV-16 and HPV-18, high-risk (cancer-associated) HPV types which together cause approximately 70% of cervical cancers; one vaccine also prevents HPV-6 and HPV-11, which together cause approximately 90% of anogenital warts. Defining type-specific HPV epidemiology in sexually experienced women will help estimate the potential clinical benefits of vaccinating this population.

OBJECTIVES

To examine HPV epidemiology in a diverse sample of sexually experienced women, and to determine factors associated with high-risk HPV and vaccine-type HPV (HPV-6, HPV-11, HPV-16 and HPV-18).

STUDY DESIGN

Cross-sectional study of 13-26-year-old women (N=409) who completed a questionnaire and provided a cervicovaginal swab. Swabs were genotyped for HPV using PCR amplification. Logistic regression models were used to determine whether participant characteristics, knowledge, and behaviors were associated with high-risk and vaccine-type HPV.

RESULTS

Most women (68.4%) were positive for >or=1 HPV type, 59.5% were positive for >or=1 high-risk type, 33.1% were positive for >or=1 vaccine-type HPV, and 3.5% were positive for both HPV-16 and HPV-18: none was positive for all four vaccine types. In adjusted logistic regression models, Black race (OR 2.03, 95% CI 1.21-3.41) and lifetime number of male sexual partners (OR 4.79, 95% CI 2.04-11.23 for >or=10 partner vs. <or=1 partner) were independently associated with high-risk HPV infection.

CONCLUSIONS

HPV prevalence was very high in this sample of sexually active young women, but <5% were positive for both HPV-16 and HPV-18, suggesting that vaccination could be beneficial for many individual women who are sexually experienced.

Mothers' intention for their daughters and themselves to receive the human papillomavirus vaccine: a national study of nurses

OBJECTIVES

The aims of this study were to examine mothers' intention to vaccinate their daughters and themselves against human papillomavirus and to determine which demographic, behavioral, and attitudinal factors were associated with intention to vaccinate daughters.

METHODS

We surveyed 10,521 US mothers, all nurses, between June 2006 and February 2007. Multivariable logistic regression models were used to determine which of the following factors were associated with a mother's intention to vaccinate a 9- to 12-year-old daughter: demographic factors, gynecologic history, belief that one's daughter should have regular Papanicolaou testing, beliefs about Papanicolaou testing outcomes (3-item scale), and beliefs about human papillomavirus vaccines (7-item scale measuring beliefs about human papillomavirus vaccine efficacy, impact of vaccination on sexual and Papanicolaou screening behaviors, severity of and susceptibility to human papillomavirus, and anticipated clinician recommendations).

RESULTS

Of the 8832 mothers who completed a survey (84% response rate), 7207 had a daughter. Among mothers with a daughter, 48% intended to vaccinate a daughter if she were 9 to 12 years of age, 68% if she were 13 to 15 years of age, and 86% if she were 16 to 18 years of age. Forty-eight percent intended to receive the vaccine themselves if recommended. In multivariable regression models, variables significantly associated with intention to vaccinate a 9- to 12-year-old daughter included belief that one's daughter should have regular Papanicolaou testing and beliefs about human papillomavirus vaccines.

CONCLUSIONS

In this first national study of mothers' attitudes about human papillomavirus vaccines, mothers' intention to vaccinate a daughter <13 years of age was lower than intention to vaccinate an older daughter, contrasting with national recommendations to target 11- to 12-year-old girls for vaccination. Educational interventions designed to affect mothers' willingness to vaccinate daughters should focus on human papillomavirus vaccine efficacy, behavioral impact of vaccination, perceived risk of human papillomavirus, and clinician support for vaccination.

Participation of adolescent girls in a study of sexual behaviors: balancing autonomy and parental involvement

STUDY OBJECTIVE

The process of research with adolescents should balance parental involvement and adolescent autonomy. The attendance of parents and peers at research study visits of girls participating in a 6-month study of topical microbicide acceptability is described, as well as the participants' conversations with their parents.

METHODS

Girls, 14 through 21 years, were recruited from previous studies (3%), advertisements (14%), clinics (17%), and recommendations by friends (66%) to participate. Girls under 18 years were required to have parental consent, but parents could provide verbal phone consent as long as a signed consent form was returned before participation.

RESULTS

The 208 participants were 41% African-American, 30% Hispanic, and 29% Caucasian. Girls averaged 18 years of age, and 95 (46%) were under 18. Seventeen percent of parents attended the first visit; only 1 parent attended with a daughter older than 18 years of age. The mothers of older adolescents were less likely to attend the appointment with them. More Caucasian than African-American girls came with a mother. Parental attendance decreased at follow-up visits. Thirty-seven percent of girls brought a peer to the first visit; there were no age or race/ethnic differences. There was no relationship between attending with a parent or peer and talking to a parent about the study. Some adolescents obtained parental consent to participate in the study while keeping their sexual behaviors private.

CONCLUSIONS

Parental attendance at study visits may not be marker of parental involvement with the study. Creative ways for balancing concerns about confidentiality, promotion of autonomy, and adult involvement should be considered.

Human papillomavirus vaccine decision-making in Da Nang, Vietnam: perceived spousal and adolescent-parent concordance

This descriptive study examined parents' perceptions of the role of mothers, fathers, and daughters in the decision to have their daughter receive the human papillomavirus (HPV) vaccine; perceived concordance between spouses and between parents and daughters; and the relationships between vaccine decision-making and (1) who takes the daughter to the doctor, and (2) the daughter's age. Health care workers (N=139) with a daughter 9-21 years old completed a self-administered questionnaire including demographic and HPV vaccine-related questions. Health care workers were employed by Da Nang General Hospital or the Da Nang Center for Reproductive Health Care in Vietnam. Most (73%) parents favored having their daughter receive the HPV vaccine and 84% would consult their spouse about having their daughter vaccinated. Sixty-six percent of parents believed that HPV vaccination should be a joint decision involving both parents and the daughter. Parents perceived concordance between themselves and their spouse, with 91% agreement between their own decision and what they thought their spouse would decide; less concordance (77%) was observed between themselves and what they thought their daughter would want. Most (87% of mothers and 62% of fathers) would consider his/her spouse's opinion in the decision regarding HPV vaccination when accompanying the daughter to a health care visit in the absence of the spouse. Perceived spousal concordance was 94% for parents of daughters under the age of consent in Vietnam (16 years). Decisions regarding HPV vaccination will likely be made jointly by parents and adolescents. Educating fathers about HPV vaccination may be important.

Intent to accept and acceptance of herpes testing in adolescents and young adults

OBJECTIVES

Understanding the intention-behaviour association with HSV-2 testing is important because it can inform interventions that might be needed to support an effective HSV-2 control programme. This study aims to understand attitudinal, symptomatic and historical precursors to intent to accept, and acceptance of, HSV-2 testing.

METHODS

The sample included 900 individuals recruited from four sites located in two US cities. Participants completed self-report questionnaires. Expressed intent to accept HSV-2 testing was assessed with an item that asked about acceptance of a test with the same characteristics as the test offered later. The health behaviour outcome was acceptance of the HSV-2 test when it was offered. Predictors examined were STI history, genital symptoms, anxiety and STI-related stigma.

RESULTS

Expressed intent significantly predicted test acceptance. However, a number of participants made testing decisions which were at odds with their stated intent. Genital symptoms and STI history significantly predicted both greater intent and test acceptance. STI stigma only predicted lower intent, whereas anxiety only predicted greater acceptance. Intent fully mediated the relationship between genital symptoms and test acceptance, but did not mediate the relationship between STI history and test acceptance.

CONCLUSIONS

This study suggests that intent does not always predict behaviour, even when the two are measured within close temporal proximity. There are factors that may predict intent only or behaviour only, or may predict behaviour, but solely through influencing intent. Understanding how these various relationships work may be important to efforts designed to maximise acceptance of HSV-2 testing.

Racial/ethnic differences in patterns of sexual behavior and STI risk among sexually experienced adolescent girls

STUDY OBJECTIVE

Racial/ethnic differences in prevalence and patterns of oral and anal sex were analyzed among girls participating in a microbicide acceptability study.

DESIGN

Cross-sectional analysis

SETTING

Recruitment to participate in a 6-month study examining microbicide acceptability was conducted at a school-based health clinic and local colleges in Galveston, Texas and through snowball sampling.

PARTICIPANTS

Sexually experienced girls (n = 202) ages 14 to 21 years of age.

MAIN OUTCOME MEASURES

Girls reported on their demographic and sexual history at the intake interview.

RESULTS AND CONCLUSIONS

Their mean age was 18.2 years; 26% were white, 43% African-American, and 31% Hispanic. African-American girls were significantly less likely than whites and Hispanics to have had oral sex; no differences were found for anal sex. African-American girls were significantly older than whites and Hispanics when they initiated oral sex. African-American girls had a greater difference between ages of vaginal and oral sex initiation than whites and Hispanics. Oral sex history was associated with a 6-factor increase and anal sex history was associated with a 3-factor increase in the likelihood of a history of sexually transmitted infection. Future studies should explore these differences in greater depth in order to develop culturally specific STI prevention efforts.

Australian men's experiences during a microbicide male tolerance study

Microbicides currently in development have the potential to provide new options for the prevention of sexually transmitted infections if proven safe and efficacious. We examined the experiences of healthy male volunteers in a male tolerance study in Victoria, Australia in relation to trial participation and product use. Men (N=36) enrolled in a seven-day, phase 1 clinical safety trial of SPL7013 were interviewed pre and post-use of the gel using a semi-structured interview guide. Interviews were digitally recorded and transcribed verbatim, and transcripts were analysed using a framework approach. All but one man completed the trial. The median age was 34 years (range 22-67 years). Most men had little pre-study knowledge of microbicides and almost all participated for altruistic or personal reasons. Men expressed few concerns about product safety during the trial and indicated trust in the information received through the consent process and from study staff. Three men were non-adherent to the request to be abstinent and an additional two did not refrain from masturbation. Most were positive about the gel, although they described it as "sticky" and found that it stuck to clothes, bed sheets and pubic hair. The type of applicator used was unfamiliar to the men, and some found it "clinical" in appearance. Men are willing to participate in male tolerance studies, often for altruistic reasons. However, counseling about ways to maintain abstinence and further research to inform anticipatory guidance regarding the "sticky" quality of gels, may be important.

Psychosocial development and puberty

The context of adolescent development in which puberty occurs is briefly reviewed, along with the psychosocial impact on timing of puberty, girls' perception of puberty, and the impact of puberty on relationships with parents and on psychological health. This information can be integrated into clinical practice in order to provide the best care for adolescents, but, first, access to confidential and comprehensive care must be available.

Chapter 24: Psychosocial aspects of vaccine acceptability

In this chapter we identify psychosocial issues that have been raised with respect to human papillomavirus (HPV) vaccination and review the research literature on HPV vaccine acceptability. Many women and physicians have relatively poor knowledge about HPV, but despite this, most healthcare providers are willing to recommend HPV vaccination and parents are interested in having their children vaccinated. Concerns about post-vaccination sexual behavior change do not appear to be justified, but can certainly be addressed through anticipatory guidance. Most research studies have come out of the United States and other English-speaking industrialized countries. More psychosocial research regarding HPV vaccination is therefore needed from developing countries.

Uptake of HPV vaccine: demographics, sexual history and values, parenting style, and vaccine attitudes

PURPOSE

To examine the relationships of demographics, parenting, and vaccine attitudes with the acceptance of the human papillomavirus (HPV) vaccine or to the intent to vaccinate in the next 12 months.

METHODS

Mothers (n = 153) with daughters ages 11 to 17 years were recruited through the pediatric clinic waiting room/announcements to complete a questionnaire.

RESULTS

Eighteen percent of the daughters had not received the vaccine, although it had been offered; 34% had not been offered the vaccine and did not intend to get it in the next 12 months; 22% had not been offered the vaccine but intended to get it in the next 12 months; 26% had started vaccination or completed the series. In a multinomial, multivariable logistic regression model, those mothers who had less than a high school degree, had a history of a sexually transmitted infection, supervised their daughter more when she was with peers, and whose daughter would not mind three shots were more likely to be favorable about their daughter being vaccinated. The following variables were not related to their attitudes about getting the vaccine: mothers' and daughters' ages, race/ethnicity, mothers' self-reported history of HPV disease and age of sexual initiation, daughters' dating status and anticipated age of sexual initiation, the number of sexual topics discussed and level of comfort, mother's sexual values, and the family environment.

CONCLUSIONS

Mothers' decisions about the HPV vaccine were not related to their sexual values or their daughters' sexual behavior, but rather their parenting, sense of vulnerability, and vaccine attitudes. Mothers who were not planning to vaccinate did not appear to not feel an urgency given the newness of the vaccine, and many planned to vaccinate eventually.

Attitudes of men in an Australian male tolerance study towards microbicide use

BACKGROUND

Vaginal microbicides are in development to provide new options for the prevention of sexually transmissible infections. Although promoted as a female-initiated product, men may influence the decision to use a microbicide and the way that it is used, so it is important to explore their views.

METHODS

Men (n = 36) enrolled in a 7-day, phase 1 clinical safety trial of SPL7013 Gel were interviewed pre- and post-use of the gel. The trial did not include use of the gel during sex. Interviews were digitally-recorded and transcribed verbatim, and analysed using a framework approach.

RESULTS

The men (mean age 37 years) were interested in the idea of vaginal microbicides, had little knowledge about them, and varied beliefs about how they work. They tended to assess microbicide use in relation to condoms and lubricants. Many would want a microbicide to be as effective as condoms. Participants did not anticipate difficulties discussing use with their partners. Many thought that a microbicide would be less intrusive than condoms; some anticipated that the lubricating properties might enhance sexual pleasure. Some anticipated using a microbicide with a condom or with a lubricant, and a few raised questions about the timing of use and use during different types of sexual activity.

CONCLUSIONS

No major barriers to microbicide use were found in this sample of Australian men, who anticipated being willing to use them if they are shown to be safe and effective. Our findings should help to inform the design of further studies as well as future information materials and anticipatory guidance.

Male partners of young women: assessing their attitudes toward topical microbicides

Male partners' attitudes toward microbicide use are important to understand; however, there are challenges in conducting research with adolescent couples. We describe the experience of recruiting male partners of adolescent females enrolled in a microbicide acceptability study. Creative solutions to enrolling partners of young women in studies need to be explored.

Adolescents' reasons for using a microbicide-like product over time

This study examined the reasons that adolescent girls used a product over time. Adolescent girls (n = 208; 14-21 years) participated in a six-month study in which they completed three face-to-face interviews and 24-weekly phone call interviews. Participants were given microbicide-like products (vaginal lubricants) and encouraged to use them with condoms when they had intercourse. Most of the reasons for use were endorsed by most of the adolescent girls, at some time during the study. Over time, the adolescents were significantly more likely to report the following reasons for use: did not think the product would leak out (z = 2.49; P < 0.01), the product felt comfortable (z = 2.41; P < 0.02) and the product was not messy to use (z = 3.11; P < 0.01). Although it appears that adolescents are interested in microbicides, they may worry about certain characteristics of the product. It will be important to develop anticipatory guidance that focuses on the experience of using the product, making sure adolescent girls continue to use over time.

Adolescent girls' communication with partners about microbicide use

BACKGROUND

Topical microbicides could be a female-controlled method of preventing sexually transmissible infections. Despite the possibility of surreptitious use, most women report that they would tell partners, and microbicides may be detectable. The purpose of the present study was to examine communication between adolescent girls and their partners regarding microbicides.

METHODS

Girls (aged 14-21 years) participated in a 6-month study in which they were given vaginal moisturisers to use when they had intercourse. Data was collected about their demographics, sexual histories and conversations with mothers and partners. Both quantitative and qualitative analyses were conducted.

RESULTS

Girls (n = 171) were asked about conversations with their partners. Talking with mothers and using the product were significantly related to talking with partners. Reasons for not talking were intrapersonal or interpersonal variables, the context of the relationship did not warrant an explanation and the lack of a decision to communicate. There seemed to be no difference in conversations for those who used or did not use. Girls had conversations with their partners when deciding to be in the study, when they were engaged in study activities or when deciding to use the product. Conversations about using the product focused on needing to use the product because of study demands, the lubricating properties or wanting to experience product use.

CONCLUSIONS

Most of the girls talked to their partners and had positive conversations. Girls may need help initiating conversations and managing reluctant partners.