Recommending STI Vaccination to Parents of Adolescents: The Attitudes of Nurse Practitioners

Improving adolescent health: focus on HPV vaccine acceptance

The success of future human papillomavirus (HPV) vaccination programs will depend on individuals' willingness to accept vaccination, parents' willingness to have their preadolescent and early adolescent children vaccinated, and health care providers' willingness to recommend HPV vaccination. The purpose of this article is to provide a qualitative review of the relevant literature, including research on knowledge and attitudes about HPV infection and its clinical sequelae, the acceptability of HPV vaccination to individuals and parents, and health care providers' attitudes about recommending HPV vaccination. Additionally, strategies are suggested by which providers of adolescent health care can discuss and recommend HPV vaccines with parents and their children. The research published to date suggests that there is a good deal of misunderstanding about HPV infection, cervical cancer screening, and the sequelae of HPV infection. However, the majority of research studies to date indicate that young women, parents, and health care providers are interested in vaccines that prevent HPV and other sexually transmitted infections (STIs). Of particular note are the consistent findings that providers are less comfortable vaccinating younger versus older adolescents and that endorsement of vaccination by a professional organization is of great importance. Furthermore, research suggests that most parents are interested in having their preadolescent and adolescent children vaccinated against HPV. Parents value the information and recommendations provided by their children's health care providers. To the extent that providers are concerned about potential negative reactions of parents to a recommendation of HPV vaccination, these findings should provide reassurance. At the same time, health care providers will need to be prepared to provide patients and parents with information about HPV and HPV immunization and to respond productively to the rare parent who expresses opposition to HPV vaccine or any other vaccine.

Pediatricians' intention to administer human papillomavirus vaccine: the role of practice characteristics, knowledge, and attitudes

PURPOSE

The objective of this study was to examine pediatrician characteristics and attitudes associated with intention to recommend two hypothetical human papillomavirus (HPV) vaccines.

METHODS

A survey instrument mailed to a random sample of 1000 pediatricians assessed provider characteristics, HPV knowledge, and attitudes about HPV vaccination. Intention to administer each of two HPV vaccines types (a cervical cancer/genital wart vaccine and a cervical cancer vaccine) to girls and boys of three different ages (11, 14, and 17 years) was assessed. Linear mixed modeling for repeated measures and multivariable linear regression models were performed to identify variables associated with intention to recommend vaccination.

RESULTS

The mean age of participants (n = 513) was 42 years and 57% were female. Participants were more likely to recommend vaccination to girls vs. boys and older vs. younger children, and were more likely to recommend a cervical cancer/genital wart vaccine than a cervical cancer vaccine (p < .0001). Variables independently associated with intention to recommend a cervical cancer/genital wart vaccine were: higher estimate of the percentage of sexually active adolescents in one's practice (beta .084, p = .002), number of young adolescents seen weekly (beta 1.300, p = .015), higher HPV knowledge (beta 1.079, p = .015), likelihood of following the recommendations of important individuals and organizations regarding immunization (beta .834, p = .001), and fewer perceived barriers to immunization (beta -.203, p = .001).

CONCLUSIONS

Vaccination initiatives directed toward pediatricians that focus on modifiable predictors of intention to vaccinate, such as HPV knowledge and attitudes about vaccination, may facilitate adherence to emerging national immunization guidelines.

Human papillomavirus vaccines and adolescents

PURPOSE OF REVIEW

This review will describe human papillomavirus (HPV) vaccines in development, summarize data regarding safety and efficacy of these vaccines, and discuss key issues related to HPV vaccine implementation.

RECENT FINDINGS

Evidence from epidemiologic and genetic studies has confirmed that HPV infection is a necessary cause of cervical cancer and contributes to the development of other cancers. HPV infection also may cause nonmalignant conditions such as external genital warts and recurrent respiratory papillomatosis. Over the past decade, several vaccines that target common HPV types have entered clinical trials. These vaccines are classified as prophylactic or therapeutic. The goal of prophylactic vaccines is to prevent primary or persistent HPV infections, and thus prevent cervical cancer and/or genital warts. Recent evidence indicates that prophylactic vaccines are well tolerated, highly immunogenic and effective in preventing persistent HPV infection and cervical intraepithelial neoplasia (CIN). Questions remain, however, concerning vaccine efficacy against HPV-related diseases other than cervical cancer, the duration of protection, vaccine acceptability and feasibility of vaccine delivery in the developing world. The goal of therapeutic vaccines is to prevent progression of HPV infection, induce regression of CIN or condylomata, or eradicate residual cervical cancer. Although therapeutic vaccines appear to induce both humoral and cell-mediated immunity, they have not consistently demonstrated clinical efficacy.

SUMMARY

HPV vaccines in development have the potential to reduce the substantial morbidity and mortality associated with cervical cancer and other HPV-associated diseases. Large-scale efficacy studies that are planned or underway will provide additional information about vaccine tolerance and efficacy.

Vaccines for sexually transmitted infections

STIs are responsible for significant human suffering and carry significant economic costs. Strategies to control STIs, such as screening programs and condoms, have had limited success. Vaccines offer an additional method that is not coitally related and does not depend on consistent use. The HPV vaccine confers protection against the most common types causing cervical dysplasia. Mathematical modeling suggests that the HSV vaccine, given universally to all young women, should reduce genital and neonatal herpes in the population at large. Much work remains on vaccines for chlamydia and gonorrhea, but they offer the hope of preventing pelvic inflammatory disease and its sequelae. As these vaccines become licensed, their successful implementation will require the support of professional organizations, families, and providers.

Progress in vaccines for sexually transmitted diseases

The development pipeline for vaccines to control sexually transmitted infections holds greater promise than ever before. Preclinical studies are encouraging in the development of chlamydia and gonococcal vaccines, and for the first time, recent clinical trials have shown the feasibility of creating vaccines to control genital herpes and cervical human papillomavirus infections. Behavioral research suggests that these vaccines will likely find acceptance among health care providers and consumers.

Parental acceptance of the human papillomavirus vaccine

We conducted focus groups and individual interviews to explore parental views on the human papillomavirus (HPV) vaccine. Parents were generally positive about the HPV vaccine. Some participants perceived their children were not at risk for acquiring HPV and questioned vaccinating young adolescents against HPV. Vaccine education should target parental beliefs about HPV and the optimal age for HPV vaccine administration.

Predictors of STI vaccine acceptability among parents and their adolescent children

PURPOSE

To identify attitudes and behavioral factors associated with parental intent to vaccinate their adolescent children against sexually transmitted infections (STI) and adolescent intent to accept vaccination for the prevention of STI.

METHODS

In this cross-sectional study, 320 parents and their adolescent children (aged 12-17 years) were recruited from urban adolescent health clinics and private practice pediatric offices to complete audio, computer-assisted self-interviews (A-CASI). Parents and their adolescents were asked about acceptability of gonorrhea, genital herpes, and human immumodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) vaccines. These three items were summed to create an STI vaccine acceptability scale, the primary outcome variable. Potential predictors measured included health beliefs, sociodemographic factors, and health and sexual behaviors.

RESULTS

A substantial majority of parents and their adolescent children rated the three STI vaccines as very acceptable. Parental health beliefs and parental history of STI diagnosis were significant independent predictors of intent to vaccinate adolescent children against STI. Parental intent to vaccinate and having a friend who had engaged in sexual intercourse were significant independent predictors of adolescents' intent to accept STI vaccination.

CONCLUSIONS

The majority of these parents and their adolescent children found STI vaccination very acceptable, suggesting that there will be great interest in these vaccines once they become available. Interventions designed to address parental health beliefs may prove successful at maintaining or increasing interest in STI vaccines. Adolescents are likely to look to their parents for guidance around acceptance of these vaccines, but personal experiences also may play a role.

Parents'/guardians' willingness to vaccinate their children against genital herpes

PURPOSE

To describe parents' acceptance of a hypothetical herpes simplex virus type 2 (HSV-2) vaccine, attitudes toward vaccine legislation, beliefs regarding appropriate timing of vaccination and correlates of vaccine acceptance.

METHODS

A telephone survey of 315 parents/guardians in the Southeast United States. Descriptive statistics describe the sample's overall attitudes toward HSV-2 vaccination, vaccine legislation, and age preferences. A logistic regression model tested the correlates of intention to vaccinate their children against HSV-2.

RESULTS

A majority of parents (69%) said they would have their children vaccinated. Nearly one-third (29.3%) thought genital herpes vaccination should take place between the ages of 11 and 13 years. Logistic regression revealed that females, single parents, parents whose children had influenza shots, those with more favorable attitudes to vaccination in general, and those who believed sexually transmitted disease (STD) vaccines would be beneficial were more likely to state they would vaccinate their children.

CONCLUSIONS

Overall, a large proportion of parents indicated they would accept HSV-2 vaccination for their children. These results help identify those parents who may or may not be open to vaccinating their children against HSV-2 and inform future interventions to encourage HSV-2 vaccination. This research highlights the need for interventions that differentially target those who would and would not be likely to support vaccination of their children. Results also indicate that many parents believe vaccination should be given after an age when many adolescents have initiated sexual activity. Interventions to promote STD vaccines should not only encourage vaccination, but should also seek to change parental attitudes about optimal timing of the vaccination.

Challenges to vaccinating adolescents: vaccine implementation issues

BACKGROUND

Adolescent immunization is a growing field, with many new vaccines in development and new or expanded immunization recommendations on the horizon.

METHODS

Characteristics of adolescents and their health care are discussed, focusing specifically on the challenges of incorporating a potential recommendation to replace tetanus-diphtheria toxoid with tetanus-diphtheria-acellular pertussis vaccine during early or middle adolescence as part of routine preventive care. Using the framework created by the Centers for Disease Control and Prevention's Task Force on Community Preventive Services, three overlapping levels at which there are opportunities for vaccine intervention are reviewed: (1) health care systems (enhancing access to vaccination services); (2) health care providers (provider-based interventions); and (3) patients and families ("increasing community demand").

RESULTS

There are several barriers to vaccine implementation that make achieving high immunization coverage rates among adolescents a challenge. Promising interventions for improving vaccination rates at the health care system level include reducing out-of-pocket costs, expanding access to immunizations, and implementing vaccination programs in schools. Provider-based interventions for improving vaccination rates include regular assessments of immunization rate with feedback to all office personnel, provider reminders, and standing orders. Client recall and reminders, education, and requirements for school entry can assist in "increasing community demand" for vaccinations in that they motivate parents and adolescents to follow through with immunizations.

CONCLUSIONS

Adolescents are unique from other populations. Previously studied interventions need to be tested in this age group as immunization becomes a more salient issue in adolescent health care.

Gynecologists' attitudes regarding human papilloma virus vaccination: a survey of Fellows of the American College of Obstetricians and Gynecologists

BACKGROUND: Human papilloma virus (HPV) is the causative agent of cervical neoplasia and genital warts. A vaccine has recently been developed that may prevent infection with HPV. Vaccination for HPV may become a routine part of office gynecology. We surveyed members of the American College of Obstetricians and Gynecologists (ACOG) to determine their attitudes to HPV vaccination. METHODS: A survey was sent to Fellows of ACOG to evaluate gynecologists' attitudes. Vaccine acceptability was analyzed using 13 scenarios with the following dimensions and respective attributes: age of patient (13, 17 and 22 years); efficacy of vaccine (50% or 80%); ACOG recommendation (yes or no); and disease targeted (cervical cancer, warts or both). Each scenario was rated by means of an 11-point response format (0 to 100). Responses were evaluated using conjoint analysis. RESULTS: Of 1200 surveys that were sent out, 181 were returned and included in our analysis. ACOG recommendation was considered the most important variable in vaccine distribution (importance score = 32.2), followed by efficacy (24.5), age (22.4) and, lastly, disease targeted (20.9). Of these variables, higher efficacy was favored; preference was given to age 17 years, with a strong disinclination to vaccinate at age 13 years; and protection against cervical cancer, or genital warts, or both, was significantly favored over a vaccine against genital warts alone. Demographic characteristics of the gynecologists (i.e., age of physician, gender, practice setting and community size) did not play an important role in the decision to recommend vaccination. CONCLUSION: Professional society recommendation is important for acceptability of a potential HPV vaccine. Gynecologists are willing to include this vaccine in their office practice.

Pediatrics and herpes simplex virus vaccines

This review explores the development of prophylactic genital herpes vaccines and their potential impact on perinatal and oral-facial disease. Vaccine strategies have included the use of whole killed virus, viral subunits, attenuated live virus, viral vectors, and bare DNA. To date, the recombinant subunit vaccine, truncated HSV-2 gD and alum/MPL, has been the most efficacious. The vaccine is 73 to 74 percent effective in preventing genital disease in herpes simplex virus seronegative women but is not effective in men or seropositive women. Models predict a significant impact on genital herpes if it limits viral shedding. Reductions in perinatal and oral-facial disease are likely to occur as well. Once an efficacious herpes vaccine is available, its effectiveness will depend ultimately on vaccine acceptance by professional organizations, healthcare professionals, and parents. Further research is required to improve on and fully understand the implications of prophylactic herpes simplex vaccines.