How can we improve the acceptability of vaccination against Human Papillomavirus (HPV) in France? An original qualitative study with focus groups comprising parents and school staff, interviewed separately

Implementation of school-based vaccination in French middle schools: Efficient or not?

INTRODUCTION

Despite various vaccination campaigns coordinated by French authorities, vaccine coverage (VC) in France remains low, especially for human papillomavirus (HPV). The Agence Regionale de Santé established a mandate for vaccination centres in Normandy to develop a school-based vaccination program in public middle schools. The aim of this study was to analyse the efficiency of this program after four academic years (2019-2023).

MATERIALS AND METHODS

Authorization from the parents was required to update each of the following recommended vaccinations for their children (aged 11-13-years-old): diphtheria-tetanus-poliomyelitis-pertussis; hepatitis B virus (HBV); measles, mumps and rubella; meningococcal C; and HPV vaccines. Adolescents for whom at least one vaccine has been accepted were seen by the doctor and were vaccinated if needed. Global VC was defined as being vaccinated for all French mandatory and recommended vaccines. The objective of this study was to compare the proportions of global VC pre and post implementation of the school vaccination program during the period study.

RESULTS

During the study period, 199 schools were visited. Among the 18,476 students, 33.6 % (n = 6217) of the students' parents accepted at least one vaccine, and 4464 students were vaccinated (81.9 %, 4464/5450). Global preintervention VC was 10.7 % (n = 585), which increased to 65.7 % (n = 3585) after the vaccine intervention (p < 0.0001). VC increased from 64.8 % in preintervention to 87.5 % in postintervention (p < 0.0001) for the meningococcal C vaccine, from 67.6 % to 85.6 % (p < 0.0001) for the HBV vaccine and from 14.6 % (n = 675/4614) to 79.9 % (n = 3685/4614) (p < 0.0001) for the HPV vaccine. In multivariate analysis, the post-COVID-19 period (2021-2022) was significantly associated with not being up to date for at least one vaccine (OR: 1.4 [1.2-1.9]).

CONCLUSION

Our study determined that school vaccination program effectively improved VC for all recommended vaccines and should not be restricted to certain vaccines, such as HPV.

A Qualitative Study of Social Processes, HPV Vaccine Attitudes, and Vaccination Behavior Among Hesitant Adopter Parents

Despite the availability of a highly effective human papillomavirus (HPV) vaccine, uptake remains below Healthy People 2030 targets, particularly in rural areas where HPV-related cancers are more prevalent. This study aimed to explore how social processes influence parents' HPV vaccination decisions, focusing on vaccine-hesitant parents who vaccinated their child(ren) against HPV despite their hesitancy, eg, "hesitant adopters." We conducted a qualitative exploratory analysis of in-depth interviews with hesitant adopter parents (n = 8) to explore how social interactions with trusted interlocutors influenced their decision-making. Hesitant adopter parents identified relevant professional expertise, direct experience with the HPV vaccine, and social proximity to interlocutors as influential factors. We argue that rather than a single moment or decision, vaccination decision-making is a dynamic, ongoing process affected by social processes. This study adds nuance to our understanding of how prior vaccination behavior functions in future vaccine acceptance.

Factors that influence caregivers' and adolescents' views and practices regarding human papillomavirus (HPV) vaccination for adolescents: a qualitative evidence synthesis

BACKGROUND

Human papillomavirus (HPV) vaccination in adolescents provides a powerful tool for preventing cervical cancer in women and other HPV-associated diseases in people of all genders. HPV vaccines have been progressively introduced in many countries. However, worldwide, many adolescents do not receive HPV vaccination, for various reasons. The HPV vaccine might be costly or unavailable, healthcare systems might lack capacity for its delivery, or adolescent health might not be prioritised. Some caregivers and adolescents may not accept available HPV vaccines and vaccination services. We currently lack a comprehensive understanding of the factors that influence HPV vaccination views and practices, and why some caregivers and adolescents may be less accepting of the vaccine. Qualitative research can contribute to this understanding and help inform policy and practice, including the development of more relevant, acceptable and effective interventions to promote public acceptance and uptake of HPV vaccination in adolescents. This qualitative evidence synthesis supplements a Cochrane review of the effectiveness of interventions to improve uptake of adolescent vaccination, including HPV vaccination.

OBJECTIVES

The objectives of the review are to identify, appraise, and synthesise qualitative studies that explore caregivers' or adolescents' views, experiences, practices, intentions, decision-making, acceptance, hesitancy, or nonacceptance of HPV vaccination; to gain an understanding of the factors that influence caregiver and adolescent views and practices regarding HPV vaccination for adolescents; and to explore how the findings of this review can enhance our understanding of the related Cochrane intervention review.

SEARCH METHODS

We searched MEDLINE, Embase, CINAHL, PsycInfo, and Scopus for eligible studies (February 2023). We updated this search in October 2024, but these results have not yet been fully incorporated.

SELECTION CRITERIA

We included studies that utilised qualitative methods for data collection and analysis; focused on caregivers' or adolescents' views, practices, acceptance, hesitancy, or refusal of HPV vaccination for adolescents aged 9 to 19 years of age; and were from any setting globally where HPV vaccination is provided.

DATA COLLECTION AND ANALYSIS

We used a prespecified sampling frame to capture a sample of eligible studies that were from a range of geographical and income-level settings, were conceptually rich in relation to the review's phenomenon of interest, and included HPV vaccination for diverse genders. We extracted contextual and methodological data from each sampled study. We used a thematic synthesis approach to analyse the evidence. We assessed methodological limitations using a list of criteria used in previous Cochrane reviews and originally based on the Critical Appraisal Skills Programme quality assessment tool for qualitative studies. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each review finding. We integrated the findings of this review with those from the related Cochrane review of intervention effectiveness (by Abdullahi and colleagues), by mapping whether the trial interventions reflected or targeted the factors identified by this review as influencing caregivers' or adolescents' views and practices regarding HPV vaccination.

MAIN RESULTS

We included 206 studies in the review and sampled 71 of these for our synthesis. Of these, 35 studies were conducted in high-income countries, 26 studies in middle-income countries, 8 studies in low-income countries, and 2 studies in multiple-income settings. Studies came from all six World Health Organization (WHO) regions and included urban and rural settings. We downgraded our confidence in several findings, mainly due to concerns about how the studies were conducted (methodological limitations), concerns about perspectives lacking from some types of participants or in some settings (relevance), or because of variability in the data or insufficient evidence to support all aspects of a review finding (coherence). Many complex factors were found to influence caregivers' and adolescents' HPV vaccination views and practices, which we categorised into eight overarching themes: 1) A lack of biomedical knowledge; 2) Perceptions of a range of interrelated risks and benefits (or lack thereof) associated with HPV vaccination; 3) Routine responses to vaccination generally or more specific views or experiences of other vaccines and vaccination programmes; 4) Complex nuclear familial decision-making dynamics; 5) Extended familial and social relations and networks, particularly extended family members, peers, traditional or religious leaders, and the media; 6) Interrelated socio-cultural beliefs and practices regarding adolescence, sexuality, gender, parenting and health; 7) Trust or distrust in the institutions, systems or experts associated with vaccination, most particularly teachers and the school, the pharmaceutical industry, government, science and biomedicine, and healthcare professionals; and 8) Access to, and experiences of, HPV vaccination programmes and delivery services, such as the convenience (or lack thereof) of HPV vaccination services, the cost of the vaccine, language barriers, the feminisation of HPV vaccination programmes and procedural aspects of school-based vaccination delivery. We did not identify any major differences in the occurrence of these overarching themes between subgroups. However, for various subthemes certain differences emerged in relation to place, gender and socio-economic status, and between caregivers and adolescents. The interventions tested in the related Cochrane review of intervention effectiveness most commonly targeted caregivers' and adolescents' lack of biomedical knowledge and their perceptions of the risks and benefits of HPV vaccination, with the other influencing factors identified by our review being underrepresented.

AUTHORS' CONCLUSIONS

Our review reveals that caregivers' and adolescents' HPV vaccination views and practices are not only influenced by issues related to individual knowledge and perceptions of the vaccine, but also an array of more complex, contextual factors and meanings: social, political, economic, structural, and moral. Successful development of interventions to promote the acceptance and uptake of HPV vaccination for adolescents requires an understanding of the context-specific factors that influence HPV vaccination views and practices in the target setting. Through this, more tailored and in turn more relevant, acceptable, and effective responses could be developed. The eight overarching themes that emerged from our review could serve as a basis for gaining this understanding.

Effectiveness of a School- and Primary Care-Based HPV Vaccination Intervention: The PrevHPV Cluster Randomized Trial

Importance

The human papillomavirus (HPV) vaccine is safe and effective, yet vaccination coverage remains below public health objectives in many countries.

Objective

To examine the effectiveness of a 3-component intervention on HPV vaccination coverage among adolescents aged 11 to 14 years 2 months after the intervention ended, each component being applied alone or in combination.

Design, Setting, and Participants

A cluster randomized trial with incomplete factorial design (PrevHPV) was conducted between July 1, 2021, and April 30, 2022, in French municipalities receiving 0, 1, 2, or 3 components of the intervention. Randomization was stratified by school district and municipalities' socioeconomic level. Analyses were carried out on 11- to 14-year-old adolescents living in all participating municipalities, regardless of what had been implemented.

Intervention

The PrevHPV intervention had 3 components: (1) educating and motivating 11- to 14-year-old adolescents in middle schools, along with their parents; (2) training general practitioners (GPs) on up-to-date HPV information and motivational interviewing techniques; and (3) free HPV vaccination at school.

Main Outcomes and Measures

The primary outcome was HPV vaccination coverage (≥1 dose) 2 months after the intervention ended among 11- to 14-year-old adolescents living in participating municipalities, based on the French national reimbursement database and data collected during the trial in groups randomized to implement at-school vaccination.

Results

A total of 91 municipalities comprising 30 739 adolescents aged 11 to 14 years (15 876 boys and 14 863 girls) were included and analyzed. Half the municipalities were in the 2 lowest socioeconomic quintiles and access to GPs was poor in more than two-thirds of the municipalities. Thirty-eight of 61 schools (62.3%) implemented actions and 26 of 45 municipalities (57.8%) had at least 1 trained GP. The median vaccination coverage increased by 4.0 percentage points (IQR, 2.0-7.3 percentage points) to 14.2 percentage points (IQR, 9.1-17.3 percentage points) at 2 months. At-school vaccination significantly increased vaccination coverage (5.50 percentage points [95% CI, 3.13-7.88 percentage points]) while no effect was observed for adolescents' education and motivation (-0.08 percentage points [95% CI, -2.54 to 2.39 percentage points]) and GPs' training (-1.46 percentage points [95% CI, -3.44 to 0.53 percentage points]). Subgroup analyses found a significant interaction between at-school vaccination and access to GPs, with a higher effect when access was poor (8.62 percentage points [95% CI, 5.37-11.86 percentage points] vs 2.13 percentage points [95% CI, -1.25 to 5.50 percentage points]; P = .007 for interaction).

Conclusions and Relevance

In this cluster randomized trial, within the context of the late COVID-19 pandemic period and limited school and GP participation, at-school HPV vaccination significantly increased vaccination coverage. The trial did not show a significant effect for training GPs and education and motivation, although it may be observed after more time has elapsed after the intervention.

Trial Registration

ClinicalTrials.gov Identifier: NCT04945655.

School Teachers' Perceptions of Adolescent Human Papillomavirus (HPV) Vaccination: A Systematic Review

School nurses are uniquely positioned to educate students about immunizations, including human papillomavirus (HPV) vaccination, but schools are often without a nurse for different reasons. In lieu of nurses, teachers who closely interact with students and are traditionally well-trusted by parents may be able to communicate about HPV vaccination, alleviating parental vaccine hesitancy. This systematic review explores school teachers' perspectives on adolescent HPV vaccination and factors influencing their willingness to make vaccine recommendations. We searched three databases with appropriate medical subject headings and keywords to identify relevant studies. We reviewed fifteen studies and provided an extensive summary and a comparison of the results across the studies. Teachers had low to moderate levels of HPV knowledge with low self-efficacy to counsel parents about the HPV vaccine and expressed concerns about the vaccine condoning adolescent sexual activity, vaccine side effects, and parental disapproval. Nonetheless, some teachers showed interest in learning about vaccine effectiveness in preventing HPV-associated cancers and wanted guidance on vaccine communication with parents, viewing schools as adequate venues to promote and deliver HPV vaccines. Schools should consider educating teachers on HPV and HPV vaccination, with a focus on effective vaccine communication practices to increase adolescent HPV vaccine uptake.