An appraisal of theoretical approaches to examining behaviours in relation to Human Papillomavirus (HPV) vaccination of young women

A Systematic Review of Human Papillomavirus Vaccination Challenges and Strategies to Enhance Uptake

Human papillomavirus (HPV) vaccination has revolutionized cervical cancer prevention. Clinical trials confirm that the quadrivalent (HPV types 6, 11, 16, 18) and bivalent (HPV types 16, 18) vaccines effectively prevent HPV infections and cervical neoplasia. The latest HPV vaccine protects against nine virus types responsible for 90% of cervical cancer cases globally. Despite their undoubted effectiveness in reducing morbidity and mortality associated with HPV infections, challenges in vaccine coverage and uptake persist. The current study aimed to identify the primary challenges associated with HPV vaccination, propose effective strategies to improve vaccination uptake, and compile relevant evidence into a comprehensive overview to inform policy and practice. A systematic review protocol, following PRISMA-P and PRISMA guidelines, was established. Articles were sourced from the Web of Science using keywords from a comprehensive review of HPV vaccination challenges and strategies. Studies published between 1 January 2020, and 1 May 2024, including RCTs and observational, qualitative, and cross-sectional studies, were included, while reviews, protocols, and commentaries were excluded. Titles, abstracts, and full texts were screened per PRISMA guidelines. The review identified five key strategies to improve HPV vaccination uptake: parental and school engagement, use of technology and multimedia tools, healthcare providers' role, multicomponent interventions, and targeted interventions for immigrant groups. This review emphasized the need for a multifaceted approach to improving vaccination rates, offering a robust foundation for policy and stakeholder initiatives.

Evaluation of Theoretical Frameworks to Detect Correlates of HPV Vaccination in the Midwest, US, Using Structural Equation Modeling

Knowledge of a valid, well-designed, and targeted theory-based framework helps better characterize reasons for HPV vaccine hesitancy and identify promising approaches to increase vaccination rates for eligible individuals. This study evaluated health theories in explaining factors affecting HPV vaccination and used a theoretical framework to identify direct and indirect predictors and mediators of HPV vaccination. A cross-sectional survey regarding HPV vaccine uptake and related factors was conducted among 1306 teenagers and young adults in the Midwest, US, in March and April 2023. Structural equation modeling confirmed fit of the framework based on the Integrated Health Theory (IHT) to the HPV vaccine data (Comparative Fit Index = 0.93; Tucker-Lewis Index = 0.92; Root Mean Square Error of Approximation = 0.053). While willingness to uptake the HPV vaccine directly predicted increased uptake (p < 0.001), perceived benefits (p < 0.001) and barriers (p < 0.023) about the vaccine indirectly predicted increased and decreased uptake, respectively. In turn, beliefs about susceptibility (p = 0.005) and severity (p < 0.001) of HPV infection and associated cancers and barriers to vaccination in general (p < 0.001) indirectly predicted willingness to uptake the vaccine. In conclusion, IHT can be appropriate in examining predictors of HPV vaccine uptake in teenagers and young adults in the US, particularly in the Midwest.

Exploring Parents' Decisions Regarding HPV Vaccination for Their Daughters in Jakarta, Indonesia: A Qualitative Study

BACKGROUND

Cervical cancer, caused by the human papillomavirus (HPV), is the fourth most common cancer among women worldwide. Although many countries have introduced national HPV vaccination programs, many girls worldwide remain unprotected. As part of a demonstration project in 2016, the Indonesian government provided the HPV vaccination for free to all year five and six female students in Jakarta and several other cities, with a plan to roll out the program nationally in the future. Understanding parents' decision-making regarding whether they will allow their daughters to receive the HPV vaccine is important to ensure optimum uptake.

Methods: Twenty-four parents in Jakarta were interviewed. Data were analysed thematically using The Theory of Planned Behaviour constructs of attitudes, subjective norms and perceived behavioural control.

Result: Some parents had limited knowledge about cervical cancer and the HPV vaccine; others did not even realise that the free HPV vaccination program had been offered in their daughter's schools. Those who had better knowledge and positive attitudes trusted their health professionals as a source of information. Peer approval, trust in the government and having the vaccine through a school-based program was important for trust, eliminated cost barriers, and increased access.

Conclusion: Parents' attitudes towards cervical cancer and HPV vaccination are influenced in part by their knowledge. Shaping positive initial attitudes is important, as once formed, attitudes are often difficult to change. Our findings suggest that a free school-based vaccine accompanied by sufficient and non-ambiguous information from trusted sources is vital to uptake.

Willingness to Vaccinate Against Herpes Zoster and Its Associated Factors Across WHO Regions: Global Systematic Review and Meta-Analysis

BACKGROUND

A life-course immunization approach would enhance the quality of life across all age groups and improve societal well-being. The herpes zoster (HZ) vaccine is highly recommended for older adults to prevent HZ infection and related complications. The proportions of willingness to receive the HZ vaccine varies across countries, and various kinds of factors, including sociodemographics and individual perceptions, influence the willingness to vaccinate.

OBJECTIVE

We aim to estimate the HZ vaccination willingness rate and identify factors associated with vaccine uptake willingness across all World Health Organization (WHO) regions.

METHODS

A global systematic search was performed on PubMed, Web of Science, and the Cochrane Library for all papers related to the HZ vaccine published until June 20, 2022. Study characteristics were extracted for each included study. Using double arcsine transformation, vaccination willingness rates with 95% CIs were pooled and reported. The willingness rate and associated factors were analyzed by geographical context. Associated factors were also summarized based on Health Belief Model (HBM) constructs.

RESULTS

Of the 26,942 identified records, 13 (0.05%) papers were included, covering 14,066 individuals from 8 countries in 4 WHO regions (Eastern Mediterranean Region, European Region, Region of the Americas, and Western Pacific Region). The pooled vaccination willingness rate was 55.74% (95% CI 40.85%-70.13%). Of adults aged ≥50 years, 56.06% were willing to receive the HZ vaccine. After receiving health care workers' (HCWs) recommendations, 75.19% of individuals were willing to get the HZ vaccine; without HCWs' recommendations, the willingness rate was only 49.39%. The willingness rate was more than 70% in the Eastern Mediterranean Region and approximately 55% in the Western Pacific Region. The willingness rate was the highest in the United Arab Emirates and the lowest in China and the United Kingdom. The perception of HZ severity and susceptibility was positively associated with vaccination willingness. The perceived barriers to vaccination willingness (main reasons for unwillingness) included low trust in the effectiveness of the HZ vaccine, concerns about safety, financial concerns, and being unaware of the HZ vaccine's availability. Older individuals, those having lower education, or those having lower income levels were less likely to willing to be vaccinated.

CONCLUSIONS

Only 1 in 2 individuals showed a willingness to be vaccinated against HZ. The willingness rate was the highest in the Eastern Mediterranean Region. Our findings show the critical role HCWs play in promoting HZ vaccination. Monitoring HZ vaccination willingness is necessary to inform public health decision-making. These findings provide critical insights for designing future life-course immunization programs.

HPV Vaccination: An Underused Strategy for the Prevention of Cancer

Human papillomavirus (HPV) vaccination prevents cervical, head and neck, and anogenital cancers. However, global HPV vaccine coverage falls short of global targets and has seen unexpected and dramatic declines in some countries. This paper synthesizes the impact of HPV on the global burden of cancer and the potential benefit of HPV vaccination. Approximately 5% of the world’s cancers are specifically attributed to HPV. While the greatest global burden of HPV is cervical cancers in low- and middle-income countries, HPV-associated head and neck cancers are increasing in high-income countries and have surpassed cervical cancer as the primary HPV-associated cancer in some countries. Therefore, it is also critical to improve gender-neutral HPV vaccination. Understanding the modifiable drivers of vaccine acceptance and uptake is important for increasing HPV vaccination. The Behavioural and Social Drivers of Vaccination framework is broadly applied to identify key factors associated with HPV vaccination including domains concerning practical issues, motivation, social processes, and thinking and feeling. Among the behavioural strategies available to reduce the incidence and mortality of cancer, increasing HPV vaccination stands out as having unrealized potential to prevent disease, financial cost, and psychological distress. An understanding of the shifting burden of HPV and the factors associated with vaccination can be leveraged to regularly measure these factors, develop interventions to promote vaccine uptake, and improve global HPV vaccine coverage. Future research in diverse contexts is necessary to investigate the barriers and facilitators of global HPV vaccination.

The role of nurses as human papillomavirus vaccination advocates in China: perception from nursing students

This study aimed to investigate nursing students' perspectives regarding the role of nurses as HPV vaccine advocates and their perception of barriers to advocacy. A cross-sectional study using a Web-based survey was sent out to all undergraduate nursing students enrolled at the Fujian Medical University, Fuzhou, China. A total of 1,041 students responded to the survey. In total, 58.0% of students expressed an intent to advocate HPV vaccines as a counselor and 56.4% as an HPV information provider in their future practice. However, 33.4% stated that they do not intend to be HPV vaccine advocates. Grade 1 students, students from homes with higher annual household incomes and those with a higher level of knowledge about HPV and HPV vaccination expressed higher intentions to advocate for HPV vaccines as a counselor. Students who have a higher level of knowledge about HPV and HPV vaccination and have received HPV vaccines reported a higher advocacy intent in the provision of HPV information. The main perceived barriers in HPV vaccine advocacy include inadequate training (87.1%) and insufficient HPV-related knowledge (84.8%); also, anxious patients may not feel comfortable with nurses discussing HPV vaccination (52.8%). Nurses are uniquely positioned to nurture patient HPV vaccine acceptance and maybe the key strategy to increase HPV vaccination coverage in China. Institutional support is needed to train nurses as HPV vaccine advocates and should focus on enhancing HPV-related knowledge while destigmatising the embarrassment around discussing HPV-related issues with patients.

Behavioural Determinants of COVID-19-Vaccine Acceptance in Rural Areas of Six Lower- and Middle-Income Countries

Delayed acceptance or refusal of COVID-19 vaccines may increase and prolong the threat to global public health and the economy. Identifying behavioural determinants is considered a critical step in explaining and addressing the barriers of vaccine refusal. This study aimed to identify the behavioural determinants of COVID-19-vaccine acceptance and provide recommendations to design actionable interventions to increase uptake of the COVID-19 vaccine in six lower- and middle-income countries. Taking into consideration the health belief model and the theory of reasoned action, a barrier analysis approach was employed to examine twelve potential behavioural determinants of vaccine acceptance in Bangladesh, India, Myanmar, Kenya, the Democratic Republic of the Congo (DRC), and Tanzania. In all six countries, at least 45 interviews with those who intended to get the vaccine (“Acceptors”) and another 45 or more interviews with those who did not (“Non-acceptors”) were conducted, totalling 542 interviews. Data analysis was performed to find statistically significant (p < 0.05) differences between Acceptors and Non-acceptors of COVID-19 vaccines and to identify which beliefs were most highly associated with acceptance and non-acceptance of vaccination based on the estimated relative risk. The analysis showed that perceived social norms, perceived positive and negative consequences, perceived risk, perceived severity, trust, perceived safety, and expected access to COVID-19 vaccines had the highest associations with COVID-19-vaccine acceptance in Bangladesh, Kenya, Tanzania, and the DRC. Additional behavioural determinants found to be significant in Myanmar and India were perceived self-efficacy, trust in COVID-19 information provided by leaders, perceived divine will, and perceived action efficacy of the COVID-19 vaccines. Many of the determinants were found to be significant, and their level of significance varied from country to country. National and local plans should include messages and activities that address the behavioural determinants found in this study to significantly increase the uptake of COVID-19 vaccines across these countries.

Parents' attitudes, beliefs and uptake of the school-based human papillomavirus (HPV) vaccination program in Jakarta, Indonesia - A quantitative study

The Indonesian government has provided free HPV vaccines for female students in years 5–6 in Jakarta since 2016. We examined parents’ beliefs, attitudes and intentions to allow their daughters to receive the HPV vaccine, as well as the uptake of the vaccine. This cross-sectional study was conducted between September and November 2019 in Jakarta. We invited 680 parents or guardians of year 6 female students from 33 primary schools who were offered the free HPV vaccine to complete a questionnaire; 484 (71%) responded. Analysis was done in two groups: the ‘Decided’ Group (those parents who allowed or denied for their daughter to receive the HPV vaccination), and the ‘Undecided’ Group (those parents who did not recall being approached about the HPV vaccine or forgot their response). In the ‘Decided’ group, 295 (83.6%) parents allowed their daughters to receive the vaccination, while 58 (16.4%) parents refused it. In the ‘Undecided’ group, 49 (70%) parents reported a strong intention to allow their daughters to receive the vaccination; 21 (30%) had weak intention. Attitude, subjective norms and perceived behavioural control were shown to be significant predictors of HPV vaccine uptake when multilevel multivariate logistic regression analysis was undertaken. On the contrary, no independent variable was seen as a significant predictor for parents’ intentions to vaccinate their daughter against HPV. No sociodemographic characteristic was significantly associated with parents’ decisions or intentions regarding HPV vaccine for their daughters. Further qualitative research is needed to explore parents’ knowledge and reasons behind their decision-making processes.

Application of theoretical frameworks on human papillomavirus vaccine interventions in the United States: systematic review and meta-analysis

PURPOSE

Theoretical frameworks are useful tools to explain the dynamics of behavioral change, develop, and implement intervention studies. The purpose of this systematic review and meta-analysis is to evaluate the application of theoretical frameworks and models to HPV vaccination intervention studies in the United States (US) from January 2006 to December 2019.

METHODS

A comprehensive search across databases, including PubMed, EMBASE, ERIC, CINAHL, Academic Search Complete, Scopus, Web of Science, and PsycINFO, was conducted. Articles were included in the systematic analysis if at least one theory was used to develop the intervention phase. All intervention studies targeting populations in the US without restrictions of age, income, sex, and ethnicity were included. Articles were included in the meta-analysis if vaccine uptake and/or vaccine completion was addressed.

RESULTS

The Health Belief Model, Motivational Interviewing, Theory of Planned Behavior, and Information-Motivation-Behavioral Skills were the most used theories. Based on theory integrity, theory rationale, and theory operationalization, most of the studies (60%) were rated high for the application of the theoretical frameworks. Our results suggest a preference for theoretical frameworks targeting individual change rather than community change and the existence of gender disparities in the application of theoretical frameworks. The association between theory and increase of likelihood in vaccine uptake and completion was not supported.

CONCLUSION

This review spotlights common issues in the application of theoretical frameworks in HPV vaccine interventions in the US. Our results suggest we are still in a developmental phase on several aspects of theory application to HPV vaccination.

Vaccination against COVID-19: A systematic review and meta-analysis of acceptability and its predictors

We aimed to estimate the coronavirus disease 2019 (COVID-19) vaccine acceptance rate and identify predictors associated with acceptance. To this end, we searched PubMed, Web of Science, Cochrane Library, and Embase databases until November 4, 2020. Meta-analyses were performed to estimate the rate with 95% confidence intervals (CI). Predictors were identified to be associated with vaccination intention based on the health belief model framework. Thirty-eight articles, with 81,173 individuals, were included. The pooled COVID-19 vaccine acceptance rate was 73.31% (95%CI: 70.52, 76.01). Studies using representative samples reported a rate of 73.16%. The pooled acceptance rate among the general population (81.65%) was higher than that among healthcare workers (65.65%). Gender, educational level, influenza vaccination history, and trust in the government were strong predictors of COVID-19 vaccination willingness. People who received an influenza vaccination in the last year were more likely to accept COVID-19 vaccination (odds ratio: 3.165; 95%CI: 1.842, 5.464). Protecting oneself or others was the main reason for willingness, and concerns about side effects and safety were the main reasons for unwillingness. National- and individual-level interventions can be implemented to improve COVID-19 vaccine acceptance before large-scale vaccine rollout. Greater efforts could be put into addressing negative predictors associated with willingness.

Exploring the behavioral determinants of COVID-19 vaccine acceptance among an urban population in Bangladesh: Implications for behavior change interventions

BACKGROUND

While vaccines ensure individual protection against COVID-19 infection, delay in receipt or refusal of vaccines will have both individual and community impacts. The behavioral factors of vaccine hesitancy or refusal are a crucial dimension that need to be understood in order to design appropriate interventions. The aim of this study was to explore the behavioral determinants of COVID-19 vaccine acceptance and to provide recommendations to increase the acceptance and uptake of COVID-19 vaccines in Bangladesh.

METHODS

We employed a Barrier Analysis (BA) approach to examine twelve potential behavioral determinants (drawn from the Health Belief Model [HBM] and Theory of Reasoned Action [TRA]) of intended vaccine acceptance. We conducted 45 interviews with those who intended to take the vaccine (Acceptors) and another 45 interviews with those who did not have that intention (Non-acceptors). We performed data analysis to find statistically significant differences and to identify which beliefs were most highly associated with acceptance and non-acceptance with COVID-19 vaccines.

RESULTS

The behavioral determinants associated with COVID-19 vaccine acceptance in Dhaka included perceived social norms, perceived safety of COVID-19 vaccines and trust in them, perceived risk/susceptibility, perceived self-efficacy, perceived positive and negative consequences, perceived action efficacy, perceived severity of COVID-19, access, and perceived divine will. In line with the HBM, beliefs about the disease itself were highly predictive of vaccine acceptance, and some of the strongest statistically-significant (p<0.001) predictors of vaccine acceptance in this population are beliefs around both injunctive and descriptive social norms. Specifically, Acceptors were 3.2 times more likely to say they would be very likely to get a COVID-19 vaccine if a doctor or nurse recommended it, twice as likely to say that most people they know will get a vaccine, and 1.3 times more likely to say that most close family and friends will get a vaccine. The perceived safety of vaccines was found to be important since Non-acceptors were 1.8 times more likely to say that COVID-19 vaccines are "not safe at all". Beliefs about one's risk of getting COVID-19 disease and the severity of it were predictive of being a vaccine acceptor: Acceptors were 1.4 times more likely to say that it was very likely that someone in their household would get COVID-19, 1.3 times more likely to say that they were very concerned about getting COVID-19, and 1.3 times more likely to say that it would be very serious if someone in their household contracted COVID-19. Other responses of Acceptors on what makes immunization easier may be helpful in programming to boost acceptance, such as providing vaccination through government health facilities, schools, and kiosks, and having vaccinators maintain proper COVID-19 health and safety protocols.

CONCLUSION

An effective behavior change strategy for COVID-19 vaccines uptake will need to address multiple beliefs and behavioral determinants, reducing barriers and leveraging enablers identified in this study. National plans for promoting COVID-19 vaccination should address the barriers, enablers, and behavioral determinants found in this study in order to maximize the impact on COVID-19 vaccination acceptance.

A Multilevel Intervention to Increase HPV Vaccination among Asian American Adolescents

Human papillomavirus (HPV) is the most common sexually transmitted infection in the US. HPV vaccine is a viable source of prevention against high-risk strains that are likely to cause cancer. However, particularly among racial and ethnic minorities such as Chinese Americans, HPV vaccination rates are suboptimal. The goal of this study was to evaluate the effect of a culturally tailored intervention on HPV vaccine uptake in Chinese Americans. We designed and implemented a multilevel longitudinal pilot study to examine the efficacy of the HPV intervention among Chinese American parents/guardians. We recruited 180 participants from federally qualified health center and community-based clinics that serve predominantly low-income Chinese Americans in Philadelphia. Participants were randomized into an intervention group (n = 110) or a control group (n = 70). The intervention group received an HPV specific intervention, while the control group received a general health intervention. The primary outcome was medical record-confirmed receipt of first shot and completion of HPV vaccine within six months of receiving the interventions. Repeated measure ANOVA was utilized to examine the intervention effect on knowledge between intervention and control groups. Knowledge differed significantly, with participants in the intervention group demonstrating the greatest improvement following the intervention. A multivariable logistic regression was used to examine the association between HPV vaccine initiation and study group assignment. There was a significant effect of provider recommendation, parent’s gender, and health insurance status on HPV vaccine uptake. This study demonstrated positive impact of a culturally tailored intervention on HPV vaccination uptake among Chinese Americans.

Brucellosis in dairy herds: Farm characteristics and practices in relation to likely adoption of three potential private-public partnership (PPP) vaccination control strategies in West and Central Africa

Brucellosis is regarded as one of the highest burden zoonotic diseases to persist in many regions globally. While sustained vaccination against B. abortus in an endemic setting can markedly reduce the prevalence of large ruminant and human brucellosis and benefit local livelihoods, the implementation of effective and sustainable control programmes has often failed in the worst affected areas. In a cross-sectional study of 728 peri-urban dairy farmers in nine areas of six West and Central African countries, levels of commercialization and farm characteristics were examined alongside B. abortus seroprevalence estimates to hypothesize the most appropriate model for brucellosis vaccination delivery in each country. Demographic and economic data were collated and used to describe the farming systems currently in place. Furthermore, these data were utilized in a likelihood assessment to generate a quantitative score to hypothesize which of three private-public partnership (PPP) vaccine delivery models, that is 1) transformative, 2) transactional or 3) collaborative, would be most appropriate in each setting. The study sites had substantial differences in their levels of dairy commercialization and the farming practices employed; the heterogeneity across the study sites was evident in the conclusions of which models would be appropriate for vaccination delivery. While Lomé (Togo) had a strong indication for a transformative PPP model, Burkina Faso had strong indication for the collaborative PPP model. Of the remaining study sites, the scores were less dominant for any one model with Cameroon and Ivory Coast sites only just scoring highest on the transformative model and Senegal and Mali sites only just scoring highest on the collaborative model. Interestingly, none of the countries included in the study scored highest on the transactional model which currently is the most commonplace delivery model in the majority of sub-Saharan African countries.

Parents' knowledge, beliefs, acceptance and uptake of the HPV vaccine in members of The Association of Southeast Asian Nations (ASEAN): A systematic review of quantitative and qualitative studies

BACKGROUND AND OBJECTIVE

Cervical cancer is the second most common malignancy affecting females in Southeast Asia. Human Papillomavirus (HPV) vaccines have been available since 2006. Several Association of Southeast Asian Nations (ASEAN) member countries have since introduced and/or piloted the HPV vaccine with adolescent females. This systematic review was conducted to understand what factors influence parents' acceptance of the HPV vaccine in the region.

METHODS

Seven databases were searched for qualitative and quantitative studies published up to 16 April 2020. Papers were included if they were peer-reviewed, in English, available in full text, and had a focus on parents' knowledge, beliefs, attitudes and acceptance of the HPV vaccine. Findings were integrated to answer the review question using framework analysis based on the Theory of Planned Behaviour.

RESULTS

Sixteen publications were included and synthesised under the Theory of Planned Behaviour domains: 1) Knowledge, attitudes and acceptance, 2) subjective norms, and 3) perceived behavioural control. Parents' attitudes to HPV vaccination were positive and acceptance to vaccinate their daughters against HPV was high. The uptake was high when the vaccine was offered for free.

CONCLUSION

Parents' acceptance and uptake of the HPV vaccine in ASEAN member-countries was high when the vaccine was offered for free even though their knowledge of cervical cancer and HPV was poor. Further research is needed to see how uptake and acceptance can be maintain when the vaccine is not offered for free.

Cognitions and behaviours of general practitioners in France regarding HPV vaccination: A theory-based systematic review

Human papillomavirus (HPV) vaccination is safe and efficacious to prevent persistent HPV infection, precancerous anogenital lesions and cervical cancer. However, in countries where vaccination programmes are implemented outside of schools, such as France, reaching high HPV vaccination coverage of the target population is challenging. Many studies have been performed in France to assess cognitions of general practitioners (GPs) regarding HPV vaccination. However, the evidence is not consistent about which cognitions are key. To provide a comprehensive overview, we performed a systematic review of studies conducted in France on GPs' cognitions regarding HPV vaccination and used the reasoned action approach to extract and synthesize data. The systematic search was performed up to July 2020 in Medline via PubMed, PsycINFO, PsycARTICLES, Embase, CINAHL Plus, Web of Science, Pascal and Francis databases. Grey literature was searched for in the French Public Health Database, Cairn. Info, yahoo.fr, and Google Scholar. Twenty-five scientific publications were selected based on eligibility criteria and assessed for quality. Our qualitative synthesis highlights that although 73% of GPs report recommending HPV vaccination, up to 50% would not recommend it because of concerns, including changes in patients' health behaviours and doubts about safety and/or efficacy. GPs' injunctive norms, i.e. trust in institutional information, were shown to be associated positively with GPs' willingness to recommend HPV vaccination. Parents' fears, girls' age, and potential connection with sexuality do not seem to affect GPs' recommendations. These results will inform the development of a professional educational intervention targeting GPs in France.

Human papillomavirus vaccine acceptability among healthcare workers, parents, and adolescent pupils: a pilot study in public health centers of Bali, Indonesia

Introduction

Knowledge and acceptability of HPV vaccination should be identified for supporting the HPV vaccine program in public health centers. Qualitative research approach is one approach that can be developed for increasing the acceptance and use of HPV vaccines in the community. Perceptions of health workers, parents, teachers, and adolescents related to HPV immunization can be explored in depth. This study was performed to explore the perception and meaning of the HPV vaccine acceptability among healthcare professionals, parents, and adolescent pupils in Bali, Indonesia.

Methods

A mixed method study was conducted among 176 elementary school children. In-depth interviews were performed with five of the parents and eight of the teachers. Then, four focus group discussions among 19 health professionals were performed for supporting data. A self-administered questionnaire was used to measure knowledge of HPV and acceptability of HPV vaccine among participants. An interview of standard guidelines was performed to identify the perception of the HPV vaccine.

Results

The study identified that perception about HPV knowledge and HPV vaccine was low among adolescents and teachers for all of the questions. However, knowledge on HPV and HPV vaccine among parents and healthcare professionals were higher. Meanwhile, the acceptability of the HPV vaccine and the personal experience of women were more positive for the healthcare professionals.

Conclusions

Knowledge and perception regarding HPV and HPV vaccination among adolescents and teachers in Indonesia, particularly in Denpasar, Bali, are still insufficient. However, the perception of vaccine administration is acceptance for parents and healthcare professionals. Therefore, socialization of HPV vaccine programs in school and community are needed to improve health promotion about the importance of the HPV vaccine.

HPV vaccination and Native Americans: protocol for a systematic review of factors associated with HPV vaccine uptake among American Indians and Alaska Natives in the USA

INTRODUCTION

The nine-valent human papillomavirus (HPV) vaccine could prevent an estimated 92% of the cancers attributable to HPV types targeted by the vaccine. However, uptake of the HPV vaccine among American Indian and Alaska Native (AI/AN) adolescents has been low. AI/ANs also bear a disproportionate burden of cervical and other HPV-associated cancers. Increasing HPV vaccination rates is a national priority, but reviews and national surveys on HPV vaccination factors are lacking for the AI/AN population. The objective of this systematic review is to assess factors associated with HPV vaccination among AI/ANs in the USA.

METHODS AND ANALYSIS

A systematic review is proposed to synthesise the current literature on HPV vaccination factors in AI/ANs from 1 July 2006 until 30 September 2019. As applicable, controlled vocabulary terms, keywords and special features (eg, limits, explode and focus) will be incorporated into database searches. To maximise the identification of relevant studies, citation indexes and databases that index dissertations, preprints and grey literature are included. Studies will be screened and selected independently in two stages. In stage 1, titles and abstracts will be screened. In stage 2, full-text articles will be screened and selected. A data extraction form and quality assessment tool will be piloted, revised and implemented. If available, measures of frequency and association will be presented. A narrative synthesis of the included studies will also be undertaken and reported.

ETHICS AND DISSEMINATION

As our review will use publicly available data and publications, an Institutional Review Board review will not be required. We will disseminate the findings from this review through peer-reviewed publication(s) and conference presentation(s).

POTENTIAL AMENDMENTS

In the event of amendments to the protocol, we will provide the date, rationale, and description of the change for each amendment.

PROSPERO REGISTRATION NUMBER

CRD42020156865.

Biopsychosocial risk factors and knowledge of cervical cancer among young women: A case study from Kenya to inform HPV prevention in Sub-Saharan Africa

Background

Cervical cancer is the second most common female reproductive cancer after breast cancer with 84% of the cases in developing countries. A high uptake of human papilloma virus (HPV) vaccination and screening, and early diagnosis leads to a reduction of incidence and mortality rates. Yet uptake of screening is low in Sub-Saharan Africa and there is an increasing number of women presenting for treatment with advanced disease. Nine women in their twenties die from cervical cancer in Kenya every day. This paper presents the biopsychosocial risk factors that impact on cervical cancer knowledge among Kenyan women aged 15 to 24 years. The findings will highlight opportunities for early interventions to prevent the worrying prediction of an exponential increase by 50% of cervical cancer incidences in the younger age group by 2034.

Methods

Data from the 2014 Kenya Demographic and Health Survey (KDHS) was analysed using complex sample logistic regression to assess biopsychosocial risk factors of knowledge of cervical cancer among young women aged 15 to 24 years (n = 5398).

Findings

Close to one third of the participants were unaware of cervical cancer with no difference between participants aged 15–19 years (n = 2716) and those aged 20–24 years (n = 2691) (OR = 1; CI = 0.69–1.45). Social predisposing factors, such as lack of education; poverty; living further from a health facility; or never having taken a human immunodeficiency virus (HIV) test, were significantly associated with lack of awareness of cervical cancer (p<0.001). Young women who did not know where to obtain condoms had an OR of 2.12 (CI 1.72–2.61) for being unaware of cervical cancer. Psychological risk factors, such as low self-efficacy about seeking medical help, and an inability to refuse unsafe sex with husband or partner, perpetuated the low level of awareness about cervical cancer (p<0.001).

Conclusions

A considerable proportion of young women in Kenya are unaware of cervical cancer which is associated with a variety of social and psychological factors. We argue that the high prevalence of cervical cancer and poor screening rates will continue to prevail among older women if issues that affect young women’s awareness of cervical cancer are not addressed. Given that the Kenyan youth are exposed to HPV due to early sexual encounters and a high prevalence of HIV, targeted interventions are urgently needed to increase the uptake of HPV vaccination and screening.

Chinese mothers' intention to vaccinate daughters against human papillomavirus (HPV), and their vaccine preferences: a study in Fujian Province

Little is known regarding Chinese mothers' intention to vaccinate their daughters against human papillomavirus (HPV) since the HPV vaccine was approved for use in China in 2016. The aim was to explore maternal HPV vaccination acceptance, preference for 2-, 4- or 9-valent HPV vaccine and acceptance of domestically manufactured HPV vaccines. Study participants were mothers of primary school children in Southeastern region of Fujian. An online cross-sectional survey was undertaken between June and August 2019. Among the total of 3,586 completed responses (response rate 28.5%), the intention to vaccinate daughter against HPV was high (83.3%). Higher maternal education and perceived benefit and barriers were associated with greater intention to vaccinate. Among mothers who did not intend to vaccinate their daughters, the three most common reasons were daughter being too young to receive HPV vaccination (40.6%), fear of side effects (31.9%) and vaccine price is too high (16.0%). The largest proportion (41.4%) preferred their daughter to be vaccinated with the 9-valent HPV vaccine (9vHPV). Greater preference for 9vHPVwas strongly associated with higher maternal education level and annual household income. The majority of mothers expressed a preference for imported HPV vaccine (56.3%). Our result indicates that lower intentions to vaccinate daughters against HPV among less educated and lower-income mothers may lead to significant social inequalities in HPV vaccine uptake in the country.

Factors associated with hindering the acceptance of HPV vaccination among caregivers - A cross-sectional study in Argentina

Background

The northeastern region of Argentina has the highest age-adjusted cervical cancer mortality rates. Given the strong link between HPV infections and cervical cancer, one of the main interventions is the population-based use of HPV vaccines. However, the acceptability is not very clear in low- and middle-income countries. The purpose of this study was to estimate the level of HPV vaccine acceptance and associated determinants among caregivers of girls in a northeastern city of Argentina.

Methods

A school-based survey was conducted in 2015 using a multistage sampling method. The primary sample unit were schools stratified by socioeconomic status selected at random, and caregivers of school girls were interviewed. The acceptability was determined using the adapted Theory of Planned Behavior. We performed logistic regression models to assess associated determinants.

Results

The study included 347 caregivers. The intention to vaccinate was 59.88%. A positive attitude of caregivers (aOR 4.67; 3.11–7.03) and positive influence of social norms (aOR 1.95; 1.03–3.70) were the main predictors independently associated to the intention to vaccinate against HPV. In contrast, practicing a Christian non-Catholic religion decreased the intention to vaccinate against HPV (OR 0.59; 0.36–0.95). All other factors evaluated were not significantly associated with intention to vaccinate against HPV.

Conclusions

This study shows that evaluating attitudes, normative social beliefs, and perceived self-efficacy regarding HPV vaccination can be of utmost importance for mapping and planning of health-related strategies in developing countries.

Factors associated with adolescent HPV vaccination in the U.S.: A systematic review of reviews and multilevel framework to inform intervention development

Multilevel factors impact HPV vaccine series initiation and completion among adolescents in the U.S. Synthesis of these factors is needed to inform intervention development and to direct future research. Current frameworks synthesizing factors focus on females only and do not include both series initiation and completion outcomes. We conducted a systematic review of reviews to identify modifiable individual-, provider-, and clinic-level factors associated with HPV vaccination outcomes among U.S. adolescents and developed a multilevel framework illustrating relations between factors to inform intervention development. We searched Medline, PsychInfo, Pubmed, CINAHL, and ERIC databases and included reviews published 2006 to July 2, 2018 describing individual-, provider-, or clinic-level factors quantitatively associated with HPV vaccination among U.S. adolescents. Two coders independently screened reviews, extracted data, and determined quality ratings. Sixteen reviews containing 481 unique primary studies met criteria. Factors synthesized into the multilevel framework included parent psychosocial factors (knowledge, beliefs, outcome expectations, intentions) and behaviors, provider recommendation, and patient-targeted and provider-targeted clinic systems. The scope of our framework and review advances research in two key ways. First, the framework illustrates salient modifiable factors at multiple levels on which to intervene to increase HPV vaccination. Second, the review identified critical gaps in the literature at each level. Future research should link the body of literature on parental intentions to vaccination outcomes, identify provider psychosocial factors associated with recommendation behaviors and subsequent vaccine uptake in their patient population, and understand clinic factors associated with successful implementation of patient- and provider-targeted system-level interventions.

Vaccipack, A Mobile App to Promote Human Papillomavirus Vaccine Uptake Among Adolescents Aged 11 to 14 Years: Development and Usability Study

BACKGROUND

More than 90% of human papillomavirus (HPV)-related cancers could be prevented by widespread uptake of the HPV vaccine, yet vaccine use in the United States falls short of public health goals.

OBJECTIVE

The purpose of this study was to describe the development, acceptability, and intention to use the mobile app Vaccipack, which was designed to promote uptake and completion of the adolescent HPV vaccine series.

METHODS

Development of the mobile health (mHealth) content was based on the integrated behavioral model (IBM). The technology acceptance model (TAM) was used to guide the app usability evaluation. App design utilized an iterative process involving providers and potential users who were parents and adolescents. App features include a vaccine-tracking function, a discussion forum, and stories with embedded messages to promote intention to vaccinate. Parents and adolescents completed surveys before and after introducing the app in a pediatric primary care setting with low HPV vaccination rates.

RESULTS

Surveys were completed by 54 participants (20 adolescents aged 11 to 14 years and 34 parents). Notably, 75% (15/20) of adolescents and 88% (30/34) of parents intended to use the app in the next 2 weeks. Acceptability of the app was high among both groups: 88% (30/34) of parents and 75% (15/20) of adolescents indicated that Vaccipack was easy to use, and 82% (28/34) of parents and 85% (17/20) of adolescents perceived the app to be beneficial. Higher levels of app acceptability were found among parents with strong intentions to use the app (P=.09; 95% CI -2.15 to 0.15).

CONCLUSIONS

mHealth technology, such as Vaccipack, may be an acceptable and nimble platform for providing information to parents and adolescents and advancing the uptake of important vaccines.

The uptake of adolescent vaccinations through the School Immunisation Program in specialist schools in Victoria, Australia

BACKGROUND

As part of the National Immunisation Program (NIP) students in Australia receive adolescent immunisations through the School Immunisation Program at 12 to 13 years. For children with disabilities attending specialist schools, no vaccine uptake data is collected at this time point. We aimed to determine uptake of diphtheria-tetanus-pertussis (dTpa) and Human Papillomavirus (HPV) immunisations amongst young people with disabilities in specialist schools in Victoria.

METHODS

A prospective cohort study was conducted in Victoria, Australia. Data was collected on immunisation days in the 2017 school year from specialist schools in Victoria. The school immunisation coordinator entered data online for eligible students for receipt of dTpa and HPV on each school immunisation day. Demographic data, motor and intellectual function of students and reasons for non-receipt of dTpa and HPV vaccine were recorded. Data were analysed using descriptive statistics.

RESULTS

Of 73 eligible specialist schools in Victoria, 28 (38%) participated. dTpa was received by 63% (237/374) of participating students and HPV dose 1 (HPV1) was received by 66% (76/114) females and 67% (174/260) male students respectively. Three doses of HPV were received by only 41% (100/241) of students. The main reasons for missed immunisation were absence from school, lack of consent and inability to immunise due to the student's behaviour and/or anxiety.

CONCLUSION

This is the first study in Australia to report that uptake of adolescent immunisations in specialist schools for young people with a disability is significantly lower than in mainstream settings. Comparative data during the same time period for students in mainstream schools demonstrated higher uptake, at 89% for dTpa and 75% for three doses of HPV. These data highlight the inequity of receipt of school-based immunisations for this group of adolescents, the barriers to which could be more thoroughly explored through qualitative inquiry from a socio-ecological perspective.

Barriers, supports, and effective interventions for uptake of human papillomavirus- and other vaccines within global and Canadian Indigenous peoples: a systematic review protocol

BACKGROUND

Despite the existence of human papilloma virus (HPV) vaccines with demonstrated safety and effectiveness and funded HPV vaccination programs, coverage rates are persistently lower and cervical cancer burden higher among Canadian Indigenous peoples. Barriers and supports to HPV vaccination in Indigenous peoples have not been systematically documented, nor have interventions to increase uptake in this population. This protocol aims to appraise the literature in Canadian and global Indigenous peoples, relating to documented barriers and supports to vaccination and interventions to increase acceptability/uptake or reduce hesitancy of vaccination. Although HPV vaccination is the primary focus, we anticipate only a small number of relevant studies to emerge from the search and will, therefore, employ a broad search strategy to capture literature related to both HPV vaccination and vaccination in general in global Indigenous peoples.

METHODS

Eligible studies will include global Indigenous peoples and discuss barriers or supports and/or interventions to improve uptake or to reduce hesitancy, for the HPV vaccine and/or other vaccines. Primary outcomes are documented barriers or supports or interventions. All study designs meeting inclusion criteria will be considered, without restricting by language, location, or data type. We will use an a priori search strategy, comprised of key words and controlled vocabulary terms, developed in consultation with an academic librarian, and reviewed by a second academic librarian using the PRESS checklist. We will search several electronic databases from date of inception, without restrictions. A pre-defined group of global Indigenous websites will be reviewed for relevant gray literature. Bibliographic searches will be conducted for all included studies to identify relevant reviews. Data analysis will include an inductive, qualitative, thematic synthesis and a quantitative analysis of measured barriers and supports, as well as a descriptive synthesis and quantitative summary of measures for interventions.

DISCUSSION

To our knowledge, this study will contribute the first systematic review of documented barriers, supports, and interventions for vaccination in general and for HPV vaccination. The results of this study are expected to inform future research, policies, programs, and community-driven initiatives to enhance acceptability and uptake of HPV vaccination among Indigenous peoples.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO Registration Number: CRD42017048844.

The next Sub Saharan African epidemic? A case study of the determinants of cervical cancer knowledge and screening in Kenya

Early cervical cancer screening has been shown to be beneficial in reducing cervical cancer related deaths. Despite the benefits of early cervical cancer screening, uptake remains limited, with wide disparities in access and uptake in most developing countries. As part of a larger study, this paper uses a socio-ecological framework to explain the determinants of cervical cancer knowledge and screening among women of reproductive age (15-49 years) in Kenya. We conducted a multilevel analysis of cervical cancer knowledge (n = 11,138) and screening (n = 10,333) using the 2014 Kenya Demographic and Health Survey (KDHS). Results show regional disparities in cancer knowledge and the utilization of cervical cancer screening services; regions with high wealth inequality (OR = 0.70, 95% CI [0.56-0.87]) emerged as vulnerable regions where women were less likely to screen for cervical cancer. Gender equity, health insurance coverage and education level significantly predicted cervical cancer screening rates. Results further revealed regional as well as rural-urban wealth inequalities in cervical cancer screening. We argue that given that Kenyan women are highly exposed to human papilloma virus (HPV) due to the legacy of human immunodeficiency virus (HIV) in the country, cervical cancer may be the next epidemic if integrated measures are not adopted to increase cervical cancer knowledge and overcome the barriers to utilizing early screening services. The paper concludes with policy recommendations and directions for future research.

Development and validation of measures to evaluate adolescents' knowledge about human papillomavirus (HPV), involvement in HPV vaccine decision-making, self-efficacy to receive the vaccine and fear and anxiety

OBJECTIVES

We describe the development and validation of measures of human papillomavirus (HPV)/HPV vaccination knowledge, fear/anxiety about vaccination, involvement in HPV vaccine decision-making, and self-efficacy with regard to getting the vaccine, designed to evaluate the efficacy of an intervention to affect these domains (collectively termed the HAVIQ: HPV Adolescent Vaccine Intervention Questionnaire).

STUDY DESIGN

Literature search, cognitive interviews and cross-sectional survey.

METHODS

A literature search identified existing items that were modified for the present measures. Experts reviewed draft measures for face and content validity. Cognitive interviews with adolescents were also used to assess content validity. Adolescents completed the measures and an internal reliability analysis of each measure was performed.

RESULTS

The four experts concurred that the measures had face validity. Cognitive interviews identified items requiring refinement. Content validity was examined with ten experts and was deemed acceptable. There were 1800 adolescents who completed the measures; Cronbach's alpha was >0.6 for three of the four measures. The four final measures are brief, comprising 25 items in total.

CONCLUSIONS

The measures are robustly developed and validity-tested. The HAVIQ may be used in research settings to evaluate adolescents' knowledge and experiences of the process of HPV vaccination in a school-based vaccination programme.

KAP Surveys and Dengue Control in Colombia: Disentangling the Effect of Sociodemographic Factors Using Multiple Correspondence Analysis

During the last few decades, several studies have analyzed and described knowledge, attitudes, and practices (KAP) of populations regarding dengue. However, few studies have applied geometric data analytic techniques to generate indices from KAP domains. Results of such analyses have not been used to determine the potential effects of sociodemographic variables on the levels of KAP. The objective was to determine the sociodemographic factors related to different levels of KAP regarding dengue in two hyper-endemic cities of Colombia, using a multiple correspondence analysis (MCA) technique. In the context of a cluster randomized trial, 3,998 households were surveyed in Arauca and Armenia between 2012 and 2013. To generate KAP indexes, we performed a MCA followed by a hierarchical cluster analysis to classify each score in different groups. A quantile regression for each of the score groups was conducted. KAP indexes explained 56.1%, 79.7%, and 83.2% of the variance, with means of 4.2, 1.4, and 3.2 and values that ranged from 1 to 7, 7 and 11, respectively. The highest values of the index denoted higher levels of knowledge and practices. The attitudes index did not show the same relationship and was excluded from the analysis. In the quantile regression, age (0.06; IC: 0.03, 0.09), years of education (0.14; IC: 0.06, 0.22), and history of dengue in the family (0.21; IC: 0.12, 0.31) were positively related to lower levels of knowledge regarding dengue. The effect of such factors gradually decreased or disappeared when knowledge was higher. The practices indexes did not evidence a correlation with sociodemographic variables. These results suggest that the transformation of categorical variables into a single index by the use of MCA is possible when analyzing knowledge and practices regarding dengue from KAP questionnaires. Additionally, the magnitude of the effect of socioeconomic variables on the knowledge scores varies according to the levels of knowledge, suggesting that other factors might be influencing higher levels of knowledge.