Factors involved in human papillomavirus (HPV) vaccine hesitancy among women in the South-East Asian Region (SEAR) and Western Pacific Region (WPR): A scoping review

Determinants of COVID-19 and non-COVID-19 vaccine confidence in low- and middle-income countries: A systematic review of qualitative evidence and thematic synthesis

BACKGROUND

The COVID-19 pandemic has shown the immediate risk for global and public health posed by vaccination inequities worldwide. The regions most affected are low- and middle-income countries (LMICs). In addition to systemic challenges, vaccine hesitancy driven by low vaccine confidence has been identified as a threat to vaccine uptake. The aim of this systematic review of qualitative literature is to explore the determinants of COVID-19 and non-COVID-19 vaccine confidence in LMICs.

METHODS

A systematic review was conducted following the PRISMA and ENTREQ guidelines. The electronic databases Cinahl, Embase, Pubmed, Scopus and Web of Science were searched for qualitative studies focusing on the topic of interest in LMICs published between 2013 and 2023. The quality of the studies was assessed using the Joanna Briggs Institute's Checklist for Qualitative Research. A thematic synthesis was conducted. The study was registered on the Open Science Framework platform.

FINDINGS

66 studies were included in the review. Three main determinants of vaccine confidence were identified: (1) General perceptions of the safety and efficacy of vaccines; (2) Information and experience; (3) Trust in healthcare providers, institutions, and systems. General perceptions of vaccine safety and efficacy were similar between COVID-19 and non-COVID-19 vaccines, and doubts regarding vaccine safety were neither new nor exclusive to the COVID-19 vaccine, indicating a persisting challenge. Furthermore, low vaccine confidence was partly determined by broader dynamics of mistrust towards Western countries and institutions, which was reflected for both vaccine groups. While conspiracy theories have been persisting determinants of low confidence, low COVID-19 vaccine confidence was partly determined by what was perceived as a lack of specific information.

CONCLUSION

Persistent challenges to vaccine confidence were identified, rooted in colonial legacies and global health inequities, as well as limited intercultural approaches to building trust with regards to vaccines.

Factors associated with HPV vaccine hesitancy among college students: A cross-sectional survey based on 3Cs and structural equation model in China

Despite the high effectiveness of HPV vaccines in preventing infection, vaccine hesitancy remains a concern, particularly in China. This study aimed to explore college students' attitudes toward HPV vaccination and identify associated factors. Data was collected through a cross-sectional survey using self-administered questionnaires in four cities from May to June 2022. Chi-square tests and logistic regression analyses were conducted to identify factors. Additionally, an integrated structural equation model (SEM) based on the 3Cs (confidence, convenience, complacency) was developed to understand underlying factors contributing to hesitancy. The results from 2261 valid questionnaires were enlightening. A significant 89.47% (59.4% for females) considered HPV vaccination necessary, with 9.82% remaining neutral and only 0.71% deeming it unnecessary. Factors like higher education, being a medical student, residing in urban areas, having medical insurance, more extraordinary living expenses, a family history of tumors, and a solid understanding of HPV played a role in perceiving the vaccine as necessary. Among the 1438 female respondents, 84.36% had no hesitancy toward HPV vaccination, 13.53% expressed hesitancy, and 2.11% refused vaccination. Factors like age, understanding of HPV, medical staff recommendations, living expenses, and family history influenced hesitancy levels. SEM revealed that the 3Cs significantly affected vaccine hesitancy. Factors like price, booking process, vaccination times, trust in vaccines, medical staff recommendations, efficiency, and risk perception collectively influenced hesitancy. In conclusion, this study found high acceptance of HPV vaccination but acknowledged the complexity of hesitancy factors. It recommends medical staff disseminate scientific knowledge, offer recommendations, simplify booking procedures, and expand vaccination sites to address vaccine hesitancy effectively.

HPV Vaccine Hesitancy and Uptake: A Conceptual Analysis Using Rodgers' Evolutionary Approach

AIM

This study examines the factors contributing to HPV vaccine hesitancy using Rodgers's evolutionary concept analysis, focusing on the impact of uncertainties about the vaccine on HPV-related diseases despite its availability.

DESIGN

Rodgers's evolutionary concept analysis was applied to explore factors leading to HPV vaccine hesitancy. The analysis included studies published in English over the past 5 years. Exclusions were studies older than 5 years, non-English publications, and those focusing on other vaccines.

DATA SOURCES

A comprehensive literature review was conducted using key databases such as PsycINFO, CINAHL, MEDLINE, and PubMed. Relevant keywords included 'HPV' and 'vaccine hesitancy' to ensure thoroughness.

REVIEW METHODS

Studies were selected based on their relevance to HPV vaccine hesitancy. Factors contributing to hesitancy were analysed, focusing on antecedents, attributes, and consequences.

RESULTS

The analysis identified key antecedents to HPV vaccine hesitancy, including false cultural beliefs, educational level, knowledge, and vaccine availability. Additional factors were insurance/income, perceived risk, and decision-making processes. Key attributes impacting hesitancy included media coverage, environmental and community influences, social factors, trust in healthcare systems, efficacy rates, and safety concerns. The consequences of hesitancy were reduced vaccine uptake, increased HPV-related diseases, and the spread of misinformation.

CONCLUSION

The study highlights the complex interplay of factors contributing to HPV vaccine hesitancy. Understanding these factors is crucial for addressing the challenges posed by vaccine hesitancy and developing effective interventions.

IMPACT

Insights from this analysis can guide public health strategies aimed at improving vaccine uptake and reducing HPV-related diseases. Targeted interventions can address misinformation and enhance trust in vaccines, ultimately leading to better public health outcomes.

PATIENT OR PUBLIC CONTRIBUTION

This concept analysis was conducted without the involvement of patients, service users, caregivers, or members of the public.

Human papillomavirus vaccination: a quantitative cross-sectional study of perceived barriers, influential advisors, and acculturation among Chinese college students aged 18-26 in the USA

HPV vaccines are highly effective in preventing HPV-associated cancers; however, HPV vaccination uptake is low among Chinese students studying at U.S. colleges. The purposes of this study were to evaluate (a) perceived barriers and influential others trusted for advice regarding HPV vaccination and (b) factors (i.e. HPV vaccination, acculturation) related to barriers and influential advisors among 18- to 26-year-old Chinese students attending U.S. colleges. We used a cross-sectional design to obtain self-reported data in 2019 from a chain-referral sample of 213 Chinese students. Among 125 respondents who were unvaccinated or partially vaccinated, the reported barriers to receiving the HPV vaccine included: (a) lack of recommendations from a healthcare provider, (b) lack of risk perception for HPV infection, and (c) limited knowledge about HPV vaccination locations. The influential advisors for receiving HPV vaccination were doctors, parents, self, nurses, and same-sex friends. Multivariate analysis revealed that unvaccinated respondents were more likely to report the following barriers to HPV vaccination: (a) lack of recommendations from a healthcare provider, (b) lack of risk perception for HPV infection, (c) limited knowledge about vaccination locations, and (d) uncertainty about effectiveness. High Asian identified respondents were more likely to perceive barriers related to limited knowledge about vaccination locations and uncertainty about effectiveness, while they were less likely to state nurses as influential advisors. Individuals who received one or more HPV vaccine doses were more inclined to view same-sex friends and nurses as influential advisors for HPV vaccination. The influence of culture on preferences for information sources, such as specific providers and provider gender, needs to be addressed. Programs designed to decrease barriers and improve HPV vaccination among Chinese students should also focus on acculturation status.

Determinants of parental self-reported uptake of influenza vaccination in preschool children during the COVID-19 pandemic

In China, the coverage rate of influenza vaccination among the general population is significantly lower than that of high-income countries, with only 2.46% of the population vaccinated. Preschool-aged children are particularly susceptible to influenza viruses, yet the factors that influence parents' willingness to vaccinate their children are not well understood. To address this research gap, we developed a theoretical model grounded in the Unified Theory of Acceptance and Use of Technology (UTAUT), which explores six key factors influencing parental self-reported uptake of influenza vaccination in preschool children: performance expectancy, effort expectancy, social influence, facilitating conditions, knowledge, and behavioral intention. We collected data from 872 parents of children in five major cities in China and employed structural equation modeling to examine the significance of the theoretical model and explore the potential moderating effects of demographic variables on path relationships. Our analysis revealed that several positive factors influenced parents' intention of influenza vaccination for preschool children, including effort expectancy (β = 0.38), social influence (β = 0.17), and knowledge (β = 0.52). Facilitating conditions (β = 0.34), knowledge (β = 0.40), and behavioral intention (β = 0.34) were found to be associated with self-reported uptake. Furthermore, we observed significant moderating effects of the child's gender and age, as well as the guardian's category and income, on the theoretical models. Parents' willingness to vaccinate preschool children against influenza is influenced by both psychological and demographic variables. Further studies are needed to determine if these relationships persist over time and across different regions.

Obstacles to routine immunization in Madagascar: Structural, relational and cultural constraints

This article proposes an overview of anthropological studies concerning childhood immunization in Madagascar, where vaccine coverage still remains low. The COVID-19 epidemic has heightened the reticence of populations to be vaccinated in the public health centres of this country. It appears necessary to study the factors which may impact immunization practices and its representations. The principal results of these studies describe immunization from the perspective of parents of children under five years of age. The role that they attribute to a vaccine is essentially that of reinforcing the health of children against illness. There is a misunderstanding of combination vaccines, one vaccine generally being associated with one disease. The findings also show a complex relationship with immunization, injections and the health passport. Finally, uptake of immunization or not is motivated by the structural and local context such as the perceived frailness of the newborn baby, the practice of post-partum confinement, or the lack of knowledge about the vaccine. Lack of understanding of immunization and mistrust of it are signs of a fragile health system. An in-depth analysis of immunization and the impact of COVID-19 on its perception will provide a clearer view of the fragility of the immunization programmes implemented in Madagascar.

A Review of Parental Vaccine Hesitancy for Human Papillomavirus in Japan

Globally, Japan has the lowest rate of vaccine confidence. The persistent parental vaccine hesitancy has been attributed to safety and efficacy concerns and is primarily driven by the negative experience with human papillomavirus (HPV) vaccines. This literature review aimed to identify factors associated with HPV vaccine uptake and potential strategies to reduce vaccine hesitancy among Japanese parents. Articles published in English or Japanese between January 1998 and October 2022 that examined Japanese parental factors for HPV vaccine uptake were identified from PubMed, Web of Science, and Ichushi-Web. In total, 17 articles met the inclusion criteria. Four key themes which affected HPV vaccine hesitancy and acceptance were identified: perceptions of risk and benefits, trust and recommendation, information and knowledge, and sociodemographic characteristics. While governmental and healthcare provider recommendations are important factors, efforts to improve parental confidence in the HPV vaccine are required. Future interventions to counteract HPV vaccine hesitancy should actively disseminate information on vaccine safety and effectiveness, along with information on the severity and susceptibility of HPV infection.

Associations between Vaccination Behavior and Trust in Information Sources Regarding COVID-19 Vaccines under Emergency Approval in Japan: A Cross-Sectional Study

We examined the association between COVID-19 vaccination behavior and trust in COVID-19-related information sources during the initial period of COVID-19 vaccination in Japan. A cross-sectional survey was conducted in August 2021, 5 months after the start of COVID-19 vaccination for the general public under emergency approval. Participants were recruited using non-probability quota sampling from among Japanese residents who were under a declared state of emergency. Sociodemographic data, vaccination behavior, and levels of trust in eight media sources of information and three interpersonal information sources were assessed using an online survey form. A total of 784 participants completed the survey. The results of multiple logistic regression analysis showed that age, household income, underlying medical conditions, and living with family were significantly associated with COVID-19 vaccination behavior. Regarding COVID-19 vaccine information sources, trust in public health experts as a source of media information and primary care physicians as a source of interpersonal information showed significantly positive associations with COVID-19 vaccination behavior (odds ratio [OR] = 1.157, 95% confidence interval [CI] 1.017-1.31; OR = 1.076; 95% CI 1.006-1.150, respectively). Increasing trust in public health experts and primary care physicians and disseminating vaccine information from these sources will help promote vaccination under emergency approval.

Megastudies: A New Approach to Reducing Vaccine Hesitation Worldwide

Vaccine hesitancy is a considerable obstacle to achieving vaccine protection worldwide. There needs to be more evidence-based research for interventions for vaccine hesitancy. Existing effectiveness evaluations are limited to one particular hypothesis, and no studies have compared the effectiveness of different interventions. A megastudy takes a large-scale, multi-intervention, uniform participant and the same evaluation criteria approach to evaluate many interventions simultaneously and find the most effective ones. Therefore, megastudies can help us find the most effective interventions for vaccine hesitancy. Additionally, considering the complex causes of vaccine hesitancy, we design interventions that involve social factors in megastudies. Lastly, quality control and justice are critical issues for megastudies in the future.

Effects of a web-based HPV vaccination intervention on cognitive outcomes among young gay, bisexual, and other men who have sex with men

Knowledge, attitudes, and beliefs are important antecedents to HPV vaccination, yet remain suboptimal among young gay, bisexual, and other men who have sex with men (YGBMSM). We report the effects of a theoretically-informed, web-based HPV vaccination intervention on these cognitive outcomes. From 2019-2021, we recruited a national sample of YGBMSM ages 18-25 in the United States who were unvaccinated against HPV (n = 1,227). Participants received either standard HPV vaccination information online (control) or population-targeted, individually-tailored content online (Outsmart HPV intervention). Mixed effects models determined if pre-post changes in cognitive outcomes differed between study groups. For five of seven knowledge items about HPV, there were larger pre-post increases among the intervention group than the control group in the percentage of participants who provided correct responses (all statistically significant at p = .05 after Holm's correction). There were also larger pre-post improvements among the intervention group than the control group for most attitudes and beliefs examined, including response efficacy of HPV vaccine (pre-post increases in means: 0.57 vs. 0.38); self-efficacy for the HPV vaccination process (pre-post increases in means: 0.23 vs. 0.10); and intention to get HPV vaccine (pre-post increases in means: 0.70 vs. 0.28) (all statistically significant at p = .05 after Holm's correction). Outsmart HPV is a promising tool for improving key cognitive antecedents to HPV vaccination among YGBMSM, supporting the use of theoretically-informed interventions to affect such outcomes. If efficacious in increasing HPV vaccine uptake in future analyses, this intervention could be utilized in clinical and other healthcare settings that provide services to YGBMSM.

Assessment of training of general practice interns in motivational interviews about vaccination

The effectiveness of motivational interviewing (MI) for reducing vaccine hesitancy (VH) has been demonstrated in Quebec. We conducted a study to evaluate the acquisition of MI skills after MI training via videoconferencing for interns training as general practitioners (GPs) in southeastern France. A vaccination-specific MI training workshop was offered to interns in 2021, consisting of two separate Zoom videoconference sessions. Participants completed the Motivational Interviewing Skills in Immunization questionnaire before and after the training to measure skills acquisition. We used pairwise exact Wilcoxon-Pratt signed rank tests for the analysis. Among 45 GP interns enrolled in the first MI session, 34 (75.6%) attended both sessions and completed the questionnaire at 3 different time points. After the first session, MI knowledge scores improved significantly (+21.1 ± 21.6; P < .0001), as did application of MI skills (+36.8 ± 36.7; P < .0001), and MI practice confidence (+21.2 ± 11.1; P < .0001). The second MI session maintained the skills developed after the first session without further improvement. Participant satisfaction was high. This is the first study in France assessing the impact of a vaccination-specific MI training for GP interns. It shows a substantial improvement in knowledge, application of MI skills, and self-confidence in the practice of MI. GP interns were highly satisfied with the training despite the videoconference format. These promising results will allow the integration of MI training in GP medical curricula in order to prepare future GPs for communication in the field of vaccination.

Adolescent girls' recommendations for the design of a human papillomavirus vaccination program in Sindh, Pakistan: a qualitative study

PURPOSE

Vaccination of adolescent girls against human papillomavirus (HPV) significantly reduces the incidence of cervical cancer. HPV vaccines are available in Pakistan but plans to develop HPV vaccination program are at a nascent stage. We conducted a formative study to explore adolescent girls' knowledge and perspectives on HPV and cervical cancer and collect their recommendations for implementing an HPV vaccination program in their community.

METHODS

Using qualitative exploratory study design, we conducted four focus group discussions (FGDs) with 12 adolescent girls per group in District West, Karachi. We recruited unmarried girls aged 16-19 years from schools and community settings between May-December 2020. Data analysis was done using NVivo.

RESULTS

Overall, participants displayed a positive attitude toward HPV vaccine. However, they were unfamiliar with basic concepts related to female reproductive health. Female relatives were indicated as girls' preferred point of contact for discussions on HPV and cervical cancer, but fathers were portrayed as decision-making authority on vaccination. Participants indicated vaccine hesitancy among parents may affect HPV vaccination uptake. Girls suggested individual household visits and community-based camps as strategies for successful implementation of HPV vaccination program. A solid foundation of trust between girls' families, program managers, and other stakeholders emerged as a key asset for the program's success.

CONCLUSION

Adolescent girls' suggestions of informing key decision-makers in the family (particularly fathers) of the benefits of HPV vaccination, establishing trust with vaccine providers, and increasing accessibility of vaccinations should be explored for successful implementation of an HPV vaccination program in Pakistan.

Awareness of and Support for HPV Vaccination Among Pacific Islander Women in Southern California

Pacific Islander (PI) women experience disproportionately high rates of cervical cancer and mortality and have lower rates of Pap testing. Since up to 70% of cervical cancers could be prevented by being vaccinated for human papilloma virus (HPV), this cross-sectional study explored the predictors of HPV and vaccine awareness, receipt of the vaccine, and attitudes toward vaccinating children among adult PI women in southern California, who historically have low rates of HPV vaccination and high rates of cervical cancer that could be prevented with HPV vaccination. Participants (n=148) consist a subsample of Chamorro, Samoan, and Tongan women, ages 21 to 65 years, who were in a larger randomized community study to promote Pap testing. Overall, younger age and higher American acculturation were significantly associated with ever hearing about HPV and the vaccine. However, American acculturation was also associated with negative attitudes toward vaccinating their children for HPV. This paper provides preliminary insights into barriers and facilitators to HPV vaccination among PIs in the USA and also informs the development of educational programs to reduce cervical cancer incidence and mortality in this underserved population.

Human papillomavirus (HPV) vaccine introduction in Sikkim state: Best practices from the first statewide multiple-age cohort HPV vaccine introduction in India-2018-2019

BACKGROUND

Cervical cancer is a leading cause of cancer-associated mortality among women in India, with 96,922 new cases and 60,078 deaths each year, almost one-fifth of the global burden. In 2018, Sikkim state in India introduced human papillomavirus (HPV) vaccine for 9-13-year-old girls, primarily through school-based vaccination, targeting approximately 25,000 girls. We documented the program's decision-making and implementation processes.

METHODS

We conducted a post-introduction evaluation in 2019, concurrent with the second dose campaign, by interviewing key stakeholders (state, district, and local level), reviewing planning documents, and observing cold chain sites in two purposefully-sampled community areas in each of the four districts of Sikkim. Using standard questionnaires, we interviewed health and education officials, school personnel, health workers, community leaders, and age-eligible girls on program decision-making, planning, training, vaccine delivery, logistics, and communication.

RESULTS

We conducted 279 interviews and 29 observations in eight community areas across four districts of Sikkim. Based on reported administrative data, Sikkim achieved >95% HPV vaccination coverage among targeted girls for both doses via two campaigns; no severe adverse events were reported. HPV vaccination was well accepted by all stakeholders; minimal refusal was reported. Factors identified for successful vaccine introduction included strong political commitment, statewide mandatory school enrollment, collaboration between health and education departments at all levels, and robust social mobilization strategies.

CONCLUSIONS

Sikkim successfully introduced the HPV vaccine to multiple-age cohorts of girls via school-based vaccination, demonstrating a model that could be replicated in other regions in India or similar low- and middle-income country settings.

Molecular markers for cervical cancer screening

INTRODUCTION

Cervical cancer remains a significant healthcare problem, notably in low- to middle-income countries. While a negative test for hrHPV has a predictive value of more than 99.5%, its positive predictive value is less than 10% for CIN2+ stages. This makes the use of a so-called triage test indispensable for population-based screening to avoid referring women, that are ultimately at low risk of developing cervical cancer, to a gynecologist. This review will give an overview of tests that are based on epigenetic marker panels and protein markers.

AREAS COVERED

There is a medical need for molecular markers with a better predictive value to discriminate hrHPV-positive women that are at risk of developing cervical cancer from those that are not. Areas covered are epigenetic and protein markers as well as health economic considerations in view of the fact that most cases of cervical cancer arise in low-to-middle-income countries.

EXPERT OPINION

While there are biomarker assays based on changes at the nucleic acid (DNA methylation patterns, miRNAs) and at the protein level, they are not widely used in population screening. Combining nucleic acid-based and protein-based tests could improve the overall specificity for discriminating CIN2+ lesions that carry a low risk of progressing to cervical cancer within the screening interval from those that carry an elevated risk. The challenge is to reduce unnecessary referrals without an undesired increase in false-negative diagnoses resulting in cases of cervical cancer that could have been prevented. A further challenge is to develop tests for low-and middle-income countries, which is critical to reduce the worldwide burden of cervical cancer.

Knowledge of HPV, its vaccines, and attitudes toward HPV vaccines among obstetrician-gynecologists, pediatricians and immunization services providers in Western China

Background

In mainland China, HPV vaccines have been available to the public. However, only a few related studies among health care providers, as the key information providers, were reported although public concerns on HPV vaccines still exist. In this study, we aim to assess the knowledge of HPV, its vaccines, and attitudes toward HPV vaccines among the three most important groups of health care providers in Western China.

Method

This was a cross-sectional questionnaire-based study. Health care providers including obstetrician-gynecologists (OB-GYNs), pediatricians, and immunization service providers in Western China were investigated regarding their knowledge of HPV and its vaccines and their attitudes toward HPV vaccines.

Results

Of 1079 health care providers completing the survey, 1015 (94.1%) knew HPV infection is the primary cause of cervical cancer. However, lower knowledge levels of other HPV-related diseases were also found (43.2%). About three-quarters (74.1%) of practitioners interviewed would be willing to recommend HPV vaccination, which was found to be lower among the OB-GYNs (69.6%) and the pediatricians (73.2%). “Lack of relevant knowledge,” “concerns on safety and efficacy” and price were the three most important concerns surrounding HPV vaccination.

Conclusion

The interviewed practitioners did not have adequate knowledge of HPV and its vaccines in depth. Education interventions are highly recommended to the health care providers, especially for OB-GYNs and pediatricians, to increase the coverage of HPV vaccination among the population. For the currently high price of vaccines, a future co-sharing mechanism between the government, the providers, and the individuals might be a solution.

Willingness to pay for and acceptance of cervical cancer prevention methods: A systematic review and meta-analysis

Background: The Willingness to pay (WTP) for and acceptance of cervical cancer prevention (CCP) methods have an important role in the control of this type of cancer. Therefore, the aim of this study was to estimate the WTP and acceptance of CCP methods with the contingent valuation method (CVM). Methods: In this systematic review and meta-analysis study, the required information was collected by searching relevant keywords in PubMed, Scopus, Embase, Web of Knowledge, and their Persian equivalent in the Scientific Information Database (SID) and Elmnet databases during January 1, 2000 to June 30, 2020. All studies that reported the WTP and CCP methods with the CVM in English or Persian were included. The reporting quality of studies was assessed by strengthening the Reporting of Observational Studies in Epidemiology (STROBE). Comprehensive meta-analysis (CMA: 2) software was used to conduct the meta-analysis. The content analysis method was used for qualitative data analysis. Results: Finally, 28 articles (with 49610 people) were included in the study. Most of the participants were women (35.7%). The HPV vaccine was the most common method of prevention (75%). The overall acceptance rate was 64% and the overall positive WTP rate was 66%. The average WTP was US$30.44, which accounts for about 0.84% of GDP per capita. The most significant effective factors included income, age, education, high-risk sexual behaviors, and awareness of cervical cancer, belief in the risk of cervical cancer, and belief about the effectiveness of prevention methods. The cost was the most important reason for the unwillingness to pay and accept. Conclusion: Results show that the WTP and acceptance rate of CCP methods are relatively high. It is recommended to reduce the cost of prevention methods, especially the HPV vaccine, and to increase awareness and improve the attitude of people. Also, it is recommended to consider other methods of estimation of WTP and other cancers in future studies.

Preference and willingness to pay of female college students for human papillomavirus vaccination in Zhejiang Province, China: A discrete choice experiment

The study aimed to quantify the preferences of female college students for human papillomavirus (HPV) vaccination in Zhejiang Province, China, using a discrete choice experiment (DCE). One medical college and one nonmedical college were selected using convenience sampling, and the respondents were identified using stratified cluster sampling. A DCE focused on vaccine-related and service-related attributes was conducted in 2019. Latent class analysis was used to estimate the vaccine-related attributes, and conditional logistic regression was used to construct the choice model for the service-related attributes. In total, 850 female college students finished the study. Two latent classes were identified. Those who had more knowledge of HPV and felt more pressure about the related infection and diseases had a significantly higher chance of belonging to class 1 and were more likely to choose vaccination (percentages of respondents choosing no vaccination was 1.1% in class 1 versus 84.7% in class 2, χ² = 641.1, P < .01). There were 742 respondents who chose vaccination in vaccine-related scenes, and 98.8% of them still chose to receive the vaccine in service-related scenes. Ways of making an appointment, number of weeks waiting for vaccination, service time for vaccination, time to the nearest vaccination site, and added cost all impacted the probability of choosing HPV vaccination services. It is concluded that higher levels of HPV knowledge and sociopsychological pressure led to a higher probability of HPV vaccination uptake in China. It is necessary to disseminate proper knowledge of HPV to improve the coverage and equality of HPV vaccination.

Current Updates on Cancer-Causing Types of Human Papillomaviruses (HPVs) in East, Southeast, and South Asia

Simple Summary

Among the over 200 human papillomavirus (HPV) genotypes identified, approximately 15 of them can cause human cancers. In this review, we provided an updated overview of the distribution of cancer-causing HPV genotypes by countries in East, Southeast and South Asia. Besides the standard screening and treatment methods employed in these regions, we unravel HPV detection methods and therapeutics utilised in certain countries that differ from other part of the world. The discrepancies may be partly due to health infrastructure, socio-economy and cultural diversities. Additionally, we highlighted the area lack of study, particularly on the oncogenicity of HPV genotype variants of high prevalence in these regions.

Abstract

Human papillomavirus (HPV) infection remains one of the most prominent cancer-causing DNA viruses, contributing to approximately 5% of human cancers. While association between HPV and cervical cancers has been well-established, evidence on the attribution of head and neck cancers (HNC) to HPV have been increasing in recent years. Among the cancer-causing HPV genotypes, HPV16 and 18 remain the major contributors to cancers across the globe. Nonetheless, the distribution of HPV genotypes in ethnically, geographically, and socio-economically diverse East, Southeast, and South Asia may differ from other parts of the world. In this review, we garner and provide updated insight into various aspects of HPV reported in recent years (2015–2021) in these regions. We included: (i) the HPV genotypes detected in normal cancers of the uterine cervix and head and neck, as well as the distribution of the HPV genotypes by geography and age groups; (ii) the laboratory diagnostic methods and treatment regimens used within these regions; and (iii) the oncogenic properties of HPV prototypes and their variants contributing to carcinogenesis. More importantly, we also unveil the similarities and discrepancies between these aspects, the areas lacking study, and the challenges faced in HPV studies.

Factors Influencing Public Attitudes towards COVID-19 Vaccination: A Scoping Review Informed by the Socio-Ecological Model

Major hindrances to getting a COVID-19 vaccine include vaccine hesitancy, skepticism, refusal, and anti-vaccine movements. Several studies have been conducted on attitudes of the public towards COVID-19 vaccines and the potential influencing factors. The purpose of this scoping review is to summarize the data available on the various factors influencing public attitudes towards COVID-19 vaccination. This scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Statement. PubMed, Embase, Web of Science, and Cochrane Central were searched without restrictions to reclaim all publications on the factors that shape individuals' attitudes towards COVID-19 vaccines from 1 January 2020 to 15 February 2021. Fifty studies were included. The scoping review revealed that the factors influencing public attitudes towards COVID-19 vaccines were embedded within the different levels of the socio-ecological model. These factors included the sociodemographic characteristics of the individuals, individual factors, social and organizational factors. In addition, certain characteristics of COVID-19 vaccines themselves influenced public attitudes towards accepting the vaccines. Understanding various population needs and the factors shaping public attitudes towards the vaccines would support planning for evidence-based multilevel interventions in order to enhance global vaccine uptake.

HPV vaccine acceptability and willingness-related factors among Chinese adolescents: a nation-wide study

BACKGROUND

Adolescents are the primary target population for human papillomavirus (HPV) vaccination. The objective of this study is to explore the acceptability of HPV vaccines and evaluate factors related to willingness to be vaccinated among Chinese adolescents.

METHODS

A nation-wide survey was conducted across 14 schools in mainland China. The questionnaire consisted of questions relating to socio-demographic characteristics, knowledge of adolescent sexual health, cervical cancer, HPV and HPV-related disease, and students' willingness to be vaccinated. Chi-square tests and multivariable logistic regression were conducted in the data analysis.

RESULTS

A total of 4,062 students participated in this study. Among them, only 17.1% of students reported having heard of HPV vaccines; however, 67.3% were willing to receive the HPV vaccine. Multivariable regression analysis showed that students who were from rural areas, have received sexual health education, have heard of cervical cancer or HPV vaccine, have a positive attitude toward vaccination, reported they were at the risk of developing cervical cancer, and those who value their parents' and teachers' opinions were more willing to receive HPV vaccination.

CONCLUSIONS

Awareness about the HPV vaccine is low among Chinese adolescents. The factors that most related to willingness to vaccinate among Chinese adolescents were school location, education about vaccination, HPV, and HPV vaccines. Integrating health education on HPV vaccination into existing school-based sexual health curricula may be an effective way to increase HPV vaccination coverage in mainland China.

Attributes of screening and vaccination for cervical cancer: insights of an online survey among female school teachers of Kota, Rajasthan, India

Background: Cervical cancer is largely preventable. The study was aimed to find out the attributes of screening and vaccination for cervical cancer among female school teachers of Kota, Rajasthan, India.

Methods: It was an observational study, cross-sectional in design conducted among female school teachers of Kota, Rajasthan, India using a predesigned structured questionnaire administered by Google Form during the months of March to May, 2020. In total, 397 schoolteachers from 18 different schools of Kota participated in our survey.

Results: Among the study subjects, 33 (8.3%) had ever undergone screening for cervical cancer, whereas only 12 (3.0%) had taken vaccine against it. In multivariable logistic regression analysis; age (>40 years) [adjusted odds ratio (AOR): 5.7 (2.0-15.8)], correct knowledge regarding frequency of screening (yes) [AOR: 6.0 (2.4-15.5)], positive attitude for the disease (yes) [AOR:3.0 (1.1-8.0)] and gynaecologist consultation behaviour (periodic) [AOR: 1.4 (1.1-8.6)] were significant attributes of ever undergoing screening for cervical cancer. On the other hand, themultivariable significant attributes of vaccination were age (≤40 years) [AOR: 7.6 (1.5-38.9)]and positive attitude for the disease (yes) [AOR: 6.4 (1.1-38.2)].

Conclusion: Acceptance of screening and vaccination for cervical cancer among the study subjects was found to be quite low. Policymakers should more actively involve school teachers in generating awareness and in raising the demand for cervical cancer screening and vaccination in their native communities to curb the disease in the country.

A systematic review of the barriers to implementing human papillomavirus vaccination programs in low- and middle-income countries in the Asia-Pacific

AIM

The increasing burden of human papillomavirus (HPV)-related diseases in low- and middle-income countries (LMICs) could be alleviated by effective HPV vaccination programs. In this systematic review, we examined barriers to introduction, implementation, and/or sustainability of HPV vaccination programs in LMICs in the Asia-Pacific region (AP-LMICs).

METHODS

A systematic search of literature from the past 10 years (2010-2019) was performed through PubMed, Cochrane CENTRAL, and Google Scholar. Studies were included if they reported barriers to HPV vaccination in AP-LMICs. All study designs were included except commentaries and editorials. The journal articles were assessed using the Joanna Briggs Institute critical appraisal checklists.

RESULTS

A total of 46 eligible articles were included. An increase in publications was noted from 2010 to 2019. Barriers were diverse and were classified into four levels--government, healthcare providers (HCPs), society, and individual. The top specific barriers that were identified across AP-LMICs are lack of funding and political support at the government level, lack of awareness among HCP and lack of vaccination programs at the level of health providers, and the perceived cost/benefit ratio for the individual level.

CONCLUSION

Barriers to successful implementation of HPV vaccination programs differ among Asia-Pacific LMICs. Policymakers will need to evaluate the relative importance of these barriers in their target areas and population in order to draft an effective dissemination and implementation strategy.

Newspaper coverage before and after the HPV vaccination crisis began in Japan: a text mining analysis

Background

The human papillomavirus (HPV) vaccination coverage rate has fallen sharply in Japan since 2013, when newspapers began covering negative campaigns against the vaccination. We examined and compared contents from newspaper articles before and after the start of this HPV vaccination crisis.

Methods

We collected articles published between January 2005 and September 2017 in the four daily national Japanese newspapers with the highest domestic circulation. We then conducted text mining analysis to chronologically examine content distribution.

Results

From among the 1178 articles analyzed, 12 types of contents were identified. Contents related to cervical cancer prevention, such as on the risk of developing cervical cancer, causes of cervical cancer, and the effects of vaccination, were frequently conveyed until 2012. However, after March 2013, they were replaced with anti-vaccination contents, such as on adverse effects to vaccines, alleged victims, and related lawsuits. Meanwhile pro-vaccination contents, such as safety statements from the World Health Organization, scarcely received coverage.

Conclusions

Newspaper contents changed profoundly before and after the start of the vaccination crisis. Those newspaper reports potentially had impact on readers’ beliefs and actions. Journalists should strive for impartial coverage so readers can make more-informed decisions. Health professionals should be expected to work with journalists to help improve impartiality in newspaper coverage. The Ministry of Health, Labour and Welfare should discus benefits and risks of the HPV vaccination based on the scientific evidences, and consider to resume the proactive recommendation of HPV vaccination. Well-organized advocacy among medical societies, scientists and health professionals will also be needed to influence the government.

Community-based household assessment of human papillomavirus (HPV) vaccination coverage and acceptability - HPV vaccine demonstration program, Cambodia - 2017

BACKGROUND

In 2017, the Cambodia Ministry of Health introduced human papillomavirus (HPV) vaccine through primarily school-based vaccination targeting 9-year-old girls. Vaccination with a two-dose series of HPV vaccine took place in six districts in two provinces as a demonstration program, to better understand HPV vaccine delivery in Cambodia.

METHODS

We conducted a community-based coverage survey using a one-stage sampling design to evaluate dose-specific vaccination coverage among eligible girls (those born in 2007 and residents in the areas targeted by the campaign). The household-level survey also assessed factors associated with vaccine acceptability and communication strategies. Trained data collectors interviewed caregivers and girls using a standard questionnaire; vaccination cards and health facility records were reviewed.

RESULTS

Of the 7594 households visited in the two provinces, 315 girls were enrolled in the survey (188 in Siem Reap; 127 in Svay Rieng). Documented two-dose HPV vaccination coverage was 84% (95% confidence interval [CI]: 78-88%) overall [85% (95% CI: 78-90%) in Siem Reap; 82% (95% CI: 73-88%) in Svay Rieng.] Almost all girls (>99%) were reported to be enrolled in school and over 90% of respondents reported receipt of vaccine in school. Knowledge of HPV infection and associated diseases was poor among caregivers and girls; however, 58% of caregivers reported "protection from cervical cancer" as the primary reason for the girl receiving vaccine. No serious adverse events after immunization were reported.

CONCLUSIONS

The HPV vaccine demonstration program in Cambodia achieved high two-dose coverage among eligible girls in both provinces targeted for vaccination in 2017, through primarily school-based vaccination. High school enrollment and strong microplanning and coordination were seen throughout the campaign. Cambodia will use lessons learned from this demonstration program to prepare for national introduction of HPV vaccine.

Acceptability of the dengue vaccination among parents in urban poor communities of Quezon City, Philippines before and after vaccine suspension

Objective

The study aims to illustrate the acceptability of the dengue vaccine before and after the dengue vaccination suspension in urban poor communities in Quezon City, Philippines.

Results

There were 12 interviews conducted in November 2017 and 5 focus group discussions in January 2018, a month after vaccine program suspension with 41 participants. All participants were selected through purposive criterion sampling. Thematic analysis showed acceptability of the dengue vaccine was associated with parental experience with vaccination and dengue, trust in public health institutions and communication received by parents. Post-dengue vaccination suspension triangulation indicated that the parents regretted the experience, trust to public institutions was eroded and the communication strategy was deemed inadequate. This led to low vaccine acceptability post-vaccine suspension.

Factors influencing intention to obtain the HPV vaccine in South East Asian and Western Pacific regions: A systematic review and meta-analysis

Since licensing in 2006, there has been poor uptake of the HPV vaccine among the targeted population in the South East Asia Region (SEAR) and Western Pacific Region (WPR). A systematic review was conducted to identify the studies exploring the relationship between factors and intention for HPV vaccination among women in SEAR and WPR countries. Nineteen studies were identified as suitable for qualitative synthesis, and three as suitable for meta-analysis. Most women had a positive intention to have an HPV vaccine (range 57%-85%). Having a positive intention to vaccinate was significantly higher among women not aware of HPV infection (OR: 1.34, 95% CI: 1.02-1.76) and HPV vaccine (OR: 1.57, 95% CI: 1.26-1.96). Lower knowledge level and less confidence in safety and efficacy of the vaccine, negatively affected intention to vaccinate. Perceiving the vaccine to be expensive, low perception of contracting HPV infection and cervical cancer, and lack of concrete recommendations from healthcare providers also negatively affected intention to vaccinate. This review suggests the decision-making processes of women in SEAR and WPR is influenced by the cost of vaccination, perceived efficacy and safety of vaccine, provision of information on vaccination, and the awareness about HPV infection and the HPV vaccine.