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

What Influences Health Professionals' Recommendations for Non-Scheduled Childhood Vaccinations? A Qualitative Study of Health Professionals' Perspectives in Three Provinces of China

Recommendations by health professionals are important for vaccines that are not included in national schedules. This study explored health professionals’ perspectives on recommending non-scheduled (user-fee) childhood vaccinations in China, identifying key influences on professionals’ interactions with caregivers. We conducted individual semi-structured interviews with 20 health professionals from three provinces in China and analyzed data thematically using deductive and inductive coding. Health professionals from all three provinces were uncomfortable about being perceived to encourage parents to accept vaccines that incurred a fee. They provided information about non-scheduled vaccines but emphasized parental autonomy in decision-making. Rural parents were less aware of unscheduled vaccines and health professionals were more likely to encourage parents living in more affluent areas to consider these vaccines; varicella vaccine was preferred by parents as a way of preventing school absence. Economic incentives for unscheduled vaccines were given to staff at most study sites, although the amount given varied widely. These variations meant that staff receiving lower incentives were not motivated to promote non-scheduled vaccines if their workload was high; on the contrary, those receiving higher incentives were more likely to promote these vaccines. Health professionals need more guidance on how to recommend unscheduled vaccines in an informative, positive and appropriate manner. It is evident that parents’ awareness of these vaccines, and their economic circumstances, influence vaccinators recommendation practice. Economic incentives prompted health professionals to recommend non-scheduled vaccines; however, the application of such staff incentives varied widely in China. To adopt appropriate economic incentives, professional organizations should develop protocols for the use of incentives that account for their influence on recommendation practices. Suitable recommendation policy needs to balance basic salaries with performance-based incentives, consider overall workload, and include monitoring and evaluation of economic incentives.

Stated-preference research in HIV: A scoping review

Discrete choice experiments (DCE), conjoint analysis (CA), and best-worst scaling (BWS) are quantitative techniques for estimating consumer preferences for products or services. These methods are increasingly used in healthcare research, but their applications within the field of HIV research have not yet been described. The objective of this scoping review was to systematically map the extent and nature of published DCE, CA, and BWS studies in the field of HIV and identify priority areas where these methods can be used in the future. Online databases were searched to identify published HIV-related DCE, CA and BWS studies in any country and year as the primary outcome. After screening 1,496 citations, 57 studies were identified that were conducted in 26 countries from 2000-2017. The frequency of published studies increased over time and covered HIV themes relating to prevention (n = 25), counselling and testing (n = 10), service delivery (n = 10), and antiretroviral therapy (n = 12). Most studies were DCEs (63%) followed by CA (37%) and BWS (4%). The median [IQR] sample size was 288 [138-496] participants, and 74% of studies used primary qualitative data to develop attributes. Only 30% of studies were conducted in sub-Saharan Africa where the burden of HIV is highest. Moreover, few studies surveyed key populations including men who have sex with men, transgender people, pregnant and postpartum women, adolescents, and people who inject drugs. These populations represent priorities for future stated-preference research. This scoping review can help researchers, policy makers, program implementers, and health economists to better understand the various applications of stated-preference research methods in the field of HIV.

Women's Health Outpatient Care Teams: Focus on Advanced Practice Providers

Team-based care in the outpatient women's health setting has the potential to help alleviate the demand for women's health care providers and to deliver improved quality of care to the growing population of US women. Although teamwork is necessary in the current health care system, most of the current obstetrics and gynecology and advanced practice provider (APP) workforce were not trained for collaborative practice. Core competencies for building an effective outpatient women's health care team are explained and current evidence regarding the specific role of APPs in women's health care is reviewed.

Association of physicians perceived barriers with human papillomavirus vaccination initiation

Physician recommendation is a strong predictor of vaccine uptake, however their perceived barriers may prevent vaccination. Therefore, we determined the association between physicians' perceived barriers to HPV vaccination and vaccination initiation. We surveyed pediatricians in a large network of clinics in Houston, Texas to assess their perceived barriers to vaccinating adolescents. We combined survey data with electronic medical records to determine HPV vaccination initiation over a 12-month study period (July 2014-June 2015). Patients were 11-18year olds who had not begun the vaccination series, had a physician visit during the study period, and whose physician completed the survey. We conducted a multilevel model clustered by physician controlling for patient and physician demographics to calculate the association between physician-reported barriers and HPV vaccination initiation. Among 36,827 patients seen by 134 pediatricians, 18.6% initiated HPV vaccination. The relative risk of initiating HPV vaccination were lower for patients whose physician reported concerns about HPV vaccine safety (RR: 0.75, 95% CI: 0.58-0.97), efficacy (RR: 0.73, 95% CI: 0.54-0.99), and the financial burden of the vaccine on patients (RR: 0.72, 95% CI: 0.58-0.88). After controlling for patient and physician characteristics, physician concern about the financial burden on patients was significantly associated with lower relative risk of initiating HPV vaccination (RR: 0.76, 95% CI: 0.64-0.90). In this large study we observed that physician-reported barriers are associated with HPV vaccination initiation. Interventions should be implemented to educate physicians on vaccine safety, efficacy, and that there is no patient cost for CDC-recommended vaccines.

Human Papillomavirus Vaccination of Adolescents with Chronic Medical Conditions: A National Survey of Pediatric Subspecialists

STUDY OBJECTIVE

Many adolescents with chronic medical conditions (CMCs) are at risk of human papillomavirus (HPV) infection, associated complications, and underimmunization and often identify a pediatric subspecialist as their main provider. This study aimed to assess the HPV-related understanding, beliefs, and practices of pediatric subspecialists, which are largely unknown.

DESIGN AND SETTING

National cross-sectional study.

PARTICIPANTS

Pediatric endocrinologists, hematologist/oncologists, pulmonologists, and rheumatologists identified using the American Medical Association Physician Masterfile (n = 418).

INTERVENTIONS

Subspecialists who care for adolescents with CMCs in the outpatient setting were recruited to complete a Web-based survey on their HPV-related knowledge, attitudes, comfort, and practices.

MAIN OUTCOME MEASURES

HPV vaccination recommendation.

RESULTS

Over half of respondents (50.4%; n = 196/389) reported sometimes or always recommending HPV vaccination to adolescent patients with CMCs. Factors positively associated with recommendation included hematology/oncology (adjusted odds ratio [AOR], 4.69; 95% confidence interval [CI], 1.86-11.81) or rheumatology (AOR, 6.55; 95% CI, 1.67-25.74) specialization, seeing more adolescent patients with CMCs (AOR, 1.01; 95% CI, 1.00-1.02), and sometimes or always discussing sexual health (AOR, 2.53; 95% CI, 1.05-6.08) or checking vaccine status (AOR, 3.83; 95% CI, 1.59-9.20) with these patients. Those who thought it was important, but were uncomfortable discussing sexual health when recommending HPV vaccination (AOR, 0.28; 95% CI, 0.12-0.70) or who reported insufficient HPV vaccine information (AOR, 0.45; 95% CI, 0.23-0.88) or lack of primary-subspecialty care provider communication (AOR, 0.38; 95% CI, 0.16-0.93) as barriers to HPV vaccination were less likely to recommend HPV vaccination.

CONCLUSION

This study revealed that many subspecialists fail to recommend HPV vaccination to adolescents with CMCs and highlights potential targets for future interventions.

Factors Associated with Increased HPV Vaccine Use in Rural-Frontier U.S. States

OBJECTIVE

This study sought to examine sociodemographic factors surrounding human papillomavirus (HPV) vaccine initiation and three-dose completion rates in the Intermountain West (IW).

DESIGN AND SAMPLE

Analysis of the Centers for Disease Control and Prevention's 2012 National Immunization Survey-Teen dataset was conducted with a survey-weighted Pearson chi-square test and multivariable Poisson regression to produce bivariate and multivariate analyses. Participants with daughters aged 13-17 with provider-verified immunization records were included. Dual-frame adjusted prevalence ratios (PR) and 95% confidence intervals (CI) were produced with provider-phase sampling weights.

MEASURES

Factors included parents' and adolescents' sociodemographic and healthcare usage variables. Outcome measures included adolescents' receipt and completion of the HPV vaccine.

RESULTS

Older parental ages (45 years and above) showed lower prevalence of adolescent HPV vaccine initiation (PR = 0.73, 95% CI = 0.59-0.87, p = .003) and completion (PR = 0.65, 95% CI = 0.44-0.96, p = .031) compared with parents younger than 35. Seventeen-year-old adolescents demonstrated highest prevalence of initiating (PR = 1.88, 95% CI = 1.47-2.39, p < .001) and completing (PR = 2.92, 95% CI = 1.97-4.33, p < .001) the vaccination series compared to 13-year olds. Those who had received meningitis vaccinations had high prevalence of initiating (PR = 1.93, 95% CI = 1.50-2.48, p < .001) and completing the HPV vaccine (PR = 2.52, 95% CI = 1.64-3.86, p < .001).

CONCLUSION

This study highlights parental, adolescent, and health care characteristics related to use of the HPV vaccine. Future research to investigate specific barriers and strategies for addressing HPV vaccination use in the IW is recommended.

Emergency medicine physician attitudes toward HPV vaccine uptake in an emergency department setting

A physician's recommendation is the most effective published method of motivating HPV vaccination initiation. The emergency department (ED) is the 'public health safety net', and often the only access to care for underserved populations. Recommendation of the HPV vaccine in the ED is a potential avenue to improve vaccination rates among sub-populations who do not have access to routine medical care. We assessed willingness of EM physicians to recommend the vaccine, target high-risk women, and disclose perceived barriers to vaccination in the ED. A cross sectional study using an 11-item survey, was used to assess physician attitudes toward recommending the HPV vaccine in an ED setting to age eligible patients. 67.4% stated they would recommend the vaccine, 23.9% were neutral, and 8.7% would not recommend the vaccine to age eligible patients in the ED. 41% noted lack of adequate reimbursement for vaccination as a barrier to vaccination in the ED (P<0.05). Physicians were comfortable targeting women at high risk for cervical cancer for vaccination (P<0.05). EM physicians are comfortable targeting high-risk women for HPV vaccination in an ED setting. Support of EM physicians in the national effort to improve HPV vaccine uptake is an important step in eradicating a largely preventable yet lethal cancer.

Is provider type associated with cancer screening and prevention: advanced practice registered nurses, physician assistants, and physicians

BACKGROUND

Physician recommendations for cancer screening and prevention are associated with patient compliance. However, time constraints may limit physicians' ability to provide all recommended preventive services, especially with increasing demand from the Affordable Care Act in the United States. Team-based practice that includes advanced practice registered nurses and physician assistants (APRN/PA) may help meet this demand. This study investigates the relationship between an APRN/PA visit and receipt of guideline-consistent cancer screening and prevention recommendations.

METHODS

Data from the 2010 National Health Interview Survey were analyzed with multivariate logistic regression to assess provider type seen and receipt of guideline-consistent cancer screening and prevention recommendations (n = 26,716).

RESULTS

In adjusted analyses, women who saw a primary care physician (PCP) and an APRN/PA or a PCP without an APRN/PA in the past 12 months were more likely to be compliant with cervical and breast cancer screening guidelines than women who did not see a PCP or APRN/PA (all p < 0.0001 for provider type). Women and men who saw a PCP and an APRN/PA or a PCP without an APRN/PA were also more likely to receive guideline consistent colorectal cancer screening and advice to quit smoking and participate in physical activity than women and men who did not see a PCP or APRN/PA (all p < 0.01 for provider type).

CONCLUSIONS

Seeing a PCP alone, or in conjunction with an APRN/PA is associated with patient receipt of guideline-consistent cancer prevention and screening recommendations. Integrating APRN/PA into primary care may assist with the delivery of cancer prevention and screening services. More intervention research efforts are needed to explore how APRN/PA will be best able to increase cancer screening, HPV vaccination, and receipt of behavioral counseling, especially during this era of healthcare reform.

Sources of HPV vaccine hesitancy in parents

Despite strong national recommendations to vaccinate adolescents against the human papillomavirus (HPV), only 14% of teenage girls completed all 3 doses in 2010. Parental hesitancy may be one of the strongest reasons behind this low uptake rate. This review investigates sources of parental hesitancy including parental concerns associated with vaccinations in general, parental knowledge as a basis of HPV vaccine hesitancy, social qualms parents may have with regards to the HPV vaccine, and parental attitudes toward allowing their sons to be vaccinated against HPV. By better understanding these sources of hesitancy, we can focus research efforts towards addressing them in an attempt to improve HPV vaccine uptake.

Health care professional communication about STI vaccines with adolescents and parents

Vaccination of adolescents against sexually transmitted infections (STIs) is an important prevention strategy that may reduce the global burden of disease. The World Health Organization, Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices, and other national health agencies recommend the use of existing STI vaccines, and many countries have incorporated them into their routine vaccination schedule. Despite this, however, data indicate that STI vaccine uptake is suboptimal for a variety of reasons. Health care professionals (HCP) have been shown to have a strong beneficial effect on STI vaccine uptake, yet studies demonstrate that many HCPs fail to discuss or recommend them to adolescent patients. This review article focuses on HCP communication about STI vaccines with adolescents and their parents. It describes STI vaccine message content and delivery as well as the context in which HCPs formulate their messaging approach. It also examines other contextual factors that may shape communication about STI vaccines. Studies from many countries indicate that HCPs often possess misinformation about adolescents, including their sexual risk behaviors, as well as STIs, vaccine safety and efficacy, and STI vaccination recommendations. They also have misconceptions of parental barriers to STI vaccination. These may impact STI vaccine communication and have a negative influence on STI vaccine uptake. These findings highlight the critical need for improved HCP education related to adolescent health, sexuality, and STI vaccination. This may be particularly important in settings without an existing infrastructure or expertise in caring for this unique patient population.

The marginal willingness-to-pay for attributes of a hypothetical HIV vaccine

This paper estimates the marginal willingness-to-pay for attributes of a hypothetical HIV vaccine using discrete choice modeling. We use primary data from 326 respondents from Bangkok and Chiang Mai, Thailand, in 2008-2009, selected using purposive, venue-based sampling across two strata. Participants completed a structured questionnaire and full rank discrete choice modeling task administered using computer-assisted personal interviewing. The choice experiment was used to rank eight hypothetical HIV vaccine scenarios, with each scenario comprising seven attributes (including cost) each of which had two levels. The data were analyzed in two alternative specifications: (1) best-worst; and (2) full-rank, using logit likelihood functions estimated with custom routines in Gauss matrix programming language. In the full-rank specification, all vaccine attributes are significant predictors of probability of vaccine choice. The biomedical attributes of the hypothetical HIV vaccine (efficacy, absence of VISP, absence of side effects, and duration of effect) are the most important attributes for HIV vaccine choice. On average respondents are more than twice as likely to accept a vaccine with 99% efficacy, than a vaccine with 50% efficacy. This translates to a willingness to pay US$383 more for a high efficacy vaccine compared with the low efficacy vaccine. Knowledge of the relative importance of determinants of HIV vaccine acceptability is important to ensure the success of future vaccination programs. Future acceptability studies of hypothetical HIV vaccines should use more finely grained biomedical attributes, and could also improve the external validity of results by including more levels of the cost attribute.

Factors associated with the intention to recommend pertussis vaccination for postpartum women: a survey in Taiwan of obstetrician-gynecologists' knowledge, beliefs, and attitudes

OBJECTIVE

To examine obstetrician-gynecologists' knowledge, beliefs, and attitudes associated with the intention to recommend adult tetanus, reduced diphtheria, and acellular pertussis (Tdap) vaccination to postpartum women.

MATERIALS AND METHODS

A survey instrument was mailed to a total of 2686 members of the Taiwan Association of Obstetrics and Gynecology to assess provider demographic characteristics, occupational information, pertussis knowledge, and beliefs and attitudes about vaccination. The intention to recommend pertussis vaccination to postpartum women was evaluated. Trend chi-square statistics and multivariate logistic models were used to determine variables that were significantly associated with intention to recommend vaccination.

RESULTS

Of the 676 surveys returned (25.2%), 510 participants were active in obstetric practice. A statistically significant difference was found in mean ± SD knowledge scores for pertussis disease and pertussis vaccination between obstetrician-gynecologists who intended to recommend and those who did not intend to recommend postpartum Tdap vaccination (disease: 2.99 ± 2.2 vs. 2.31 ± 1.9, respectively, p < .001; vaccination: 2.64 ± 2.2 vs. 1.36 ± 1.8, respectively, p < .001). Obstetrician-gynecologists who were in favor of postpartum Tdap vaccination were more likely to: (1) rate the change in pertussis incidence among adults as increased; (2) rate pertussis disease among newborn infants as highly severe; (3) rate pertussis as highly contagious; and (4) understand the current recommendation of important organizations for protecting infants against pertussis.

CONCLUSION

Our study of obstetrician-gynecologists' attitudes and intentions concerning postpartum Tdap vaccination may be useful in guiding the design of effective perinatal Tdap immunization programs nationwide.

Provider perceptions of barriers and facilitators of HPV vaccination in a high-risk community

BACKGROUND

Maximizing HPV vaccine uptake among those at highest risk for cervical cancer is critical. We explored healthcare provider perspectives on factors influencing HPV vaccination among adolescent girls in a community with high cervical cancer rates.

METHODS

From March to May 2009, we conducted in-depth interviews with 21 medical staff providing care to adolescent girls at two clinics in Los Angeles, CA, serving a predominantly Hispanic population with high cervical cancer rates. Interviews were recorded and transcribed data were reviewed for coding and thematic content related to potential barriers and facilitators of HPV vaccination.

RESULTS

Providers and medical staff overwhelmingly focused on parental beliefs as barriers to HPV vaccination. Perceived parental misconceptions acting as barriers included the belief that adolescents do not need vaccinations and that no-cost vaccine programs like Vaccines for Children are only available for younger children. Perceived parental concerns that the vaccine will promote sexual activity were prevalent, which prompted providers to frame HPV vaccine as a "routine" vaccine. However, the medical staff felt mothers with a friend or relative supportive of HPV vaccination were more likely to request the vaccine. The staff also noted that for Hispanic parents the "preferred" source of information is peers; if the "right people" in the community were supportive of HPV vaccine, parents were more willing to vaccinate. Other barriers included lack of immunization records among immigrant parents and a difficult-to-reach, mobile clientele.

CONCLUSIONS

Providers noted a number of barriers to HPV vaccination, including some perceived parental misconceptions that could be addressed with education about the need for adolescent vaccines and available free vaccine programs. Because community support appears particularly important to Hispanic parents, the use of promotoras - peer liaisons between health organizations and the community - may increase HPV vaccine uptake in this population.

[Gynaecologists' attitudes and practices towards HPV vaccination: a quantitative-qualitative study in Rhône-Alpes]

OBJECTIVES

Acceptance of the human papilloma virus (HPV) vaccine by targeted population will mainly depend on its acceptability among gynaecologists. We examined the perceptions, attitudes and practices of gynaecologists in relation to HPV vaccination 1 year after licensing.

POPULATION AND METHODS

From November 2007 to April 2008, a cross-sectional survey was carried among a representative 10% sample of gynaecologists in the French Rhône-Alpes region. Both quantitative (self-administered questionnaire) and qualitative (interview) approaches were used.

RESULTS

Among the 52 respondents, 90.4% of gynaecologists reported a favourable opinion about HPV vaccination, 5.8% were uncertain and 1.9% was opposed (one did not answer). The main justification for a favourable opinion related to the public health effects of the HPV vaccination (cited by 31.9% of those favouring vaccination). The main justification for an uncertain or opposed opinion was the too recent introduction of the vaccine (cited by 100%). During the month preceding the survey, 40.4% had provided HPV vaccination, mainly in 15-23 years old girls (38.5%). The major difficulties in providing HPV vaccination were questions asked by patients (cited by 44.2% of the respondents) and the targeted age of 14 years (13.5%). A total of 87.5% of respondents reported to have discussed with 14-year-old vaccinated girls of Pap-smear and 12.5% of STI prevention.

CONCLUSION

One year after HPV vaccine licensing, gynaecologists of Rhône-Alpes region had a favourable opinion about it, despite some difficulties. Little information about STI prevention to vaccinated girls was reported opposite to information about Pap-smear.

Adolescent Understanding and Acceptance of the HPV Vaccination in an Underserved Population in New York City

Background. HPV vaccination may prevent thousands of cases of cervical cancer. We aimed to evaluate the understanding and acceptance of the HPV vaccine among adolescents. Methods. A questionnaire was distributed to adolescents at health clinics affiliated with a large urban hospital system to determine knowledge pertaining to sexually transmitted diseases and acceptance of the HPV vaccine. Results. 223 adolescents completed the survey. 28% were male, and 70% were female. The mean age for respondents was 16 years old. Adolescents who had received the HPV vaccine were more likely to be female and to have heard of cervical cancer and Pap testing. Of the 143 adolescents who had not yet been vaccinated, only 4% believed that they were at risk of HPV infection and 52% were willing to be vaccinated. Conclusions. Surveyed adolescents demonstrated a marginal willingness to receive the HPV vaccine and a lack of awareness of personal risk for acquiring HPV.

Human papillomavirus vaccination recommendation may be linked to reimbursement: a survey of Virginia family practitioners and gynecologists

OBJECTIVE

Concerns have been raised about gynecologists as vaccinators. This survey evaluated use of the human papillomavirus (HPV) vaccine, attitudes, and barriers among gynecologists and family practitioners for differences between the 2 specialties.

DESIGN

A cross-sectional survey was conducted using a 50-item, self-administered questionnaire mailed to participants.

SETTING

The study was conducted in Virginia through the University of Virginia Center for Survey Research.

PARTICIPANTS

The questionnaire was mailed to 500 family practitioners and 500 gynecologists.

INTERVENTIONS

The questionnaire asked provider and practice demographics, vaccine practices, knowledge, HPV vaccine attitudes, and barriers to vaccination.

MAIN OUTCOME MEASURES

We compared gynecologists to family practitioners for the outcome of offering HPV vaccination. Logistic regression was performed to determine factors associated with providers choosing to offer and recommend the HPV vaccine.

RESULTS

After exclusion of ineligible physicians, 385 of 790 doctors responded (48.7%). Seventy percent of family practitioners and 73.5% of gynecologists currently offer the HPV vaccine. There were no significant differences in demographics or practice patterns between the specialties. The most frequent barrier to vaccination reported by both groups was reimbursement. In multivariate logistic regression, inadequate reimbursement was negatively associated with offering the HPV vaccine (odds ratio [OR] 0.41; 95% confidence interval [CI] 0.15-1.1) and with recommending the vaccine to patients (OR 0.45; 95% CI 0.26-0.76). Experience treating HPV- related disease was positively associated with offering the HPV vaccine (OR 2.3; 95% CI 1.1-4.8).

CONCLUSIONS

Gynecologists are providing HPV vaccination at rates similar to family practitioners. Reimbursement concerns may negatively have an impact on doctors' recommendation of the HPV vaccine.

School nurses' experiences of delivering the UK HPV vaccination programme in its first year

BACKGROUND

In the United Kingdom (UK) in September 2008, school nurses began delivering the HPV immunisation programme for girls aged 12 and 13 years old. This study offers insights from school nurses' perspectives and experiences of delivering this new vaccination programme.

METHODS

Thirty in-depth telephone interviews were conducted with school nurses working across the UK between September 2008 and May 2009. This time period covers the first year of the HPV vaccination programme in schools. School nurses were recruited via GP practices, the internet and posters targeted at school nurse practitioners.

RESULTS

All the school nurses spoke of readying themselves for a deluge of phone calls from concerned parents, but found that in fact few parents telephoned to ask for more information or express their concerns about the HPV vaccine. Several school nurses mentioned a lack of planning by policy makers and stated that at its introduction they felt ill prepared. The impact on school nurses' workload was spoken about at length by all the school nurses. They believed that the programme had vastly increased their workload leading them to cut back on their core activities and the time they could dedicate to offering support to vulnerable pupils.

CONCLUSION

Overall the first year of the implementation of the HPV vaccination programme in the UK has exceeded school nurses' expectations and some of its success may be attributed to the school nurses' commitment to the programme. It is also the case that other factors, including positive newsprint media reporting that accompanied the introduction of the HPV vaccination programme may have played a role. Nevertheless, school nurses also believed that the programme had vastly increased their workload leading them to cut back on their core activities and as such they could no longer dedicate time to offer support to vulnerable pupils. This unintentional aspect of the programme may be worthy of further exploration.

Examining future adolescent human papillomavirus vaccine uptake, with and without a school mandate

PURPOSE

To develop a model of adolescent (HPV) human papillomavirus vaccine utilization that explored future HPV vaccination rates, with and without a school mandate, for the vaccine at middle school entry.

METHODS

A dynamic, population-based, compartmental model was developed that estimated over a 50-year time horizon HPV vaccine uptake among female adolescents living in the United States. The model incorporated data on parental attitudes about this vaccine and adolescent health care utilization levels.

RESULTS

Without a mandate, our model predicted that 70% coverage, a lower threshold value used in many previous modeling studies of HPV vaccination, would not be achieved until a mean of 23 years after vaccine availability. Maximal coverage of 79% was achieved after 50 years. With a school mandate in place, utilization increased substantially, with 70% vaccination coverage achieved by year 8 and maximal vaccination coverage, 90%, achieved by year 43.

CONCLUSIONS

Our results suggest that vaccine utilization is likely to be low for several years, though strong school mandates might improve HPV vaccine uptake. These results affect the interpretation of previous modeling studies that estimated the potential clinical effects of HPV vaccination under assumptions of very high vaccine utilization rates.

HIV vaccine acceptability: a systematic review and meta-analysis

OBJECTIVE

To conduct a systematic review of the literature to examine HIV vaccine acceptability and factors impacting acceptability of future HIV vaccines.

DESIGN

Systematic review and meta-analysis of peer-reviewed articles that assessed HIV vaccine acceptability.

METHODS

We used a comprehensive search strategy across multiple electronic databases to locate original quantitative or qualitative studies that examined rates or correlates of HIV vaccine acceptability. We conducted meta-analysis on studies reporting correlates or predictors of HIV vaccine acceptability.

RESULTS

Twenty studies (n=7576) reported HIV vaccine acceptability ranging from 37.2 to 94.0 on a 100-point scale; weighted mean acceptability =65.6 (SD=21.1). Eleven studies compared HIV vaccine acceptability at high (80-95%) efficacy (mean =73.8; SD=9.2) versus moderate (50%) efficacy (mean =40.4; SD=20.2). Among 13 studies (n=5023) included in meta-analysis, efficacy and non 'risk group' membership had medium effect sizes, and pragmatic obstacles, cost, perceived susceptibility to HIV infection, side effects/safety concerns, fear of vaccines, perceived vaccine benefits, duration of protection, and ethnicity had small effect sizes on HIV vaccine acceptability.

CONCLUSION

Public health strategies to promote the benefits of partial efficacy HIV vaccines and accurate HIV risk perceptions, and to dispel vaccine fears, along with structural interventions to subsidize vaccine costs and facilitate access, may increase future HIV vaccine uptake and, in turn, the effectiveness of HIV vaccines in controlling the epidemic.

"Is cancer contagious?": Australian adolescent girls and their parents: making the most of limited information about HPV and HPV vaccination

INTRODUCTION

Australia has implemented a nation-wide program providing HPV vaccination to girls at school. To date, there are no published studies that explore knowledge about HPV and HPV vaccine post-implementation of the national school-based HPV vaccination program.

METHODS

A purposive sample of schools was selected to reflect a range of vaccination coverage (high versus lower uptake), and different school types (Catholic, Independent or Government). Semi-structured focus groups and interviews were conducted with girls and their parents respectively, until saturation was reached. Transcripts were analysed, letting themes emerge from the data.

RESULTS

A core theme from both girls and parents was lack of knowledge. Supporting themes were lack of knowledge of HPV, lack of knowledge of vaccine, and realisation of their lack of knowledge. Their lack of knowledge was common in three areas: what HPV is, how HPV is transmitted, and the HPV and cervical cancer connection. The lack of knowledge about HPV vaccination was reflected in what the vaccine protects against, how the vaccine works, HPV vaccination recommendations, the vaccine and Pap smear connection, and myths about HPV vaccination. Both girls and parents wanted more information, had a tendency to defer responsibility, and parents expressed judgment of themselves as parents.

DISCUSSION

Low levels of knowledge and understanding about HPV vaccination among adolescents and parents have implications for adolescents' future health practices, including sexual risk behaviour, condom usage, and cervical screening. Reasons for the low levels of knowledge are explored, as are implications for school-based educational interventions.

Correlates for human papillomavirus vaccination of adolescent girls and young women in a managed care organization

The authors studied the characteristics of those who initiated the human papillomavirus (HPV) vaccine versus those who did not. Female members of Kaiser Permanente Southern California aged 9-26 years were identified and assessed for HPV vaccination between October 2006 and March 2008. Multivariable log-binomial regression was used to examine the association of the following factors with vaccine initiation: 1) demographics, 2) provider characteristics, 3) health care utilization, 4) women's health-related conditions, and 5) selected immune-related conditions. The study included 285,265 females. All analyses were stratified by 2 age groups: 9-17 years and 18-26 years. Black race (relative risk (RR)(9-17 years) = 0.93, RR(18-26 years) = 0.82), having a male primary care provider (RR(9-17 years) = 0.93, RR(18-26 years) = 0.84), and history of hospitalizations were associated with a lower likelihood of vaccine initiation. Higher neighborhood income level, physician office visits, and history of influenza vaccination (RR(9-17 years) = 1.20, RR(18-26 years) = 1.34) were associated with higher HPV vaccine uptake. Those with a history of sexually transmitted diseases were more likely and those with immune-related conditions were not less likely to initiate the HPV vaccine. These findings are helpful for interpreting the results of observational safety studies and providing insights for developing targeted HPV vaccination programs.

Integrating clinical, community, and policy perspectives on human papillomavirus vaccination

Infection with genital human papillomavirus (HPV) may cause anogenital cancers, oropharyngeal cancers, anogenital warts, and respiratory papillomas. Two prophylactic vaccines (a bivalent and a quadrivalent vaccine) are now licensed and currently in use in a number of countries. Both vaccines prevent infection with HPV-16 and HPV-18, which together cause approximately 70% of cervical cancers, and clinical trials have demonstrated 90%-100% efficacy in preventing precancerous cervical lesions attributable to HPV-16 and HPV-18. One vaccine also prevents HPV-6 and HPV-11, which cause 90% of genital warts. A growing literature describes psychosocial, interpersonal, organizational, and societal factors that influence HPV vaccination acceptability. This review summarizes the current literature and presents an integrated perspective, taking into account these diverse influences. The resulting integrated framework can be used as a heuristic tool for organizing factors at multiple levels to guide intervention development and future research.

Health care provider attitudes and practices regarding adolescent immunizations: a qualitative study

OBJECTIVE

Assess health care providers' attitudes and practices regarding adolescent immunizations, including factors that either impede or facilitate vaccination.

METHODS

Focus groups-In 2005, 3 focus groups were conducted in Monroe County, NY for (1) urban primary care physicians (PCPs); (2) suburban PCPs; and (3) nurses from practices represented in PCP groups. Audiotaped discussions were transcribed and analyzed using Atlas.ti. Key informant interviews-We recruited knowledgeable informants (18 physicians, 6 nurses) from across the US. The authors conducted in-depth telephone interviews with the participants, typed their interview notes, and sent them to the participant for verification. Separately for nurses, urban physicians, and suburban physicians results for each question were listed and reviewed by the authors. Themes were added to those from the focus groups.

RESULTS

Three overarching themes were identified: professional buy-in (e.g., reimbursement, professional organization recommendations, disease and vaccine characteristics, office consensus); parent/adolescent buy-in (e.g., school requirements, perception of MD recommendations, cost and insurance coverage, media reports, disease and vaccine characteristics, "vaccine fatigue"), and delivery factors (e.g., vaccine supply, ordering, timing and scheduling, consent).

CONCLUSIONS

Providers identified intertwined system issues that color their attitudes about adolescent immunization.

PRACTICE IMPLICATIONS

Buy-in and delivery factors must be addressed before high immunization rates will be achieved.

Physicians' experiences with HPV vaccine delivery: evidence from developing country with multiethnic populations

Physicians' experiences in providing human papillomavirus (HPV) immunization were assessed by mailed questionnaire. Response rate of 41.4% was achieved. Malay Muslim physicians were more likely to agree that cultural sensitivity is an issue when recommending HPV vaccines. Pediatricians and family physicians were more likely to agree that acceptance is better if vaccines were recommended to prevent cervical cancer than to prevent a sexually transmitted disease. Near 70% rated success of HPV vaccines recommendation in their practice as very poor with the majority patients preferred to postpone immunization. Physicians reported cultural disparities in vaccine uptake and perceived high vaccination cost limits its use.

Chapter 24: Psychosocial aspects of vaccine acceptability

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

Sex, drugs, and politics: the HPV vaccine for cervical cancer

HPV is the most common sexually transmitted infection in the world. While most strains are relatively harmless, some increase a woman's risk of developing cervical cancer. This article explores the intimate, contested relationships among etiologies of cervical cancer, development and use of the new HPV vaccine, and contested notions of sexuality. We particularly focus on shifts in US health care and sexual politics, where the vaccine has animated longstanding concerns about vaccination (e.g. parental rights, cost, specialisation) and young women's bodies and behaviour. We conclude that vaccines are a distinctive kind of pharmaceutical, invoking notions of contagion and containment, and that politics shape every aspect of the pharmaceutical life course.

Vignette studies of medical choice and judgement to study caregivers' medical decision behaviour: systematic review

Background

Vignette studies of medical choice and judgement have gained popularity in the medical literature. Originally developed in mathematical psychology they can be used to evaluate physicians' behaviour in the setting of diagnostic testing or treatment decisions. We provide an overview of the use, objectives and methodology of these studies in the medical field.

Methods

Systematic review. We searched in electronic databases; reference lists of included studies. We included studies that examined medical decisions of physicians, nurses or medical students using cue weightings from answers to structured vignettes. Two reviewers scrutinized abstracts and examined full text copies of potentially eligible studies. The aim of the included studies, the type of clinical decision, the number of participants, some technical aspects, and the type of statistical analysis were extracted in duplicate and discrepancies were resolved by consensus.

Results

30 reports published between 1983 and 2005 fulfilled the inclusion criteria. 22 studies (73%) reported on treatment decisions and 27 (90%) explored the variation of decisions among experts. Nine studies (30%) described differences in decisions between groups of caregivers and ten studies (33%) described the decision behaviour of only one group. Only six studies (20%) compared decision behaviour against an empirical reference of a correct decision. The median number of considered attributes was 6.5 (IQR 4–9), the median number of vignettes was 27 (IQR 16–40). In 17 studies, decision makers had to rate the relative importance of a given vignette; in six studies they had to assign a probability to each vignette. Only ten studies (33%) applied a statistical procedure to account for correlated data.

Conclusion

Various studies of medical choice and judgement have been performed to depict weightings of the value of clinical information from answers to structured vignettes of care givers. We found that the design and analysis methods used in current applications vary considerably and could be improved in a large number of cases.

Current issues in adolescent immunization

Based on the December 2006 Fondation Mérieux International Scientific Symposium, the current state of adolescent immunization is reviewed with a focus on the policy and programmatic issues that impact the acceptability, initiation, and successful implementation. Key questions are identified with proposed strategies to help achieve successful adolescent immunization programs. The role of current vaccines targeted to adolescents, such as those directed against invasive meningitis, pertussis, and the human papillomavirus, is reviewed as well as their role in rejuvenating interest in adolescent immunization, and more importantly, adolescent health as a whole.

Appropriate Use of Cervical Cancer Vaccine

Human papillomavirus (HPV) is a necessary, though not sufficient, cause of cervical cancer. Two vaccines have been developed that prevent two HPV types associated with 70% of cervical cancers. One of the vaccines (a quadrivalent vaccine) also prevents two HPV types associated with 90% of genital warts. Both HPV vaccines have shown very good efficacy and safety. This review summarizes the guidelines for use of the quadrivalent vaccine published by the Advisory Committee on Immunization Practices, presents data on vaccine efficacy and safety, and gives an overview of the findings of cost-effectiveness studies. In addition, we summarize the research on the attitudes of parents and health care providers toward HPV vaccine and critically evaluate controversial and challenging issues surrounding HPV vaccination, including concerns about sexual disinhibition and potential obstacles to vaccine distribution and uptake.

Pediatrician knowledge and attitudes regarding human papillomavirus disease and its prevention

Between 1 September and 8 October 2006, we used a self-administered, anonymous questionnaire in order to evaluate knowledge and attitudes regarding HPV disease and its prevention in a nationally representative sample of Italian pediatricians. Three hundred and eleven of the 400 enrolled physicians (175 primary care pediatricians, 160 hospital pediatricians and 65 residents in pediatrics) returned completed surveys (227 females; mean age+/-standard deviation, 45.3+/-11.61 years). The results showed a lack of knowledge concerning HPV disease and its prevention, with marginal differences between the subgroups, even though the majority would recommend HPV vaccination. These findings highlight an urgent need to improve pediatrician information in order to ensure the optimal implementation of HPV vaccination, and the adequate acceptability of HPV vaccines to adolescents and their parents.

HPV and cervical cancer prevention counseling with younger adolescents: implications for primary care

PURPOSE

Primary care clinicians will continue to play an important role in cervical cancer prevention, particularly with regard to administration of the newly licensed human papillomavirus (HPV) vaccine and continued administration of Papanicolaou tests. Little is known about the factors that influence cervical cancer prevention counseling, particularly in the adolescent encounter. We conducted a qualitative study to better understand the implications for counseling about cervical cancer prevention by primary care clinicians who care for adolescents.

METHODS

We conducted in-depth interviews with 37 primary care clinicians in New Mexico to understand the context in which they provide anticipatory guidance about sexual health risks as well as their attitudes about counseling for the forthcoming HPV vaccine.

RESULTS

Clinicians identified 4 categories of factors related to their counseling experiences with adolescents about HPV: (1) the need to build rapport with adolescent patients, (2) the presumption that adolescent patients engage in high-risk behaviors, (3) the situational delivery and complexity of HPV counseling, and (4) perceptions of clinician and community receptivity to the HPV vaccine.

CONCLUSION

Our findings show that conditions of the preadolescent and young adolescent visit pose a challenge to the successful integration of counseling about cervical cancer prevention in primary care. Counseling strategies that are designed to emphasize a preventive focus while including parents in the discussion at the time of vaccination and that are appropriate to populations with different cultural values and beliefs will help to enhance communication about cervical cancer prevention and the particular role of the HPV vaccine.

A semi-qualitative study of attitudes to vaccinating adolescents against human papillomavirus without parental consent

Background

The first vaccine to prevent human papillomavirus (HPV) and cervical cancer has been licensed, and in future, vaccination may be routinely offered to 10–14 year old girls. HPV is a sexually transmitted virus and some parents may refuse consent for vaccination. Under-16s in the UK have a right to confidential sexual health care without parental consent. We investigated parents' views on making available HPV vaccination to adolescent minors at sexual health clinics without parental consent.

Methods

This was a semi-qualitative analysis of views of parents of 11–12 year old school children collected as part of a population-based survey of parental attitudes to HPV vaccination in Manchester. Parents were firstly asked if they agreed that a well-informed child should be able to request vaccination at a sexual health clinic without parental consent, and secondly, to provide a reason for this answer. Ethical perspectives on adolescent autonomy provided the framework for descriptive analysis.

Results

307 parents answered the question, and of these, 244 (80%) explained their views. Parents with views consistent with support for adolescent autonomy (n = 99) wanted to encourage responsible behaviour, protect children from ill-informed or bigoted parents, and respected confidentiality and individual rights. In contrast, 97 parents insisted on being involved in decision-making. They emphasised adult responsibility for a child's health and guidance, erosion of parental rights, and respect for cultural and moral values. Other parents (n = 48) wanted clearer legal definitions governing parental rights and responsibilities or hoped for joint decision-making. Parents resistant to adolescent autonomy would be less likely to consent to future HPV vaccination, (67%) than parents supporting this principle (89%; p < 0.001).

Conclusion

In the UK, the principle of adolescent autonomy is recognised and logically should include the right to HPV vaccination, but this may concern parents who would otherwise approve vaccination.

A national survey of pediatrician knowledge and attitudes regarding human papillomavirus vaccination

OBJECTIVE

A human papillomavirus vaccine was licensed in June 2006. The vaccine is quadrivalent, protecting against 2 human papillomavirus strains that cause cervical cancer and 2 that cause genital warts. The objective of this study was to determine physician characteristics, knowledge, and attitudes associated with an intention to recommend human papillomavirus vaccination.

METHODS

Between August and October 2005, a cross-sectional survey was administered to a national network of 431 pediatricians. The network was developed from a random sample of American Academy of Pediatrics members and was designed to be representative of the organization's membership with respect to urban/rural location, practice type, and region. The survey was conducted before human papillomavirus vaccine licensure and therefore focused on a candidate quadrivalent human papillomavirus vaccine and a range of potential vaccination recommendations. The main outcome measure was intention to recommend a quadrivalent human papillomavirus vaccine to young adolescent (10- to 12-year-old) females.

RESULTS

Survey response rate was 68%. If endorsed by national health organizations, 46% of respondents would recommend vaccination for 10- to 12-year-old females, 77% for 13- to 15-year-old females, and 89% for 16- to 18-year-old females. Corresponding rates for males were 37%, 67%, and 82%, respectively. Whereas 60% of respondents thought that parents would be concerned that human papillomavirus vaccination may encourage risky sexual behaviors, 11% reported that they themselves had this concern. Respondents who believed that other new adolescent immunization recommendations (eg, meningococcal, pertussis) would facilitate human papillomavirus vaccine implementation were more likely to intend to recommend vaccination.

CONCLUSIONS

Although a national sample of pediatricians expressed a high level of acceptance of human papillomavirus vaccination in older adolescent females, fewer than one half anticipated giving human papillomavirus vaccine to younger female patients. Provider concerns about parental vaccine acceptance will need to be addressed to optimize human papillomavirus vaccination implementation.

Perceptions of parents seeking an experimental herpes simplex vaccine for their adolescent and preadolescent daughters

Perceptions of parents willing to enroll their daughters in genital herpes vaccine trials were examined by questionnaire. Respondents were knowledgeable about genital herpes and endorsed personal and societal protection as important reasons to vaccinate. A belief among some that the vaccine might promote sexual activity did not prevent them from seeking protection for their daughters.

Pediatric HIV type 1 vaccine trial acceptability among mothers in Kenya

Vaccination of infants against human immunodeficiency virus type 1 (HIV-1) may prevent mother-to-child HIV-1 transmission. Successful trials and immunization efforts will depend on the willingness of individuals to participate in pediatric vaccine research and acceptance of infant HIV-1 vaccines. In a cross-sectional study, pregnant women presenting to a Nairobi antenatal clinic for routine care were interviewed regarding their attitudes toward participation in research studies and HIV-1 vaccine acceptability for their infants. Among 805 women, 782 (97%) reported they would vaccinate their infant against HIV-1 and 729 (91%) reported willingness to enroll their infant in a research study. However, only 644 (80%) would enroll their infants if HIV- 1 testing was required every 3 months and 513 (64%) would agree to HIV-1 vaccine trial participation. Reasons for not wanting to enroll in a pediatric HIV-1 vaccine trial included concerns about side effects (75%), partner objection (34%), and fear of discrimination (10%), HIV-1 acquisition (8%), or false-positive HIV-1 results (5%). The strongest correlate of pediatric vaccine trial participation was maternal willingness to be a vaccine trial participant herself; in univariate and multivariate models this was associated with a 17-fold increased likelihood of participation (HR 17.1; 95% CI 11.7-25; p < 0.001). We conclude from these results that immunizing infants against HIV-1 and participation in pediatric vaccine trials are generally acceptable to women at high risk for HIV-1 infection. It will be important to address barriers identified in this study and to include male partners when mobilizing communities for pediatric HIV-1 vaccine trials and immunization programs.

Understanding and overcoming barriers to human papillomavirus vaccine acceptance

New vaccines designed to prevent human papillomavirus (HPV) infection have the potential to reduce the incidence of serious illness and death worldwide among women, substantially reduce the emotional suffering associated with abnormal Papanicolaou (Pap) test results and the diagnosis of cervical cancer, and save significant health care dollars. However, these benefits may not be fully realized until the vaccine is accepted by patients, parents, and health care practitioners. Furthermore, there may be unique issues related to the acceptance of a vaccine designed to prevent a sexually transmitted infection that is poorly understood by many women. Among the acceptance issues are: individual comfort with a sexually transmitted infection (STI) vaccine; parental comfort with vaccination of their preadolescent/early adolescent daughters; physician comfort with recommending a human papillomavirus vaccine to women and parents of preadolescents; and physician communication skills related to talking with women and parents about the vaccine. Potentially difficult as it might be to implement a vaccination program, vaccination and prevention of HPV-associated disease are still infinitely preferable to observation and treatment. This article will review some of the potential barriers to HPV Vaccine acceptance, with a particular focus on factors relevant to female patients, parents, and health care providers.

Attitudes about human papillomavirus vaccine among family physicians

STUDY OBJECTIVE

Human papillomavirus (HPV) vaccines will soon be available for clinical use, and the effectiveness of vaccine delivery programs will depend largely upon whether providers recommend the vaccine. The objectives of this study were to examine family physicians' attitudes about HPV immunization and to identify predictors of intention to recommend immunization.

DESIGN

Cross-sectional survey instrument assessing provider and practice characteristics, knowledge about HPV, attitudes about HPV vaccination, and intention to administer two hypothetical HPV vaccines.

PARTICIPANTS

Surveys were mailed to a national random sample of 1,000 American Academy of Family Physicians (AAFP) members.

MAIN OUTCOME MEASURE

Intention to administer two hypothetical HPV vaccines (a cervical cancer/genital wart vaccine and a cervical cancer vaccine) to boys and girls of different ages.

RESULTS

One hundred fifty-five surveys (15.5%) were returned and 145 were used in the final sample. Participants reported higher intention to recommend both hypothetical HPV vaccines to girls vs. boys (P < 0.0001) and to older vs. younger adolescents (P < 0.0001). They were more likely to recommend a cervical cancer/genital wart vaccine than a cervical cancer vaccine to boys and girls (P < 0.001). Variables independently associated with intention (P < 0.05) included: female gender of provider, knowledge about HPV, belief that organizations such as the AAFP would endorse vaccination, and fewer perceived barriers to vaccination.

CONCLUSIONS

Female gender, knowledge about HPV, and attitudes about vaccination were independently associated with family physicians' intention to recommend HPV vaccines. Vaccination initiatives directed toward family physicians should focus on modifiable predictors of intention to vaccinate, such as HPV knowledge and attitudes about vaccination.