Parents' Recall and Reflections on Experiences Related to HPV Vaccination for Their Children

Communication Interactions, Needs, and Preferences During Clinical Encounters of African American Parent-Child Dyads

Human papillomavirus (HPV) vaccination rates remain suboptimal among African American adolescents. Although provider recommendations during clinical encounters are believed to be highly effective in increasing uptake and series completion, little has been reported about parent-child perspectives on the counseling received during these encounters. Among African American parent-child dyads, we sought to explore and compare interactions, needs, and preferences during clinical encounters by child's HPV vaccination status. We applied a qualitative, phenomenological study design to conduct semi-structured interviews with African American parent-child dyads representing children who were unvaccinated (n = 10), had initiated but not completed (n = 11), or had completed the HPV vaccine series (n = 9). Using iterative, inductive-deductive thematic analysis, five themes were generated: (1) parents' attitudes varied about the HPV vaccine but were mostly positive for vaccines in general; (2) patient-parent-provider clinical encounters from the parent perspective; (3) patient-parent-provider clinical encounters from the child perspective; (4) methods of distribution of supplemental HPV information; and (5) communication desired on HPV vaccination by parents and children. Parents stating they received a provider's recommendation increased by vaccination status (unvaccinated: 6 out of 10; initiated: 7 out of 11; completed: 9 out of 9). Most parents and children were not satisfied with provider communication on the HPV vaccine and used supplemental materials to inform decision-making. Ongoing communication on the HPV vaccine was requested even post-vaccination of the child. During clinical encounters, children and parental messaging needs are similar yet dissimilar. We offer communication strategies and messaging that can be used for African American parent-child dyads by child HPV vaccination status during a clinical encounter.

Patient-Provider Health Communication Strategies: Enhancing HPV Vaccine Uptake among Adolescents of Color

Cervical cancer remains a public health issue in the United States, particularly among stigmatized racial and ethnic populations. The human papillomavirus (HPV) vaccine has been clinically proven to prevent cervical cancers, and other HPV-associated cancers, among men and women. However, HPV vaccine uptake is suboptimal; only 55% of adolescents complete the two-dose series by age 15. Past research has shown that provider HPV vaccine communication for people of marginalized races/ethnicities is subpar. This article focuses on provider communication strategies to promote HPV vaccine uptake effectively and equitably. The authors reviewed the literature on evidence-based patient-provider HPV vaccine communication techniques to create a set of communication language providers could use and avoid using to enhance HPV vaccine acceptance and uptake among adolescents of marginalized racial and ethnic groups. Evidence has shown that information and the manner of dissemination are critical for influencing HPV vaccine uptake. These communication strategies must be suited to the context of the targeted population, and the message content can be broadly categorized into source, content, and modality. Strategies to improve patient-provider communication among adolescents of color using source, modality, and content include the following: (1) Source: increase provider self-efficacy to provide the recommendation, building rapport between providers and parents; (2) Content: persistent, forceful language with minimal acquiescence should be employed, reframing the conversation focus from sex to cancer; and (3) Modality: use multiple vaccine reminder modalities, and work with the community to culturally adapt the vaccination language. Utilizing effective behavior-change communication adapted for adolescents of color can reduce missed opportunities for HPV prevention, potentially decreasing racial and ethnic disparities in HPV-related morbidity and mortality.

How Perceptions of Responsibility and Affective Consequences Influence Parents' Digital Media Engagement in Relation to Human Papillomavirus Vaccination

Individuals are expected to be responsible for their own health and that of their families-and act accordingly. Yet, being in a position of responsibility might be undesirable for individuals either unable or reluctant to comply with the expectations this responsibility entails. In this article, I explore how parents experience the process of engaging responsibly with digital media in relation to the question of human papillomavirus vaccination. The study is based on interviews with eighteen Danish parents, and my findings show that these parents not only understand themselves but also other actors in terms of responsibility, and that being positioned in terms of responsibility can have negative affective consequences. I argue that meeting the expectations of biological citizenship should not necessarily be a goal in relation to complex health topics.

Barriers towards HPV Vaccinations for Boys and Young Men: A Narrative Review

Background: HPV vaccination of both girls and boys can protect against infection and eliminate the risk for HPV-associated cancer. Due to a common misconception that the virus only poses risks to women, vaccine coverage is suboptimal among men in many countries. It is urgent to identify barriers to vaccination of boys and men. Methods: We conducted a narrative review of publications examining attitudes and beliefs regarding HPV vaccination for boys and young men. The electronic databases searched were PubMed, PsychInfo and Scopus (December 2020; last update July 2021). A total of 103 original articles were included in the final analysis. Results: The central barriers against vaccination of boys and men are: (1) lack of knowledge, (2) vaccine hesitancy in general, (3) lack of recommendation from and/or discussions with healthcare providers, (4) cost and logistics, and (5) the idea that HPV vaccination may promote promiscuity. Men who have sex with men and families belonging to ethnic minorities express a need for information tailored to their situation. Conclusions: Boys should be included in national immunization programs and men should also be offered catch-up vaccinations. Future studies should focus on addressing vaccine hesitancy and developing interventions to promote pan-gender HPV vaccination.

Nurses' and teachers' perceived barriers and facilitators to the uptake of the Human Papilloma Virus (HPV) vaccination program in Iquitos, Peru: A qualitative study

Globally, over 300,000 women die of cervical cancer annually. Given that human papillomavirus vaccines are highly effective in the primary prevention of cervical cancer, it is important to explore the barriers and facilitators to vaccination uptake in areas where the burden of disease remains high. This study, informed by the socio-ecological model, aimed to qualitatively explore vaccination uptake via in-depth interviews with eleven nurses and ten teachers involved in vaccine delivery in Iquitos, Peru. The results highlighted that vaccine uptake was influenced by multiple factors including individuals' knowledge and attitudes, community beliefs, geography, and policy level variables. Findings suggested that professionals were informed and supportive of the HPV vaccination program but perceived that parents were uninformed about the vaccine. There is a need for community education programs, for a revision of the process of obtaining parental consent, for improved communication between professionals and for involvement of grassroots staff in policy making.

Development and evaluation of an online continuing education course to increase healthcare provider self-efficacy to make strong HPV vaccine recommendations to East African immigrant families

OBJECTIVE

To develop and evaluate an online continuing education (CE) course designed to improve healthcare provider self-efficacy to make strong adolescent HPV vaccine recommendations to East African immigrant families.

METHODS

Focus groups with providers and East African immigrant mothers informed course development. Providers serving East African immigrant families were recruited to view the course and complete pre-/post-test and two-month follow-up surveys. Pre-/post differences were compared with paired t-tests.

RESULTS

202 providers completed the course and pre-/post-test; 158 (78%) completed two-month follow-up. Confidence to make strong HPV vaccine recommendations to East African families increased from 68% pre-test to 98% post-test. Confidence to address common parental concerns also increased: safety, 54% pre-test, 92% post-test; fertility, 55% pre-test, 90% post-test; child too young, 68% pre-test, 92% post-test; and pork gelatin in vaccine manufacturing, 38% pre-test, 90% post-test. Two-month follow-up scores remained high (97% for overall confidence, 94%-97% for addressing parental concerns). All pre-/post-test and pre-test/two-month follow-up comparisons were statistically significant (p < 0.05).

CONCLUSIONS

The online CE course focused on culturally appropriate strategies for making strong recommendations and addressing specific parental concerns was effective for increasing provider self-efficacy to recommend HPV vaccination to East African families. Similar courses could be tailored to other priority populations.

Knowledge, attitudes and perceptions of Nigerian parents towards human papilloma virus (HPV) vaccines

INTRODUCTION

Human papilloma virus (HPV) is a renowned cause of cervical cancer, which has resulted in high mortality of individuals. Cervical cancer could be reduced by screening and HPV vaccination. This study investigated knowledge, attitudes and perceptions of parents towards HPV vaccines in Ibadan, South-West L.G.A, Oyo State, Nigeria.

METHODS

A cross-sectional descriptive design was used with a multi-stage sampling technique to select 186 parents from Ibadan South-West local government area of Oyo state. A validated structured questionnaire (r=0.78) was used for data collection.

RESULTS

The mean age of the respondents was 30.2 years. The parents had good knowledge of the HPV vaccine (mean=3.12) and most had a high level of knowledge (98.9%). Parents demonstrated negative attitude (mean=2.97) and positive perception to HPV vaccines. Major factors affecting their attitude towards the uptake of HPV vaccines were: finance (86%), level of education (81%), distance to health facilities (83%), inadequate knowledge about the vaccine (89%), fear of promiscuity (82%), and concern about adverse effect (80%).

CONCLUSIONS

Factors responsible for a negative attitude were the high cost, distance from vaccination site, inadequate knowledge, fear of subsequent adolescent promiscuity and concern about adverse effects. In light of the benefits of HPV vaccination, the Nigerian government should make HPV vaccines available, affordable, and accessible to the public.

Barriers to Human Papillomavirus Vaccine Uptake Among Racial/Ethnic Minorities: a Systematic Review

BACKGROUND

Human papillomavirus (HPV) is associated with poor health outcomes, including cervical cancer. Racial/ethnic minority populations experience poor health outcomes associated with HPV at higher rates. A vaccine is available to protect against HPV infections and prevent HPV-related sequelae; however, vaccination rates have remained low in the United States (U.S.) population. Thus, there is an urgent need to increase the HPV vaccination rate. Moreover, little is known about barriers to HPV vaccination in racial/ethnic minority groups. This paper highlights the most recent findings on barriers experienced by these groups.

METHODS

The PubMed database was searched on July 30, 2020, for peer-reviewed articles and abstracts that had been published in English from July 2010 to July 2020 and covered racial/ethnic disparities in HPV vaccination.

RESULTS

Similar findings were observed among the articles reviewed. The low HPV vaccination initiation and completion rates among racial/ethnic minority populations were found to be associated with lack of provider recommendations, inadequate knowledge and awareness of HPV and HPV vaccination, medical mistrust, and safety concerns.

CONCLUSIONS

Provider recommendations and accurate distribution of information must be increased and targeted to racial/ethnic minority populations in order to bolster the rate of vaccine uptake. To effectively target these communities, multi-level interventions need to be established. Further, research to understand the barriers that may affect unvaccinated adults in the catch-up age range, including males, may be beneficial, as majority of the previous studies focused on either parents of adolescents or women.

Cognitive Bias in Clinicians' Communication about Human Papillomavirus Vaccination

National guidelines recommend human papillomavirus (HPV) vaccination for all 11-12-year-olds, but uptake among United States adolescents remains low. A major barrier to greater uptake is the lack of effective recommendations for HPV vaccine from clinicians. One potential influence on clinicians' recommendations for HPV vaccine that has been relatively unexplored is that of cognitive biases, or errors in judgement that result from 'mental shortcuts' used to make decisions under uncertainty. Therefore, we analyzed qualitative data from interviews with 32 pediatric clinicians using a framework of nine cognitive biases relevant to HPV vaccination: omission bias, ambiguity aversion, present bias, availability bias, optimism bias, naturalness bias, protected values, anchoring bias, and confirmation bias. We used a directed content analysis approach to iteratively code and analyze all transcripts in the dataset. We found evidence for several cognitive biases that were related to weaker recommendations for HPV vaccine. Commonly identified biases included anchoring bias (perception that vaccination unnecessary due to age/pubertal status); present bias (perception of burdens related to discussing vaccination), and optimism bias (belief that patient at low risk for HPV acquisition). We found less frequent evidence for ambiguity aversion (perception of missing information regarding vaccination) and omission bias (deferring vaccination). Other biases were identified infrequently or not at all. Our findings suggest that several cognitive biases may be an influence on clinicians' communication about HPV vaccine. Raising awareness of cognitive biases related to making HPV vaccine recommendations could help to strengthen the recommendations that clinicians provide.

Completion of the Human Papillomavirus Vaccination Series Among Adolescent Users and Nonusers of School-Based Health Centers

OBJECTIVES

Uptake and completion of the human papillomavirus (HPV) vaccine series among adolescents are suboptimal in the United States. We examined immunization registry data to determine completion of the 3-dose HPV vaccine series among adolescents in Seattle, Washington, born during 1995-2000 who received ≥1 dose of HPV vaccine.

METHODS

Immunization data included the administrating facility, which identified adolescents who used school-based health centers (SBHCs) for any HPV vaccine dose. We calculated completion of the 3-dose series at any time and on time by the 13th birthday. We stratified analyses by sex and assessed differences in on-time and any-time completion between users and nonusers of SBHCs.

RESULTS

Overall, 67.9% (8612 of 12 676) of females and 41.8% (3560 of 8521) of males with ≥1 dose of HPV vaccine completed the 3-dose series. Compared with female SBHC nonusers, female SBHC users had 37% higher odds of completing the series at any time (adjusted odds ratio [aOR] = 1.37; 95% CI, 1.19-1.58) and 33% higher odds of completing the series on time (aOR = 1.33; 95% CI, 1.08-1.64). Compared with male SBHC nonusers, male SBHC users had 45% higher odds of completing the series at any time (aOR = 1.45; 95% CI, 1.23-1.70) and 79% higher odds of completing the series on time (aOR = 1.79; 95% CI, 1.11-2.89).

CONCLUSION

Adolescent SBHC users had higher odds of completing the HPV vaccine series than adolescents who received all doses in traditional health care settings. SBHCs should be leveraged to increase adolescent immunization rates.

HPV vaccine recommendation profiles among a national network of pediatric practitioners: understanding contributors to parental vaccine hesitancy and acceptance

Background: Practitioner communication is one of the most important influences and predictors of HPV vaccination uptake. The objective of this study was to conduct a latent class analysis characterizing pediatric practitioner HPV recommendation patterns. Methods: Pediatric practitioners of the American Academy of Pediatrics' (AAP) Pediatric Research in Office Settings (PROS) national network completed an online survey where they were presented with 5 hypothetical vignettes of well child visits and responded to questions. Questions asked about their use of communication strategies, assessments about the adolescent patient becoming sexually active in the next 2 years for decision-making about HPV vaccine recommendation, and peer norms. Latent class analysis characterized practitioner subgroups based on their response patterns to 10 survey questions. Multinomial logistic regression examined practitioner characteristics associated with each profile. Results: Among 470 respondents, we identified three distinct practitioner HPV vaccine recommendation profiles: (1) Engagers (52%) followed national age-based guidelines, strongly recommended HPV vaccination, and perceived peers as strongly recommending; (2) Protocol Followers (20%) also strongly recommended HPV vaccination, but were less likely to engage families in a discussion about benefits; and (3) Ambivalent HPV Vaccine Recommenders (28%) delayed or did not recommend HPV vaccination and were more likely to use judgment about whether adolescents will become sexually active in the next two years. Practicing in a suburban setting was associated with twice the odds of being an Ambivalent Recommender relative to being an Engager (OR = 2.2; 95% CI:1.1-4.1). Conclusions: Findings underscore the importance of continued efforts to bolster practitioner adoption of evidence-based approaches to HPV vaccine recommendation especially among Ambivalent Recommenders.

Vaccine Hesitancy in Pediatric Primary Care Practices

Understanding how pediatric practices handle parental vaccine hesitancy is important as it impacts the efficiency and effectiveness of pediatric practices. In total, 21 semi-structured interviews with pediatric practice staff within a primary care network were conducted between May 2012 and March 2013. Thematic analysis focused on the barriers and challenges of vaccine hesitancy and strategies to reduce the burden at the practice level. Barriers and challenges of vaccine hesitancy included time constraints, administrative challenges, financial challenges and strained patient-provider relationships. Strategies to minimize the burden of vaccine hesitancy included training for vaccine counseling, screening for vaccine hesitancy prior to immunization visits, tailored vaccine counseling, and primary care provider visits for follow-up immunization. Pediatric practices reported many challenges when caring for vaccine-hesitant families. Multiple strategies were identified to reduce the burden of vaccine hesitancy, which future studies should explore to determine how effective they are in increasing vaccine acceptance in pediatric practices.

Indicated or elective? The association of providers' words with HPV vaccine receipt

BACKGROUND

Appropriate provider recommendation is crucial to raising HPV vaccination uptake, yet scant research has explored actual conversations between providers and parents, the effect of parental pre-visit vaccine intention on vaccination, or the effect of conversation style on parental satisfaction with that conversation.

METHODS

We analyzed 146 audio-recorded clinical encounters between providers, parents/guardians, and HPV vaccine-eligible adolescents, from May 2015 to March 2017, at eight practices in Northeastern U.S. Parents completed pre-visit measures of intent to vaccinate and post-visit assessments of satisfaction with vaccine conversations. We qualitatively analyzed transcribed audio recordings and evaluated associations between providers' vaccine introductions and vaccine receipt.

RESULTS

Provider recommendations were empirically defined as "indicated" (clear recommendation that the child receive HPV vaccination at that visit), "elective" (vaccination presented as optional), or "contraindicated" (delay recommended). The vaccination rates were 87%, 68%, and 0% following "indicated," "elective," and "contraindicated" presentations respectively. Providers' statements attesting to the vaccine's value to the child did not affect receipt. Parental pre-visit intent to vaccinate was associated with vaccine receipt: 100% for likely/very likely compared to 28% for very unlikely. The association between vaccine recommendation style and vaccine receipt was most pronounced with undecided parents, with 92% accepting vaccination after an "indicated" recommendation vs. 68% after an "elective" recommendation. Satisfaction with vaccine conversations was high regardless of recommendation style.

CONCLUSIONS

The results suggest that the words used to introduce HPV vaccination have the potential to inform parents' HPV vaccination decisions. Providers should be encouraged to simply state, "Your child is due for the HPV vaccine today."

Saturation in qualitative research: exploring its conceptualization and operationalization

Saturation has attained widespread acceptance as a methodological principle in qualitative research. It is commonly taken to indicate that, on the basis of the data that have been collected or analysed hitherto, further data collection and/or analysis are unnecessary. However, there appears to be uncertainty as to how saturation should be conceptualized, and inconsistencies in its use. In this paper, we look to clarify the nature, purposes and uses of saturation, and in doing so add to theoretical debate on the role of saturation across different methodologies. We identify four distinct approaches to saturation, which differ in terms of the extent to which an inductive or a deductive logic is adopted, and the relative emphasis on data collection, data analysis, and theorizing. We explore the purposes saturation might serve in relation to these different approaches, and the implications for how and when saturation will be sought. In examining these issues, we highlight the uncertain logic underlying saturation-as essentially a predictive statement about the unobserved based on the observed, a judgement that, we argue, results in equivocation, and may in part explain the confusion surrounding its use. We conclude that saturation should be operationalized in a way that is consistent with the research question(s), and the theoretical position and analytic framework adopted, but also that there should be some limit to its scope, so as not to risk saturation losing its coherence and potency if its conceptualization and uses are stretched too widely.

Provider Communication and Mothers' Willingness to Vaccinate Against Human Papillomavirus and Influenza: A Randomized Health Messaging Trial

OBJECTIVE

To understand the effect of a health messaging intervention focused on provider communication about vaccination on mothers' willingness to vaccinate children against human papillomavirus (HPV) and seasonal influenza.

METHODS

A total of 2476 mothers of 9- to 13-year-olds in the United States completed a Web-based survey in August 2014. Mothers were randomized to 1 of 2 groups targeting HPV or influenza vaccine. Mothers whose child had not received the target vaccine (ie, zero doses of HPV vaccine/no prior-year administration of influenza vaccine) were randomized to the intervention. The study used a 3 × 2 between-subjects design; illustrated vignettes depicted 1 of 3 levels of provider recommendation strength (brief mention of vaccination, strong recommendation of vaccination, or personal disclosure of vaccination of own children), and presence or absence of information comparing safety of vaccination to the safety of a common daily activity. Outcome was mothers' willingness to have their child receive the target vaccine. Perceived benefits of vaccination were assessed before viewing the intervention and were included as a covariate in analyses, along with child gender.

RESULTS

For HPV vaccine, there was a main effect of safety information (F(1,684) = 7.99, P = .005) and perceived benefits of vaccination (F(1,684) = 221.64, P < .001) on mothers' willingness to vaccinate. For influenza, perceived benefits of vaccination significantly related to willingness to vaccinate (F(1,462) = 105.78, P < .001). Child gender was not associated with willingness.

CONCLUSIONS

Provider communication about vaccination may need to be tailored to the vaccine in question. A next step to increasing coverage for both HPV and influenza vaccines may be an intervention aimed at increasing mothers' perceived benefits of vaccination.

Human Papillomavirus Vaccination: Narrative Review of Studies on How Providers' Vaccine Communication Affects Attitudes and Uptake

The burden of human papillomavirus (HPV) infections is substantial, causing thousands of cancers and deaths in the United States yearly. Safe and effective vaccines exist, yet remains underutilized, particularly among younger adolescents for whom the vaccine is targeted. Provider communication techniques are known to affect parents' and adolescents' acceptance of this vaccine. In this review, we examine the influence that provider communication techniques have on parental attitudes regarding HPV vaccine, as well as how those techniques affect vaccination uptake. We explore the limited literature that has directly measured the influence of provider communication techniques on parental attitudes, which suggests that the strength of a provider recommendation strongly influences parents' perceptions regarding the safety of HPV vaccine, and that brief recommendations might be best for parents without significant concerns. We also review the literature regarding the use of so-called 'presumptive' recommendations, and how these types of recommendations are associated with increased HPV vaccine uptake. Finally, we present new information regarding the use of motivational interviewing as a provider communication technique to improve vaccination uptake, particularly among vaccine-hesitant parents. We close with suggestions for 'best practices' that include using brief, strong, unambiguous language to introduce the HPV vaccine, followed by more nuanced communication techniques, such as motivational interviewing, when encountering resistance.

Lack of school requirements and clinician recommendations for human papillomavirus vaccination

BACKGROUND

A strong recommendation from a clinician is one of the best predictors of human papillomavirus (HPV) vaccination among adolescents, yet many clinicians do not provide effective recommendations. The objective of this study was to understand how the lack of school entry requirements for HPV vaccination influences clinicians' recommendations.

DESIGN AND METHODS

Semi-structured interviews with a purposive sample of 32 clinicians were conducted in 2015 in Connecticut USA. Data were analysed using an iterative thematic approach in 2016-2017.

RESULTS

Many clinicians described presenting HPV vaccination as optional or non-urgent because it is not required for school entry. This was noted to be different from how other required vaccines were discussed. Even strong recommendations were often qualified by statements about the lack of requirements. Furthermore, lack of requirements was often raised initially by clinicians and not by parents. Many clinicians agreed that requirements would simplify the recommendation, but that parents may not agree with requirements. Personal opinions about school entry requirements were mixed.

CONCLUSIONS

The current lack of school entry requirements for HPV vaccination is an important influence on clinicians' recommendations that are often framed as optional or non-urgent. Efforts are needed to strengthen the quality of clinicians' recommendations in a way that remains strong and focused on disease prevention yet uncoupled from the lack of requirements that may encourage delays. Additionally, greater support for requirements among clinicians may be needed to successfully enact requirements in the future.

"My mom said it wasn't important": A case for catch-up human papillomavirus vaccination among young adult women in the United States

The human papillomavirus (HPV) vaccine prevents HPV-related diseases, including anogenital cancers and genital warts. In the United States, while it is recommended to adolescents ages 11 to 12, catch-up vaccination is available for those previously unvaccinated until age 26. Parental decisions or lack of provider recommendation during adolescence are barriers to on-time vaccination. Young adult women, ages 18 to 26, are a key catch-up vaccination population as this is a period for autonomous decision-making, high healthcare utilization, and other recommended prevention behaviors. Additional intervention research is required to promote HPV vaccine uptake among young adult women. Evidence-based and theory-informed interventions need to be developed and evaluated to reach a large number of women. In order to improve HPV vaccination among young adult women, future research should integrate the themes of health literacy, alternative healthcare settings, and OB/GYN providers to facilitate improved access and shared decision-making for the vaccine. This last chance for HPV-related cancer prevention should not be forgotten in public health efforts.

Saturation in qualitative research: exploring its conceptualization and operationalization

Saturation has attained widespread acceptance as a methodological principle in qualitative research. It is commonly taken to indicate that, on the basis of the data that have been collected or analysed hitherto, further data collection and/or analysis are unnecessary. However, there appears to be uncertainty as to how saturation should be conceptualized, and inconsistencies in its use. In this paper, we look to clarify the nature, purposes and uses of saturation, and in doing so add to theoretical debate on the role of saturation across different methodologies. We identify four distinct approaches to saturation, which differ in terms of the extent to which an inductive or a deductive logic is adopted, and the relative emphasis on data collection, data analysis, and theorizing. We explore the purposes saturation might serve in relation to these different approaches, and the implications for how and when saturation will be sought. In examining these issues, we highlight the uncertain logic underlying saturation—as essentially a predictive statement about the unobserved based on the observed, a judgement that, we argue, results in equivocation, and may in part explain the confusion surrounding its use. We conclude that saturation should be operationalized in a way that is consistent with the research question(s), and the theoretical position and analytic framework adopted, but also that there should be some limit to its scope, so as not to risk saturation losing its coherence and potency if its conceptualization and uses are stretched too widely.

Acceptability of School-Based Health Centers for Human Papillomavirus Vaccination Visits: A Mixed-Methods Study

BACKGROUND

Countries with high human papillomavirus (HPV) vaccination rates have achieved this success largely through school-based vaccination. Using school-based health centers (SBHCs) in the United States, where HPV vaccine remains underutilized, could improve uptake. In this mixed-methods study, we examined acceptability, facilitators, and barriers of HPV vaccination visits at SBHCs from the perspectives of adolescents and parents.

METHODS

We conducted qualitative interviews and structured surveys with adolescents and parents recruited from an urban, hospital-based clinic. Interviews with parents (N = 20) and adolescents (N = 20) were audio-recorded and transcribed for analysis using an iterative thematic approach. Quantitative measures for a survey administered to parents (N = 131) were derived from the qualitative findings. Survey results were analyzed by chi-square tests.

RESULTS

Many participants expressed favorable opinions of HPV vaccination at SBHCs in qualitative interviews. Facilitators included convenience, ease of scheduling, and not missing work or school. However, barriers were noted including concerns about obtaining care outside the medical home, fragmentation of medical records, and negative perceptions about SBHCs. Quantitative findings revealed that a higher proportion of parents with experience using SBHCs were willing to use a middle school (59.5%) or high school (80.5%) SBHC for HPV vaccinations compared with those who had not used SBHCs (p < .05 for both comparisons).

CONCLUSIONS

HPV vaccination visits at SBHCs were acceptable, and SBHC users expressed more favorable attitudes. Barriers to HPV vaccination at SBHCs can be addressed through more education about SBHCs' role, and improvement of systems to coordinate care.

A Narrative Engagement Framework to Understand HPV Vaccination Among Latina and Vietnamese Women in a Planned Parenthood Setting

Disparities in cervical cancer and human papillomavirus (HPV) vaccination persist among Vietnamese and Latina women. Through a partnership with Planned Parenthood of Orange and San Bernardino Counties (PPOSBC) in Southern California, we conducted in-depth interviews with young adult Latina ( n = 24) and Vietnamese ( n = 24) women, and PPOSBC staff ( n = 2). We purposively sampled vaccinated women to elicit HPV vaccine decision narratives to uncover rich data on motivators, cultural values, and implicit vaccine attitudes. Unvaccinated women were interviewed to identify barriers. Women were also asked to discuss their observations of men's HPV vaccine attitudes. Narrative engagement theory guided the study privileging the meaning women ascribed to their experiences and conversations related to vaccine decision making. Vaccine decision narratives included (a) mother-daughter narratives, (b) practitioner recommendation of HPV vaccination, (c) independence narratives among Vietnamese women, (d) HPV (un)awareness narratives, and (d) school exposure to HPV knowledge. Barriers to vaccinating included trust in partner HPV status, and family silence and stigma about sexual health. Participants conveyed the importance of including messages aimed at reaching men. Practitioners described insurance barriers to offering same day vaccination at PPOSBC health center visits. Narrative communication theory and methodology address health equity by privileging how Vietnamese and Latina women ascribe meaning to their lived experiences and conversations about HPV vaccination. Identifying authentic and relatable vaccine decision narratives will be necessary to effectively engage Vietnamese and Latina women. These findings will guide the process of adapting an existing National Cancer Institute research-tested HPV vaccine intervention.

Pediatrician-Parent Conversations About Human Papillomavirus Vaccination: An Analysis of Audio Recordings

PURPOSE

We sought to establish which human papillomavirus (HPV) vaccine communication approaches by pediatricians were associated with same-day HPV vaccination of 11- to 12-year-olds by evaluating audio recordings of visits.

METHODS

Verilogue, a market research company maintaining a panel of primary care pediatricians, provided audio recordings and transcriptions of well-child visits for 11- to 12-year-old patients from January through June 2013. Seventy-five transcripts from 19 pediatricians were coded for use of presumptive language (i.e., words conveying assumption of vaccine delivery), offer of delay, recommendation strength, and information provision. Using logistic regression, we evaluated the association between pediatrician communication approaches and agreement to same-day HPV vaccination. Generalized estimating equations accounted for clustering of patients within pediatricians.

RESULTS

Same-day agreement to HPV vaccination occurred in 29% of encounters. Pediatricians in the sample often provided parents with inconsistent, mixed messages and sometimes offered information about HPV or HPV vaccination that was inaccurate. Pediatricians used presumptive language in only 11 of 75 encounters; when used, presumptive language was associated with higher odds of accepting HPV vaccine (73% vs. 22%; odds ratio = 8.96; 95% confidence interval = 2.32-34.70). Pediatricians offered or recommended delay in most encounters (65%). HPV vaccine acceptance occurred far more often when pediatricians did not mention delaying vaccination (82% vs. 6%; odds ratio = 80.84; 95% confidence interval = 15.72-415.67). Same-day vaccination was not associated with strength of recommendation or pediatrician reference to vaccinating their own children.

CONCLUSIONS

Our findings highlight the need to develop and evaluate physician-focused trainings on using presumptive language for same-day HPV vaccination.

A study of physicians' experiences with recommending HPV vaccines to adolescent boys

Assessing physicians' experiences in HPV vaccine recommendation and delivery to adolescent boys is essential to providing an understanding of the issues of vaccine acceptance and an insight for policymakers to enhance HPV vaccinations among adolescent boys. Between January and April 2014 a mail survey was conducted using physicians in Malaysia known to provide either one or both HPV vaccine (Gardasil and Cervarix) immunisation services. A total of 357 completed questionnaires were received (response rate 22.5%). Of these, 335 physicians see adolescent boys aged 11 to 18 years old in their practice. Only 26.3% (n = 88) recommended the HPV vaccine to these boys. A total of 46.6% (n = 41) have successfully given the HPV vaccine to adolescent boys. A lack of proper guidelines from the health authorities regarding the recommendation of HPV vaccine to the boys (37.2%) and a lack of awareness of the availability of the vaccine for boys (32.8%) were the most commonly cited reasons for non-recommendation. Impact statement Recommending the HPV vaccine for adolescent boys remains a challenge for physicians. Our study provides evidence of challenges and barriers faced by Malaysian physicians who recommend the HPV vaccines (Gardasil and Cervarix) in their practices. In this study, physicians reported HPV vaccine uptake by adolescent boys was very poor. A lack of proper guidelines from the health authorities regarding the recommendation of HPV vaccine to boys and a lack of awareness of the availability of the vaccine for boys were the most commonly cited reasons for non-recommendation. Physicians viewed that support and encouragement from the health authorities are needed to promote the recommendation of the HPV vaccine to adolescent boys. Physicians were also of the opinion that the lay public should be educated about the availability of the HPV vaccine for boys, and its benefits, safety and efficacy, and the high susceptibility of boys to getting HPV infections. The findings provide insights that could be helpful to policymakers or high-level decision-makers of the potential strategies to enhance HPV uptake among adolescent boys.

"I think they're all basically the same": parents' perceptions of human papilloma virus (HPV) vaccine compared with other adolescent vaccines

BACKGROUND

Human papillomavirus (HPV) vaccination is recommended for routine administration at ages 11-12 years. However, uptake is lower than for other vaccines that are also routinely recommended for adolescents (MCV4 and Tdap). Understanding parental perceptions of HPV vaccine compared with other vaccines may help to inform strategies to increase uptake.

METHODS

Parents and caregivers (n = 45) of adolescents ages 10-18 years from a low-income, ethnic minority population participated in a qualitative study. Interviews were transcribed verbatim and coded for emergent themes.

RESULTS

Many participants perceived the HPV vaccine to be similar to other routine vaccines. Noted similarities included the vaccines' ability to prevent disease, similar methods of administration and belief in health care providers' recommendation. Some parents noted the greater benefit of HPV vaccine in preventing cancer, which was viewed as a serious disease. Parents also noted the different mode of transmission (sexual) for HPV, which evoked mixed opinions.

CONCLUSION

Overall, most participants viewed the HPV vaccine in a positive light and similar to other adolescent vaccines with the added benefit of cancer prevention. Strategies that treat all three vaccines equally such as presenting them similarly as a 'bundle' to parents or considering policy initiatives such as school entry requirements might help increase raise coverage for HPV vaccine.

Provider communication about HPV vaccination: A systematic review

BACKGROUND

Improving HPV vaccination coverage in the US will require healthcare providers to recommend the vaccine more effectively. To inform quality improvement efforts, we systematically reviewed studies of provider communication about HPV vaccination.

METHODS

We searched MEDLINE, CINAHL, EMBASE, and POPLINE in August 2015 to identify studies of provider communication about HPV vaccination.

RESULTS

We identified 101 qualitative and quantitative studies. Providers less often recommended HPV vaccine if they were uncomfortable discussing sex, perceived parents as hesitant, or believed patients to be low risk. Patients less often received recommendations if they were younger, male, or from racial/ethnic minorities. Despite parents' preference for unambiguous recommendations, providers often sent mixed messages by failing to endorse HPV vaccine strongly, differentiating it from other vaccines, and presenting it as an "optional" vaccine that could be delayed.

CONCLUSION

Interventions are needed to help providers deliver effective recommendations in the complex communication environment surrounding HPV vaccination.