Understanding parents' views toward the newly enacted HPV vaccine school entry policy in Puerto Rico: a qualitative study

Stakeholders' Perceptions on the Implementation of the HPV Vaccine School-Entry Requirement in Puerto Rico during the COVID-19 Pandemic

This study explored the implementation of the human papillomavirus (HPV) vaccine school-entry requirement in Puerto Rico during the COVID-19 pandemic. We conducted 26 semi-structured interviews with stakeholders and community-based organizations from August 2021 to March 2022. The interview guide was developed using the 2009 Consolidated Framework for Implementation Research (CFIR). The interviews were recorded and transcribed in Spanish. Data were analyzed using applied thematic techniques. These themes included the following: (i) Intervention characteristics: Participants noted that the school-entry requirement was effective in increasing vaccination uptake prior to the pandemic. Issues with the immunization registry were noted; (ii) Outer setting: External influences, access barriers, and an increase in HPV vaccine exemptions since the implementation of the COVID-19 vaccine were discussed; (iii) Inner setting: Communication within organizations and HPV vaccination efforts improved as the pandemic progressed; (iv) Characteristics of individuals: Most agreed with the school-entry requirement, including exemptions; and (v) Process: Results showed the need to reinforce the population's education about HPV and the vaccine. Implementation of the policy was challenging during the early stages of the pandemic due to measures enacted to stop the spread of COVID-19 and focus on the COVID-19 vaccine. Efforts to increase HPV vaccine should focus on increasing HPV vaccine education and creating collaborations.

Implementing a School-Entry Mandate for the Human Papillomavirus Vaccine: Benefits and Challenges

Human papillomavirus (HPV), a common sexually transmitted infection, has prompted the development of vaccines to mitigate associated cancer risks, particularly cervical cancer. Regions that have achieved a high rate of vaccination coverage are witnessing a transformative impact on public health, with a notable reduction of up to 30% in the incidence of cervical cancer cases. Emphasizing the broader impact of vaccination on public health, this review investigates the role of a school-entry mandate for the HPV vaccine, aiming to inform decisions about its potential benefits and challenges. With a focus on understanding the significance of vaccination, the review delves into its potential to reduce the physical, emotional, and financial burdens associated with HPV-associated cancers. Implementing school-entry mandates for the HPV vaccine offers benefits such as increased vaccination rates, protection against HPV-related diseases, and long-term health advantages. However, challenges include ethical concerns, parental opposition, and logistical issues. Successful implementation requires clear communication, collaboration, and education, with legal and ethical considerations addressing constitutional rights, liability concerns, autonomy, and equitable access. In summary, the implementation of school-entry mandates for the HPV vaccine offers the potential for increased vaccination rates and the reduction of health disparities. However, this approach is challenged by factors such as opposition, associated costs, and legal and ethical considerations. The decision to mandate the HPV vaccine requires a delicate balance between public health priorities and individual rights, necessitating clear communication, education, and collaborative efforts to address the complexities involved.

Perceptions of a State-Level HPV Vaccine Mandate and Exemption Option in Rural Virginia: A Qualitative Study

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States; yet, despite the availability of safe and effective HPV vaccines, only half of eligible adolescents have completed the vaccine series. School-entry requirements are one proven strategy to increase vaccination rates among children and youth and reduce the burden of HPV-related cancer. This study investigated community perceptions of an HPV vaccine school-entry mandate in Virginia and the consequences of a low threshold exemption option included in the legislation. We conducted 40 interviews with community members including 15 interviews with parents, 19 with healthcare providers, and 6 with community leaders. Interviews asked about knowledge, beliefs, and attitudes concerning the HPV vaccine and mandate. Interviews were recorded, transcribed, and thematically analyzed. Despite healthcare provider support for the mandate, there was widespread confusion over the school-entry policy and concern that the exemption option undermined vaccination efforts. Understanding variations in community-level perceptions and response to school-based vaccination mandates is crucial for designing effective public health strategies. Findings suggest statewide vaccination initiatives should preemptively identify low uptake areas and provide targeted information to communities. Future mandates should avoid the use of ambiguous and contradictory language in vaccine-related legislation.

Is It Safe for Me to Get It? Factors Influencing COVID-19 Vaccination Decision-Making among Postpartum Women Who Are Black and Hispanic in Deep South

BACKGROUND

COVID-19 vaccination is vital for ending the pandemic, yet safety concerns persist among pregnant and postpartum women, especially those who are Black and Hispanic. This study aims to explore factors that influence postpartum women's vaccination decision-making during pregnancy and postpartum through women's lived experiences and maternal care providers' (MCPs) observations.

METHODS

From January to August 2022, we conducted semi-structured interviews with postpartum women who are Black and Hispanic and with MCPs. Participants were recruited from obstetric and pediatric clinics in South Carolina and had given birth in 2021. Thematic analysis was employed for data analysis.

RESULTS

The study involved 19 Black and 20 Hispanic women, along with 9 MCPs, and revealed both barriers and facilitators to COVID-19 vaccination. The factors that influence pregnant and postpartum women's decision about COVID-19 vaccine uptake included: 1) awareness of health threats associated with COVID-19 vaccines, 2) vaccine availability and accessibility, 3) vaccine-related knowledge and exposure to misinformation, 4) concerns regarding pre-existing health conditions and potential side effects of COVID-19 vaccines, 5) emotional factors associated with vaccination decision-making processes, 6) concerns about the well-being of infants, 7) cultural perspectives, and 8) encouragement by trusted supporters.

CONCLUSION

The findings suggest that reliable information, social support, and trusted MCPs' advice can motivate COVID-19 vaccination among pregnant and postpartum women who are Black and Hispanic. However, barriers such as misinformation, mistrust in the health care system, and fears of potential side effects impede vaccination uptake. Future interventions should address these barriers, consider health disparities, involve trusted MCPs, and initiate conversations about vaccines to promote vaccination among these populations.

Epidemiology of Cervical Cancer in the Caribbean

Cervical cancer (CvC) is considered a preventable disease; however, in the Caribbean, it is still one of the fourth most common causes of death in women. Efforts to overcome obstacles to the treatment and control of this preventable disease are being made by several countries within the Caribbean. However, no health issue can be readily managed without first acquiring an understanding of the dynamics relating to its severity of impact reaching the target population, its clinical pathology, and the availability of treatment and/or preventative measures to control or halt its progression. To assess the status of CvC in the Caribbean, a review of the literature was conducted using PubMed. The Caribbean was defined in the review as comprising nations and islands whose coastlines are touched by the Caribbean Sea. This led to an assessment of the available literature on CvC for 33 Caribbean territories. The review showed a lack of published information on CvC and highlights the need for greater research. This also serves as a template for subsequent investigations.

HPV vaccination and cervical cancer screening promotion among Black individuals: social ecological perspectives from key informants interviews

OBJECTIVES

Rates of HPV infection and HPV-related cancers are elevated in the Black population of the US. Efforts to promote HPV vaccination and cervical cancer screening are important to reducing the cancer burden among Black populations. The purpose of this qualitative descriptive study guided by social ecological model (SEM) was to describe from the perspective of key informants, the challenges and opportunities for HPV vaccination and cervical cancer screening promotion among Black adults.

DESIGN

Twenty-three key informants participated in individual interviews over zoom video conferencing. The sessions were audio-recorded, transcribed verbatim, and checked for accuracy prior to data analysis. Two qualitatively trained researchers analyzed the data using content analysis.

RESULTS

Participants were aged 50 ± 4.1 years, 12 were females, and 18 identified as Black. Participants included health care providers, teachers, church and community leaders. Themes included HPV and cancer literacy, influence of religion, health care provider recommendations, social and cultural influences, accessibility and availability of services, economic constraints, limited community resources, and HPV vaccine mandates.

CONCLUSIONS

SEM factors contribute to low HPV vaccine uptake and cervical cancer screening and these factors need to be addressed. Interventions addressing SEM factors peculiar to Black populations may promote HPV vaccination and cancer screening in this population.

Patient-centeredness-a cultural targeted survey among junior medical managers

BACKGROUND

Patient-centeredness is a core element in healthcare. However, there is a gap between the understanding of this term by healthcare professionals, and patients' capability, self-efficacy, and willingness to take part in medical decisions. We aim to expose standpoints toward "patient centeredness" among junior medical managers (JMM), as they bridge between policy strategies and patients. We try to reveal cultural differences by comparing the views of the majority and the minority subpopulations of Israel (Arabic and Hebrew speakers).

METHODS

A cross-sectional survey among JMM studying for an advanced degree in health-system management at three academic training colleges in Israel was conducted in February-March 2022. The respondents completed a structured questionnaire comprising four sections: a) perceptions of trust, accountability, insurance coverage, and economic status; b) perceptions regarding decision-making mechanisms; c) preferences toward achieving equity, and d) demographic details.

RESULTS

A total of 192 respondents were included in the study-50% Hebrew speakers and 50% Arabic speakers. No differences were found between Arabic and Hebrew speakers regarding perception of trust, accountability, insurance coverage, and economic status. JMM from both subpopulations believed that patients' gender and age do not influence physicians' attitudes but Arabic-speaking respondents perceived that healthcare professionals prefer educated patients or those with supportive families. All respondents believed that patients would like to be more involved in medical decisions; yet Arabic-speakers perceived patients as tending to rely on physicians' recommendations while Hebrew speakers believed that patients wish to lead the medical decision by themselves.

CONCLUSIONS

Patient-centeredness strategy needs to be implemented bottom-up as well as top-down, in a transparent nationwide manner. JMM are key actors in carrying out this strategy because they realize policy guidelines in the context of social disparities, enabling them to achieve a friendly personalized dialogue with their patients. We believe that empowering these JMM may create a ripple effect, yielding a bottom-up perception of equity and initiating change.

Factors influencing COVID-19 vaccination decision-making among African American and Hispanic pregnant and postpartum women in Deep South

Background

COVID-19 vaccination is vital for ending the pandemic but concerns about its safety among pregnant and postpartum women, especially among African American (AA) and Hispanic women, persist. This study aims to explore factors that influence vaccination decision-making among AA and Hispanic pregnant and postpartum women through women's experiences and maternal care providers' (MCPs) observations.

Methods

From January and August 2022, we conducted semi-structured interviews with AA and Hispanic women and MCPs. Participants were recruited from obstetric and pediatric clinics in South Carolina, and all births took place after March 2020. Thematic analysis was employed for data analysis.

Results

The study involved 19 AA and 20 Hispanic women, along with 9 MCPs, and revealed both barriers and facilitators to COVID-19 vaccination. The factors that influence pregnant and postpartum women's decision about COVID-19 vaccine uptake included: 1) awareness of health threats associated with COVID-19 vaccines, 2) vaccine availability and accessibility, 3) vaccine-related knowledge and exposure to misinformation, 4) concerns regarding pre-existing health conditions and potential side effects of COVID-19 vaccines, 5) emotional factors associated with vaccination decision-making processes, 6) concerns about the well-being of infants, 7) cultural perspectives, and 8) encouragement by trusted supporters.

Conclusion

Findings suggest that reliable information, social support, and trusted doctors' advice can motivate COVID-19 vaccination. However, barriers such as misinformation, mistrust in the health care system, and fears related to potential side effects impede vaccination uptake among AA and Hispanic pregnant and postpartum women. Future interventions should target these barriers, along with health disparities, involve trusted doctors in outreach, and initiate vaccine conversations to promote vaccination among this population.

Indiana Parental Perceptions of the Acceptability of General and HPV-Specific State Vaccine Requirements

State vaccine requirements are a tool for improving child and adolescent vaccination immunization coverage, but to be effective, parental buy-in is needed. The objective of this study was to assess the demographic, healthcare characteristics, and health beliefs associated with parental acceptance of general and HPV-specific state vaccine requirements. Indiana parents (N = 601) with children ages 11-17 years old completed a survey during March 2020.Results showed that 47.2% and 43.1% of parents believed there should always be general and HPV-specific state vaccine requirements, respectively. In multivariable analysis, higher odds of parental support for general state vaccine requirements were associated with being unsure whether HPV-associated cancer is a problem in the participant's county and having higher perceived benefits of HPV vaccines. Lower odds were associated with private insurance, having less than a bachelor's degree, and having less confidence in vaccines. In comparison, parents had higher odds of agreeing with HPV-specific state vaccine requirements if they reported higher interpersonal altruism and higher perceived benefits of HPV vaccines; they had lower odds if they were non-Hispanic White. Findings indicate that while similar percentages of parents agreed with general and HPV-specific state vaccine requirements, there were different characteristics associated with acceptance of each. Results can inform the development of tailored interventions for improving parental support for general and HPV-specific state vaccine requirements.

The predictive role of parental attitudes toward COVID-19 vaccines and child vulnerability: A multi-country study on the relationship between parental vaccine hesitancy and financial well-being

Background and purpose

Recent new mutations and increases in transmission of COVID-19 among adolescents and children highlight the importance of identifying which factors influence parental decisions regarding vaccinating their children. The current study aims to explore whether child vulnerability and parents' attitudes toward vaccines mediate the association between perceived financial well-being and vaccine hesitancy among parents.

Method

A predictive, cross-sectional, multi-country online questionnaire was administered with a convenience sample of 6,073 parents (Australia, 2,734; Iran, 2,447; China, 523; Turkey, 369). Participants completed the Parent Attitude About Child Vaccines (PACV), the Child Vulnerability Scale (CVS), a Financial Well-being (FWB) measure, and Parental Vaccine Hesitancy (PVH) questionnaire.

Results

The current study revealed that perceived financial well-being had significant and negative associations with parents' attitudes toward COVID-19 vaccines and child vulnerability among the Australian sample. Contrary to the Australian findings, results from Chinese participants indicated that financial well-being had significant and positive predictive effects on parent attitudes toward vaccines, child vulnerability, and parental vaccine hesitancy. The results of the Iranian sample revealed that parents' attitudes toward vaccines and child vulnerability significantly and negatively predicted parental vaccine hesitancy.

Conclusion

The current study revealed that a parents' perceived financial well-being had a significant and negative relationship with parental attitudes about vaccines and child vulnerability; however, it did not significantly predict parental vaccine hesitancy among Turkish parents as it did for parents in Australia, Iran, and China. Findings of the study have policy implications for how certain countries may tailor their vaccine-related health messages to parents with low financial wellbeing and parents with vulnerable children.

The adoption of the HPV vaccine school-entry requirement in Puerto Rico: How practical lessons can inform future vaccine policies

Vaccine requirements are policy-level strategies used to improve population health outcomes; however, discourse politicization of vaccines may hinder adoption and implementation. An example of the complexities related to adoption of vaccine policies in the United States (US) is the human papillomavirus (HPV) vaccine school-entry requirement. In 2018, Puerto Rico's (PR) Department of Health adopted this policy. This study assessed stakeholders' recommendations for adoption of the HPV vaccine school-entry requirement that could inform future vaccine policies. Stakeholders (e.g., researchers, members of medical and non-profit organizations) were interviewed from May to August 2018. Participants (n = 20) discussed recommendations for public health professionals interested in adopting such policy. Data were analyzed using applied thematic techniques. Participants emphasized the importance of raising HPV vaccine awareness and providing education prior to the requirement. They recommended using real stories and making the problem relevant by using local data. Participants recommended considering the local culture and government bureaucracies, and promoting multisectoral collaborations to combine limited resources. The combination of education efforts, local data, and multisectoral collaborations facilitated the adoption of the HPV vaccine school-entry requirement in PR. Findings highlight the need to understand the contextual distinctions of the communities where vaccination requirements may be adopted and implemented to anticipate barriers and leverage existing resources. Consideration of the politico-cultural context may be important as political beliefs have become entrenched with vaccine policy. These practical lessons can inform public health professionals and policymakers who are seeking to adopt and implement vaccine policies in other settings to ensure equitable vaccine access.

Sex and educational attainment differences in HPV knowledge and vaccination awareness among unvaccinated-sexually active adults in Puerto Rico

Human papillomavirus (HPV) knowledge and HPV vaccination uptake remain suboptimal. We assessed sex and educational attainment differences in HPV knowledge and vaccine awareness. Data from a cross-sectional study (2018–2021) in Puerto Rico among adults aged 21–49 was analyzed (n = 278). Adequate knowledge was defined as a score of ≥70% of correct responses on a 13-item knowledge scale. Multivariable logistic regression was used to assess the association of sex (men vs. women) and education (high school or less vs. more than high school) categories with adequate HPV knowledge and vaccine awareness. Adequate HPV knowledge was higher among women (53%) and men (46%) with more than high school and was lower among women (46%) and men (27%) with high school or less. For HPV vaccine awareness, similar results were observed. Women (OR = 3.0 ; 95%CI = 1.4–6.2) and men (OR = 2.3 , 95%CI = 1.1–4.8) with more than high school and women with high school or less (OR = 2.3 , 95%CI = 1.0–5.2) were more likely to have adequate HPV vaccine knowledge than men with high-school or less education. Heightened HPV vaccine awareness was also seen among more educated women and men and women with similar lower education when compared to men with ≤ high school. Men and individuals with lower educational attainment were more likely to have inadequate HPV knowledge and vaccine awareness. HPV vaccine-oriented educational interventions should target these high-risk groups.