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

Perspectives on Human Papilloma Virus Vaccination Barriers, Knowledge and Beliefs, and Practices: Providers Serving Arab-American Populations

Little is known of HPV vaccination (HPVV) recommendation practices among healthcare providers who treat the Arab American community. Evidence indicates that HPVV patient uptake is low in this population. A survey was administered to healthcare providers (N = 46, 63% response rate) who treated ≥ 5% Arab American patients aged 9-26 years in areas of New York City and New Jersey with large Arab American populations. They were asked about barriers to HPVV recommendation and uptake among their Arab American patients. Providers (Doctors of Medicine and Osteopathy, Nurse Practitioners, and Physician Assistants) mostly worked in pediatrics (41%), primary care/internal medicine (26%), obstetrics/gynecology (20%), and family medicine (15%). Most (91%) were confident in their ability to effectively counsel their patients on HPVV. The most frequent provider-reported barriers to administering the HPVV to Arab American patients were patient cultural/religious practices (reported by 67%) and patient and provider difficulties with insurance reimbursement (44%). Most providers (84%) agreed that organizations/programs to increase HPVV uptake among Arab American patients were needed. Providers felt that HPVV uptake could be increased with educational materials in the patients' native languages ("very useful," 81%) and provider cultural competency training ("very useful," 65%). In responses to open-ended questions, cultural and religious HPVV barriers were a salient topic, as were linguistic barriers and provider burdens related to HPVV costs and regulations. HPVV uptake could potentially be improved with Arabic language education materials, provider education that is culturally and linguistically tailored to the Arab American community, and policies to address HPVV financial and regulatory burdens.

HPV Vaccination in Bangladesh: Ethical Views

Human papillomavirus (HPV) vaccination of young adolescent girls as a part of primary prevention of cervical cancer is now a routine practice in many countries. Bangladesh, a lower-middle income country, observed a successful HPV vaccination demonstration program recently. As much as the benefits of the vaccination programs are well-recorded, the ethics of administration of it is not focused highly; rather the focus tends to be on the most efficient method to get it done. In countries like Bangladesh, vaccination-related ethical issues are often overlooked. Thus, addition of HPV vaccination to the existing immunization programs calls for logical discussion and consideration to preserve the highest ethical standard in administering this vaccine to a sensitive age group of adolescence. This chapter summarizes some ethical concerns related to the HPV vaccination implementation in Bangladesh.

Understanding HPV-positive women's needs and experiences in relation to patient-provider communication issues: a qualitative study

Background

HPV testing has been integrated in cervical cancer screening program. Patient-providers relationship is extremely important to improve cervical cancer screening outcomes. This qualitative study aims to understand HPV-positive women’s needs and preferences about HCPs and patient-provider communication based on their experiences of accessing primary and specialized care.

Methods

We conducted 40 semi-structured interviews with HPV-positive women. Recorded interviews transcribed and analyzed using conventional content analysis approach.

Results

The analysis of the data led to the extraction of three main categories, including: provider’s communication and counseling skills, commitment to professional principles, and knowledgeable and competent provider. Women needed understandable discussion about HPV, emotional support and acceptance, receiving HPV-related guidance and advice, and some considerations during clinical appointments. Women needed HCPs to treat them respectfully, gently and with non-judgmental attitude. “Precancerous” and “high-risk” words and watching colposcopy monitor during procedure had made women anxious. Weak referral system and limited interactions among gynecologists and other HCPs highlighted by participants.

Conclusion

The results of this study, based on the experiences and perceptions of HPV women receiving health care, contain messages and practical tips to healthcare providers at the primary and specialized levels of care to facilitate patient-provider communication around HPV. Providers need to approach the discussion of HPV with sensitivity and take individual needs and preferences into account to improve the HPV-positive women’s healthcare experience.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06283-w.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

A Select Bibliography of Actions to Promote Vaccine Literacy: A Resource for Health Communication

In this bibliography, the researchers provide an introduction to the available evidence base of actions to promote vaccine literacy. The research team organized interventions to create a tool that can inform health communicators and practitioners seeking a resource focused on strategy and implementation design for actions that support vaccine literacy. This scoping bibliography is honed specifically to respond to the urgency of the current pandemic, when supporting and increasing vaccine literacy offers promise for achieving the critically needed high levels of vaccination. Over the course of the coming months and year, this bibliography will be a dynamic and "living" document hosted and maintained on vaccineliteracy.com.

Ethical issues related to human papillomavirus vaccination programs: an example from Bangladesh

Background

Human Papilloma Virus (HPV) vaccine was introduced in Bangladesh through the arrangement of a demonstration project in Gazipur district in 2016, targeting grade five female students and non-school going girls (age range 10–12 years). HPV vaccination is expected to be eventually included in the nationwide immunization program if the demonstration project is successful. However, introduction and implementation of such a vaccination program raises various ethical concerns. This review paper illustrates a step by step assessment of the ethical concerns surrounding the HPV vaccination implementation in Bangladesh considering specific elements in administering and conducting the program as well as the intended results. Policy-makers, vaccine implementers, vaccine recipients, and an ethics specialist in Bangladesh were interviewed. Electronic database and websites have also been reviewed for relevant published literature and government statements.

Main body of the abstract

This program imparted inadequate knowledge about HPV and cervical cancer to the recipients and participants. There was lack of autonomous and informed choice of the girls and their parents about taking the vaccine. The program did not have any follow-up plan for the adverse effects in the long run. The impact of a female-only strategy in the larger societal context was overlooked. There was lack of awareness among the implementers about safeguarding the ethical issues pertaining to HPV vaccination.

Conclusion

Adolescent health education imparted in the scope of the vaccination program should contain adequate information about HPV, its mode of transmission, risk factors along with the importance of secondary prevention despite primary prevention. Adolescent boys should be given HPV related health education as well. The right of making informed choice should be appreciated and respected. More ethical discussion and debate should be done among the public health professionals of Bangladesh in order to increase awareness about ethical issues related to human health.

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

SYSTEMATIC REVIEW REGISTRATION

PROSPERO Registration Number: CRD42017048844.

Interventions to Improve HPV Vaccine Uptake: A Systematic Review

CONTEXT

The human papillomavirus (HPV) vaccine is a safe, effective cancer prevention method that is underutilized in the United States. Despite increased understanding of barriers to vaccination, rates remain low. Globally, developed and developing nations have achieved high rates of vaccination.

OBJECTIVE

Identification of effective strategies is necessary to optimize uptake of the HPV vaccine. We systematically reviewed the literature for national and international interventions that have successfully increased HPV vaccine uptake.

DATA SOURCES

We used a standardized protocol to search for articles published between January 1, 2006, and April 30, 2015, in 3 electronic databases: PubMed, Scopus, and Embase.

STUDY SELECTION

We identified interventions designed to increase HPV vaccine uptake among adolescents and young adults aged 11 to 26 years. All study designs were acceptable. Only articles that included postintervention vaccination rates were included.

DATA EXTRACTION

Two authors independently reviewed each article for data extraction and quality assessment. Interventions were classified according to the Community Preventive Service Task Force guide.

RESULTS

Results were reported according to the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework. Fifty-one articles met eligibility criteria: 2 informational interventions, 18 behavioral interventions, and 31 environmental interventions. Factors associated with HPV vaccine uptake were increased vaccine availability, decreased financial barriers, and interventions targeting both providers and patients.

LIMITATIONS

Lack of consistent RE-AIM metric reporting, limiting our ability to assess intervention validity and quality.

CONCLUSIONS

Population-based vaccination strategies that increased vaccine availability reached the greatest number of adolescents and were most successful in achieving high rates of vaccination.

Human papillomavirus vaccine-related risk perceptions and subsequent sexual behaviors and sexually transmitted infections among vaccinated adolescent women

OBJECTIVE

To examine the association between risk perceptions after human papillomavirus (HPV) vaccination and sexual behaviors and sexually transmitted infection (STI) diagnosis over 30months following vaccination.

METHODS

Participants included 112 sexually experienced girls aged 13-21years who were enrolled at the time of first HPV vaccination and completed ⩾2 of 4 follow-up visits at 2, 6, 18, 30months and including 30months. At each visit, participants completed surveys assessing risk perceptions (perceived need for safer sexual behaviors, perceived risk of STIs other than HPV) and sexual behaviors. STI testing was done at 6, 18, and 30months. Outcomes were condom use at last intercourse with main male partner, number of sexual partners since last study visit, and STI diagnosis. Associations between risk perceptions and sexual behaviors/STIs were examined using generalized linear mixed models.

RESULTS

Mean age was 17.9years; 88% were Black; 49% had a history of STI at baseline. Scale scores for perceived need for safer sexual behaviors did not change significantly over time. Scale scores for perceived risk of STIs other than HPV significantly changed (p=0.027), indicating that girls perceived themselves to be more at risk of STIs other than HPV over 30months following vaccination. Multivariable models demonstrated that greater perceived need for safer sexual behaviors following vaccination was associated with condom use (p=0.002) but not with number of partners or STI diagnosis. Perceived risk of STIs other than HPV was not associated with the three outcomes.

CONCLUSIONS

The finding that perceived risk for STIs other than HPV was not associated with subsequent sexual behaviors or STI diagnosis is reassuring. The association between perceived need for safer sexual behaviors and subsequent condom use suggests that the HPV vaccination visit is an important opportunity to reiterate the importance of safer sexual behaviors to sexually experienced girls.

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.

Catching Up With the HPV Vaccine: Challenges and Opportunities in Primary Care

PURPOSE

Data confirm that high rates of human papillomavirus (HPV) vaccination have not been achieved despite strong clinician endorsement of the vaccine. We conducted a study of primary care clinicians to assess the broad range of health care delivery, health policy, and attitudinal factors influencing vaccination uptake and opportunities for informed decision making.

METHODS

We implemented a mixed methods study in RIOS Net, a primary care practice-based research network in New Mexico. We first conducted qualitative, in-depth interviews with primary care clinicians, health policy makers, and immunization experts, and followed up with a confirmatory survey distributed to RIOS Net clinician members.

RESULTS

Health service delivery challenges emerged as the greatest barrier to HPV vaccination, specifically the lack of capacity to track and distribute reminders to eligible patients. Clinicians also reported variations in counseling approaches attributable to both age and emphasis on the cancer prevention benefits of the vaccine. There was no evidence of sociocultural influences on vaccine decision making, nor did concerns about perceived overprotection emerge.

CONCLUSIONS

Our findings, based on a long-term program of research, suggest that both patients' attributes and health system delivery are most influential in HPV vaccination coverage challenges. Interventions targeting innovative communication techniques, as well as health system changes that build on efforts toward coordinated care and utilization of other venues to promote vaccination, will be necessary to address these challenges.

Risk perceptions, sexual attitudes, and sexual behavior after HPV vaccination in 11-12 year-old girls

OBJECTIVES

Among 11-12 year-old girls who received the human papillomavirus (HPV) vaccine, we explored, over the subsequent 30 months: (1) trajectories of knowledge about HPV/HPV vaccines and vaccine-related risk perceptions; (2) whether knowledge and risk perceptions impacted sexual attitudes and sexual experience; (3) whether mothers, clinicians, and media influenced girls' risk perceptions, attitudes, and behavior.

METHODS

Girls and mothers (n=25dyads) completed separate, semi-structured interviews within 2 days of, and 6, 18, and 30 months after, their first HPV vaccine dose. Knowledge, risk perceptions related to HPV and other sexually transmitted infections (STIs), and attitudes about sexual behaviors were assessed. Sexual experience was assessed at girls' 30 month interviews. Clinicians completed interviews at baseline. Transcribed interviews were analyzed using framework analysis.

RESULTS

Girls' baseline knowledge was poor but often improved with time. Most girls (n=18) developed accurate risk perceptions about HPV but only half (n=12) developed accurate risk perceptions about other STIs by 30 months. The vast majority of girls thought that safer sex was still important, regardless of knowledge, risk perceptions, or sexual experience. Girls whose HPV knowledge was high at baseline or increased over time tended to articulate accurate risk perceptions; those who were able to articulate accurate risk perceptions tended to report not having initiated sexual activity. Girls whose mothers demonstrated higher knowledge and/or communication about HPV vaccination tended to articulate accurate risk perceptions, whereas clinicians and media exposure did not appear to influence risk perceptions.

CONCLUSIONS

Higher knowledge about HPV vaccines among mothers and girls was linked with more accurate risk perceptions among girls. Clinicians may play an important role in providing education about HPV vaccines to mothers and girls.

Race, ethnicity, and income factors impacting human papillomavirus vaccination rates

BACKGROUND

Human papillomavirus (HPV) infection and cervical cancer disproportionately affect low-income and minority women. HPV vaccines have the potential to either reduce or exacerbate racial disparities in HPV-related diseases and cervical cancers, depending on the equitability of vaccine uptake.

OBJECTIVES

This review aims to identify barriers and facilitators of equitable uptake of HPV vaccination among low-income and minority girls. This review discusses factors related to race, ethnicity, and income that are associated with initiation and completion rates of the 3-dose HPV vaccine series and presents targets for intervention.

METHODS

We reviewed relevant English-language literature to identify current vaccination rates and factors associated with vaccine uptake. Study findings related to race (black, Latino, Asian), and incomes were summarized.

RESULTS

Current trends in the United States indicate low uptake among all adolescents, and that rates stagnated between 2011 and 2012. Low-income and minority adolescents are equally or more likely to start the HPV vaccination series than are white and higher-income adolescents, but are less likely to complete all 3 shots. Provider recommendation is a key factor in HPV vaccination, and minorities are less likely to report receiving recommendations for HPV vaccination.

CONCLUSIONS

As black, Hispanic, and Asian populations continue to grow in the United States over the next several decades, it is imperative that we not only improve HPV vaccination rates overall, but also focus on high-risk populations to prevent an increase in cervical cancer disparities.

Missed opportunities for HPV vaccination in adolescent girls: a qualitative study

OBJECTIVE

The goal of this study was to identify the rationale by parents/guardians and providers for delaying or administering human papillomavirus (HPV) vaccination to girls.

METHODS

Qualitative interviews were conducted with parents/guardians accompanying their vaccine-eligible 11- to 17-year-old daughters to medical visits. Interviews were conducted in 1 public clinic and 3 private practice settings to ascertain why girls did or did not receive HPV vaccination. Questions probed vaccine decision-making from the point of view of parents/guardians and providers.

RESULTS

A total of 124 parents/guardians and 37 providers participated. The most common reasons parents reported for not vaccinating their daughters was the lack of a physician recommendation (44%). Both parents and providers believed that HPV vaccination provided important health benefits, but the timing of vaccination with relation to sexual activity was an important theme related to vaccine delay. Providers with lower self-reported vaccination rates delayed vaccine recommendations in girls perceived to be at low risk for sexual activity, and several parents reported that their providers suggested or supported delaying vaccination until their daughters were older. However, parents/guardians and providers agreed that predicting the timing of sexual debut was extremely difficult. In contrast, providers with high vaccination rates presented HPV vaccination as a routine vaccine with proven safety to prevent cancer, and parents responded positively to these messages.

CONCLUSIONS

Although most parents and providers believe that HPV vaccination is important, missed opportunities result from assumptions about the timing of vaccination relative to sexual activity. Routinely recommending HPV vaccination as cancer prevention to be coadministered with other vaccines at age 11 years can improve vaccination rates.

HPV vaccination in women aged 27 to 45 years: what do general practitioners think?

Background

Although the Human Papillomavirus (HPV) vaccine is registered in Australia for females aged 9 to 45 years, females aged 27 to 45 years have shown limited vaccine uptake. Our study explored general practitioners’ (GPs) views concerning HPV vaccination of females in this age group, with particular focus on the barriers and the facilitators to the delivery of the HPV vaccine.

Methods

Semi-structured telephone interviews were conducted with 24 randomly selected general practitioners from metropolitan Melbourne. Questions were based on a theoretical framework that explained the barriers and facilitators to professional behaviour change.

Results

According to the GPs, the major barriers to the uptake of the HPV vaccine included the cost of the vaccine, time constraints, and the three-dose schedule. Other barriers that were identified included GPs’ and patients’ beliefs that females in this age group were at low risk of contracting HPV, lack of awareness about the vaccine, and uncertainty about the benefits of this vaccine for females in this age group. In contrast, the facilitators that were identified included the availability of the vaccine on site, the availability of vaccine clinics or nurses for administering the vaccine, the availability of information related to the vaccine either on site or online, and positive opinions from experts in the field.

Conclusions

Our study has identified some of the barriers and facilitators to the delivery and uptake of the HPV vaccine in females aged 27 to 45 years, as perceived by GPs. Further studies should be conducted to determine which of these should be targeted or prioritised for intervention. The views of women in this age group should also be considered as these would also be influential in designing effective intervention strategies for improving the delivery and uptake of the HPV vaccine.

Barriers and facilitators to HPV vaccination of young women in high-income countries: a qualitative systematic review and evidence synthesis

BACKGROUND

Vaccination against Human Papillomavirus (HPV) is recommended for adolescent young women prior to sexual debut to reduce cervical cancer related mortality and morbidity. Understanding factors affecting decision-making of HPV vaccination of young women is important so that effective interventions can be developed which address barriers to uptake in population groups less likely to receive the HPV vaccine.

METHODS

We undertook a qualitative systematic review and evidence synthesis to examine decision-making relating to the HPV vaccination of young women in high-income countries. A comprehensive search of databases from inception to March 2012 was undertaken to identify eligible studies reporting the perspectives of key stakeholders including policy makers, professionals involved in programme, parents, and young women. Factors affecting uptake of the vaccine were examined at different levels of the socio-ecological model (policy, community, organisational, interpersonal and intrapersonal).

RESULTS

Forty-one studies were included. Whether young women receive the HPV vaccine is strongly governed by the decisions of policy makers, healthcare professionals, and parents. These decisions are shaped by: financial considerations; social norms and values relating to sexual activity, and; trust in vaccination programmes and healthcare providers. Financial constraints may be overcome through universal healthcare systems offering the HPV vaccine free at the point of delivery. In the healthcare setting, judgements by healthcare professionals about whether to recommend the vaccine may restrict a young woman's access to the vaccine irrespective of her own beliefs and preferences. Parents may decide not to allow their daughters to be vaccinated, based on cultural or religious perceptions about sexual activity.

CONCLUSIONS

Barriers to the uptake of the HPV vaccine have implications for young women's future sexual, physical and reproductive health. Interventions to address barriers to uptake of the vaccine should target appropriate, and multiple, levels of the socio-ecological model. Issues of trust require clear, accessible, and sometimes culturally appropriate, information about the HPV vaccination programme. Although young women are central to the HPV vaccination programme, their views are underrepresented in the qualitative literature. Future research should consider young women's perceptions of, and involvement in, consent and decision-making.

Ethical considerations of universal vaccination against human papilloma virus

BACKGROUND

From an epidemiological perspective, the practice of universal vaccination of girls and young women in order to prevent human papilloma virus (HPV) infection and potential development of cervical cancer is widely accepted even though it may lead to the neglect of other preventive strategies against cervical cancer.

DISCUSSION

It is argued that removing the deterrent effect--the fear of developing cancer--could encourage teenage sex. This paper reflects on the ethical legitimacy of the universal vaccination of girls and young women against HPV infection, especially regarding safety issues, the need to vaccinate people who have opted to abstain from sex, the presumption of early onset of sexual relations, the commercial interests of the companies that manufacture the vaccine, and the recommendation of universal vaccination in males.

SUMMARY

Based on the aforementioned information, we believe that the universal vaccination against HPV in young women is acceptable from an ethical point of view, given the medical advantages it presents.

"HPV? Never heard of it!": a systematic review of girls' and parents' information needs, views and preferences about human papillomavirus vaccination

BACKGROUND AND OBJECTIVE

Two human papillomavirus vaccines were licenced in 2006/2007 for cervical cancer prevention. National vaccination programmes for schoolgirls were subsequently introduced in some European countries, North America and Australia. To understand factors influencing vaccine uptake and to inform the development of appropriate UK educational materials, we aimed to synthesise evidence of girls' and parents' information needs, views and preferences regarding HPV vaccination.

DESIGN

Systematic review and mixed method synthesis of qualitative and survey data.

DATA SOURCES

Twelve electronic databases; bibliographies of included studies 1980 to August 2011.

REVIEW METHODS

Two reviewers independently screened papers and appraised study quality. Studies were synthesised collaboratively using framework methods for qualitative data, and survey results integrated where they supported, contrasted or added to the themes identified.

RESULTS

Twenty-eight qualitative studies and 44 surveys were included. Where vaccination was offered, uptake was high. Intention to decline was related to a preference for vaccinating later to avoid appearing to condone early sexual activity, concerns about vaccine safety and low perception of risk of HPV infection. Knowledge was poor and there were many misconceptions; participants tried to assess the potential benefits and harms of vaccination but struggled to interpret limited information about HPV in the context of existing knowledge about sexually transmitted infections and cancer. Conclusion Many girls and their parents have limited understanding to an extent that impinges on their ability to make informed choices about HPV vaccination and could impact on future uptake of cervical screening. This is a considerable challenge to those who design and provide information, but getting the messages right for this programme could help in developing patient information about other HPV related cancers.

Human papillomavirus vaccine communication: perspectives of 11-12 year-old girls, mothers, and clinicians

OBJECTIVES

Because little is known about the content of human papillomavirus (HPV) vaccine-related discussions with young adolescent girls in clinical settings, we explored communication between 11- and 12 year-old girls, mothers, and clinicians regarding HPV vaccines and concordance in reports of maternal and clinician communication.

METHODS

We conducted individual interviews with 33 girls who had received the quadrivalent HPV vaccine in urban and suburban clinical settings, their mothers, and their clinicians. Data were analyzed using qualitative methods.

RESULTS

From the perspectives of both girls and mothers, clinicians and parents were the preferred sources of HPV vaccine information for girls. Vaccine efficacy and risks/benefits of vaccination were the most commonly reported desired and actual topics of discussion by mothers, girls, and clinicians. Clinician recommendation of vaccination was reported by nearly one-fifth of girls and nearly half of mothers. The most common concordant messages were related to efficacy of the vaccine, with concordance in 70% of triads. The most common discordant messages were related to sexual health. Approximately half of clinicians (16) reported discussing sexual health, but only 5 mothers (15%) and 4 girls (12%) reported this. Triads recruited from suburban (vs. urban) practices had higher degrees of concordance in reported vaccination communication.

CONCLUSIONS

HPV vaccine efficacy and safety are important topics for clinicians to discuss with both girls and mothers; educating mothers is important because parents are a preferred source of vaccine-related information for girls. Because girls may be missing important vaccine-related messages, they should be encouraged to actively engage in vaccine discussions.

Race, ethnicity and income as factors for HPV vaccine acceptance and use

If distributed equitably, Human Papillomavirus (HPV) vaccines have the potential to reduce racial disparities in HPV-related diseases and cervical cancers. However, current trends in the US indicate low uptake among all adolescents, with persistent disparities among minority and low-income adolescents despite largely positive views of vaccination among their parents. As Black, Hispanic, and Asian populations continue to grow in the US over the next 40 y, it is imperative that we not only improve HPV vaccination rates overall, but focus on high-risk populations to prevent an increase in cervical cancer disparities. This review discusses initiation and completion rates of the three-dose HPV vaccine series among adolescents in high-risk groups and describes cultural similarities and differences in motivation and barriers to vaccination. The goal of this review is to highlight factors leading to vaccination in different adolescent racial groups and to help guide the development of strategies to increase rates of vaccine initiation and completion among groups at the highest risk for developing cervical cancer.

HPV vaccination of boys in primary care practices

OBJECTIVE

In October 2011, the Advisory Committee on Immunization Practices (ACIP) recommended the quadrivalent human papillomavirus vaccine (HPV4) for the routine immunization schedule for 11- to 12-year-old boys. Before October 2011, HPV4 was permissively recommended for boys. We conducted a study in 2010 to provide data that could guide efforts to implement routine HPV4 immunization in boys. Our objectives were to describe primary care physicians': 1) knowledge and attitudes about human papillomavirus (HPV)-related disease and HPV4, 2) recommendation and administration practices regarding HPV vaccine in boys compared to girls, 3) perceived barriers to HPV4 administration in boys, and 4) personal and practice characteristics associated with recommending HPV4 to boys.

METHODS

We conducted a mail and Internet survey in a nationally representative sample of pediatricians and family medicine physicians from July 2010 to September 2010.

RESULTS

The response rate was 72% (609 of 842). Most physicians thought that the routine use of HPV4 in boys was justified. Although it was permissively recommended, 33% recommended HPV4 to 11- to 12-year-old boys and recommended it more strongly to older male adolescents. The most common barriers to HPV4 administration were related to vaccine financing. Physicians who reported recommending HPV4 for 11- to 12-year-old boys were more likely to be from urban locations, perceive that HPV4 is efficacious, perceive that HPV-related disease is severe, and routinely discuss sexual health with 11- to 12-year-olds.

CONCLUSIONS

Although most physicians support HPV4 for boys, physician education and evidence-based tools are needed to improve implementation of a vaccination program for males in primary care settings.

Knowledge about human papillomavirus (HPV), and health beliefs and intention to recommend HPV vaccination for girls and boys among Korean health teachers

The human papillomavirus (HPV) vaccination rate in Korea is very low because a school-based HPV vaccination program has not yet been introduced. This study was designed to assess HPV knowledge, compare the health beliefs toward HPV vaccination and intention to recommend HPV vaccination for girls and boys, and identify the factors influencing the intention to recommend HPV vaccination for girls and boys among Korean health teachers. A descriptive cross-sectional study design was employed, in which 757 health teachers who worked at elementary, middle, high, and special schools in Korea participated via an online survey. A self-administered, structured questionnaire was applied, which included items on sociodemographics, HPV awareness, HPV knowledge, perceived benefits, susceptibility, severity, and barriers toward HPV vaccination for girls and boys, and intention to recommend HPV vaccination for girls and boys. The rate of correct HPV knowledge items ranged from 5.2% to 89.2%; 23.4% of the health teachers answered that they had ever taught about HPV, 97% answered that both boys and girls should receive HPV vaccination, and 47.6% answered that the best time for HPV vaccination is when students are at middle school. There were differences regarding the perceived benefits (Z=-7.69, p<0.001), perceived susceptibility (Z=-3.37, p=0.001), perceived severity (Z=-4.13, p<0.001), and perceived barriers (Z=-4.90, p<0.001) toward HPV vaccination, and regarding intention to recommend HPV vaccination (Z=-15.21, p<0.001) for girls and boys. Factors associated with the intention to recommend HPV vaccination for girls were the HPV vaccination status of the health teachers' children [odds ratio (OR)=4.24, 95% confidence interval (95% CI)=1.14-15.72], and the teachers' Pap-test experience (OR=2.50, 95% CI=1.05-5.91), perceived benefits (OR=3.30, 95% CI=1.26-7.40), perceived susceptibility (OR=3.25, 95% CI=1.58-6.68), and perceived barriers (OR=0.51, 95% CI=0.30-0.99); these factors for boys were the health teachers' career duration (OR=1.61, 95% CI=1.12-2.32), HPV knowledge (OR=1.45, 95% CI=1.01-2.09), perceived benefits (OR=3.46, 95% CI=2.27-5.26), perceived susceptibility (OR=1.55, 95% CI=1.04-2.29), and perceived severity (OR=1.71, 95% CI=1.15-2.56). General awareness of HPV should be increased and more specific information about HPV-including that related to vaccination of boys and men-should be provided for health teachers. Although a school-based HPV vaccine program has yet to be introduced in Korea, health teachers should possess general knowledge about HPV and HPV vaccination, and differences in attitudes and intentions related to HPV vaccination between girls and boys should be reduced.

HPV-DNA testing for cervical cancer precursors: from evidence to clinical practice

The large amount of literature published over the last two decades on human papillomavirus (HPV)-DNA testing has definitely demonstrated the association between high-risk viral genotypes (hrHPV) and cervical cancer. Moreover, hrHPV-DNA testing has shown excellent performance in several clinical applications, from screening settings to the follow-up of treated patients, compared to conventional cytology or colposcopy options. On the other hand, when a huge number of reports are published on the same subject in a relatively short period of time, with many variations in settings, study designs and applications, the result is often confusion and decreased comprehension by readers. In daily office practice, several different situations (in symptomatic or asymptomatic women) can be positively managed by the correct use of hrHPV-DNA testing. Validated hrHPV-DNA testing and, specifically, the HC2® assay, due to its excellent sensitivity and negative predictive value together with optimal reproducibility, currently represent a powerful tool in the clinician’s hands to optimally manage several situations related to HPV infection and the potential development of cervical cancer.

Perspectives on decision making about human papillomavirus vaccination among 11- to 12-year-old girls and their mothers

Introduction. The aims of this qualitative study were to explore (a) the factors influencing mothers' decisions to vaccinate 11- to 12-year-old daughters against human papillomavirus (HPV) and (b) the mothers' and daughters' perspectives about HPV vaccine-related decision making. Methods. Participants were girls (N = 33) who had received an HPV vaccine and their mothers (N = 32), recruited from suburban and urban pediatric practices. Semistructured interviews were conducted with girls and mothers separately, and data were analyzed using framework analysis. Results. The primary factors influencing mothers' decisions to vaccinate daughters against HPV were (a) mother's beliefs and experiences; (b) interactions with clinicians, friends, and family members; and (c) exposure to media reports/marketing. Most daughters believed the decision to be vaccinated was a mutual one, although most mothers believed the decision was theirs. Conclusions. This study provides novel insights into perspectives on decision making about HPV vaccination among mothers and 11- to12-year-old daughters, which can be used in interventions to improve vaccination rates.

[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.

Uptake of the human papillomavirus vaccine: a review of the literature and report of a quality assurance project

PURPOSE

The aims of this study were to review predictors of knowledge about human papillomavirus (HPV), HPV vaccine, and factors related to HPV vaccine uptake and report a quality assurance project that evaluated HPV vaccine uptake and three-dose completion rates.

METHODS

The setting was a small private urban pediatric practice. Chart review was used to describe HPV vaccine uptake and dose completion rates in 2007. The convenience sample included 189 girls aged 12 to 21 years with HPV vaccine uptake.

RESULTS

During 2007, 153 girls aged 12 to 17 years and 42 girls aged 18 to 21 years were seen at well-child care visits. HPV vaccine uptake was 72% (n = 110) for the younger group and 79% (n = 33) for the older group. There was no significant difference in HPV vaccine uptake by group. One quarter (24%, n = 46) received the HPV vaccine dose at an episodic visit. The dose completion rate was 64% (n = 120).

DISCUSSION

HPV vaccine uptake and dose completion rates were higher than rates reported by the Centers for Disease Control and Prevention. Effective strategies are needed to promote HPV vaccine uptake and dose completion.

Providing adolescent-friendly HPV education

Human papillomavirus (HPV) is the most common sexually transmitted infection, affecting more than 6.2 million individuals every year. Most new infections occur in adolescents and young adults shortly after the onset of sexual activity. Nurse practitioners play a key role in preventing HPV infection in teens through adolescent-friendly HPV education, prevention, and vaccination.

Predicting pediatricians' communication with parents about the human papillomavirus (hpv) vaccine: an application of the theory of reasoned action

This study examines the ability of the theory of reasoned action (TRA) and the theory of planned behavior (TPB) to predict whether or not pediatricians encourage parents to get their adolescent daughters vaccinated against the human papillomavirus (HPV). Four-hundred and six pediatricians completed a mail survey measuring attitudes, subjective norms, perceived behavioral control, intentions, and behavior. Results indicate that pediatricians have positive attitudes, subjective norms, and perceived behavioral control toward encouraging parents to get their daughters vaccinated, that they intend to regularly encourage parents to get their daughters vaccinated against HPV in the next 30 days, and that they had regularly encouraged parents to get their daughters vaccinated against HPV in the past 30 days (behavior). Though the data were consistent with both the TRA and TPB models, results indicate that perceived behavioral control adds only slightly to the overall predictive power of the TRA, suggesting that attitudes and norms may be more important targets for interventions dealing with this topic and audience. No gender differences were observed for any of the individual variables or the overall fit of either model. These findings have important theoretical and practical implications for the development of health communication messages targeting health care providers in general, and for those designed to influence pediatricians' communication with parents regarding the HPV vaccine in particular.

The "ins" and "outs" of provider-parent communication: perspectives from adolescent primary care providers on challenges to forging alliances to reduce adolescent risk

PURPOSE

For several decades, the goal to protect adolescents' confidentiality in addition to state and professional mandates to provide confidential health services have sometimes outweighed the interest of involving parents in risk reduction efforts. More recently, experts acknowledge that a balance must be found between maintaining adolescent confidentiality and involving parents in preventing poor adolescent outcomes resulting from risky behaviors. The purpose of this research was to elucidate the challenges in and identify solutions to realizing this newer vision in the primary care setting.

METHODS

We conducted a qualitative study featuring in-depth interviews with 37 primary care providers among whom a significant component of their practice involved adolescent patients. Purposeful sampling was aimed at a diversity of gender, practice specialty, practice venues, and geographic areas.

RESULTS

We identified individual and structural barriers and facilitators to involving parents in their adolescents' primary care. Barriers included parents' lack of knowledge and awareness of their children's risk behaviors; providers time constraints and competing clinical demands, concerns for confidentiality and developing a trusting relationship with the child; and legal and system requirements that limit engagement with parents. Facilitators included interest and for some, planned approaches by the provider to engage the parent; encouragement by the provider to the adolescent to communicate with a trusted adult about their risky behavior; and opportunities to educate the parent about risk reduction in general.

CONCLUSION

Opportunities for further research on strategies to improve communication and develop a partnership between providers and parents are described.

Issues surrounding HPV vaccine delivery in a multi-ethnic country in Asia: the physician's perspective

The study was conducted to investigate issues surrounding human papillomavirus (HPV) vaccine delivery in a multi-ethnic, multi-religious and multi-cultural society. A qualitative in-depth interview study was conducted with a sample of 20 physicians. Physicians described the success of HPV vaccines recommendation as very poor. Many expressed reluctance to offer the vaccine to preadolescents. The most notable barrier to vaccination was the vaccine's high cost. Parents of eligible vaccinees were concerned about the efficacy and side effects of the new vaccine, while adult women have low risk perception for HPV infection. Promoters and inhibitors of HPV vaccination in our multi-ethnic, multi-religious and multi-cultural community were identified. This study suggests the need to strengthen the infrastructure necessary for HPV vaccine delivery and to specifically target poor underserved women.

Patient-provider communication and human papillomavirus vaccine acceptance

The authors performed telephone interviews of parents of adolescents (n = 430) and their older adolescents (n = 208) in Monroe County, New York to measure parent and adolescent acceptance of human papillomavirus (HPV) vaccine, its association with ratings of provider communication, and vaccine-related topics discussed with the adolescent's provider. More than half of adolescent girls had already received an HPV vaccination, with fewer than one quarter refusing. Parent and teen ratings of provider communication was high, and not related to HPV vaccine refusal. Parents were more likely to refuse if they were Hispanic (odds ratio [OR] = 5.88, P = .05) or did not consider vaccines "very safe" (OR = 2.76, P = .04). Most parents of boys (85%) believed males should be given HPV vaccine if recommended. Few parents and teens recalled discussing that vaccination does not preclude future Pap smear testing. Providers should address cultural and vaccine safety concerns in discussions about HPV vaccine.

Communication challenges of HPV vaccination

BACKGROUND

The UK has introduced a national human papillomavirus (HPV) immunisation programme for girls aged 12-13 from autumn 2008. Previous research has explored public understanding of the causes of cervical cancer and found little awareness of the role of HPV.

OBJECTIVE

To explore GPs' and practice nurses' views of HPV vaccination, prior to implementation of the national immunisation programme, with a focus on their role and anticipated difficulties.

METHODS

Qualitative semi-structured interviews were conducted with 17 GPs and practice nurses from practices in Hampshire and Wiltshire, in March 2008.

RESULTS

The prevailing theme of new communication challenges was identified and these were connected to the activities of (i) explaining, (ii) consenting and (iii) managing conflicts between parents and their children with respect to vaccination decisions. The importance of decisions being fully informed was emphasized and concern was expressed about the adequacy of the information provided to girls and their parents in schools. Whether consent would be granted by the parent or by the child and how potential disagreements should be managed remained ambiguous. Participants considered it appropriate to offer the vaccine without parental consent if other criteria, such as an assessment of competency, were met.

CONCLUSIONS

Success of the national immunization programme will depend on overcoming the challenges of providing explanations to ensure that individuals understand the potential benefits of HPV vaccination. Primary care can play an important role, but this study suggests there are fundamental issues that need further clarification.

Clinical preventive services for adolescents

CONTEXT

Most of the many clinical preventive services (CPS) recommended for adolescents by various national organizations lack good evidence of effectiveness. Improving adolescent preventive care will require focusing on those CPS for which there is such evidence and on developing better delivery strategies. The objective of the current study was to identify those CPS for adolescents that do have a strong evidence base, to update the literature review and summarize evidence gaps where research is needed, and to summarize current delivery prevalence and opportunities.

EVIDENCE ACQUISITION

A summary was conducted of the recommendations for adolescents of the U.S. Preventive Services Task Force (USPSTF) and the CDC's Advisory Committee on Immunization Practices (ACIP). An update is provided of the literature review for services with an inadequate evidence base to support a recommendation. A summary was prepared of the types of evidence still needed. A literature search was also conducted for current delivery prevalence of recommended services for those aged 11-17 years, and common gaps in the evidence were identified.

EVIDENCE SYNTHESIS

Although 24 CPS for adolescents have been reviewed by the USPSTF, only ten received definite recommendations and only seven of these favored delivery of the service. In addition, the ACIP recommends four immunizations for all adolescents, and two additional ones for those at high risk. There are many gaps in the evidence supporting most of the other services as well as in the information about current delivery prevalence.

CONCLUSIONS

There are too many CPS recommended for adolescents with insufficient evidence of effectiveness, and there is low delivery prevalence for the few services with good evidence of effectiveness. Both more research and more attention to the practice changes that might improve delivery prevalence are needed.

Human papillomavirus vaccine and adolescents

PURPOSE OF REVIEW

The present review describes recent advances in our understanding about the epidemiology of human papillomavirus infection among female adolescents and describes several adolescent-specific issues related to administering human papillomavirus vaccines.

RECENT FINDINGS

National estimates demonstrate that human papillomavirus infection is most prevalent among adolescents and young adults. Parents, patients, and providers have a high interest in vaccination against this virus, but current patterns of adolescent healthcare utilization suggest that changes in adolescent preventive care delivery may be needed to provide these vaccines in a timely manner. Debate over whether adolescents should be legally allowed to self-consent to vaccination is another issue that remains unresolved and could have a substantial impact on vaccination rates. Legislation on school entry requirements related to human papillomavirus vaccination has been introduced in many states as a mechanism to circumvent some of these concerns, but the details of this legislation and its effect on adolescent vaccine utilization remain to be determined.

SUMMARY

Female adolescents are at a high risk for human papillomavirus infection and are likely to derive significant benefits from vaccination against this virus. However, administering human papillomavirus vaccines to this age group will require providers to be familiar with several issues unique to the adolescent population.

`What, Me Worry?'

Little is known about the bases of parental worry about adolescents' risk for acquiring a sexually transmitted infection (STI). Parents ( N = 247) of adolescents 12—17 years endorsed reasons that explained their worry or nonworry. Parents' past experience of an STI, perception of the child's sexual activity, and racial self-identification were predictors of worry. Cluster analyses identified five groups of worriers and four groups of nonworriers. Worriers tended to select reasons reflecting an external parental locus of control or child-specific reasons. Nonworriers endorsed reasons consistent with internal parental locus of control. Findings suggest that preventive health communication should be tailored to parents' perceptions of risk and protective factors.

Ethics and the HPV Vaccine: Considerations for School Nurses

School nurses are at the forefront of health care providers for many families of junior high and high school students and are used as primary sources of information and guidance about recommended student vaccinations. In the case of the relatively new vaccine for human papillomavirus (HPV), school nurses must be both knowledgeable about the infection itself and unbiased when asked to give students and families information about the vaccine. This article explores the development and current status of HPV and the HPV vaccine and the ethical principles of autonomy, utilitarianism, beneficence, nonmaleficence, justice, and cultural and religious issues as they relate to discussions with students and families about HPV vaccinations. School nurses are advocates for the health of students. Therefore, they must critically evaluate the application of these ethical principles when providing information and recommendations about the HPV vaccination.

HPV and cervical cancer testing and prevention: knowledge, beliefs, and attitudes among Hispanic women

Cervical cancer is a preventable disease resulting from infection with high-risk types of sexually transmitted human papillomaviruses (HPVs). Public knowledge of HPVs and their link to cervical cancer is limited. Participation in cervical cancer prevention programs, including Pap and HPV screening and HPV vaccine acceptance, is crucial for limiting the incidence of cervical cancer. Hispanic women suffer the highest cervical cancer incidence rates in the United States. In this study, we conducted community-based focus groups with Hispanic women to explore knowledge and attitudes relating to cervical cancer, HPV, HPV testing, and HPV vaccination. Study findings suggest a need to increase public health literacy in relation to HPV, the link between HPV and cervical cancer, and HPV primary and secondary prevention options. Health care providers should be prepared to share information with patients that supports and promotes informed decision making about HPV testing and vaccines and their complementary roles in cervical cancer screening and prevention.