Vaccinating sons against HPV: results from a U.S. national survey of parents

HPV Vaccination in Young Males: A Glimpse of Coverage, Parental Attitude and Need of Additional Information from Lombardy Region, Italy

Background: In the Lombardy Region, Italy, HPV vaccination is recommended and offered free of charge to 12-years-old males since 2017. The expected vaccination thresholds are still far to be reached. Methods: A cross-sectional survey to investigate parents’ attitudes towards the HPV vaccine and knowledge about HPV was administered to parents of boys aged 6 to 18 years attending a large pediatric hospital for outpatient specialistic evaluations. Two parallel multiple logistic regression analyses were conducted to estimate the odds ratios (ORs) and the corresponding 95% confidence intervals (CIs) for attitude towards HPV vaccination and perceived need for more information about HPV vaccination. Results: A positive attitude towards HPV vaccination was found in 74% of interviewed parents. Knowledge of HPV, having a generally positive attitude toward vaccination, and mothers filling in the survey were positively associated with a positive attitude to the HPV vaccine. Parents’ perceived need for more information about HPV vaccination was positively associated with the child’s age, general positive attitude toward vaccination, Christian religion, and positive attitude toward HPV vaccination; knowing that HPV vaccination is free of charge significantly reduced the risk of asking for more information on HPV vaccination. Conclusions: The majority of parents of male children and adolescents in our study have a positive attitude toward HPV vaccination. Attitude toward HPV vaccination and perceived need for more information on HPV vaccination were directly related to a positive attitude toward vaccines in general. In addition, knowledge of HPV and related pathologies favors a positive attitude toward HPV vaccination. Future health programs should target an even wider diffusion of evidence-based information on vaccines in general and on the HPV vaccine in young males, to support a positive attitude toward vaccines in the general population.

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.

A systematic review of human papillomavirus vaccination among US adolescents

The human papillomavirus (HPV) causes many anogenital and oral cancers affecting young adults in the United States. Vaccination during adolescence can prevent HPV-associated cancers, but vaccine uptake among adolescents is low and influenced by factors serving as barriers and facilitators to HPV vaccination. In this systematic review, we synthesized research using the socioecological framework model to examine individual-level, relationship-level, community-level, and societal-level factors that influence HPV vaccine initiation and completion among US adolescents. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to guide the methodology for this review. An electronic search was conducted in January 2020 using PubMed, Cumulative Index of Nursing and Allied Health Literature, ProQuest Central, Scopus, and American Psychological Association PsycInfo databases. The Joanna Briggs Institute tools were used to assess the quality for the 57 studies included in this review. The most consistent influences of HPV vaccination included age at vaccination, awareness, and knowledge about HPV vaccination, socioeconomic status, insurance status, race/ethnicity, and preventative care behaviors at the individual level. Provider recommendation, familial/peer support of vaccination, and parental health behaviors were influences at the relationship level. Although fewer findings elucidated community-level and societal-level influences, high-poverty areas, high-risk communities with large proportions of racial/ethnic minority groups, healthcare facilities servicing children, and combined health policies appear to serve as facilitators of HPV initiation and completion. Findings from this review can inform culturally relevant and age-specific interventions and multi-level policies aiming to improve HPV vaccination coverage in the United States.

"We fear the unknown": Emergence, route and transfer of hesitancy and misinformation among HPV vaccine accepting mothers

Although licensed since 2006, US HPV vaccination rates remain suboptimal. Since mothers are decision-makers for young adults' vaccination, assessing ongoing knowledge deficits and misunderstanding among parents is important for determining the content and mode of interventions to reach parents. Guided by the social-ecological model and health belief model, 30 interviews with vaccine accepting mothers in the U.S. Midwest were conducted from January through June 2020. Researchers examined ecological determinants of acceptance, perceptions of vaccination barriers, and perceived cues to action for empowering other mothers to vaccinate their children. Data were analyzed using thematic analysis. Results found vaccine accepting mothers exhibited ongoing misconceptions and negative attitudes toward HPV vaccine. Physicians, peers and the media were identified as primary pro-HPV vaccine sources, yet hesitancy and misinformation occurred with each source. Trust in provider recommendation was the primary source for decision-making, yet trust was still lacking. While mothers looked to the media for HPV information, the media were identified as the main source of confusion and distrust. Results show that parents who accept the HPV vaccine can still be hesitant. Thus, mothers who have vaccinated their children for HPV may still need attitudinal and educational training prior to establishing them as role models in interventions for empowering other parents to vaccinate their children. Results showing that the media sow confusion and hesitancy also call for more attention to social media policies to guard against misinformation about the HPV vaccine.

Vaccipack, A Mobile App to Promote Human Papillomavirus Vaccine Uptake Among Adolescents Aged 11 to 14 Years: Development and Usability Study

BACKGROUND

More than 90% of human papillomavirus (HPV)-related cancers could be prevented by widespread uptake of the HPV vaccine, yet vaccine use in the United States falls short of public health goals.

OBJECTIVE

The purpose of this study was to describe the development, acceptability, and intention to use the mobile app Vaccipack, which was designed to promote uptake and completion of the adolescent HPV vaccine series.

METHODS

Development of the mobile health (mHealth) content was based on the integrated behavioral model (IBM). The technology acceptance model (TAM) was used to guide the app usability evaluation. App design utilized an iterative process involving providers and potential users who were parents and adolescents. App features include a vaccine-tracking function, a discussion forum, and stories with embedded messages to promote intention to vaccinate. Parents and adolescents completed surveys before and after introducing the app in a pediatric primary care setting with low HPV vaccination rates.

RESULTS

Surveys were completed by 54 participants (20 adolescents aged 11 to 14 years and 34 parents). Notably, 75% (15/20) of adolescents and 88% (30/34) of parents intended to use the app in the next 2 weeks. Acceptability of the app was high among both groups: 88% (30/34) of parents and 75% (15/20) of adolescents indicated that Vaccipack was easy to use, and 82% (28/34) of parents and 85% (17/20) of adolescents perceived the app to be beneficial. Higher levels of app acceptability were found among parents with strong intentions to use the app (P=.09; 95% CI -2.15 to 0.15).

CONCLUSIONS

mHealth technology, such as Vaccipack, may be an acceptable and nimble platform for providing information to parents and adolescents and advancing the uptake of important vaccines.

Comparison of the implementation of human papillomavirus and hepatitis B vaccination programs in the United States: Implications for future vaccines

Vaccines for two viruses which cause cancer, human papillomavirus (HPV) and hepatitis B virus (HBV), are recommended for all children in the United States. Numerous parallels exist between the two vaccines in addition to their roles in cancer prevention, including transmission through sexual contact, multiple doses needed for series completion, and vaccine administration in adolescence for HPV and in the initial phase of the HBV vaccination program. All of these factors were viewed as potential barriers to achieving high rates of coverage, yet the ultimate success of the HBV vaccination program led to predictions that similarly high rates of coverage could be achieved for the HPV vaccine. However, currently, only the recommendation for HBV vaccination is supported by mandates for school entry in most states. Uptake of the HPV vaccine has lagged far behind U.S. goals for public health promotion. The aim of this paper is to examine factors which may account for the divergent pathways of the two vaccines. Four main factors are identified: logistical challenges of vaccine administration, attitudes of parents and healthcare providers, safety concerns, and cost. For each factor examined, recommendations are offered to confront similar barriers likely to arise for future vaccines. The authors conclude that gender-neutral state mandates coupled with school-located vaccination programs, stronger gender-neutral messaging from pharmaceutical companies and healthcare providers, and younger age of vaccine administration, if approved, present the most promising approaches to improving uptake of the HPV vaccine, and similar vaccines down the road.

Correlates of HPV vaccine initiation and provider recommendation among male adolescents, 2014 NIS-Teen

Vaccination is a safe and effective way to prevent Human Papillomavirus (HPV) infection and related cancers; however, HPV vaccine uptake remains low in the US. After the 2011 Advisory Committee on Immunization Practices (ACIP) recommendation for routine HPV vaccination of adolescent males, several studies have examined predictors for initiating the vaccine series in this population of interest, particularly with regard to provider recommendations. This study examined racial and ethnic differences for HPV vaccine initiation and provider recommendation in male adolescents. Based on prior HPV vaccine uptake estimates and healthcare utilization data, we hypothesized that minority adolescents would be more likely to initiate HPV vaccines, but less likely to receive a provider recommendation compared to white counterparts. We analyzed the 2014 National Immunization Survey-Teen (NIS-Teen), which included 10,753 male adolescents with provider-verified vaccination data in 50 US states, using multivariate logistic regression models to evaluate racial/ethnic differences in HPV vaccine initiation and provider recommendation. The odds of HPV vaccine initiation were 76 percent higher for Hispanic adolescents and 43 percent higher for non-Hispanic Other or Multiple race adolescents compared to white adolescents. Approximately half of parents reported receiving a provider recommendation for vaccination, with no significant difference in the odds of receiving a provider recommendation across racial/ethnic groups. Despite similar frequency of recommendations across racial and ethnic groups, male adolescents who are racial/ethnic minorities are more likely to initiate vaccination. Future research should focus on developing tailored interventions to increase HPV vaccine receipt among males of all racial/ethnic groups.

Parents' uptake of human papillomavirus vaccines for their children: a systematic review and meta-analysis of observational studies

OBJECTIVE

To examine factors associated with parents' uptake of human papillomavirus (HPV) vaccines for their children.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Cochrane Library, AIDSLINE, CINAHL, EMBASE, PsycINFO, Social Sciences Abstracts, Ovid MEDLINE, Scholars Portal, Social Sciences Citation Index and Dissertation Abstracts International from inception through November 2017.

METHODS

We included studies that sampled parents and assessed uptake of HPV vaccines for their children (≤18 years) and/or sociodemographics, knowledge, attitudes or other factors associated with uptake. Study risk of bias was assessed using the Effective Public Health Practice Project tool. We pooled data using random-effects meta-analysis and conducted moderation analyses to examine variance in uptake by sex of child and parent.

RESULTS

Seventy-nine studies on 840 838 parents across 15 countries were included. The pooled proportion of parents' uptake of HPV vaccines for their children was 41.5% (range: 0.7%-92.8%), twofold higher for girls (46.5%) than for boys (20.3%). In the meta-analysis of 62 studies, physician recommendation (r=0.46 (95% CI 0.34 to 0.56)) had the greatest influence on parents' uptake, followed by HPV vaccine safety concerns (r=-0.31 (95% CI -0.41 to -0.16)), routine child preventive check-up, past 12 months (r=0.22 (95% CI 0.11 to 0.33)) and parents' belief in vaccines (r=0.19 (95% CI 0.08 to 0.29)). Health insurance-covered HPV vaccination (r=0.16 (95% CI 0.04 to 0.29)) and lower out-of-pocket cost (r=-0.15 (95% CI -0.22 to -0.07)) had significant effects on uptake. We found significant moderator effects for sex of child.

CONCLUSIONS

Findings indicate suboptimal levels of HPV vaccine uptake, twofold lower among boys, that may be improved by increasing physician recommendations, addressing parental safety concerns and promoting parents' positive beliefs about vaccines, in addition to expanding insurance coverage and reducing out-of-pocket costs. Limitations of this meta-analysis include the lack of intervention studies and high risk of bias in most studies reviewed. Further studies should disaggregate HPV vaccine uptake by sex of child and parent.

The feminization of HPV: How science, politics, economics and gender norms shaped U.S. HPV vaccine implementation

Human papillomavirus (HPV) can cause a number of anogenital cancers (i.e., cervical, penile, anal, vaginal, vulvar) and genital warts. A decade ago, the HPV vaccine was approved, and has been shown to be a public health achievement that can reduce the morbidity and mortality for HPV-associated diseases. Yet, the mistaken over-identification of HPV as a female-specific disease has resulted in the feminization of HPV and HPV vaccines. In this critical review, we trace the evolution of the intersection of science, politics, economics and gender norms during the original HPV vaccine approval, marketing era, and implementation. Given the focus on cervical cancer screening, women were identified as bearing the burden of HPV infection and its related illnesses, and the group responsible for prevention. We also describe the consequences of the feminization of HPV, which has resulted primarily in reduced protection from HPV-related illnesses for males. We propose a multilevel approach to normalizing HPV vaccines as an important aspect of overall health for both genders. This process must engage multiple stakeholders, including providers, parents, patients, professional organizations, public health agencies, policymakers, researchers, and community-based organizations.

Intention of Mothers in Israel to Vaccinate their Sons against the Human Papilloma Virus

PURPOSE

This study investigated the intention of mothers in Israel to vaccinate their sons against HPV, using the Health Belief Model (HBM) as a framework, while comparing between Arab and Jewish mothers.

DESIGN AND METHODS

The study has a quantitative cross-sectional design. A convenience sample of 200 Jewish and Arab mothers of boys aged 5-18 completed a questionnaire based on the HBM.

RESULTS

The research findings indicate that only 14% of the mothers, constituting mostly Arab mothers, vaccinated their sons against HPV. Moreover, mothers showed a moderate level of intention to vaccinate their sons. This level was similar among Arab and Jewish mothers. However, the health beliefs of Jewish and Arab mothers differed. The HBM was found to explain 68% of mothers' intention to vaccinate their sons against HPV, and the perceived benefits of the vaccine were the factor most affecting this intention.

CONCLUSIONS

Although mothers' health beliefs concerning vaccinating their sons against HPV may vary between sectors, the HBM can be used to explain what motivates mothers to vaccinate their sons.

PRACTICE IMPLICATIONS

The research findings can assist in designing a national project among mothers of boys aimed at raising HPV vaccination rates, in both the Jewish and the Arab sector.

Factors associated with parents' attitudes to the HPV vaccination of their adolescent sons : A systematic review

OBJECTIVE

The objective of the study was to identify factors associated with human papilloma virus (HPV) vaccine acceptability in parents of adolescent boys. This information is critical to the development of approaches to optimise HPV vaccine uptake among this population group.

METHODS

We performed a systematic search of the literature in addressing factors influencing parental attitudes to and beliefs about HPV vaccine and its acceptability for use. The findings were organised within the framework of the Health Belief Model (HBM) and summarised using a semi quantitative method.

RESULTS

Eighteen studies met the inclusion criteria. Parental decisions were predominantly shaped by the perceived benefits of the vaccine; perceived risk of sons contracting the HPV infection, and having recommendations from health care providers. Fear of side effects and uncertainty about vaccine effectiveness, as well as cost and lack of healthcare, were barriers to HPV vaccination. Other factors such as knowledge, family characteristics, parent-child dialogue and egalitarian values appeared to be important when deciding whether to vaccinate boys.

CONCLUSIONS

HPV vaccine uptake among male adolescents is suboptimal. Future programs need to address the predictors of uptake by educating parents about the boys' high susceptibility to infection, the benefits of vaccination, and reduce concerns regarding perceived barriers. Additionally, uptake may be facilitated by encouraging health care provider endorsement, particularly in countries without government-funded immunisation programs.

Psychosocial determinants of parental human papillomavirus (HPV) vaccine decision-making for sons: Methodological challenges and initial results of a pan-Canadian longitudinal study

Background

HPV vaccination decision-making is a complex process that is influenced by multiple psychosocial determinants. Given the change in policy recommendation to include males in routine HPV vaccination, our goals were to assess the HPV vaccination uptake in Canada, to understand where Canadian parents were situated in the HPV vaccine decision-making process for their son, how they changed over time and which psychosocial determinants were relevant for this process.

Methods

We used an online survey methodology and collected data from a nationally representative sample of Canadian parents of boys aged 9–16 at baseline (T1, February 2014) and at 9 months’ follow-up (T2). Our analyses were guided by the Precaution Adoption Process Model (PAPM), a theoretical health behavior model that classifies parents in one of six stages: unaware, unengaged, undecided, decided not to vaccinate, decided to vaccinate and those who had already vaccinated their sons. Rigorous methods were used to filter out careless responders: response variance, bogus items, psychometric antonyms and psychometric synonyms.

Results

At T1 and T2, we received 3,784 and 1,608 respectively completed questionnaires; after data cleaning 3,117 (T1) and 1,427 (T2) were retained. Less than 3% of boys were vaccinated at both time points. At both T1 and T2, most parents (over 70%) belonged to the earlier vaccination adoption stages: 57% were unaware (T1) and 15.3% (T2); 20.9% were unengaged (T1) and 32.4% (T2); and 9.1% were undecided (T1) and 25.2% (T2). At follow-up, 37.7% of participants did not move from their initial PAPM decision-making stage. Most parents (55%) preferred to receive information from their healthcare provider (HCP) but only 6% (T1) and 12% (T2) had actually spoken with a HCP about the HPV vaccine for their son.

Conclusions

HPV vaccination uptake in Canadian boys was very low in the absence of a publicly funded HPV vaccination programs for boys. Optimal HPV information preferences were identified and can be used in interventions to increase HPV knowledge and increase HPV vaccine uptake. Intentions to vaccinate or planning to speak to one’s HCP did not translate into action for most parents over the 9-month follow up; this finding is critical to consider to inform implementation strategies. Methodological challenges are described and suggestions for future research are offered.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3828-9) contains supplementary material, which is available to authorized users.

Parent HPV vaccine perspectives and the likelihood of HPV vaccination of adolescent males

In 2013, approximately one-third of US adolescent males age 13-17 y had received ≥1 doses of HPV vaccines and only 14% had received ≥3 doses. This study used a nationally representative, online survey to explore experiences and attitudes related to HPV vaccination among parents with adolescent sons. Analyses compared the perspective of parents who do not intend to initiate HPV vaccine for ≥1 adolescent son to that of parents who are likely to initiate or continue HPV vaccination. Of 809 parents of sons age 11-17 years, half were classified as Unlikely to Initiate HPV vaccination and 39% as Likely to Vaccinate. A higher proportion of the Likely to Vaccinate group felt their son's doctor was knowledgeable about HPV vaccine, did a good job explaining its purpose, and spent more time discussing HPV vaccine; in contrast, over half of the Unlikely to Initiate group had never discussed HPV vaccine with their child's doctor. The majority of parents in both groups showed favorable attitudes to adolescent vaccination in general, with lower levels of support for HPV vaccine-specific statements. Physician-parent communication around HPV vaccine for adolescent males should build on positive attitude toward vaccines in general, while addressing parents' HPV vaccine-specific concerns.