The moral justification for a compulsory human papillomavirus vaccination program

Recording harms in randomized controlled trials of behavior change interventions: a scoping review and map of the evidence

OBJECTIVES

Randomized controlled trials evaluate diverse interventions. This can include medical interventions such as drugs or surgical procedures, or behavior change interventions (BCIs) that aim to change a habit, belief, or attitude to improve health, for example, healthy eating, psychological wellbeing. Harms are often recorded poorly or inconsistently within randomized controlled trials of BCIs. This scoping review aimed to collate and describe literature on categories, definitions, and mechanisms of harms from BCIs; methods of identifying plausible harms; and recommendations for recording harms.

STUDY DESIGN AND SETTING

A scoping review was conducted. Three databases (MEDLINE, PsycINFO, and CINAHL) were searched. Reference list checking and citation searching were performed. Articles were included if they discussed (1) interventions that aimed to modify behavior, (2) categories or mechanisms of harms, and (3) methods or recommendations for recording harms. All research designs were included. One reviewer reviewed titles, abstracts, and full texts; queries were checked with another reviewer. Data were extracted and synthesized descriptively by one reviewer and checked by another reviewer. A thematic map was constructed to summarize the review findings. Harms described from specific BCIs were identified, and examples were selected and summarized.

RESULTS

The review included 37 articles. Nineteen of 37 articles contributed to a thematic review. Three articles described categories of harms; categories of harm included physical, psychological, group and social interactions, cultural, equity, opportunity cost, environmental, and economic. Seven articles included mechanisms or underlying factors for harms including feelings of failure leading to shame or stigma, and group interventions enabling knowledge exchange on unhealthy behaviors. Twelve articles provided recommendations for recording harms, including taking a proportionate approach by focusing on the most plausible and important harms, collecting different perspectives on whether harms had occurred (eg, caregivers and family members), and using qualitative research methods to identify harms. One article described a three-step method to identify plausible harms from an intervention, and six articles supported aspects of the method. Eighteen of 37 articles contributed to a review which collated harms arising from specific interventions, for example, a peer support intervention in inflammatory bowel disease caused distressing conversations which might lead to anxiety and confrontation with a possible negative future.

CONCLUSION

BCIs can cause harm. This review identified categories and proposed mechanisms of harms, as well as methods and recommendations for identifying and recording harms in BCIs for inclusion in forthcoming recommendations.

The determinants of knowledge of cervical cancer, attitude towards screening and practice of cervical cancer prevention amongst antenatal attendees in Ibadan, Southwest Nigeria

Cervical cancer (CC) is an extremely preventable and curable disease with early detection and treatment. Unfortunately, the practice of cervical cancer prevention (CCP) remains poor in resource constrained countries. This study aimed to identify determinants of knowledge of CC, attitude towards cervical cancer screening (CCS) and practice of CCP among antenatal attendees in a tertiary hospital in Southwest Nigeria as they are sexually active women. This was a cross-sectional survey of a cohort of 287 antenatal attendees using a self-administered structured questionnaire to assess their knowledge of CC, attitude towards screening and uptake of screening and human papillomaviruses (HPVs) vaccination as methods of practice of CCP. Data was analysed using the Statistical Package for Social Sciences version 20.0. Descriptive statistics were conducted for all relevant data. Categorical variables were explored using chi-square test and the independent variables with significant associations (p-value < 0.05) entered into logistic regression analysis. The mean age was 30.62 ± 4.5 years. Three-fifths (60.6%) of the women had good knowledge of CC while 47.4% had heard about CCS. Majority (75.6%) were willing to undergo CCS thereby exhibiting positive attitude towards screening. The practice of CCP was poor as only 27 (9.4%) had ever been screened for CC while 10 (3.5%) had received the HPV vaccine. Interestingly, none of the women who had received the HPV vaccine had been screened for CC. Those with tertiary education were more likely (OR = 2.140, 95% CI = 1.166-4.979) to exhibit positive attitude to CCS, while those with poor knowledge were about two times less likely to have a positive attitude (OR = 0.532, 95% CI = 0.291-0.972). Poor knowledge of CC was associated with lesser odds (OR = 0.061, 95% CI = 0.008-0.471) of practice of CCP. In Nigeria, the burden of CC can be reduced if women are educated and health care providers challenged to recommend CCS and HPV vaccination.

Vaccine Hesitancy, History, and Human Nature: The 2018 Stanley A. Plotkin Lecture

Navigating the waters of vaccine hesitancy requires a view towards history and a deep understanding of how humans think. Getting children vaccinated is as much, or more, about connecting with people as it is about communicating scientific information.

The Ethical Case for Mandating HPV Vaccination

When the HPV vaccine was released over a decade ago, there was intense opposition to mandating the vaccine, including among bioethics and legal scholars. Some of the original concerns are now obsolete, while other objections continue to present an obstacle to mandating the vaccine. This essay responds to earlier critiques of mandatory HPV vaccination and offers a series of arguments in support of a vaccine mandate. The first section briefly addresses initial concerns that are no longer relevant. The second section makes the ethical case for mandating HPV vaccination, based on three principles: 1) the best interests of children, 2) solidarity, and 3) health equity. The final section addresses concerns related to implementation of the vaccine, including the validity of linking vaccination to school entry. The essay concludes that we have a moral imperative to protect children from the leading cause of cervical cancer, and that mandating HPV vaccination is the best way to ensure that children of all backgrounds receive the vaccine before they have been exposed to the virus.

Using the Health Belief Model to Examine the Link between HPV Knowledge and Self-Efficacy for Preventive Behaviors of Male Students at a Two-Year College in New York City

The human papillomavirus (HPV) is one of the most common and easily transmitted sexually transmitted infections in the United States; infected individuals are frequently unaware that they are carriers, and transmission occurs unknowingly. Infection can lead to genital warts or cervical, penile, anal, or oral cancer. The object of this study was to examine the link between HPV knowledge and self-efficacy for preventive behaviors among college students as well as HPV vaccine acceptability. A cross-sectional survey of students at a two-year college in New York City was conducted electronically. The current study focuses on male students (N = 120). We found that HPV knowledge was low among this sample, but that self-efficacy and vaccine acceptability were high. Self-efficacy and perceived susceptibility to HPV predicted vaccine acceptability, but not condom use. The challenge for health care practitioners and health educators is to provide focused, comprehensive education about HPV without causing undue fear.

Impact of school-entry and education mandates by states on HPV vaccination coverage: Analysis of the 2009-2013 National Immunization Survey-Teen

OBJECTIVE

To determine the effectiveness of existing school entry and education mandates on HPV vaccination coverage, we compared coverage among girls residing in states and jurisdictions with and without education and school-entry mandates. Virginia and the District of Columbia enacted school entry mandates, though both laws included liberal opt-out provisions. Ten additional states had mandates requiring distribution of education to parents or provision of education within school curricula.

METHODS

Using data from the National Immunization Survey-Teen from 2009-2013, we estimated multilevel logistic regression models to compare coverage with HPV vaccines for girls ages 13-17 residing in states and jurisdictions with and without school entry and education mandates, adjusting for demographic factors, healthcare access, and provider recommendation.

RESULTS

Girls residing in states and jurisdictions with HPV vaccine school entry mandates (DC and VA) and education mandates (LA, MI, CO, IN, IA, IL, NJ, NC, TX, and WA) did not have higher HPV vaccine series initiation or completion than those living in states without mandates for any year (2009-2013). Similar results were seen when comparing girls ages 13-14 to those ages 15-17, and after adjustment for known covariates of vaccination.

CONCLUSIONS

States and jurisdictions with school-entry and education mandates do not currently have higher HPV vaccination coverage than states without such legislation. Liberal opt-out language in existing school entry mandates may weaken their impact. Policy-makers contemplating legislation to improve vaccination coverage should be aware of the limitations of existing mandates.

Parents' and providers' attitudes toward school-located provision and school-entry requirements for HPV vaccines

OBJECTIVE

To determine parents' and providers' attitudes toward school-located provision and school-entry requirements for HPV vaccination.

METHODS

Parents/guardians of 11-17 y old girls and pediatric healthcare providers at one inner-city public clinic and three private practices completed semi-structured interviews in 2012-2013. Participants were asked open-ended questions regarding their attitudes toward school-located provision and school-entry requirements for HPV vaccination. Parents' answers were analyzed with relationship to whether their daughters had not initiated, initiated but not completed, or completed the HPV vaccine series. Qualitative analysis was used to identify themes related to shared views.

RESULTS

129 parents/guardians and 34 providers participated. 61% of parents supported providing HPV vaccinations in schools, citing reasons of convenience, improved access, and positive peer pressure. Those who opposed school-located provision raised concerns related to privacy and the capacity of school nurses to manage vaccine-related reactions. Parents whose daughters had not completed the series were more likely to intend to vaccinate their daughters in schools (70%) and support requirements (64%) than parents who had not initiated vaccination (42% would vaccinate at school, 46% support requirements) or completed the series (42% would vaccinate at school, 32% support requirements; p < 0 .05 for all comparisons). 81% of providers supported offering vaccination in schools, wanting to take advantage of the captive audience, improve vaccine completion rates, and decrease the administrative burden on medical office staff, but were concerned about adequate information transfer between schools and medical offices. Only 32% of providers supported school-entry requirements, largely because they felt that a requirement might provoke a public backlash that could further hinder vaccination efforts.

CONCLUSIONS

School-located provision of HPV vaccination was widely accepted by healthcare providers and parents whose children have not completed the series, indicating that this venue might be a valuable addition to improve completion rates. Support for school-entry requirements was limited among both parents and healthcare providers.

Concept Analysis: Health-Promoting Behaviors Related to Human Papilloma Virus (HPV) Infection

PROBLEM

The concept of health-promoting behaviors incorporates ideas presented in the Ottawa Charter of Public Health and the nursing-based Health Promotion Model. Despite the fact that the concept of health-promoting behaviors has a nursing influence, literature suggests nursing has inadequately developed and used this concept within nursing practice. A further review of literature regarding health promotion behaviors and the human papilloma virus suggest a distinct gap in nursing literature.

METHOD

This article presents a concept analysis of health-promoting behaviors related to the human papilloma virus in order to encourage the application of the concept into nursing practice, promote continued nursing research regarding this concept, and further expand the application of health-promoting behaviors to other situations and populations within the nursing discipline.

CONCLUSION

Attributes of health-promoting behaviors are presented and include empowerment, participation, community, and a positive concept of health. Antecedents, consequences, and empirical referents are also presented, as are model, borderline, and contrary cases to help clarify the concept. Recommendations for human papilloma virus health-promoting behaviors within the nursing practice are also provided.

A scoping review of unintended harm associated with public health interventions: towards a typology and an understanding of underlying factors

OBJECTIVES

Unintended harm theory as related to public health interventions (PHI) is under developed, with harm evaluation and reporting often absent or incomplete. This review presents a typology for, and underlying factors linked to, PHI-associated unintended harm.

METHODS

This scoping review was conducted electronically and includes articles from 1992 to June of 2013. Out of 2,490 originally identified titles, 26 full-text articles were included that discussed unintended harm associated with PHI. An iterative data analysis process was utilized to identify both a typology and underlying factors associated with unintended harm.

RESULTS

A typology of PHI-associated unintended harm was identified: (1) physical; (2) psychosocial; (3) economic; (4) cultural and (5) environmental. Five underlying factors associated with PHI unintended harm emerged: (1) limited and/or poor quality evidence; (2) prevention of one extreme leads to another (boomerang effects); (3) lack of community engagement; (4) ignoring root causes; and (5) higher-income country PHI implementation in a lower- or middle-income country.

CONCLUSIONS

PHI planning and evaluation frameworks may benefit from the consideration and potential incorporation of the unintended harm typology and underlying factors.

Human papillomavirus (HPV), HPV-associated oropharyngeal cancer, and HPV vaccine in the United States--do we need a broader vaccine policy?

BACKGROUND

Human papillomavirus (HPV) is a sexually transmitted infection (STI) of global importance; it is the most prevalent STI in the United States, with strains causally linked to oropharyngeal and other cancers. Efforts to prevent HPV have been made to varying degrees by policies implemented by different state governments; however, HPV and associated oropharyngeal cancer continue to show increasing incidence rates in the US.

DESIGN

A narrative review based on search on SciVerse, PubMed/Medline, Google Scholar, and EMBASE databases, as well as literature/documents from the World Health Organization, Centers for Disease Control and Prevention, American Cancer Society, National Conference of State legislatures, and the U.S. Department of Health and Human Services relevant to HPV and HPV vaccine policy in the US.

RESULTS

Vaccination has proved to be a successful policy in the US, and an extant recommendation aimed at preventing HPV and associated cervical and other anogenital cancers is the routine use of HPV vaccines for males and females. However, HPV vaccines are presently not recommended for preventing oropharyngeal cancer, although they have been shown to be highly effective against the HPV strains that are most commonly found in the oropharynx. And while there is a history of successful vaccine mandate in the US with resulting decrease in occurrence of infectious diseases, implementing HPV vaccine mandate has proved to be very unpopular.

CONCLUSIONS

With emerging evidence of the efficacy of the use of the HPV vaccine in preventing oral-HPV, more focus should be put on extending HPV vaccine to present oral HPV infection and oropharyngeal cancer. Also, implementing a broader HPV vaccine policy that include mandating HPV vaccines as a school-entry requirement for both sexes may increase vaccine use in the US for the greater good of the public.

Enhancing Children against Unhealthy Behaviors-An Ethical and Policy Assessment of Using a Nicotine Vaccine

Health behaviors such as tobacco use contribute significantly to poor health. It is widely recognized that efforts to prevent poor health outcomes should begin in early childhood. Biomedical enhancements, such as a nicotine vaccine, are now emerging and have potential to be used for primary prevention of common diseases. In anticipation of such enhancements, it is important that we begin to consider the ethical and policy appropriateness of their use with children. The main ethical concerns raised by enhancing children relate to their impact on children's well-being and autonomy. These concerns are significant, however they do not appear to apply in the case of the nicotine vaccine; indeed the vaccine could even further these goals for children. Nevertheless, concerns about broadly applying this enhancement may be more challenging. The vaccine may be less cost-effective than alternative public efforts to prevent tobacco use, utilizing it could distract from addressing the foundational causes of smoking and it might not be publically acceptable. Empirical research about these concerns is needed to ascertain their likelihood and impact as well as how they could be minimized. This research could help determine whether behavior-related enhancements hold promise for improving children's health.

Mutual Moral Obligations in the Prevention of Infectious Diseases

Not so long ago health policy was about little more than the provision of medical care. The availability of treatment is important for those in need of cure, but by now it is a well-shown fact that health is generally determined to a much greater extent by other factors. Genetic constitution, lifestyle choices and socio-economic environment largely explain why some of us become ill or die earlier than others who remain healthy (Mackenbach 1996; McKeown 1976; Wilkinson and Marmot 2003). While some of these factors fall under the control of an individual, the majority does not. Research increasingly indicates how remarkably sensitive our health seems to be to what has become known as the ‘social determinants of health’. These factors generally fall beyond the control of an individual, but can nonetheless be influenced on a population level. This causes a shift in the focus of health policy from the classic provision of health care to policies specifically designed to influence the causal factors of ill-health in different non-medical fields. The flipside of that evolution is a significant increase of the state’s influence in the sphere of individual lives. A pertinent question remains the one that asks for the legitimate role of governments in modifying, discouraging or prohibiting behaviors that lead to ill-health. To what extent can and should we hold public policy responsible for us leading a healthy life? Most scholars will argue that governments indeed have a role to play, but that the limits will be reached when public health measures would imply large sacrifices of individual liberty.

Another look at the human papillomavirus vaccine experience in Canada

Policy debates about immunization frequently focus on classic trade-offs between individual versus collective well-being. Publicly funded immunization programs are usually justified on the basis of widespread public benefit with minimal individual risk. We discuss the example of the policy process surrounding the adoption of the human papillomavirus (HPV) vaccine in Canada to consider whether public good arguments continue to dominate immunization policymaking. Specifically, we show how a range of stakeholders framed HPV vaccination as a personal-rather than a public-matter, despite the absence of a controversy over mandatory immunization as was the case in the United States. Our findings suggest an erosion of the persuasiveness of public good arguments around collective immunization programs in the policy discourse.

The ethics of implementing human papillomavirus vaccination in developed countries

Human papillomavirus (HPV) infection is the world's most common sexually transmitted infection. It is a prerequisite for cervical cancer, the second most common cause of death in cancer among women worldwide, and is also believed to cause other anogenital and head and neck cancers. Vaccines that protect against the most common cancer-causing HPV types have recently become available, and different countries have taken different approaches to implementing vaccination. This paper examines the ethics of alternative HPV vaccination strategies. It devotes particular attention to the major arguments for and against one strategy: voluntary, publicly funded vaccination for all adolescent boys and girls. This approach seems attractive because it would protect more people against cervical cancer and other HPV-related cancers than less inclusive alternatives, without the sacrifice of autonomy that a comparably broad compulsory programme would require. Also, the herd immunity that it would likely generate would protect those who remain unvaccinated, a major advantage from a justice perspective. However, there is a possibility that a HPV vaccination programme targeting all adolescents of both sexes is not considered sufficiently cost-effective. Also, it might pose more difficulties for achieving informed consent than comparable vaccination programmes against other diseases. Ultimately, society's choice of HPV vaccination strategy requires careful consideration not only of the values at stake but also of available and emerging scientific evidence.

Parents' opinions of mandatory human papillomavirus vaccination: does ethnicity matter?

OBJECTIVE

To explore parents' opinions of school-entry requirements for human papillomavirus (HPV) vaccination.

METHODS

We interviewed parents of vaccine-eligible girls attending medical appointments in an urban academic medical center and an affiliated community health center. We used qualitative methods to explore parents' opinions about mandating routine childhood vaccines and HPV vaccine, as well as their feelings about vaccinating their own daughters against HPV.

RESULTS

We included 19 Caucasian, 18 African-American, 12 Afro-Caribbean, 3 African, and 21 Latino parents. Nearly all parents had allowed their children to receive routine vaccinations and expressed support for mandating these vaccines. Most parents also vaccinated their daughters against HPV: 100% of Caucasian parents, 90% of African-American parents, 73% of Afro-Caribbean/African parents, and 90% of Latino parents. Only 11% of Caucasian parents supported HPV vaccine mandates, however, compared with 78% of African-American, 60% of Afro-Caribbean/African, and 90% of Latino parents. Immigrants supported mandates more frequently than U.S.-born parents. Most Caucasian parents opposed mandatory HPV vaccination because they believed the HPV vaccine should be an individual decision because the virus can only be spread by sexual contact. African-American, Afro-Caribbean, African, and Latino parents generally viewed mandates as the most effective way to protect their daughters from cervical cancer. Latino parents gave special importance to protecting their daughters from sexually transmitted infections.

CONCLUSION

Parents from different racial and ethnic backgrounds expressed unique perspectives about mandatory HPV vaccination. Caucasians were less likely than parents of other races/ethnicities to support vaccine mandates.

Human papillomavirus status in head and neck cancer: the ethics of disclosure

Human papillomavirus (HPV) is an emerging causative factor for squamous carcinoma of the oropharynx and perhaps other head and neck cancers. There is a great deal of uncertainty regarding the clinical significance and implications of HPV status in this patient population. As a result, there is no established protocol for informing patients of the potential link between viral infection and their cancer. This paper discusses some of the ethical issues involved with informing head and neck cancer patients of their HPV status, recognizing the dilemma posed by unresolved clinical questions and the need to respect the autonomy of patients by disclosing relevant information.

Ethical dilemmas and great expectations for human papilloma virus vaccination

When the first preventive HPV vaccine became available in 2006, it drew both enthusiasm and multiple ethical problems. In the case of HPV vaccination, there is a clear conflict between the scientific data that claim a definitive advantage for preventing HPV infection in the exposed population and the ethical and moral issues resulting from a compulsory program. Despite the evident success of routine and compulsory vaccination in young women, there is increasing concern about safety, efficacy, and equity of the vaccine and to close the knowledge "gaps" about HPV infection and consequent health outcomes. Some of these fears are expressed particularly in conservative groups that link these arguments to those of religious and moral issues contending that HPV vaccination is an indirect license for liberal sexual activity in youths, resulting in promiscuity and/or less participation in cervical cancer screening. It has been well demonstrated that HPV infection can lead to harm through the induction of premalignant and cancerous lesions. Therefore, any proven method for preventing infection, such as HPV vaccines, should be used in persons at risk. These policies, however, should be strictly linked to cervical cancer screening programs.