US Primary Care Physicians' Viewpoints on HPV Vaccination for Adults 27 to 45 Years

Healthcare worker practices for HPV vaccine recommendation: A systematic review and meta-analysis

Healthcare workers (HCWs) are trusted sources of information for vaccination and their attitude toward vaccination is thus critical. We aimed to synthesize existing literature on healthcare workers' HPV vaccine confidence and their practices of recommending this vaccine. We conducted a systematic literature review and meta-analysis, with the search conducted last in March 2024. For the inclusion criteria, the studies needed to include healthcare worker practices or behaviors on recommending the HPV vaccination. Seventy-three articles were included. The proportions of HCWs recommending varied considerably by region and gender of the recipient, but there was no statistically significant difference in income level or pre- or post-HPV vaccine introduction into the national vaccination program. The main barriers to recommending HPV vaccination were concerns around safety and efficacy, cost, parental concerns, and systemic barriers. The results illustrate the importance of contextually adapted approaches to improving vaccine acceptance and recommendation.

Patterns of single and multiple HPV infections in female: A systematic review and meta-analysis

Background

Data on the patterns of single and multiple HPV infections are largely limited to small size studies, and the regional difference have not been systematically examined.

Methods

A literature search was conducted using PubMed, Embase, and Web of Science databases up to Sept 22, 2023. The pooled prevalence of HPV infection were calculated using random-effects meta-analysis. Subgroup analysis was used to explore the heterogeneity, and publication bias was evaluated by Egger's test and Begg's test.

Results

There were 121 studies included with 1,682,422 participants. Globally, the most common genotypes of single HPV infection were HPV16 (7.05 %), 18 (1.94 %), 52 (1.93 %), 58 (1.68 %), and 31 (1.53 %), as well as HPV 16 (4.91 %), 31 (2.68 %), 52 (2.20 %), 51 (1.99 %), and 18 (1.96 %) in multiple HPV infections. Apart from HPV16 and 18, HPV52 and 58 were common in Asia, HPV31 and 51 was in Europe, North and South America, and HPV35 and 45 were in Africa. The prevalence of HPV infection among different age groups (<30, 30-50, >50 years age groups) was 20.93 %, 16.27 %, and 18.69 %, respectively. The single HPV infection prevalence in the No-ILs, LSILs, HSILs, and cervical cancer groups were 16.17 %, 51.60 %, 57.12 %, and 62.88 %, respectively, as well as in multiple infections were 5.09 %, 30.93 %, 32.86 %, and 21.26.

Conclusion

Developing local HPV vaccines is necessary based on the HPV infection pattern. It is essential to educate young women to get vaccinated and encourage elderly women to have regular cervical cancer screenings to reduce the danger of cervical cancer.

Factors Associated with HPV Vaccination Among Middle-Aged Adults in the United States

OBJECTIVE

To examine prevalence of partial and complete HPV vaccination among middle-aged adults and factors associated with vaccination status.

STUDY DESIGN

Nationally representative cross-sectional survey.

SETTING

United States.

METHODS

Cohort includes adults aged 30 to 44 years from 2018 to 2022 Behavioral Risk Factor Surveillance System (BRFSS) survey who completed questions about HPV vaccination status. Survey-weighted multivariable logistic regression was utilized to explore factors associated with partial and complete HPV vaccination status.

RESULTS

In this nationally representative cohort of 26,470 US middle-aged adults, 15.8% [95% confidence interval [CI]: 15.1%-16.6%] reported any HPV vaccination, and 6.5% [95% CI: 6.0%-7.0%] reported complete HPV vaccination. On multivariable regression, younger age, female sex, residence in the West or Northeast, higher educational attainment, unmarried status, having a personal healthcare provider, and gay or lesbian sexual orientation were associated with increased likelihood of vaccination. Race was variably associated with vaccination status. Annual income, insurance status, cancer history, head and neck cancer history, and time of last physician checkup were not associated with HPV vaccination status.

CONCLUSION

HPV vaccination among middle-aged adults who were not previously vaccinated should be based on risk for new HPV infection and possible benefits of vaccination. While our analysis shows that consideration of personal factors likely plays a role in HPV vaccination in this cohort, we also find that gaps in vaccination may exist due to other socioeconomic disparities between sexes, educational attainment levels, racial/ethnic groups, geographic regions, and access to a personal healthcare provider. These factors' influence suggests potential room for improved public health measures.

HPV vaccine behaviors and intentions among a diverse sample of women aged 27-45 years: implications for shared clinical decision-making

BACKGROUND

The Advisory Committee on Immunization Practices issued a shared clinical decision-making (SCDM) recommendation for HPV vaccination in persons aged 27-45. Since expanded eligibility for the vaccine was issued, little information has been available about HPV vaccine behaviors and intentions among women in this age group.

METHODS

We conducted a cross-sectional online survey among women aged 27-45 years recruited through a Qualtrics™ respondent panel (N = 324) to answer the following questions (1) What is the prevalence of HPV vaccination among a diverse sample of adult women aged 27-45 years? (2) What are the characteristics of those who have or have not previously been vaccinated? and (3) What factors are associated with the intention to obtain the HPV vaccine among those who had never been vaccinated? Multivariable logistic regression analyses estimated adjusted odds ratios (AORs) and 95% confidence intervals (95% CIs).

RESULTS

Only 31.1% had at least one dose of the HPV vaccine. In multivariable analyses, those more likely to have been vaccinated were younger and were more likely to believe that the vaccine was effective. Of those unvaccinated or unsure, 54.8% indicated they were likely to get vaccinated in the future. Factors associated with future vaccine intention (compared to those not intending) included beliefs about vaccine testing, perceived likelihood of HPV infection, greater comfort in asking one's provider for vaccination, and prior negative healthcare experiences.

CONCLUSIONS

Our findings suggest that many women in this age group are interested in HPV vaccination. While the recommendation is for SCDM rather than routine vaccination for all women in this age group, efforts to promote informed decision-making among mid-adult women may include educating women about the rigorous vaccine testing and approval process, their risk factors for HPV infection, and encouraging them to engage in SCDM with their medical providers. Targeted efforts to reach women who have had negative experiences with healthcare may also be needed.

Human papillomavirus vaccination uptake among 27-to-45-year-olds in the United States

OBJECTIVE

The human papillomavirus (HPV) vaccine prevents six types of cancer. Previously, this vaccine was only approved for 9-26-year-olds. However, in October 2018 the U.S. Food and Drug Administration approved the HPV vaccine for 27- to 45-year-olds (mid-adults). The current study aimed to assess HPV vaccination among a national sample of U.S adults aged 27-45 years. This study also assessed factors associated with HPV vaccine initiation after age 26.

METHODS

Data were analyzed using the 2019 National Health Interview Survey. The study included two samples: (1) mid-adults aged 27-45 (n = 8556), and (2) mid-adults who self-reported they had initiated HPV vaccination within the 27-45 age range and those who were unvaccinated (n = 7307). The outcome variables were HPV vaccination status and HPV vaccine initiation. The independent variables represented constructs from Andersen's Behavioral Model of Health Services Use. The odds of HPV vaccination were estimated using weighted multivariable logistic regression models.

RESULTS

Overall, 15.6% had ever received the HPV vaccine and 13.1% initiated their first dose of the vaccine after age 26. Hispanic (aOR = 0.73; 95% CI = 0.58, 0.92) and non-Hispanic Asian persons (aOR = 0.59; 95% CI = 0.41, 0.84) had lower odds of ever receiving the vaccine than non-Hispanic White persons. Females (aOR = 2.17; 95% CI = 1.42, 3.32) had higher odds of initiating the vaccine after age 26 than males.

CONCLUSIONS

The ACIP recommendation of shared clinical decision-making emphasizes the role of clinical interactions in HPV vaccine decision-making. Study findings highlight the need to further explore contextual factors that may influence HPV vaccine behavior among mid-adults.

Health care provider knowledge around shared clinical decision-making regarding HPV vaccination of adults aged 27-45 years in the United States

BACKGROUND

The Advisory Committee on Immunization Practices (ACIP) recommends shared clinical decision-making (SCDM) regarding HPV vaccination for adults aged 27-45 years who are not adequately vaccinated. The objective of this survey was to understand physician knowledge, attitudes, and practices regarding HPV vaccination in this age group.

METHODS

An online survey was administered in June 2021 to physicians who reported practicing internal medicine, family medicine, or obstetrics and gynecology (targeted N = 250 in each practice specialty), selected randomly from potentially eligible physicians from a panel of 2 million U.S. health care providers.

RESULTS

In total, 753 physicians participated in the survey: 33.3% practiced internal medicine, 33.1% practiced family medicine, and 33.6% practiced obstetrics/gynecology; 62.5% were male and mean physician age was 52.7 years. Despite the COVID-19 pandemic, at least a third of participating physicians in each practice specialty reported having more HPV vaccine SCDM discussions with patients aged 27-45 years in the past 12 months. While a majority of physicians (79.7%) reported being aware of the SCDM recommendation for adults in this age group, only half of physicians answered an objective knowledge question about SCDM recommendations correctly.

CONCLUSIONS

Findings suggest that there are physician knowledge gaps related to SCDM for HPV vaccination. To improve access to HPV vaccination for people most likely to benefit, increasing availability and use of decision aids to support SCDM discussions might help healthcare providers and patients jointly make the most informed decisions about HPV vaccination.

"If People Were Told About the Cancer, They'd Want to Get Vaccinated": Knowledge, Attitudes, and Beliefs About HPV Vaccination Among Mid-Adult Men

In 2018, nine-valent human papillomavirus (HPV) vaccine eligibility expanded to include adults aged 27 to 45. This study aimed to identify knowledge, attitudes, and beliefs (KABs) about HPV and HPV vaccination among newly eligible mid-adult men, for whom uptake in adolescence and younger adulthood remains suboptimal. We conducted six virtual focus groups (N = 34 participants) with unvaccinated men aged 27 to 45 living in Southern California's Inland Empire. Data were systematically analyzed to identify emergent themes using the rigorous and accelerated data reduction technique. The sample of men was diverse (79% Hispanic, non-Hispanic Black, Asian, or mixed race/ethnicity; 26% gay or bisexual) and captured participants from across the socioeconomic spectrum. Eighty-eight percent of participants had never received a provider recommendation to be vaccinated against HPV. Many had unanswered questions about HPV and HPV vaccination, could not recall any HPV-related cancers that affect men, and were unaware of their current eligibility for vaccination. Embarrassment and stigma surrounding vaccination against a sexually transmitted infection, concerns about vaccine side effects and safety, and preferences for preventing HPV via "safer sex" and monogamy were salient barriers to vaccination. Nevertheless, many men were eager to learn more about HPV vaccination and engage with health care providers around that topic. Interventions aimed at improving men's knowledge, changing social norms, and supporting health providers to identify HPV vaccine-eligible patients may be especially fruitful for facilitating shared clinical decision-making between mid-adult men and their health care providers.

Clinical and Public Health Considerations for HPV Vaccination in Midadulthood: A Narrative Review

Human papillomavirus (HPV) is an important cause of anogenital and oropharyngeal cancers, anogenital warts, and recurrent respiratory papillomatosis. Beginning in 2019, US guidelines recommended shared clinical decision-making (SCDM) for HPV vaccination among midadults (27-45 years). We conducted a narrative review of existing literature on HPV vaccination in midadults. The available evidence demonstrates that HPV vaccination in midadults is safe, efficacious, and likely to benefit both HPV-naïve midadults and those with previous infections. However, gaps in knowledge related to HPV vaccination have been identified among clinicians and midadult patients. Universal midadult HPV vaccination in the United States could avert 20 934-37 856 cancer cases over 100 years, costing $141 000-$1 471 000 per quality-adjusted life-year gained. Wide variation in these estimates reflects uncertainties in sexual behavior, HPV natural history, and naturally acquired immunity. Greater awareness among clinicians and midadult patients and broad implementation of SCDM may accelerate progress toward eliminating HPV-associated cancers and other diseases.

Human Papillomavirus Vaccine Administration Trends Among Commercially Insured US Adults Aged 27-45 Years Before and After Advisory Committee on Immunization Practices Recommendation Change, 2007-2020

Importance

In 2019, the Advisory Committee on Immunization Practices (ACIP) recommended patient-clinician shared decision-making for human papillomavirus (HPV) vaccination in adults aged 27 to 45 years. Less is known about the HPV vaccine administration trends in this age group before and after this recommendation update.

Objective

To examine the association between the ACIP recommendation update and the HPV vaccine administration among US adults aged 27 to 45 years.

Design, Setting, and Participants

This large commercial claim-based retrospective cohort study used the Optum Clinformatics database for validated claims from January 1, 2007, through December 31, 2020. A total of 22 600 520 US adults aged 27 to 45 years without previous HPV vaccination claims during the study and enrollment period were included.

Main Outcomes and Measures

The first-appearing HPV vaccination claim per individual was defined as a new HPV vaccine administration. Interrupted time-series analyses were conducted to assess the association between the ACIP update and the quarterly vaccine administration rate change. The annual rate trends across race and ethnicity groups and the proportions of vaccination cases by sub-age groups and valent types were also estimated. Vaccine administration trends were assessed by race and ethnicity in this age group because HPV vaccination trends were found to differ by race and ethnicity in the initially eligible population.

Results

Among 22 600 520 final study participants, the majority were men (50.9%) and non-Hispanic White (53.4%), and the mean (SD) age when first observed was 34.6 (5.8) years. In women, the ACIP update was associated with an immediate increase in vaccine administration rate (coefficient β2, 40.18 per 100 000 persons; P = .01) and an increased slope (coefficient β3, 9.62 per 100 000 persons per quarter; P = .03) over time postupdate. The ACIP update was only associated with an immediate increase in vaccine administration in men (coefficient β2, 27.54; P < .001). The annual rate trends were similar across race and ethnicity groups. Age at vaccine administration shifted over time (eg, women aged 40-45 years comprised only 4.9% of vaccinations in 2017, then 19.0% in 2019, and 22.7% in 2020). The most administered HPV vaccines in 2020 were 9 valent (women, 97.0%; men, 97.7%).

Conclusions and Relevance

In this population-based cohort study, there were statistically significant increases in HPV vaccine administration in adults aged 27 to 45 years after the ACIP recommendation update. Patient-clinician shared decision-making may have been the main associated factor for this increase. Further research is warranted to explore the decision-making process in receiving HPV vaccination and to develop effective decision aids to maximize the cancer prevention benefit in this age group.

Understanding Primary Care Physician Vaccination Behaviour: A Systematic Review

BACKGROUND

Vaccine hesitancy decreases adult vaccination coverage and has been recognized by WHO as a major health threat. Primary care physicians (PCP) play a key role in vaccination by giving vaccine counselling to their patients. The aim of this systematic review is to identify the knowledge, beliefs, attitudes and barriers (KBAB) associated with own vaccination and patient recommendation in primary care physicians.

METHODS

MEDLINE/PubMed, EMBASE and Cochrane Library databases were used to search and identify relevant studies based on their title and abstract. In the next step, the full text of each previously selected article was read for eligibility. Articles were selected by two independent reviewers and data extraction was performed using tables. The following information was extracted: methodological characteristics, demographic factors, professional characteristics, and intrinsic or extrinsic factors influencing vaccination or recommendation.

RESULTS

Our search yielded 41 eligible papers, data-sources, previous practices, belief in the effectiveness or safety of the vaccine, perceived risk, and trust in health authorities were all shown to be related to own vaccination and patient recommendation.

CONCLUSION

Internet is the main source of information for PCP related to vaccine hesitancy. It is therefore essential to increase the presence and access to pro-vaccination content in this area. In addition, involving PCP in the establishment of vaccination recommendations could improve their credibility in the institutions. On the other hand, training in communication skills and establishing reminder systems could reflect higher vaccination coverage among their patients.

Leveraging teachable moments in cancer prevention by improving HPV vaccination in health professional students (HPS): A systematic review

Introduction

Vaccination against HPV is safe and effective in cancer prevention, yet vaccination uptake remains low. Strong recommendation of HPV vaccination by healthcare providers increases immunization rates, but gaps in knowledge persist surrounding HPV and HPV vaccination amongst health professional students (HPS). It is critical to educate HPS in all professions to maximize vaccination opportunities and increase vaccine uptake. The objective of this study is to evaluate evidence on HPV knowledge, vaccine uptake, and educational interventions in HPS to identify specific deficits to improve education.

Methods

A systematic literature search for articles on HPV vaccine uptake, knowledge, and educational interventions in HPS was performed in PubMed, Embase, Web of Science, CINAHL, and Scopus from January 1, 2006 – July 21, 2021. Included studies assessed HPS for HPV vaccine uptake, knowledge, counseling comfort, or educational interventions to increase HPV vaccine knowledge. Studies were screened for inclusion by 2 independent reviewers and evaluated for risk of bias. PRISMA guidelines for reporting were followed.

Results

Twenty-one unique articles met inclusion criteria and were included in the analysis. Of the studies included, 20 included knowledge, 11 included vaccine uptake, 8 included interventions, and 12 included counseling comfort. The students in the studies included medical (n=14), dental (n=7), dental hygiene (n=6), nursing (n=3), physician assistant (n=2), public health (n=1), and pharmacy (n=1). Across studies, HPV vaccine series initiation ranged from 34.6-70.3%, with 28.3-58.3% up to date on vaccination. Most students knew that HPV causes cervical cancer (99%), but fewer knew that HPV causes head and neck cancer (40-47%) and oropharyngeal cancer (45%). Educational interventions included team-based approaches and lectures, and improved outcomes including vaccine knowledge, vaccination schedule, and cancer knowledge. Medical students with lower knowledge of HPV were more hesitant to recommend vaccination at baseline but were more likely to recommend vaccination after an education session.

Discussion

Across HPS, inadequacies persist in HPV vaccine uptake, knowledge, and counseling comfort. It is critical to target vaccine uptake in this population and improve existing educational efforts to reduce preventable cancers. Institutions must prioritize HPV vaccine education to impact HPV related death.

Association between patient characteristics and HPV vaccination recommendation for postpartum patients: A national survey of Obstetrician/Gynecologists

Human papillomavirus (HPV) vaccination rates in the U.S. are relatively low. Provider recommendation rates for HPV vaccination often vary by patient age and relationship status. Obstetrician/gynecologists (OB/GYNs) represent a key provider group that can recommend the HPV vaccine. This study examined differences in OB/GYN recommendation of HPV vaccination for inpatient postpartum patients by age, parity, and marital status. Data were collected from OB/GYNs nationally via a cross-sectional survey. Participants were randomized to two vignette groups (23-year-old patient or 33-year-old patient). Within each group, participants received 4 vignettes that were identical except for patient marital status (married/not in a committed relationship) and number of children (first/third child), and were asked to indicate HPV vaccination recommendation likelihood on a scale of 0 (definitely would not) to 100 (definitely would). A 2 × 2 × 2 general linear model with repeated measures was used to examine main and interaction effects of patient age, relationship status, and parity. 207 OB/GYNs were included in the final analyses. Recommendation was high for 23-year-old patients (range: 64.5-84.6 out of 100). When marital status and parity were held constant, recommendation likelihood was higher for the younger vs. older patient and was also higher for patients not in a committed relationship, compared to married patients (all p-values < 0.001). Differences in recommendation exist when considering age and relationship status, which provides insight into OB/GYN clinical decision-making. Findings highlight the need to address barriers to HPV vaccination recommendation, including awareness of risk factors to consider when recommending the vaccine.

"I Thought It Was Just For Teenagers": Knowledge, Attitudes, and Beliefs about HPV Vaccination Among Women Aged 27 to 45

PURPOSE

We aimed to identify human papillomavirus (HPV) and HPV vaccine-related knowledge, attitudes, and beliefs among women aged 27-45 years, who became eligible for HPV vaccination in 2018.

METHODS

Eight virtual focus groups were conducted with 52 unvaccinated cisgender women aged 27-45 years living in Southern California's Inland Empire. Themes related to women's knowledge, attitudes, and beliefs were systematically identified using the rigorous and accelerated data reduction technique.

RESULTS

The sample was diverse: 62% of participants were Hispanic, Black, or Asian; 17% identified as lesbian or bisexual; and annual household incomes ranged from $0 to $260,000 (median, $60,500). Key qualitative themes centered on 1) questions about HPV and HPV vaccination, 2) knowledge and beliefs about HPV and HPV vaccination, 3) concerns about vaccine side effects and safety, 4) low perceived benefits of vaccination, and 5) social factors influencing vaccine acceptance. Few participants were aware adults aged 27-45 years are eligible for HPV vaccination or that vaccination can still be beneficial after sexual debut. Many believed HPV vaccination caused serious side effects among adolescents and questioned whether safety had been adequately studied for newly eligible adults. Although many participants associated HPV vaccination with social stigma, some emphasized that vaccination was a way to exercise control over their health and prevent illness, given they could not always control the actions of their sexual contacts.

CONCLUSIONS

Findings provide insight into knowledge, attitudes, and beliefs about HPV and HPV vaccination among women aged 27-45 years, which may be useful for informing interventions to promote shared clinical decision-making between patients and health providers.

Decision support needs for shared clinical decision-making regarding HPV vaccination among adults 27-45 years of age

OBJECTIVE

Identify HPV information needs and shared clinical decision-making preferences among adults 27-45 and describe differences in needs and preferences among underserved and vulnerable populations.

METHODS

Participants 27-45 years old with no history of HPV vaccination completed a cross-sectional web-based survey between April-May 2020 (N = 702). Preferred role in shared clinical decision making was described across demographic groups and sociodemographic correlates of HPV vaccine information needs.

RESULTS

Most (77.6%) reported a preference to make a medical decision on their own or after consulting with a healthcare provider, while the remaining respondents preferred to make a joint decision (17.0%) or for their doctor to make the decision (5.4%). Over 80% needed more information about safety, effectiveness, personal benefit, provider recommendation, side effects, and risks. Education was the strongest demographic factors associated with higher information needs (p<0.05).

CONCLUSION

The majority of individuals across demographic groups were individually focused with regard to their healthcare decisions and wanted more information about HPV vaccine safety, side effects, and risks, in addition to personalized information about benefits from HPV vaccination.

PRACTICAL IMPLICATIONS

Patient-centered interventions are needed to engage adults in shared decision-making regarding HPV vaccination.