Understanding facilitators and barriers of HPV vaccination amongst adolescent boys and their parents in high-income countries through the social-ecological model: a scoping review.

Vaccinating Adolescents—New Evidence of Challenges and Opportunities

Human papillomavirus (HPV) infects nearly 85% of sexually active Americans during their lifetime, causing most cervical and five other cancers. Routine HPV vaccination is recommended for adolescents to prevent HPV-attributable cancers, but HPV vaccination coverage remains low, especially in Tennessee. In 2021, 54.6% of the population in Shelby County, Tennessee was Black or African American, reporting higher rates of new cervical cancer cases than other counties in Tennessee. While medical and public health professionals (HPs) play a critical role in promoting vaccination coverage, little is known about the factors HPs perceive to influence HPV vaccination for this population. This study sought to explore HPs’ perceived facilitators and barriers of HPV vaccination among African American adolescents. Qualitative individual interviews with 26 HPs in Shelby County were conducted between October 2019 and February 2020. Interpretive content analysis of the interview data guided by the socio-ecological model revealed several important themes regarding the facilitators and barriers across the individual, interpersonal, and community levels. At the individual level, parental vaccine hesitancy emerged as a leading barrier to HPV vaccination, while appropriate education facilitated the vaccination. At the interpersonal level, a lack of strong provider recommendations impeded HPV vaccination, whereas improved communication skills with patients facilitated the vaccination. Finally, the community-level barriers included a lack of education and social/religious norms; the community-level facilitators included community outreach efforts. HPs should consider development of comprehensive community-based approaches that leverage the facilitators and barriers at multiple levels to increase HPV vaccination among African American adolescents in this region.

Human Papillomavirus and Vaccination

Human papillomavirus (HPV) is the most common cause of cervical cancer in women. However, among adolescent boys, initial exposure to HPV is associated with a higher risk of developing oropharyngeal and oral cancers compared with girls. Notably, the incidence of oropharyngeal cancer has been rising sharply in high-income countries, yet HPV vaccination coverage among adolescent boys remains suboptimal. Therefore, understanding the perceptions of adolescent boys and their parents regarding HPV vaccination in high-income countries is crucial for the development of effective public health strategies. This scoping review aims to explore the perceptions of adolescent boys and their parents regarding HPV vaccination and investigate the facilitating factors and barriers influencing HPV vaccination. The method framework of Arksey and O'Malley, the Joanna Briggs Institute, as well as the recommendations of Levac will be used to conduct the scoping review. This scoping review will be reported in accordance with the PRISMA extension for scoping reviews checklist. A systematic literature search will be performed on Ovid-MEDLINE, CINAHL, Cochrane CENTRAL, Ovid-Embase, PsycINFO and Web of Science. Two reviewers will independently perform the study selection and data extraction. Identified studies will be extracted using a customised extraction template on Covidence and analysed descriptively using narrative synthesis. The review commenced in April 2024 and will be completed in July 2025. Formal ethical approval is not required, as primary data will not be collected for this study. The findings will be disseminated through publication in a peer-reviewed journal. This protocol has been registered with the Open Science Framework (https://doi.org/10.17605/OSF.IO/M5NH2).

Introduction: Implementation of school-entry policies for vaccination for human papillomavirus (HPV) vaccination (HPV-PIVac study) is a five-year prospective study started in 2018 to evaluate the implementation of the HPV vaccine as a requirement for school entry in Puerto Rico. As part of these study efforts, we organized a Community Advisory Board (CAB) whose members are from government and private organizations, coalitions, and community-based organizations working for HPV prevention. As part of the preliminary results of the HPV-PIVac study presented to the CAB, key informant interviews demonstrated the lack of knowledge and the need to train school staff on the HPV vaccine and its school policy. CAB members worked on an educational initiative about vaccines to respond to these barriers, called Puerto Rico Libre de Enfermedades Prevenibles (Puerto Rico Free of Preventable Diseases). As a first step, a needs assessment survey was conducted to identify the most significant topics of interest and need issues about vaccines and the new HPV vaccine school requirement in this population. Methods: In February 2020, CAB members distributed a self-administration survey during the 2019-2020 Education Congress, an event in which teaching and non-teaching staff from the island's private education sector assisted in continuing education training. Data collection was gathered by convenience sampling. The survey collected the following variables: knowledge of the HPV school-entry policy, knowledge of HPV infection and the HPV vaccine, confidence in talking to parents about the HPV vaccine, and information of interest about the HPV vaccine. Results: A total of 76 participants were recruited. The largest number of participants (73%) were teachers, and 19% were school directors. At least 61% of the participants were unaware of the HPV vaccine as a requirement to enter school. We identified an insufficient knowledge of the following items: HPV-related cancers (43%) and HPV vaccine series (32%). Only 21% of school personnel reported been prepared to talk to parents about the HPV vaccine. According to the participants' responses, the top five information about HPV that they were interested in were: (1) Side effects of the vaccine; (2) Effectiveness of the vaccine, (3) Safety of the vaccine; (4) Messages to give to parents; and (5) Information on HPV vaccination policy. Conclusion: Through the need assessment, we were able to identify topics that should be addressed as information about the HPV vaccination series, HPV-associated cancers, HPV vaccine school entry policy, safety and effectiveness of the HPV vaccine. Based on this data, we developed an educational curriculum for the initiative. The collaboration of the different members of the CAB was essential to carry out this first step. Citation Format: VOCES PR Coalition, Josheili S. Llavona, Diana T. Medina Laabes, Omayra Salgado Cruz, JAC-HPV-PIVac PR, Roxana Soto Abreu, Olga L. Diaz Miranda, Marta M. Sánchez Aracil, Vivian Colón-López. Community coalition and academic need assessment: Our first step for the development of an educational intervention on HPV vaccination targeting school staff during pandemic era in Puerto Rico [abstract]. In: Proceedings of the AACR Virtual Conference: 14th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2021 Oct 6-8. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr PO-029.

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Toward a Deeper Understanding of the Spectrum of Parental Human Papillomavirus Vaccine Hesitancy

Attitudes and beliefs about the human papilloma virus vaccine amongst patients with and without cervical dysplasia in a large urban academic hospital (366)

Increasing HPV vaccine interest via standardized multimodal education in an underserved patient population (363)

Background: The Latinx population in the United States faces tremendous health disparities, particularly with regards to cervical cancer. Data from the American Cancer Society show that cervical cancer incidence and mortality rates among Latinx women in the US are 40% and 26% higher than in US whites, respectively. These data are surprising considering cervical cancer is highly preventable through use of the Human Papilloma Virus (HPV) vaccination. About 70% of cervical cancer cases are the result of infection with HPV 16 or 18. The 9vHPV vaccine targets HPV 16 and 18 as well as 7 other HPV strains, and it was recently approved for use by the CDC in women through the age of 45. In 2015, only 44% of US Hispanic girls between the ages of 13 and 17 were vaccinated with all three HPV doses. Prior studies have shown that lack of information, cost, and fear are some of the main barriers that prevent Latinx women from receiving the HPV vaccination and vaccinating their children, and that these factors differ across subgroups of Latinx women. Methods: Our goal was to address these health disparities by assessing whether the Latinx population in East Los Angeles also showed low rates of HPV vaccination, and if so, why these women had not received the vaccination. We administered a promotora led survey (in Spanish) to a random sample of 89 Latinx women (aged 25-79) in East Los Angeles to assess rates of HPV vaccination in women and their children, attitudes towards the HPV vaccine, knowledge about the vaccine, and barriers to vaccination. We hypothesized that there would be differences in knowledge about the HPV vaccine, as well as differences in vaccination rates, based on age (>50) and country of origin (Mexico or other) in Latinx women. Results: We found a significant lack of knowledge about the HPV vaccine that persisted across all 89 women. None of the women surveyed had received a single dose of the HPV vaccinations themselves, either because they “did not think it was necessary,” or “did not know why it was important.” About 76% of women surveyed said they did not know what causes most cervical cancer (99% CI [65%-88%]), and of the 23% of women who said they did know what causes cervical cancer, none of the women cited HPV as a cause (99% CI [12%-35%]). Only 55% of women surveyed had heard about the HPV vaccine (99% CI [41%-68%]), and 82% of women did not understand the purpose of the HPV vaccine (99% CI [72%-93%]). However, Chi Square analysis revealed no significant age or country of origin differences in knowledge about the HPV vaccine or vaccination rates. Conclusions: These data show the need for culturally appropriate interventions that are both language specific and literacy level appropriate, in order to increase knowledge about the importance of HPV vaccination among Latinx women of East Los Angeles, particularly how it relates to cervical cancer prevention. Improved access to health education in the community could increase vaccination rates and decrease rates of cervical cancer in this population. Citation Format: Sarita Sooklal, Rosa Barahona, Lourdes Baezconde- Garbanati. Human papillomavirus vaccination rates and knowledge among Latinx women in East Los Angeles [abstract]. In: Proceedings of the AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2020 Oct 2-4. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(12 Suppl):Abstract nr PO-274.

Objective: Human papilloma virus (HPV) infection is the most common sexually transmitted viral infection worldwide. It is the cause of cervical cancer, and also causes many malignant, and benign diseases. Although it has an effectual vaccine, vaccination rates are still at an undesired level. In this cross-sectional study, it was aimed to investigate the knowledge and attitudes of pediatricians about HPV vaccine. Method: A questionnaire consisting of 18 questions about HPV disease and vaccine was applied to pediatricians working in our hospital via face-to-face interviews. Demographic characteristics, duration of their working in the field of pediatrics, and some questions and suggestions about HPV disease and vaccine were included in the questionnaire. Results: Ninety-eight (66.6%) out of 147 pediatricians participated in the questionnaire survey..The median age of the participants was 30.5 years (min-max: 25-66), and they were consisted mostly (70.4%).of female pediatricians. In terms of distribution of their academic positions, 54 (55.1%) of them were working as pediatric residents. Only 15.3% of the participants had received HPV vaccine. When questions about the vaccine were analyzed, 94.9% of the participants knew that the HPV vaccine was not included in the national vaccination schedule, 64.3% knew the recommended vaccination age, and 84.7% knew that application gender of the vaccine. Some ( 60.2%) participants recommended HPV vaccine to their patients. When pediatricians were asked why they did not recommend the vaccine, according to their responses, the most important factor was the fact that had not sufficient knowledge about the vaccine (14.3%) and had not encountered a patient within the indication (14.3%).The vaccine recommendation rates of the vaccinated physicians were statistically significantly higher than unvaccinated physicians (p=0.028).There was no statistically significant difference between medical experience and recommendation for HPV vaccine beforehand and knowing the names of HPV vaccines (p=0.316, p=0.414, respectively). Conclusion: Although the overall attitude towards HPV vaccination was generally positive in our study, additional training should be provided to both pediatricians and healthcare professionals in order to achieve higher HPV vaccination coverage rates in Turkey.

Background: Approximately 43,000 human papillomavirus (HPV)-associated cancers and 350,000 genital warts are diagnosed annually in the United States. The HPV vaccine can prevent HPV-associated cancers and genital warts. The Advisory Committee on Immunization Practices recommends routine HPV vaccination for adolescents between 11 and 12 years of age, and catch-up vaccination up to 45 years recently. Despite the availability, safety, and efficacy of HPV vaccines, uptake has been suboptimal compared to other routine vaccinations in adolescents, and even worse for adults in the catch-up group. As little is known about geographic variation in HPV vaccine uptake among adults, we explored how HPV vaccine initiation and completion rates among 18–34 year olds (both men and women) varies by geographic region. Methods: We analyzed data from 16 states (Alabama, Arkansas, Connecticut, Georgia, Hawaii, Massachusetts, Mississippi, Missouri, New Hampshire, Nebraska, North Carolina, South Carolina, South Dakota, Tennessee, Texas, and West Virginia) which conducted the adult HPV module survey during 2015–2017 Behavioral Risk Factor Surveillance System. Two variables were used to define geographic region: census region (South, Northeast and Midwest/west) and residential area (urban and rural). HPV vaccine initiation was defined as receipt of at least one dose of the vaccine and completion as receipt of three doses. Weighted, multivariable binary logistic regression models were used to assess the association between geographic region and HPV vaccine uptake, adjusting for demographic, socioeconomic, and healthcare utilization factors. Results: A total of 18,078 adults were included in the study, of whom 80% resided in the South. The overall HPV initiation and completion rates were 23.4% and 11.0%, respectively. Vaccine initiation was higher among those who resided in the Northeast (38.6%) followed by Midwest/west (23.8%) and lowest for those in the South (21.8%). But initiation rates was similar between those who reside in urban (24.1%) and rural (21.0%) areas. Completion rates followed the same trend as initiation for both census region and residential area. In the adjusted models, compared to adults residing in the South, those living in the Northeast were more likely to initiate (adjusted odds ratio: 2.14; 95 % CI: 1.81–2.53) and complete (1.80; 1.47–2.20) the HPV vaccine. There were no significant differences observed for initiation or completion by residential area. Conclusions: Both the South and the Northeast have low HPV vaccination initiation and completion rates compare to the Healthy People 2020 goal of 80%, but vaccine uptake were significantly lower in the South region. No difference in HPV vaccine uptake was observed between the rural and urban areas. This demonstrates the need to develop and implement interventions programs to reduce geographical disparities in HPV vaccine uptake and ultimately to improve HPV vaccine uptake, especially in the South region. Citation Format: Eric Adjei Boakye, Maggie Wang, Wiley D Jenkins, Nosayaba Osazuwa-Peters, Oluwole Babatunde, Min Jee Lee, Minjin Kim. Geographic variation in human papillomavirus (HPV) vaccination initiation and completion among adults in the United States [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr C084.

We are writing in response to the article entitled ‘‘Increasing fear of adverse effects decreases intention to vaccinate after the introduction of prophylactic HPV vaccine’’ published in the Archives of Gynecology and Obstetrics [1]. The human papilloma virus (HPV) vaccine has been used in South Korea since 2006 and we have reviewed the implementation and complications associated with this vaccine in this population to understand its use in our country. HPV is a widely prevalent, known risk factor for cervical cancer. In a single-center study of 208 patients, we found that 33.9 % were infected with HPV and the prevalence of highrisk HPV infection was 56.8 % [2]. Although the HPV vaccine protects against cervical cancer and HPV vaccination at a young age appears to be cost effective (as well as partially paid by the government for adolescents in the USA, Austria, and England), its use remains controversial [3]. The HPV vaccine has been used since 2006 in Republic of Korea. At our hospital, the HPV vaccine has been used since 2009. The HPV vaccination prices are not fixed in Republic of Korea; the cost and subsidy associated with the vaccine are based on the welfare and price policies of individual hospitals. From 2009 to 2010, our hospital held five reduced-price vaccination clinics and vaccinated 370 patients who were hospital employees and relatives. In 2012, we offered additional clinics and vaccinated 515 patients. We attribute the increased interest in the vaccine to patient awareness of the benefits due to media coverage and education sponsored by obstetrics and gynecologicrelated medical societies. However, in August 2013, only 17 women were vaccinated during the reduced-price clinics, possibly due to widely reported side effects in the Korean media that increased the fear for the vaccine. In response to this, we evaluated the HPV vaccine using it as a keyword in two of the most popular online domain sites and Google. The online domain sites were chosen by Korean click, which evaluates and analyzes online behavior. We categorized the positive and negative reports regarding HPV vaccination from 100 recent articles on three online sites, finding 91 positive articles and 85 negative articles. On June 15, 2013, a negative media article was posted that supported the elimination of the HPV vaccine recommendation in Japan. It is clear that reports in the media hastened the initial acceptance of the HPV vaccine, and at least two subsequent articles on adverse effects similarly decreased acceptance. We agree the fear of the media’s negative report which decreases the acceptance of HPV vaccination [1]. Data from our single-center study indicate that providing accurate information is important for increasing awareness of the vaccine and we recommend further studies to examine the relationship between media reports and acceptance of the HPV vaccination.