The human papillomavirus (HPV) is the most common sexually transmitted disease in the United States. HPV is responsible for almost all cervical cancer linked to causing The HPV vaccine is a cost-effective way to protect against several types of cancers and genital warts and yet it remains one of the most underused vaccines in the United States. A review of 11 articles was performed to examine the factors associated with HPV vaccine hesitancy and expand on the overlapping themes in the literature. The review also identifies gaps in the research and further recommends areas for future research. A concept map and research questions were developed based on the emerging themes and gaps in research that were identified.
Keywords: HPV vaccine, vaccine hesitancy, provider recommendation, sexual behavior
HPV Vaccine Hesitancy
Human papillomavirus (HPV) is one of the most common sexually transmitted infections in the United States (Lehtinen et al., 2017). Certain genotypes of HPV have been associated with an increased risk of cervical cancers and other cancers such as anal, penile, oropharyngeal and vaginal (Markowitz, Gee, Chesson, & Stokley, 2018).. The Center for Disease Control and Prevention (CDC) currently recommends the HPV vaccine for all 11 and 12-year-old boys and girls but it can be administered up until the age of 26 years old( CDC 2018 ). According to the CDC, in the United States HPV causes 33,700 cancers in men and women (CDC 2018). It is estimated that HPV vaccination can prevent about 31,200 of the cancers from even developing (CDC 2018). Although the HPV vaccine is an effective way to protect young boys and girls from several types of cancer, it is still underused in the United States. The underuse or hesitancy of this vaccine has been linked to such things such as lack of knowledge regarding the vaccine, increased risk for sexual behavior, misconceptions and lack of provider recommendation. Most of the studies regarding HPV hesitancy have been focused on the perspective of the parent, some from the provider perspective but little research from the teens’ perspective. Those few studies that focused on the adolescents’ perspective are mostly from the perspective of female teens with little data supporting the perspective of male adolescents’. This gap in research would be beneficial in exploring because the administration of this vaccine is most effective when administered to younger adolescents who have not experienced sexual contact (CDC 2018).
A literature search using Cinahl and PubMed databases was performed using keywords “human papillomavirus”, “HPV vaccine” and “HPV vaccine hesitancy.” These searches yielded 11 research articles that were found to be useful to this review. The literature results were very interesting because many of the studies were performed by some of the same researchers. Many of the authors overlap and appear throughout this literature review.
One of the main factors that contribute to underuse is parental hesitancy. In a 2017 quantitative study, reasons for nonvaccination vary based on the age of the adolescent and the hesitancy of the parent (Thompson, Rosen, Vamos, Kadono, & Daley, 2017) . This same study, which occurred between 2013 to 2015, factors that affect parental hesitancy are lack of knowledge, safety, and side effects and indication/recommendation for the teen(Thompson et al., 2017). A statewide survey of health care providers in Minnesota yielded results that indicate improving provider’s ability to address parental hesitancy, should improve the vaccine uptake in the target age group(McRee, Gilkey, & Dempsey, 2014). It was suggested that providing tools to parents to address hesitancy such as information brochures that are tailored to parent concerns along and discussion of the HPV vaccine prior to the clinical visit, may positively impact the parents’ decision to vaccinate their child(McRee et al., 2014). About half of the 575 providers in this study perceived HPV vaccine hesitancy common in parents which can impact providers from delivering recommendations according to the guidelines(McRee et al., 2014) .
Lack of Recommendation by Provider
One of the most influential determinants of HPV vaccination is provider recommendation(Rahman, Laz, McGrath, & Berenson, 2015). This 2015 study by Rahman, Laz, McGrath & Berenson examined the association between parental HPV awareness and HPV vaccine administration and explored if it was influenced by provider mediation. Its data was received through a 2011 National Immunization Survey-Teen. It compared 11,236 adolescent girls and 12,328 adolescent boys who completed the HPV vaccination. This study showed that provider recommendation independently predicted vaccine initiation and completion.(Rahman et al., 2015). This study shows the clinical significance of provider recommendation but lacks any research on why providers may not recommend the HPV vaccine to their patients’.
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Another study that compared parent’s primary reasons for non-HPV vaccination showed that lack of recommendation was significantly more likely to be the reason for nonvaccination in 2012 and 2013 versus 2015(Thompson et al., 2017). This is interesting because this study collected its data from the 2012-2015 National Immunization Survey-Teen so the results are a continuum of the previously mentioned study by Rahman, Laz, McGrath & Berenson(2015). This comparison is important because it is an accumulation of data over a 4 year period from the same survey tool which can make findings more clinically significant.
In a study of 776 physicians regarding communication in relation to the HPV vaccine, meningococcal vaccine, and the Tetanus,diphtheria & pertussis (Tdap) vaccine, it was shown that 70 % of physicians choose to discuss the HPV vaccine last (Gilkey et al., 2015). Another reason physicians may not choose to discuss the HPV vaccine may be due to time constraints or consider it burdensome. The data showed that 34% of the physicians reported that the HPV vaccine takes too long to discuss in relation to meningococcal and the Tdap vaccine(Gilkey et al., 2015). Only 13% of physicians perceived HPV vaccine being highly important to parents which is extremely less then meningococcal and Tdap (Gilkey et al., 2015).
In a systematic review of literature regarding HPV vaccination completeness, the data shows the overall completeness rate of the HPV vaccine remain low in relation to the initiation rate(Kang, De Gagne, Son, & Chae, 2018). Out of the five studies included in this systematic review, 3 reported increased HPV vaccine completeness after interventions(Kang et al., 2018). These interventions that increased vaccine completeness included reminder messages, reminder letter, and DVD based instruction.
Lack of Knowledge/Education
Kinder (2016) explored the reasons why parents may defer administration of the HPV vaccine to their children. In this small mixed methods study of 23 parents, mostly mothers, 75 % of participants stated they refused the HPV vaccine because there was not enough information about the vaccine or they would like more research to be available(Kinder, 2016). The 23 parents that were included in Kinder’s study were predominantly mothers and took place in a suburban private practice which makes the data lack transferability. While this study was small it was a good pilot study to initiate further research.
Kinder(2017) re-explored the reasons why parents may refuse the administration of the HPV vaccine to their children. This study was a multi-site design with 72 parents completing the same survey that was used in the pilot study in 2016. In this study, 58 % of parents refused the vaccine because it was too new and 50 % believed it needed more research. This data correlated with the previous study but showed that parental perceptions may be improving.
McRee, Gilkey & Dempsey (2014) performed a quantitative study to describe health care providers’ HPV vaccine recommendations practices and explore their perceptions of and approaches to dealing with HPV vaccine hesitancy among parents of the 11-12 year olds. Their study was based off of 575 providers in Minnesota and it showed that 76% healthcare providers reported routinely recommending the HPV vaccine for girls and 46 % for boys(McRee et al., 2014). This trend is common in the HPV vaccine research. The HPV vaccine was initially recommended for girls in 2006 and the national guidelines extended in 2011 to include adolescent males(Markowitz, Gee, Chesson, & Stokley, 2018).
Riskier Sexual Behavior
Despite the known effectiveness of the HPV vaccine, many parents and clinicians are concerned that vaccination could lead to riskier sexual behavior. Mayhew et al (2014) performed a quantitative study to examine whether adolescent risk perceptions at the time of first HPV vaccine dose predicted sexual behaviors at two and six months post vaccination. The study included 339 women between the ages of 13 and 21 years of age. The researchers identified participants at a hospital-based primary care center who fit the required criteria of the first HPV vaccine within the previous two days(Mayhew et al., 2014). Once the participants were identified, consent was obtained and participants returned two and six months after the initial vaccination dose and complete follow up surveys. The data from this study showed that there was no linkage to the administration of the HPV vaccine and riskier sexual behaviors six months post vaccination (Mayhew et al., 2014). This longitudinal study indicates that the HPV vaccine is very unlikely to alter sexual risk behaviors in adolescent women. It is important to note that there was a previous study done by these researchers in which they examined risk perceptions after HPV vaccination in adolescent girls and its findings, which were congruent with their current study, prompted the need for this more structured quantitative study to be done.
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A qualitative study by Mullins, Widdice, Rosenthal, Zimet, & Kahn ( 2015) showed higher knowledge about HPV vaccines among mothers and girls was liked with more accurate risk perceptions among girls. This study by Mullins, Widdice, Rosenthal, Zimet & Zahn (2015) occurred over a four year period and followed 11 to 12 year old girls for 30 months to assess perceptions, attitude and sexual behavior after HPV vaccination. This study was composed of 33 girls, 32 moms, and 19 clinicians. Over the 30 months after initial HPV vaccination interviewers met with the participants several times over this time period to continue to assess risk perceptions and sexual behavior(Mullins et al., 2015). These findings suggest that receiving the HPV vaccination is unlikely to change girls’ sexual attitudes or behaviors.
Mullins et al (2016) did a follow-up study to further asses the association between risk perceptions after HPV vaccination, sexual behaviors and diagnosis of a sexually transmitted infection (STI) 30 months following vaccination. This study by Mullins et al (2016) included 112 sexually experienced females from the ages of 13-21 years who followed up at 2,6,18 and 30 months. At each of the follow-up visits, the girls were given a survey and STI testing was done. This study found that the HPV vaccine related risk perceptions were not associated with subsequent sexual behaviors or STI daisgnosis, which should proved some reassurance to parents and providers(Mullins et al., 2016).
The only study in the review of literature that focuses on HPV vaccine and adolescent males is a quantitative study by Reiter, McRee, Kadis & Brewer (2011). In this study males ages, 11-17 and their parents were surveyed online to examine their attitudes and beliefs about the HPV vaccination in males. This study which included 547 parents and 421 sons showed that 90% of both parents and sons were either unaware or not interested in the HPV vaccine recommendation (Reiter, McRee, Kadis, & Brewer, 2011). It’s important to recognize that this study is fro 2011 so the data may not be as relevant for the present day. This study does show the gap in research including adolescent males as this was the most recent study yielded in the literature search.
This review of the literature on HPV vaccine hesitancy shows there are many factors that effect the acceptability of HPV vaccine. Many studies that were presented have overlapping themes and overlapping researchers. This subject would benefit from more future studies focused on the perspective of both male and female adolescents who receive and refuse the vaccine. Only one study from 2011 mentioned the perspective of adolescent male and the other studies that included adolescent girls were focused on sexual behavior. More research should be done focusing on the safety and comparing both the benefits and risks of the HPV vaccine to reassure parents and clinicians. The studies that do address the long-term outcomes of the HPV vaccine discuss the benefits but not necessarily the risks.
Overall, the HPV vaccine remains a subject of conflict in the health care system. Many factors that influence HPV vaccination were identified in this review. As mentioned above, further research on this topic could greatly benefit parents and teens to make more educated decisions regarding HPV administration.
After reviewing the literature on factors that contribute to HPV hesitancy, 3 research questions were developed to aid in future research. These research questions are:
1. What are the risk perceptions and acceptability of the HPV vaccine from the perspective of both male and female adolescents in the United States?
2. What are the benefits and risks of the HPV vaccine?
3. What tools can be used to educate and inform young adolescents in their parents about the HPV vaccine?
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- Kang, H., De Gagne, J., Son, Y., & Chae, S. (2018). Completeness of the human papilloma virus vaccination: A systematic review. Journal of Pediatric Nursing, 39(), 7-14. http://dx.doi.org/10.1016/j.pedn.2017.12.003
- Kinder, F. (2016, November/December). Parental refusal of the human papillomavirus vaccine. Journal of Pediatric Healthcare, 30(6), 551-557. http://dx.doi.org/10.1016/j.ped.2015.11.013
- Kinder, F. (2018, March/April). Parental refusal of the human papillomavirus vaccine: Multisite study. Journal of Pediatric Health Care, 32(2), 150-156. http://dx.doi.org/10.1016/j.pedhc.2017.09.003
- Lehtinen, M., Lagheden, C., Luostarinen, T., Erikson, T., Apter, D., Harjula, K., … Dillner, J. (2017). Ten-year follow-up of human papillomavirus vaccine efficacy against the most stringent cervical neoplasia end-point-registry-based follow up of three cohort randomized trials. BMJ Open, 7, 1-8. http://dx.doi.org/10.1136/bmjopen-2017-015867
- Markowitz, L., Gee, J., Chesson, H., & Stokley, S. (2018, March). Ten years of human papillomavirus vaccination in the United States. Academic Pediatrics, 18(2), S3-S10. http://dx.doi.org/10.1016/j.acap.2017.09.014
- Mayhew, A., Mullins, T., Ding, L., Zimet, G., Morrow, C., & Kahn, J. (2014, March). Risk perceptions and subsequent sexual behaviors after HPV vaccination in adolescents. Pediatrics, 133(), 404-411. http://dx.doi.org/10.1542/peds.2013-2822
- McRee, A., Gilkey, M. B., & Dempsey, A. F. (2014, December). HPV vaccine hesitancy: Findings from a statewide survey of health care providers. Journal of Pediatric Health Care, 28(6), 541-549. http://dx.doi.org/10.1016/j.pedhc.2014.05.003
- Mullins, T., Widdice, L., Rosenthal, S., Zimet, G., & Kahn, J. (2015, July 31). Risk perceptions, sexual attitudes, and sexual behavior after HPV vaccination in 11-12 year old girls. Vaccine, 33(32), 3907-3912. http://dx.doi.org/10.1016/j.vaccine.2015.06.060
- Mullins, T., Zimet, G., Rosenthal, S., Morrow, C., Ding, L., Huang, B., & Kahn, J. (2016, July 25). Human papillomavirus vaccine-related risk perceptions and subsequent sexual behaviors and sexually transmitted infections among vaccinated adolescent women. Vaccine, 34(34), 4040-4045. http://dx.doi.org/10.1016/j.vaccine.2016.06.026
- Rahman, M., Laz, T. H., McGrath, C. J., & Berenson, A. B. (2015). Provider recommendation mediates the relationship between parental human papillomavirus (HPV) vaccine awareness and HPV vaccine inititiation and completion among 13 to 17 year-old adolescent children. Clinical Pediatrics, 54(), 371-375.
- Reiter, P., McRee, A., Kadis, J., & Brewer, N. (2011, August 5). HPV vaccine and adolescent males. Vaccine, 29(34), 5595-5602. http://dx.doi.org/10.1016/j.vaccine.2011.06.020
- Thompson, E., Rosen, B., Vamos, C., Kadono, M., & Daley, E. (2017). Human papillomavirus vaccination: What are the reasons for nonvaccination among U.S. adolescents. Journal of Adolescent Health, 61(), 288-293. http://dx.doi.org/10.1016/j.jadohealth.2017.05.015
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