Parents' reasoning about HPV vaccination in Sweden

Factors that influence caregivers' and adolescents' views and practices regarding human papillomavirus (HPV) vaccination for adolescents: a qualitative evidence synthesis

BACKGROUND

Human papillomavirus (HPV) vaccination in adolescents provides a powerful tool for preventing cervical cancer in women and other HPV-associated diseases in people of all genders. HPV vaccines have been progressively introduced in many countries. However, worldwide, many adolescents do not receive HPV vaccination, for various reasons. The HPV vaccine might be costly or unavailable, healthcare systems might lack capacity for its delivery, or adolescent health might not be prioritised. Some caregivers and adolescents may not accept available HPV vaccines and vaccination services. We currently lack a comprehensive understanding of the factors that influence HPV vaccination views and practices, and why some caregivers and adolescents may be less accepting of the vaccine. Qualitative research can contribute to this understanding and help inform policy and practice, including the development of more relevant, acceptable and effective interventions to promote public acceptance and uptake of HPV vaccination in adolescents. This qualitative evidence synthesis supplements a Cochrane review of the effectiveness of interventions to improve uptake of adolescent vaccination, including HPV vaccination.

OBJECTIVES

The objectives of the review are to identify, appraise, and synthesise qualitative studies that explore caregivers' or adolescents' views, experiences, practices, intentions, decision-making, acceptance, hesitancy, or nonacceptance of HPV vaccination; to gain an understanding of the factors that influence caregiver and adolescent views and practices regarding HPV vaccination for adolescents; and to explore how the findings of this review can enhance our understanding of the related Cochrane intervention review.

SEARCH METHODS

We searched MEDLINE, Embase, CINAHL, PsycInfo, and Scopus for eligible studies (February 2023). We updated this search in October 2024, but these results have not yet been fully incorporated.

SELECTION CRITERIA

We included studies that utilised qualitative methods for data collection and analysis; focused on caregivers' or adolescents' views, practices, acceptance, hesitancy, or refusal of HPV vaccination for adolescents aged 9 to 19 years of age; and were from any setting globally where HPV vaccination is provided.

DATA COLLECTION AND ANALYSIS

We used a prespecified sampling frame to capture a sample of eligible studies that were from a range of geographical and income-level settings, were conceptually rich in relation to the review's phenomenon of interest, and included HPV vaccination for diverse genders. We extracted contextual and methodological data from each sampled study. We used a thematic synthesis approach to analyse the evidence. We assessed methodological limitations using a list of criteria used in previous Cochrane reviews and originally based on the Critical Appraisal Skills Programme quality assessment tool for qualitative studies. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each review finding. We integrated the findings of this review with those from the related Cochrane review of intervention effectiveness (by Abdullahi and colleagues), by mapping whether the trial interventions reflected or targeted the factors identified by this review as influencing caregivers' or adolescents' views and practices regarding HPV vaccination.

MAIN RESULTS

We included 206 studies in the review and sampled 71 of these for our synthesis. Of these, 35 studies were conducted in high-income countries, 26 studies in middle-income countries, 8 studies in low-income countries, and 2 studies in multiple-income settings. Studies came from all six World Health Organization (WHO) regions and included urban and rural settings. We downgraded our confidence in several findings, mainly due to concerns about how the studies were conducted (methodological limitations), concerns about perspectives lacking from some types of participants or in some settings (relevance), or because of variability in the data or insufficient evidence to support all aspects of a review finding (coherence). Many complex factors were found to influence caregivers' and adolescents' HPV vaccination views and practices, which we categorised into eight overarching themes: 1) A lack of biomedical knowledge; 2) Perceptions of a range of interrelated risks and benefits (or lack thereof) associated with HPV vaccination; 3) Routine responses to vaccination generally or more specific views or experiences of other vaccines and vaccination programmes; 4) Complex nuclear familial decision-making dynamics; 5) Extended familial and social relations and networks, particularly extended family members, peers, traditional or religious leaders, and the media; 6) Interrelated socio-cultural beliefs and practices regarding adolescence, sexuality, gender, parenting and health; 7) Trust or distrust in the institutions, systems or experts associated with vaccination, most particularly teachers and the school, the pharmaceutical industry, government, science and biomedicine, and healthcare professionals; and 8) Access to, and experiences of, HPV vaccination programmes and delivery services, such as the convenience (or lack thereof) of HPV vaccination services, the cost of the vaccine, language barriers, the feminisation of HPV vaccination programmes and procedural aspects of school-based vaccination delivery. We did not identify any major differences in the occurrence of these overarching themes between subgroups. However, for various subthemes certain differences emerged in relation to place, gender and socio-economic status, and between caregivers and adolescents. The interventions tested in the related Cochrane review of intervention effectiveness most commonly targeted caregivers' and adolescents' lack of biomedical knowledge and their perceptions of the risks and benefits of HPV vaccination, with the other influencing factors identified by our review being underrepresented.

AUTHORS' CONCLUSIONS

Our review reveals that caregivers' and adolescents' HPV vaccination views and practices are not only influenced by issues related to individual knowledge and perceptions of the vaccine, but also an array of more complex, contextual factors and meanings: social, political, economic, structural, and moral. Successful development of interventions to promote the acceptance and uptake of HPV vaccination for adolescents requires an understanding of the context-specific factors that influence HPV vaccination views and practices in the target setting. Through this, more tailored and in turn more relevant, acceptable, and effective responses could be developed. The eight overarching themes that emerged from our review could serve as a basis for gaining this understanding.

Children's and parents' attitudes to and knowledge about HPV vaccination following a targeted information intervention

The aim of this study was to investigate Swedish children's and parents' attitudes and knowledge about human papillomavirus (HPV) vaccination a year after gender-neutral HPV vaccination was introduced in Sweden's national immunization program (NIP). Additional information about HPV and vaccine was provided in the extended immunazation program. In total, 276 parents and 206 children from 22 School Health Services responded to a web-based survey. Results showed that half of the children and about a third of the parents received additional Public Health Agency information about HPV vaccination, and a majority were satisfied. Parents considered HPV vaccination being important for their children's health, and both children and parents considered it important to vaccinate all genders against HPV. Both children and parents rated school nurses as most reliable source of HPV vaccination information. Teachers were also a common source of HPV and HPV vaccination information for children. Further research among teachers in Sweden is needed to explore their knowledge and abilities to inform students and parents about HPV and vaccination.

Parental views and the key role of nurses for high vaccine acceptance in Sweden - a focus group study

BACKGROUND

In Sweden, vaccine uptake is exceptionally high due to an efficient child immunization program. More than 97% of Swedish children were vaccinated at child health care centers (CHCs) according to the schedule at 2 years of age in 2021. From the age of 6 years, vaccinations are given within the school health care. Maintaining high vaccination coverage over time is one of the central motives to explore and understand drivers for vaccine acceptance. The current study aimed to assess parental vaccine acceptance concerning the national immunization program and explore factors contributing to the high vaccine acceptance in Sweden.

METHODS

Parents of children aged 1-2 years and 8-12 years were recruited through purposive sampling and asked to participate in focus groups held in three cities in Sweden, in February and March 2019. In total, 47 parents participated in two focus groups per city, one session for parents of younger (1-2 years) and older (8-12 years) children respectively. The focus group discussions were analyzed using qualitative content analysis.

RESULTS

Parents of children aged 1-2 years expressed the themes; strong compliance to and protection of the value of vaccinations; parents feel safe with an attentive relationship with their nurse; the spectrum of communication needs is essential to meet. For parents to children aged 8-12 years, the themes expressed were; vaccinate to do good for the individual and society; a foundation of trust is built at CHCs for decisions later on; decisions for vaccination become more complex as children get older; communication changes as children get older and need to be explicit and tailored to the situation.

CONCLUSION

Both individual and societal perspectives were shown to influence the vaccination decision for childhood immunizations, as manifested in parental reflections and experiences. As nurses have a key role, it is important to provide them with continued support and tools to facilitate their support for parents in making informed decisions. Continuous work for supporting driving factors for vaccination over time is needed to maintain high vaccine acceptance in Sweden.