Quadrivalent human papillomavirus vaccine uptake in adolescent boys and maternal utilization of preventive care and history of sexually transmitted infections

Association of Maternal Cervical Cancer Screening Adherence with Adolescent HPV Vaccination Among Adolescent-Mother Pairs

Less than two-thirds of US adolescents are up-to-date with HPV vaccination. While mothers engaged in preventive care are more likely to seek preventive care for their children, current studies on associations between maternal cervical cancer screening (CCS) and adolescent HPV vaccination are needed. We assessed associations between maternal preventive service utilization and adolescent HPV vaccination using electronic health record data from a healthcare system in Washington State. We included adolescents (11-17 years) and their mothers with ≥ 1 primary care visit between 2018 and 2020. Outcomes were HPV vaccine initiation and completion. The primary exposure was maternal adherence to guideline-recommended CCS. Secondary exposures were maternal breast cancer screening adherence (for mothers ≥ 52 years) and ≥ 1 wellness visit ≤ 2 years. We used Generalized Estimating Equations to estimate prevalence ratios, and explore effect modification by adolescent sex, adolescent provider characteristics, and maternal language interpreter use. Of 4121 adolescents, 66% had a CCS-adherent mother, 82% initiated HPV vaccination, and 49% completed the series. CCS adherence was associated with higher initiation (adjusted prevalence ratio (APR):1.10, 95%CI:1.06-1.13) and completion (APR:1.16, 95%CI:1.08-1.23). Associations were stronger for male vs. female adolescents, adolescents who had a primary care provider in family practice vs. pediatrics, and adolescents who had the same primary care provider as their mother vs. not. Recent maternal wellness visit was also associated with higher initiation (APR:1.04, 95%CI:1.01-1.07) and completion (APR:1.12, 95%CI:1.05-1.20). Results suggest that delivering healthcare through a family-centered approach and engaging mothers in broad preventive care could increase adolescent HPV vaccination coverage.

Factors affecting human papillomavirus (HPV) vaccination in men: A systematic literature review (Preprint)

Background

Despite the high risks associated with human papillomavirus (HPV), the HPV vaccination rate of men is far lower than women. Most previous review studies have focused on female vaccination and related affecting factors. However, previous studies have reported that the factors affecting HPV vaccination differ by gender.

Objective

The aim of this review was to identify the factors affecting HPV vaccine initiation in men through a systematic review approach.

Methods

A literature review was conducted across 3 central electronic databases for relevant articles. A total of 30 articles published between 2013 and 2019 met the inclusion criteria and were reviewed in this study.

Results

In total, 50 factors affecting HPV vaccination in men were identified, including 13 sociodemographic factors and social structure factors, 12 belief-related variables, 4 family factors, 4 community factors, 14 variables related to needs, and 3 environmental factors.

Conclusions

To increase HPV vaccination rates in men, strategies targeting young males and their families should consider frequent visits to or contact with health care providers so that health care professionals can provide recommendations for HPV vaccination.

The association between maternal human papillomavirus (HPV) experiences and HPV vaccination of their children

HPV vaccination prevents most HPV-related cancers yet vaccination rates remain low. In this cross-sectional study, we examined the association between maternal HPV experiences and HPV vaccination uptake among children and whether this association may be explained by perceived benefits of vaccination. We used logistic regression models to estimate the effect of (1) maternal history of abnormal Pap smear, (2), family/friend history of cervical cancer, and (3) maternal history of cervical cancer on HPV vaccination uptake among children. Separate mediation analyses were conducted to determine if perceived benefits mediated the relationship between each maternal HPV experience and HPV vaccination uptake. History of abnormal Pap smear (OR = 1.50, 95% CI = 1.15, 1.97), family history of cervical cancer (OR = 1.72, CI = 1.26, 2.35), and personal history of cervical cancer (OR = 3.00, CI = 1.82, 4.95) predicted HPV vaccination of children. Perceived benefits mediated the relationship between history of abnormal Pap smear (indirect effect =.146, SE =.069, 95% CI =.014, .289), family history of cervical cancer (indirect effect =.228, SE =.079, CI =.080, .387), and personal history of cervical cancer (indirect effect =.298, SE =.116, CI =.082, .533) on HPV vaccination. Our results suggest that personal experiences with HPV-related disease may influence maternal HPV vaccine decision-making.

Parents' uptake of human papillomavirus vaccines for their children: a systematic review and meta-analysis of observational studies

OBJECTIVE

To examine factors associated with parents' uptake of human papillomavirus (HPV) vaccines for their children.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Cochrane Library, AIDSLINE, CINAHL, EMBASE, PsycINFO, Social Sciences Abstracts, Ovid MEDLINE, Scholars Portal, Social Sciences Citation Index and Dissertation Abstracts International from inception through November 2017.

METHODS

We included studies that sampled parents and assessed uptake of HPV vaccines for their children (≤18 years) and/or sociodemographics, knowledge, attitudes or other factors associated with uptake. Study risk of bias was assessed using the Effective Public Health Practice Project tool. We pooled data using random-effects meta-analysis and conducted moderation analyses to examine variance in uptake by sex of child and parent.

RESULTS

Seventy-nine studies on 840 838 parents across 15 countries were included. The pooled proportion of parents' uptake of HPV vaccines for their children was 41.5% (range: 0.7%-92.8%), twofold higher for girls (46.5%) than for boys (20.3%). In the meta-analysis of 62 studies, physician recommendation (r=0.46 (95% CI 0.34 to 0.56)) had the greatest influence on parents' uptake, followed by HPV vaccine safety concerns (r=-0.31 (95% CI -0.41 to -0.16)), routine child preventive check-up, past 12 months (r=0.22 (95% CI 0.11 to 0.33)) and parents' belief in vaccines (r=0.19 (95% CI 0.08 to 0.29)). Health insurance-covered HPV vaccination (r=0.16 (95% CI 0.04 to 0.29)) and lower out-of-pocket cost (r=-0.15 (95% CI -0.22 to -0.07)) had significant effects on uptake. We found significant moderator effects for sex of child.

CONCLUSIONS

Findings indicate suboptimal levels of HPV vaccine uptake, twofold lower among boys, that may be improved by increasing physician recommendations, addressing parental safety concerns and promoting parents' positive beliefs about vaccines, in addition to expanding insurance coverage and reducing out-of-pocket costs. Limitations of this meta-analysis include the lack of intervention studies and high risk of bias in most studies reviewed. Further studies should disaggregate HPV vaccine uptake by sex of child and parent.

Implementation of a Postpartum HPV Vaccination Program in a Southeast Texas Hospital: A Qualitative Study Evaluating Health Care Provider Acceptance

Introduction The objective of this qualitative study was to assess healthcare providers' acceptability of an ongoing postpartum human papillomavirus (HPV) vaccination program in Southeast Texas and its integration into everyday clinical care. Methods In 2012, the Department of Obstetrics & Gynecology at the University of Texas Medical Branch (UTMB) began offering HPV vaccination as part of standard postpartum care to increase vaccination rates among young women in Galveston County. Initial vaccine doses were offered on the postpartum unit while subsequent doses were coordinated with postpartum and well-baby visits. Thirty months after project initiation, semi-structured interviews of physicians (n = 12) and nurses (n = 6) involved in postpartum and pediatric care at UTMB were conducted. Interview transcripts were analyzed using thematic analysis in Nvivo10. Results Overall, providers demonstrated "pro-vaccine" attitudes and stated the program was an effective strategy for vaccinating hard-to-reach women. Cancer prevention was the main perceived benefit while follow-up compliance was the primary perceived patient barrier. The initial challenges with integrating postpartum HPV vaccination included miscommunication between providers regarding vaccine orders and coordination issues with well-baby visits for follow-up doses. One novel finding was providers' beliefs that women's personal HPV vaccine practices may positively impact their decisions about later vaccinating their children against HPV. Providers' suggestions to improve the program included: enhancing postpartum HPV vaccine education for patients, offering more continuing education for providers, and increasing community awareness of HPV vaccination. Discussion These findings can help providers of postpartum care understand how to integrate postpartum HPV vaccination into their current practices and how to overcome perceived vaccination barriers.

Association between mothers' screening uptake and daughters' HPV vaccination: a quasi-experimental study on the effect of an active invitation campaign

OBJECTIVES

In Emilia-Romagna, the Human Papillomavirus (HPV) vaccination campaign started in 2008 offering free vaccines for 1996 and 1997 cohorts. Systematic active invitation was implemented for the 1997 cohort. Our study aimed at measuring the impact of the active invitation campaign on HPV vaccine coverage and on coverage inequalities in 11-year-old girls. Second, we evaluated the effect of the HPV vaccination campaign on participation in cervical cancer screening by mothers of target girls.

METHODS

We collected information on vaccination status for girls residing in Reggio Emilia in 2008 and mothers' screening history, before and after the 2008 vaccination campaign. Log-binomial regression models were performed to estimate Relative Risk (RR) and 95% confidence intervals (CIs) of being vaccinated as regarded citizenship, siblings, mothers' education, marital status and screening history, stratified by birth cohort. We also calculated RR of receiving a Pap test after the vaccination campaign as regarded education, daughter's cohort and mothers' decision to have their daughter vaccinated. Interaction between education and cohort in mothers overdue for Pap testing was calculated.

RESULTS

Vaccination coverage was 46.3% for the uninvited cohort (1046/2260) and 77.9% for the invited cohort (1798/2307). In the uninvited cohort, daughters' vaccination showed association with mothers' education (8 to 11 years of education vs. graduated mothers, RR 1.61 95% CI 1.14-2.28), citizenship (foreigners vs. Italians, RR 0.45 95% CI 0.37-0.56) and screening history (regular vs. non-participant; RR 1.72 95% CI 1.26-2.36). In the invited cohort, only a slight association with screening history persisted (regular vs. non-participant; RR 1.20 95% CI 1.04-1.40). Highly educated under-screened mothers of the invited cohort showed a higher probability of receiving a Pap test after the vaccination campaign period (RR 1.27 95% CI 1.04-1.56) compared with those not invited, CONCLUSION: Active invitation could increase overall HPV immunisation coverage and reduce socio-demographic inequalities and the association with mothers' screening participation.

Socioeconomic predictors of human papillomavirus vaccination in Danish men - A nationwide study

Background

The quadrivalent human papillomavirus vaccine was licensed in Denmark in 2006. Unlike women, men are not offered human papillomavirus vaccination free of charge but can have it at their own expense. We investigated human papillomavirus vaccine uptake by men in Denmark and the socioeconomic factors that may predict human papillomavirus vaccination.

Methods

Using the Civil Registration System, we identified all boys and men aged 9–26 years in 2006–2013 and their mothers. By linkage to Statistics Denmark and the National Prescription Registry, we obtained information on socioeconomic variables and human papillomavirus vaccination during the study period. Using Cox regression, we examined the associations between socioeconomic variables and human papillomavirus vaccination.

Results

Between 2006 and 2013, 6253 (0.8%) males aged 9–26 years were vaccinated against human papillomavirus. The strongest predictor identified was ethnicity. Males who were immigrants (hazard ratio, 0.12; 95% confidence interval, 0.08–0.180) or sons of immigrant parents (hazard ratio, 0.13; 95% confidence interval, 0.10–0.17) were less likely to be vaccinated than Danish males. Additionally, sons of mothers who were unemployed, unmarried, had a low income, and basic education initiated human papillomavirus vaccination less frequently. Finally, sons of mothers who were physicians or nurses were more likely to be vaccinated than sons of other highly educated mothers.

Conclusion

We found low uptake, with social disparities in human papillomavirus vaccination of boys and young men in Denmark.

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In Denmark only women are included in the national HPV vaccination programme.

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The uptake in men in Denmark is low especially among more socially disadvantaged.

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Sons of heath care workers are more likely to be vaccinated than others.

Physicians', Nurses', and Medical Assistants' Perceptions of the Human Papillomavirus Vaccine in a Large Integrated Health Care System

CONTEXT

Vaccination against the human papillomavirus (HPV) decreases risks of cancer and genital warts and the need for gynecologic procedures, yet nationwide vaccination rates are low. Previous surveys exploring this phenomenon have not included input from nurses and medical assistants, who play integral roles in HPV vaccine delivery.

OBJECTIVE

To understand perceptions of HPV vaccine delivery among physicians, nurses, and medical assistants in a large integrated health care system in Southern California.

DESIGN

Online surveys were sent to 13 nurse administrators and 75 physicians. Physicians were instructed to forward the survey to nurses and medical assistants with whom they work.

RESULTS

A total of 76 surveys were completed, consisting of 52 physicians, 16 clinical nurses and medical assistants, and 8 nurse administrators. Physicians' perceptions of vaccine safety or strength of recommendation did not differ by specialty department. Physicians reportedly perceived the HPV vaccine as safer than did clinical nurses and medical assistants (p < 0.001), who indicated they wanted more education on the safety and efficacy of the vaccine before being comfortable strongly recommending it. Respondents advised that all clinicians could improve in their roles as HPV vaccine advocates through patient counseling and providing informational literature and that workflow standardization was needed to minimize missed vaccination opportunities.

CONCLUSION

Physicians reportedly perceive the HPV vaccine as safer compared with nurses and medical assistants. Both groups think that more education of nonphysician staff is needed. Having proper systems in place is also vital to improving vaccination compliance.

Influence of Gender and Gender-Specific Recommendations on Adolescent Human Papillomavirus Vaccination

INTRODUCTION

The human papillomavirus (HPV) vaccine was introduced for female adolescents prior to male adolescents. Understanding coverage patterns related to gender-specific recommendations and factors associated with early adoption and timely completion may be important for future vaccines.

METHODS

Retrospective analysis of HPV vaccine initiation (one or more dose) and completion (three or more doses) patterns in adolescents aged 11-18 years using 2009-2013 New York Citywide Immunization Registry data. Log binomial models assessed patient-specific (age, insurance) and practice-specific (facility type, number of adolescents, poverty level) variables on early adoption (within 1 year of recommendation) and timely completion (within 12 months) by gender.

RESULTS

Of 1,494,767 adolescents, 50.2% were male, 57.5% were vaccinated in private practices, 58.7% in practices with more adolescents, and 48.8% in highest poverty locations. More female (54.0%) than male (33.5%) adolescents initiated vaccination (p<0.001). Of those, 56.1% received three or more doses, 34.1% within 12 months (30.0% male, 36.8% female, p<0.001). In 2009-2012, the proportion of still-eligible male adolescents who newly initiated increased from 0.1% to 17.0%; rates for female adolescents increased from 15.4% to 17.3%. Vaccination initiation within 1 year of gender-specific recommendations was similar (27.4% female, 27.3% male). For both genders, the uninsured were less likely to have early adoption and timely completion. Being publicly insured was associated with early adoption in both genders, but with timely completion in male adolescents only. Being seen in a public facility and in a practice with more adolescents was also associated with early adoption.

CONCLUSIONS

Changing HPV vaccine recommendations had minimal cross-gender impact. Early adoption and timely completion patterns were mostly similar across genders.

Human Papillomavirus Vaccine Uptake in Adolescent Boys: An Evidence Review

BACKGROUND

Despite evidence-based guidelines recommending routine vaccination against human papillomavirus (HPV) for adolescent boys, ages 11-12 years, vaccine uptake among this population remains low.

AIMS

To examine reasons for low HPV quadrivalent vaccine uptake and methods available to increase vaccine uptake among adolescent males, ages 11-12 years.

METHODS AND RESULTS

Of 341 identified studies, 30 were included from three databases. The 30 studies were grouped into six categories: population-specific, problem-specific, educational interventions, theory-specific, political implications, and foundational guidelines and Websites.

DISCUSSION

Among eight studies, low vaccine uptake was attributed to lack of parental, adolescent, and physician knowledge of HPV4 vaccine availability and recommendations. HPV4 vaccine educational interventions for parents and adolescents were the most effective for promoting vaccine uptake. Theory applications and gain-framed messages were shown to be effective for assessing HPV vaccine attitudes and perceptions. Political implication studies reveal the need for political and financial measures to encourage HPV vaccine acceptability among the population.

IMPLICATIONS FOR CLINICIANS

To promote HPV vaccine uptake among adolescent males, providers must remain current with HPV vaccine recommendations and offer parental and adolescent HPV education focusing on benefits of vaccine acceptance and risks of vaccine refusal.

LINKING EVIDENCE TO ACTION

The results of this review inform our understanding of effective educational strategies to positively impact HPV vaccine uptake in adolescent males. Based on this review, clinicians can employ several evidence-based educational strategies to facilitate HPV vaccine uptake.

Quadrivalent Human Papillomavirus Vaccine Initiation in Boys Before and Since Routine Use: Southern California, 2009-2013

OBJECTIVES

We examined the trends and correlates of quadrivalent human papillomavirus vaccine (HPV4) initiation in insured boys during the periods before and after routine use recommendation.

METHODS

We grouped data from electronic medical records of boys aged 9 to 17 years from the Kaiser Permanente Southern California prepaid health plan into 3 open cohorts: permissive use: 2009 to 2010; anal cancer indication added: 2010 to 2011; and routine use: 2011 to 2013. We estimated adjusted risk ratios (ARRs) between demographics and vaccination initiation using Poisson regression.

RESULTS

HPV4 initiation increased across cohorts--1.6%, 3.4%, and 18.5%--with the greatest increase among boys aged 11 to 12 years in cohort 3. Initiation was associated with receiving influenza vaccination in the previous year in all cohorts (cohort 3: ARR = 1.48; 95% confidence interval [CI] = 1.46, 1.51) and with non-White race/ethnicity following routine recommendation (cohort 3, non-Hispanic Black: ARR = 1.18; 95% CI = 1.08, 1.30; Hispanic: ARR = 1.23; 95% CI = 1.17, 1.29; Asian/Pacific Islanders: ARR = 1.16; 95% CI = 1.11, 1.20).

CONCLUSIONS

Routine use recommendation increased the uptake of HPV4 in boys. System-level interventions to encourage providers to routinely recommend HPV4 vaccination may help increase HPV4 uptake in boys.

Initiation of Human Papillomavirus Vaccination Among Predominantly Minority Female and Male Adolescents at Inner-City Community Health Centers

OBJECTIVES

We examined the prevalence and correlates of human papillomavirus (HPV) vaccine initiation among adolescents in low-income, urban areas.

METHODS

The study consisted of electronic health record data on HPV vaccination for 3180 adolescents (aged 10-20 years) at a multisite community health center in 2011.

RESULTS

Only 27% initiated the HPV vaccine. The adjusted odds ratio (AOR) of HPV vaccination was lower among older adolescents (AOR = 0.552; 95% confidence interval [CI] = 0.424, 0.718) and those seen by nonpediatric health care providers (HCPs; AOR = 0.311; 95% CI = 0.222, 0.435), and higher among non-English speakers (AOR = 1.409; 95% CI = 1.134, 1.751) and those seen at 2 site locations (AOR = 1.890; 95% CI = 1.547, 2.311). Insurance status was significant only among female and Hispanic adolescents. Language was not a predictor among Hispanic adolescents. Across all analyses, the interaction of age and HCP specialty was associated with HPV vaccination. Dramatically lower HPV vaccination rates were found among older adolescents seen by nonpediatric HCPs (3%-5%) than among other adolescents (23%-45%).

CONCLUSIONS

Improving HPV vaccination initiation in low-income urban areas is critical to reducing disparities in cervical and other HPV-related cancer, especially among Black, Hispanic, and low-income populations.

Vaccinating sons against HPV: results from a U.S. national survey of parents

Purpose

The quadrivalent HPV vaccination was approved for use in males ages 9 to 26 in 2009 and recommended for routine administration in 2011. The purpose of this study was to uncover predictable commonalities amongst parents who chose to vaccinate their 11–17 year old sons against HPV.

Methods

We compiled data from a U.S. national sample of 779 parents with sons 11–17 years old using a web-based survey to gather information about behavioral and sociodemographic factors which predicted receipt of 1 or more HPV vaccine doses based on parental report. Predictors were first modeled individually for univariable associations. Significant predictors (p<0.10) were combined in a multivariable model.

Results

In the adjusted model, independent predictors included receipt of flu vaccination, health insurance coverage and sexual health topic discussions with sons. Sons who had received a flu shot in the last two years more frequently received at least one dose of the vaccine (OR 1.82; 95% CI 1.45–2.26). Sons covered by private health insurance had decreased odds of HPV vaccination (OR 0.56 95% CI 0.37–0.83). Lastly, parents who had discussed sexual health topics with their sons were more likely to vaccinate (OR 1.61; 95% CI 1.37–1.89).

Conclusions

Male vaccination rates in the U.S. have increased, but males continue to be under-immunized. Utilization of health care is an important factor in HPV vaccine uptake; therefore, health care providers should use every contact as an opportunity to vaccinate. Communication about sexual health topics may provide a forum for parents and health care providers to have conversations about HPV vaccination as those more comfortable discussing these topics may also be more comfortable discussing HPV vaccination.