Parent-reported reasons for nonreceipt of recommended adolescent vaccinations, national immunization survey: teen, 2009

Factors associated with recommendation behaviors of four non-National Immunization Program vaccines: a cross-sectional survey among public health workers in China

BACKGROUND

Immunization is a crucial preventive measure to safeguard children under five years old against a range of diseases. In China, the coverage rate of non-National Immunization Program (non-NIP) vaccines can be improved by leveraging the recommendation from public health workers. Hence, understanding the influencing factors of recommendation behaviors assume paramount importance. This study aims to investigate influencing factors of public health workers' recommendation behaviors towards non-NIP vaccines, with a particular emphasis on financial incentives.

METHODS

A cross-sectional survey was conducted using a multi-stage sampling method in 2019 from August to October. 627 public health workers were recruited from 148 community healthcare centers in ten provincial-level administrative divisions in China. An anonymous questionnaire was used to collect demographic information, attitudes towards vaccination, and recommendation behaviors towards non-NIP vaccines, including Haemophilus influenzae type b (Hib) vaccine, pneumococcal conjugate vaccine, varicella vaccine, and rotavirus vaccine. Descriptive analysis and multivariate logistic regression analysis were adopted in this study.

RESULTS

Of the 610 public health workers with complete survey data, 53.8%, 57.4%, 84.1%, and 54.1% often recommended Hib vaccine, pneumococcal pneumonia vaccine (PCV), varicella vaccine, and rotavirus vaccine, respectively. Logistic regression revealed that gender (Hib vaccine: OR = 0.4, 95% CI: 0.2-0.8; PCV: OR = 0.4, 95% CI: 0.2-0.8; rotavirus vaccine: OR = 0.3, 95% CI: 0.2-0.6), financial incentives for non-NIP vaccination (Hib vaccine: OR = 1.9, 95% CI: 1.1-3.6; PCV: OR = 2.1, 95% CI: 1.1-3.9; rotavirus vaccine: OR = 2.0, 95% CI: 1.1-3.8) and perception of vaccine safety (Hib vaccine: OR = 2.7, 95% CI: 1.1-7.0; PCV: OR = 3.2, 95% CI: 1.2-8.0; rotavirus vaccine: OR = 3.0, 95% CI: 1.2-7.7) were associated with public health workers' recommendation towards Hib vaccine, PCV and rotavirus vaccine.

CONCLUSIONS

The findings highlighted public health workers' recommendation behaviors of non-NIP vaccines in China and revealed strong association between vaccine recommendation and financial incentives. This highlights the importance of financial incentives in public health workers' recommendation toward non-NIP vaccines in China. Proper incentives are recommended for public health workers to encourage effective health promotion in immunization practices.

An Evaluation of Knowledge and Comfort in Discussing the Human Papillomavirus (HPV) Vaccine Among a Sample of Physicians Practicing in South Carolina

Objective To determine knowledge and comfort in discussing the human papillomavirus (HPV) vaccine among a sample of physicians practicing in South Carolina. Methods This descriptive cross-sectional study utilized a 33-question survey assessing knowledge of HPV, the HPV vaccine, and comfort in discussing associated topics with patients among a sample of physicians across the state of South Carolina. Descriptive and correlational analyses were performed. Results Of the total 66 participants, most self-reported having sufficient knowledge about HPV, yet responses to fact-based questions yielded an average score of only 7.03/13. Most felt comfortable discussing HPV, while some reported discomfort discussing sex-related topics (3.6%). A positive significant correlation was determined between having sufficient knowledge of HPV and comfort levels discussing both HPV and sex-related topics ((p-value < 0.001), (p = .0028)), comfort levels discussing HPV and comfort levels discussing sex (p = .0030), and comfort level discussing sex and previous communication training (Mantel-Haenszel chi-square = 0.0447). Conclusions The results of this study support the role of future interventions aimed at increasing the HPV knowledge base and training in discussions of sex for providers to help increase HPV vaccination rates in South Carolina.

Understanding barriers to vaccination against invasive meningococcal disease: a survey of the knowledge gap and potential solutions

INTRODUCTION

Invasive meningococcal disease (IMD) is a leading cause of life-threatening bacterial meningitis and septicemia. Evidence points to a knowledge gap among parents, teenagers, and healthcare providers (HCPs) regarding IMD and available vaccines, including those against the highly prevalent serogroup B.

AREAS COVERED

An online survey was conducted between March 27 and April 12, 2019, to gather insights into the knowledge that parents/guardians have about IMD vaccines. The children were aged 2 months-10 years in Australia, Brazil, Germany, Greece, Italy, and Spain, 5-20 years in the UK, and 16-23 years in the US. The findings were discussed in the context of the available literature and solutions were proposed to minimize the knowledge gap and the barriers to vaccination against IMD.

EXPERT OPINION

The survey demonstrated that parents have a good understanding of IMD but a limited understanding of the different serogroups and vaccines. The available literature highlighted multiple barriers to IMD vaccine uptake; these may be reduced through education of HCPs, clear recommendations to parents by HCPs, the use of technology, and disease-awareness initiatives that engage parents through physical and digital channels. Further studies are warranted to assess the impact of the COVID-19 pandemic on IMD vaccination.

Role of Healthcare Professionals and Sociodemographic Characteristics in COVID-19 Vaccination Acceptance among Uro-Oncology Patients: A Cross-Sectional Observational Study

At the time when mass COVID-19 vaccination began, providing appropriate vaccination advice to uro-oncology patients became a challenge. This was a single-center cross-sectional observational study aimed to investigate the rate of COVID-19 vaccination among uro-oncology patients receiving systemic therapy for metastatic renal cell carcinoma and metastatic castration-resistant prostate cancer. Furthermore, we aimed to assess patients' attitudes and identify factors influencing their decision to vaccinate against COVID-19. Data on patients' sociodemographic characteristics, vaccination status, and awareness and attitudes about COVID-19 vaccination were collected from questionnaires completed by the patients. A total of 173 patients were enrolled in this study, and 124 (71.7%) of them completed the COVID-19 vaccination. Significantly higher vaccination rates were found in male patients, and also in older patients, highly educated patients, and those who lived with one household member. Furthermore, we found significantly higher vaccination rates in patients who had consulted with doctors involved in their treatment, particularly with urologists. A significant association was observed between COVID-19 vaccination and doctor's advice, family member influence, and personal beliefs toward the vaccination. Our study showed multiple associations of patients' sociodemographic characteristics with vaccination rates. Furthermore, consultation with doctors who are particularly involved in oncology treatment and advice received from them were associated with significantly higher vaccination rates among uro-oncology patients.

Integrated Health Maintenance Reminders for Improved HPV Vaccine Administration: Toward Improvements in Completion Disparities

OBJECTIVE

To evaluate the effect of a health maintenance reminder (HMR) on human papillomavirus (HPV) vaccine administration and completion across different age, insurance, and race cohorts.

STUDY DESIGN

Retrospective pre-post analysis.

SETTING

Academic primary care.

METHODS

Patients aged 9 to 26 who had initiated the HPV vaccine series from 2016 to 2021 were analyzed, based on current age-based standards. The cohort was divided based on vaccine uptake before and after the implementation of the HMR program in February 2020. The multivariate analysis estimated the odds of vaccine completion based on sociodemographic factors, and variable interactions were investigated to determine independent associations between sociodemographic factors and HMR implementation.

RESULTS

There were 7654 individual patients (mean age was 15.8 years; 46.7 were males; and 50.7% were white). HPV vaccine completion rates increased post-HMR implementation by 59.2% (37% pre-, and 58.9% post-HMR; p < .001) in the entire cohort. Overall, black patients (adjusted odds ratio [aOR] = 0.68; 95% confidence interval [CI]: 0.60, 0.70) and patients ≥18 years (aOR = 0.13; 95% CI: 0.11, 0.15) were significantly less likely to complete their vaccine series; however, this improved significantly following HMR in these groups (p < .001). Post-HMR, race, and insurance status were not independently associated with disparate vaccine completion rates, however, age was, and patients ≤14 or younger had higher odds of vaccine completion (aOR = 3.54; 95% CI: 2.91, 4.32).

CONCLUSION

The implementation of an HMR was associated with increased HPV vaccine uptake across age and race groups in this single-institution study. Future research should explore barriers to implementing HMRs in different healthcare settings.

Could oral health care professionals help increase human papillomavirus vaccination rates by engaging patients in discussions?

BACKGROUND

Oral health care professionals are well positioned to contribute to the prevention of human papillomavirus (HPV)-related oropharyngeal and other HPV-related cancers through engaging patients in conversations about HPV vaccination. This scoping review evaluates evidence regarding oral health care provider knowledge of, and discussion related to, HPV prevention, transmission, and associated risks, including oropharyngeal cancer. This review outlines relevant barriers to, and facilitators of, this knowledge and discussion. In addition, to determine the potential population that could be reached by an oral health care provider for a conversation about HPV vaccination, this review evaluates the prevalence of HPV vaccination as well as dental visits in a US population.

TYPES OF STUDIES REVIEWED

Four databases were systematically searched (MEDLINE [PubMed], EMBASE, APA PsycInfo, Cumulative Index to Nursing and Allied Health Literature). Studies written in English and conducted in the United States were eligible. Eligibility criteria were not restricted to publication year or oral health care provider type. Behavioral Risk Factor Surveillance System 2018 data were analyzed to evaluate the prevalence of HPV vaccination and dental visits among patients aged 18 through 49 years.

RESULTS

After duplicate record removal and second-stage screening, 32 full-text articles were retrieved, and data were independently extracted by 2 reviewers. Twenty-four studies were included in this review. Knowledge regarding HPV prevalence, transmission, disease processes, and risks varied. In general, discussions related to HPV in dental settings were infrequent. Facilitators to improve knowledge and discussion included guidance from professional dental organizations, education, and communication skills. Behavioral Risk Factor Surveillance System data showed that most people who are not vaccinated have visited their oral health care providers in the past year, highlighting the potential role of oral health care providers regarding discussion of HPV and promoting awareness and acceptance of vaccination.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

This review indicates that discussions related to HPV were infrequent in the oral health care setting, which may be related to lack of knowledge and communication skills among oral health care professionals; however, evidence exists supporting the interest of oral health care professionals in improving vaccine uptake to prevent oropharyngeal cancer.

Factors that differentiate COVID-19 vaccine intentions among Indiana parents: Implications for targeted vaccine promotion

Given low rates of uptake of the COVID-19 vaccine for children 12-17 and 5-11 years old, research is needed to understand parental behaviors and behavioral intentions related to COVID-19 vaccination for their children. In the state of Indiana, we conducted a non-random, online survey of parents or caregivers (N = 10,266) about their COVID-19 vaccine intentions or behaviors, demographic characteristics, and potential motivating reasons for getting the vaccine. In terms of behaviors/intentions, 44.8% of participants indicated they were vaccine acceptors (i.e., had already had their children vaccinated or would as soon as it was possible), 13.0% indicated they were vaccine hesitators (i.e., wanted to wait and see), and 42.2% indicated they were vaccine rejecters (i.e., would not vaccinate or only would if mandated). Compared to vaccine rejecters, vaccine hesitators were more likely to be motivated by perceptions of vaccine safety and efficacy, normative influences such as close friends/family who had been vaccinated and a recommendation from a provider, as well as if they were vaccinated themselves. These findings have implications for the development of targeted vaccine promotion strategies, such as social norms messaging and a focus on vaccine safety, in order to increase COVID-19 vaccination for eligible children.

Informing Content and Feature Design of a Parent-Focused Human Papillomavirus Vaccination Digital Behavior Change Intervention: Synchronous Text-Based Focus Group Study

Background

Human papillomavirus (HPV) is a common and preventable sexually transmitted infection; however, vaccination rates in the United States among the target age group, which is 11-12 years, are lower than national goals. Interventions that address the barriers to and facilitators of vaccination are important for improving HPV vaccination rates. Web-based, text-based focus groups are becoming a promising method that may be well suited for conducting formative research to inform the design of digital behavior change intervention (DBCI) content and features that address HPV vaccination decision-making.

Objective

This study aims to explore parental HPV vaccination decision-making processes using a web-based, text-based focus group protocol to inform content and feature recommendations for an HPV prevention DBCI.

Methods

We conducted 4 web-based, text-based synchronous focus groups via Skype with the parents of patients aged 11-13 years within a large urban US pediatric clinic network.

Results

The 22 parents were mostly female, White, non-Hispanic college graduates, and they mostly had private health insurance for their children. Approximately half (14/25, 56%) of the parents' 11-13 year old children had initiated HPV vaccination. Most parents had experience using Skype (19/22, 86%). Approximately half (8/17, 47%) of parents expressed no preference for the focus group format, whereas 47% (8/17) requested a text-only chat format and 6% (1/17) requested an audiovisual format. The three main themes from the qualitative data were barriers to HPV vaccination, facilitators of HPV vaccination, and suggestions for improving the HPV vaccination clinic experience. A total of 11 intervention content and feature recommendations emerged from the themes, including addressing HPV knowledge barriers using trusted sources, designing for a family audience, focusing on the framing of messages, reporting reputable HPV research in a comprehensible format, and expanding the clinic visit experience.

Conclusions

Synchronous text-based focus groups are feasible for conducting formative research on HPV vaccination decision-making. Among well-educated and well-resourced parents, there are barriers such as misinformation and facilitators such as pediatrician recommendations that influence HPV vaccination decision-making. Parents want to conduct their own HPV research as well as receive relevant HPV vaccination advice from their child’s pediatrician. In addition, parents want an enhanced clinic visit experience that lets them access and connect to tailored information before and after clinic visits. The results gathered provide guidance for content and features that may inform a more responsive DBCI to address HPV vaccination decision-making among parents.

National and State-Specific Estimates of Settings of Receiving Human Papillomavirus Vaccination Among Adolescents in the United States

PURPOSE

Human papillomavirus (HPV) vaccination in the United States has been recommended for girls since 2006 and for boys since 2011. However, settings of receiving HPV vaccination have not been assessed. The purpose of this study is to assess settings of receiving HPV vaccination among adolescents in order to understand what strategies are needed to improve vaccination uptake.

METHODS

Data from the 2018 National Immunization Survey-Teen (NIS-Teen) were analyzed to assess place of HPV vaccination overall, and by gender, quarter, and other selected variables among adolescents in the United States. The 2016-2018 NIS-Teen data were combined to assess state-specific place of HPV vaccination.

RESULTS

Among vaccinated adolescents aged 13-17 years, a doctor's office was the most common place where HPV vaccination was received (79.2%), followed by clinics, health centers, or other medical facilities (13.5%), health department (4.1%), hospital or emergency room (2.3%), schools (.5%), and pharmacies or stores (.4%). Overall, 99.1% of adolescents aged 13-17 years received HPV vaccination at medical settings and only .9% at nonmedical settings. Reported vaccination in nonmedical settings by state ranged from less than .1% in Delaware, Florida, and New Hampshire to 4.1% in North Dakota, with a median of 1.0%.

CONCLUSIONS

Doctor's offices were the most common medical setting for adolescents to receive HPV vaccination. Less than 1% of adolescents received vaccination at nonmedical settings. Continuing work with medical and nonmedical settings to identify and implement appropriate strategies are needed to improve HPV vaccination coverage among adolescents.

Perceptions and Knowledge About the MenB Vaccine Among Parents of High School Students

Serogroup B meningococcal disease (MenB) causes almost 60% of meningitis cases among adolescents and young adults. Yet, MenB vaccine coverage among adolescents remains below 10%. Since parents are the primary medical decision makers for adolescents, we examined MenB vaccination rates and parent attitudes about meningitis and the MenB vaccine. In 2018, in conjunction with a county-wide, school-based immunization campaign, we conducted a mixed methods study among parents of 16- to 17-year-olds. We facilitated focus groups asking parents about their knowledge of meningitis and reactions to educational materials and sent behavioral surveys based on Health Belief Model constructs to parents through the county high school system. Parents in three focus groups (n = 8; participation rate = 13%) expressed confusion about their child's need to receive the MenB vaccine in addition to the meningococcal conjugate vaccine (MenACWY), but conveyed strong trust in their physicians' recommendation. Among survey participants (n = 170), 70 (41%) had heard of the MenB vaccine. Among those 70 parents, the most common barriers to vaccination were concerns about side effects (55%) and uncertainty of susceptibility due to receipt of the MenACWY vaccine (30%). The percentage of teens that received at least one dose of the MenB vaccine was 50% (n = 35) by parent report and 23% (n = 16) by state vaccination records. Parents demonstrated uncertainty and confusion about the MenB vaccine particularly due to the existence of another meningitis vaccine and limited health care provider recommendations. Confirmatory studies of parent confusion about the MenB vaccine are needed to develop interventions.

Resources for assessing parents' vaccine hesitancy: a systematic review of the literature

The concept of Vaccine Hesitancy has begun to appear in the scientific landscape, referring to the reluctance of a growing proportion of people to accept the vaccination offer. A variety of factors were identified as being associated with vaccine hesitancy but there was no universal algorithm and currently there aren’t any established metrics to assess either the presence or impact of vaccine hesitancy. The aim of this study was to systematically review the published questionnaires evaluating parental vaccine hesitancy, to highlight the differences among these surveys and offer a general overview on this matter. This study offers a deeper perspective on the available questionnaires, helping future researches to identify the most suitable one according to their own aim and study setting.

Seasonal Influenza Vaccination and Recommendation: The Difference between General Practitioners and Public Health Workers in China

Seasonal influenza vaccination for healthcare workers (HCWs) is critical to the protection of HCWs and their patients. This study examined whether the separation of public health workers and general practitioners could affect the influenza vaccine uptake and recommendation behaviors among HCWs in China. A survey was conducted from August to October 2019, and HCWs from 10 provinces in China were recruited. A self-administered and anonymous questionnaire was used to assess HCWs’ demographic information, knowledge, and attitudes toward influenza vaccination, as well as vaccine uptake and recommendation behaviors. The primary outcome was HCWs’ vaccination and recommendation status of seasonal influenza vaccine. Multivariate logistic regression models were used to identify the influence factors of influenza vaccine uptake and recommendation among HCWs. Of the 1159 HCWs in this study, 25.3% were vaccinated against influenza in the previous season. “No need to get vaccinated” was the primary reason for both unvaccinated public health workers and general practitioners. Multivariate logistic regression showed that public health workers were more likely to get vaccinated against influenza (OR = 2.20, 95% CI 1.59–3.05) and recommend influenza vaccination to children (OR = 2.10, 95% CI 1.57–2.80) and the elderly (OR = 1.69, 95% CI 1.26–2.25) than general practitioners. Besides, the knowledge and perceived risk of influenza can give rise to HCWs’ vaccination and recommendation behaviors, and HCWs who got vaccinated in the past year were more likely to recommend it to children and the elderly in their work. The influenza vaccine coverage and recommendation among HCWs are still relatively low in China, especially for general practitioners. Further efforts are needed to improve the knowledge and attitudes toward influenza and influenza vaccination among HCWs, and coherent training on immunization for both public health workers and general practitioners might be effective in the face of separated public health and clinical services in China.

Recommending immunizations to adolescents in Turkey: a study of the knowledge, attitude, and practices of physicians

Introduction: The aim of this study was to determine the knowledge, attitudes, and practices of family physicians and pediatricians in regard to adolescent immunization.Methods: The study was conducted from March to May 2017. A total of 665 physicians participated. Participants were asked 31 questions about their personal sociodemographic characteristics and their knowledge, attitudes, and practices around adolescent immunization.Results: The study sample consisted of 348 family physicians (52.3% of the sample) and 317 pediatricians (47.7%). The results showed that 5.4% of family physicians and 10.4% of pediatricians thought that they had enough knowledge about adolescent immunization (p < .01). Overall, 15.8% of family physicians and 12.7% of pediatricians provided adolescents with information about vaccines 'always/most of the time'. A variety of reasons for not providing information about adolescent vaccines was provided, including 'inability to allocate time' (50.2% of family physicians, 69.3% of pediatricians); 'forgetfulness' (34.8% of family physicians, 28.5% of pediatricians); 'lack of knowledge about vaccines' (34.1% of family physicians, 27.4% of pediatricians); and 'no need to immunize adolescents' (15.7% of family physicians, 6.5% of pediatricians) (p < .01). HPV immunization was recommended only to girls by 30.5% of family physicians and 38.8% of pediatricians (p < .01). The percentages of family physicians and pediatricians not recommending that adolescents be immunized with the Tdap vaccine were 53.4% and 42.6%, respectively (p = .016). Meningococcal immunization was not recommended by 20.7% of family physicians and 11.4% of pediatricians (p < .01), and influenza immunization was not recommended by 10.3% of family physicians and 8.2% of pediatricians (p < .01).Conclusion: Family physicians and pediatricians in Turkey have low rates of recommendation of immunization to adolescents. Reasons for not recommending immunization include an inability to allocate time, forgetfulness, and lack of knowledge about vaccines. We conclude that educational programs should be used to improve knowledge of adolescent immunization among family physicians and pediatricians.

Determinants of Meningococcal ACWY vaccination in adolescents in the US: completion and compliance with the CDC recommendations

Since 2011, the Advisory Committee on Immunization Practices (ACIP) guidelines for routine MenACWY vaccination in the US include a primary dose before age 16 y, preferably at ages 11-12 y, with a booster dose at age 16 y. Data on rates and drivers of meningococcal vaccination completion (receipt of both doses) and compliance with recommendations (receipt of primary dose at ages 11-12 y followed by booster at 16 y) down to state-level are limited.This study evaluated rates and determinants of MenACWY vaccination completion and compliance in adolescents aged 17 y based on data from the annual National Immunization Survey-Teen between 2011 and 2016. Individual- and state-level determinants of completion and compliance were assessed using uni-level and multi-level multivariable regression models. Average national rates were 23.2% and 12.1% for completion and compliance, respectively, with large inter-state variation observed (completion: 8.7-39.7%; compliance: 3.1-26.2%). Beyond the state of residence, factors significantly associated with a higher likelihood of both completion and compliance included being male, up-to-date on other routine vaccines, having private or hospital-based vaccine providers (vs. public) and having >1 child in the household. Factors specifically associated with completion included having >1 annual health-care visit and presence of a booster-dose vaccine mandate, while a history of asthma and high-risk health conditions had a positive association with compliance. State-level determinants of completion and compliance included pediatricians-to-children ratio and the proportion of Immunization Information System use among adolescents, respectively. Outcomes of this study may help guide clinical, policy and educational interventions to further increase MenACWY completion rates and reduce disparities in vaccination.

Are Boys Ready for Human Papillomavirus Vaccine? A National Study of Boys in Malaysia

BACKGROUND

The aim of this study was to investigate factors associated with the willingness of boys to accept the human papillomavirus (HPV) vaccine.

METHODS

A nationwide cross-sectional survey among Secondary One male students in Malaysia.

RESULTS

Among 2823 respondents, knowledge about HPV infection and the HPV vaccine was extremely poor. The mean total knowledge score was only 3.17 (SD ± 2.14), out of a possible score of 10. The majority of respondents were unaware that vaccinating boys can help protect girls against HPV infection (81.6%), and HPV is a sexually transmitted infection (70.1%). Many had the misconception that only females get HPV (78.9%). In multivariable analysis, the factors associated with the intention to receive the HPV vaccination were: agreeing boys need to be vaccinated against HPV infection (odds ratio [OR], 2.05; 95% confidence interval [CI], 1.57-2.68), perceiving their parents might allow them to get the HPV vaccine (OR, 1.66; 95% CI, 1.18-2.34), perceived susceptibility to HPV infection (OR, 1.63; 95% CI, 1.06-2.52), and attending a rural school (OR, 1.49; 95% CI, 1.14-1.95).

CONCLUSIONS

Public health educational programs that are focused and tailored on parents consenting to HPV vaccination for boys at a young age can be useful in improving HPV vaccination rates among boys. There is also a pressing need to educate boys about the benefits of HPV vaccination in males and about HPV disease susceptibility to facilitate adoption of the HPV vaccine by young adults in the future.

Japanese physicians' attitudes and intentions regarding human papillomavirus vaccine compared with other adolescent vaccines

INTRODUCTION

Japan has experienced extremely low human papillomavirus vaccine (HPVV) coverage following the suspension of proactive governmental recommendations in 2013. Several studies have reported that recommendations from physicians increase adolescents' vaccine acceptance. In this survey, we evaluated the attitudes and intentions of Japanese physicians related to adolescent immunizations, particularly HPVV.

METHODS

We conducted a cross-sectional study using a mailed questionnaire targeting 330 Japanese physicians including 78 pediatricians, 225 internists and 27 obstetricians and gynecologists (OB/GYNs) in Kawasaki City, Japan in 2016. The survey measured physicians' reported frequency of educating adolescents about vaccines as well as their own perceptions and intentions related to adolescent immunizations.

RESULTS

Valid responses were obtained from 148 (45%) physicians. Though 53% agreed that the HPVV should be recommended, only 21% reported educating about HPVV. The majority of respondents (90%) agreed that they would restart HPVV for adolescents if the government reinstated its recommendation.

CONCLUSIONS

Although Japanese physicians reported support for adolescent immunizations, they were less likely to recommend or discuss HPVV compared with other adolescent vaccines. Responses indicated this was, at least in part, due to the lack of governmental support for HPVV, indicating that their recommendations would improve with government endorsement of the vaccine.

Caregiver acceptance of a patient navigation program to increase human papillomavirus vaccination in pediatric clinics: a qualitative program evaluation

Objective: The purpose of this evaluation was to examine the acceptability of a multi-component patient navigator (PN) intervention program designed to decrease barriers to human papillomavirus (HPV) vaccination among caregivers of adolescents. We sought to understand the most important components of the program from the caregivers' perspective and to evaluate remaining barriers to vaccination. Method: Caregivers of children 9-17 years old (N = 102) participated in qualitative semi-structured interviews with questions informed by the Theory of Planned Behavior. These interviews assessed experiences with a PN program which offered HPV vaccination, scheduling, and reminders in pediatric clinics. We included randomly selected 46 program participant transcripts and 11 decliner transcripts. A thematic approach was used to analyze transcripts for themes related to acceptability of HPV vaccination, important program components, and any problems encountered. Results: Major themes included: reasons for making HPV vaccination decision, helpful program components and suggestions for improvement, and remaining barriers to vaccination. Those who declined vaccination stated that their child was too young or not ready to think about sex, or they did not have enough information to make a decision. However, they felt that PNs were respectful of their decision. Program participants felt that vaccination was an important way to prevent cancer. Program participants had often not been aware of the vaccine and felt that having it explained was very helpful. Conclusion: This program evaluation found that caregivers of pediatric patients, even those who declined the HPV vaccine, appreciated the program and felt it provided important information about the vaccine.

Reaching 80% human papillomavirus vaccination prevalence by 2026: How many adolescents need to be vaccinated and what are their characteristics?

BACKGROUND

Human papillomavirus vaccination (HPVV) prevents several types of cancer. The American Cancer Society recently established a goal that by 2026, 80% of adolescents will be up to date (UTD) before their 13th birthday. However, the number in need of vaccination to reach this goal is unknown. This study estimated the number of additional adolescents (11-12 years old) who need HPVV for 80% prevalence to be reached by 2026.

METHODS

The study used de-identified and publicly available data and exempt from institutional review board approval and informed consent. The 2016 National Immunization Survey for Teens was used to estimate the baseline HPVV prevalence. Linear growth to 80% HPVV prevalence by 2026 was applied to set intermediate targets. US Census Bureau data were used for population projections. This study estimated the cumulative number of additional adolescents 11 to 12 years old who would need to become UTD (ie, receive 2 doses) by first subtracting the number who would need to be vaccinated to achieve an intermediate target prevalence from the estimated number currently compliant and then summing these numbers between 2018 and 2026.

RESULTS

Nationwide, an additional 7.62 million males (95% confidence interval [CI], 6.78 million to 8.40 million) and an additional 6.77 million females (95% CI, 5.95 million to 7.55 million), aged 11 to 12 years, would need to receive 2 doses of the vaccine between 2018 and 2026 for 80% prevalence to be achieved. Most adolescents not UTD (80%) also needed to initiate vaccination, and more than 90% recently visited a health care provider.

CONCLUSIONS

It is estimated that at least 14.39 million additional adolescents aged 11 to 12 years in the United States will need to receive 2 doses of HPVV for a UTD HPVV prevalence of 80% to be achieved by 2026. To reach this goal, improvements in facilitators of HPVV initiation, including physician recommendations and parental acceptability, are needed.

National Trends in Parental Human Papillomavirus Vaccination Intentions and Reasons for Hesitancy, 2010-2015

Background

Human papillomavirus (HPV) vaccination uptake remains lower than other recommended adolescent vaccines in the United States. Parental attitudes are important predictors of vaccine uptake, yet little is known about how they have changed over time.

Methods

Participants included US residents aged 13-17 years with documented vaccination status who had received <3 doses of HPV vaccine whose parents responded to the National Immunization Survey-Teen, 2010-2015.

Results

Of the 76971 participants, 63.0% were male, 58.8% were non-Hispanic white, and 14.4 years was the median age. The percentage of unvaccinated teens decreased from 2010 to 2015, yet, annually, parents of unvaccinated teens of both sexes most often reported that they were "not likely at all" to vaccinate their teen. The percentage decreased significantly from 41.5% to 31.2% (P < .001) for parents of unvaccinated females from 2010 to 2015 but did not change among parents of males from 2012 to 2015. Conversely, parents of undervaccinated teens of both sexes reported higher and increasing vaccination intent over time. In 2015, nearly one-third of parents of unvaccinated teens reported that the vaccine was "not needed/necessary." Concerns about vaccine safety and side effects declined among parents of unvaccinated females but increased among parents of males (7.3% to 14.8%; P < .001).

Conclusions

Although parental vaccination intent and knowledge improved over time, intent remains low and many parents still have significant concerns about HPV vaccination, even after series initiation. Multiple strategies are needed to improve series initiation and completion in the United States.

Addressing Vaccine Hesitancy in Clinical Practice

Vaccines have had a profound impact on public health; however, parents are increasingly refusing or delaying vaccines for their children. Population-based studies have demonstrated the safety and efficacy of vaccines. Pediatricians should be well informed about vaccine development, safety, and efficacy to inspire parental confidence in vaccines. Systemic challenges in discussing and providing immunizations exist. Discussions about immunizations may be lengthy and time spent discussing immunizations is not routinely reimbursed. Adolescents may be inadequately immunized because they do not routinely present for preventive health visits. Routine immunizations should be offered and discussed at sick visits, particularly for adolescents. Improving immunization rates requires a multifaceted approach. [Pediatr Ann. 2018;47(9):e366-e370.].

Evaluating the impact of multilevel evidence-based implementation strategies to enhance provider recommendation on human papillomavirus vaccination rates among an empaneled primary care patient population: a study protocol for a stepped-wedge cluster randomized trial

Background

Each year, human papillomavirus (HPV) causes 30,000 cancers in the USA despite the availability of effective and safe vaccines. Uptake of HPV vaccine has been low and lags behind other adolescent vaccines. This protocol describes a multilevel intervention to improve HPV vaccination rates.

Methods

Using a cluster randomized trial, we will evaluate the independent and combined impact of two evidence-based implementation strategies with innovative enhancements on HPV vaccination rates for female and male patients. The clusters are six primary care sites providing care to pediatric populations. We will use a stepped-wedge cluster randomized design, including process evaluation, to test the hypothesis that compared with the current course of care and a practice-level intervention using reminder-recall interventions coupled with provider-level audit and feedback with education increases HPV vaccination rates in exposed clusters. The factorial design allows us to use a single trial to test these two interventions and to assess each individually and in combination. Our design has four 12-month steps. The first step will be a baseline period; data collected during it will provide a within-practice control group for each cluster. Second, two clusters will be randomly assigned to receive intervention 1 (reminder and recall), and two clusters will be randomly selected to receive intervention 2 (audit and feedback with education). Third, the other two clusters will be randomly allocated to intervention 1 or 2. Clusters initially with intervention 1 will be randomly allocated to 1 + 2 or 1; clusters initially with intervention 2 will be randomly allocated to 1 + 2 or 2. Fourth, all clusters will receive both interventions. To ensure balance of patient numbers across interventions, we will use block randomization at the first step, with the six clusters grouped into three pairs according to volume. Our primary outcome will be vaccination rates.

Discussion

Results of our clinical trial and process evaluation will provide evidence showing whether practice- and provider-level interventions improve HPV vaccination rates and will offer insight into contextual factors associated with direction and magnitude of trial outcomes.

Trial registration

ClinicalTrials.gov, NCT03501992, registered April 18, 2018.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0778-x) contains supplementary material, which is available to authorized users.

Correlates of HPV vaccine initiation and provider recommendation among male adolescents, 2014 NIS-Teen

Vaccination is a safe and effective way to prevent Human Papillomavirus (HPV) infection and related cancers; however, HPV vaccine uptake remains low in the US. After the 2011 Advisory Committee on Immunization Practices (ACIP) recommendation for routine HPV vaccination of adolescent males, several studies have examined predictors for initiating the vaccine series in this population of interest, particularly with regard to provider recommendations. This study examined racial and ethnic differences for HPV vaccine initiation and provider recommendation in male adolescents. Based on prior HPV vaccine uptake estimates and healthcare utilization data, we hypothesized that minority adolescents would be more likely to initiate HPV vaccines, but less likely to receive a provider recommendation compared to white counterparts. We analyzed the 2014 National Immunization Survey-Teen (NIS-Teen), which included 10,753 male adolescents with provider-verified vaccination data in 50 US states, using multivariate logistic regression models to evaluate racial/ethnic differences in HPV vaccine initiation and provider recommendation. The odds of HPV vaccine initiation were 76 percent higher for Hispanic adolescents and 43 percent higher for non-Hispanic Other or Multiple race adolescents compared to white adolescents. Approximately half of parents reported receiving a provider recommendation for vaccination, with no significant difference in the odds of receiving a provider recommendation across racial/ethnic groups. Despite similar frequency of recommendations across racial and ethnic groups, male adolescents who are racial/ethnic minorities are more likely to initiate vaccination. Future research should focus on developing tailored interventions to increase HPV vaccine receipt among males of all racial/ethnic groups.

Barriers to HPV Vaccination Among Unvaccinated, Haitian American College Women

Background: Haitian women residing in the United States are disproportionately affected by cervical cancer. Human papillomavirus (HPV) vaccine has been licensed in the United States since 2006. Vaccination rates are less than optimal overall, and the rates are particularly low among young black women. We investigated barriers to HPV vaccination in a sample of Haitian American college women. Methods: Thirty self-identified Haitian American women, aged 17-26 years, were recruited from a large university campus in southeastern United States (n=30). They completed in-depth face-to-face interviews. The research team analyzed the transcripts using thematic analysis. Results: More than half of the participants (n=18) had not yet initiated the HPV vaccine series. Most of the unvaccinated participants stated that they had received a provider recommendation for the vaccine. Lack of provider recommendation, negative vaccine perception and attitudes, and side effect concerns constituted barriers to vaccination. Conclusions: Haitian American college women at high risk of cervical cancer have cited several barriers to HPV vaccination, with the most prominent being lack of physician recommendation. Healthcare providers should continue recommending the vaccine to college women as many of them may not have received a recommendation. When recommending the HPV vaccine, discussions should be framed with the intent to positively influence HPV vaccine perceptions and ultimately vaccine attitudes.

On surmounting the barriers to HPV vaccination: we can do better

The major impediment to increased human papillomavirus (HPV) vaccination coverage in young males and females is lack of health care provider recommendation. Despite its efficacy in preventing cervical cancer, HPV vaccination in females (49.5%) and males (37.5%) ages 13 through 17 falls well below the Centers for Disease Control and Prevention's (CDC) Healthy People 2020 target of 80% coverage. Parents' willingness to vaccinate their child has been shown to be much higher when physicians share personal vaccination decisions for their own children as well as what other parents have done at that particular clinic. Furthermore, the vaccine must be presented presumptively as a "bundle" along with the rest of the standard adolescent vaccine panel. Multiple exemplars presented including in several European countries, low-income countries and Rwanda, demonstrate that school-based health care systems dramatically increase vaccination coverage. Finally, acceptability for vaccination of males must improve by increasing provider recommendation and by presenting the HPV vaccine as a penile, anal and oropharyngeal cancer prevention therapy in males and not merely a vaccine to prevent cervical cancers in females. Paediatricians, obstetrician/gynaecologists and primary care physicians should consider these data as a call-to-action. Key messages   • Despite recent efforts in the US, only 49.5% of females and only 37.5% of males ages 13 through 17 have received all recommended HPV vaccine doses. These numbers fall well below the 80% target set forth by the Healthy People 2020 initiative.   • According to the CDC, if health care providers increase HPV vaccination rates in eligible recipients to 80%, it is estimated that an additional 53,000 cases of cervical cancer could be prevented during the lifetime of those younger than 12 years. Furthermore, for every year that the vaccination rate does not increase, an additional 4400 women will develop cervical cancer.   • First and foremost, healthcare providers (HCPs) must make a strong recommendation to vaccinate patients and these recommendations must become routine, including for males.   • It is clear that HPV vaccination rates improve significantly when vaccine administration occurs at designated, well-organized sites such as school-based vaccination programmes. Furthermore, HPV vaccination should be a high school requirement and offered in the standard adolescent vaccine panel as a bundle with Tdap and MenACWY vaccines in order to promote maximum adherence.   • Finally, research on immunogenicity and antibody titre longevity needs to be done in newborns. The HPV vaccine may be recommended in the newborn panel of vaccines to avoid any issues of sexualization and misplaced fears of sexual disinhibition, akin to the success of the Hepatitis B vaccine in the 1980s.   • The HPV vaccine is a vaccine against cancer and should be aggressively marketed as such. As healthcare providers, we need to make every effort to overcome barriers, real or perceived, to protecting our population from potential morbidity and mortality associated with this virus.

Cancer-salient messaging for Human Papillomavirus vaccine uptake: A randomized controlled trial

BACKGROUND AND OBJECTIVES

Vaccination with Human Papillomavirus (HPV) vaccine is recommended for 11-12 years-old, but uptake is suboptimal. Current messaging focuses on HPV infection transmission and prevention. Parents and providers are often uncomfortable discussing sexual practices of adolescents, contributing to the delay/refusal of vaccine. We created a cervical cancer-salient message encouraging HPV vaccination, emphasizing disease salience and disease threat, while promoting self-efficacy. We hypothesized this message would have greater effects on vaccine confidence and intent to vaccinate compared to Centers for Disease Control and Prevention (CDC) and non-vaccine control messages.

METHODS

A 3-arm randomized trial was conducted. Parents of girls aged 9-17 were eligible for the study. We measured participants' vaccine confidence and intent to vaccinate at baseline and post intervention message. Recruitment and surveys were administered online through Amazon Mechanical Turk.

RESULTS

762 participants completed both surveys. We saw modest increases in vaccine confidence when comparing cervical cancer arm and control arm, and CDC arm and control arm; estimates were not statistically significant. The odds of reporting intent to vaccinate among the cervical cancer message arm were 1.13 times the odds of reporting intent to vaccinate in the control arm (95% CI: 0.30. 4.29). Intent to vaccinate was also not statistically significantly different between CDC message arm and control arm (OR = 1.25, 95%CI: 0.66, 2.37).

CONCLUSION

Neither message had effect on intent to vaccinate, highlighting need for research to identify successful messaging strategies for HPV. Exploratory analyses suggest among parents with 'Low' vaccine confidence at baseline, the cervical cancer framed message may be more effective in changing intention than the CDC message or non-vaccine control. Future work should target groups with 'Low' or 'Medium' vaccine confidence at baseline - they may be more amenable to change, and more receptive to disease-salient messaging.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov, Reference #: NCT03002324.

Quality of Web-Based Educational Interventions for Clinicians on Human Papillomavirus Vaccine: Content and Usability Assessment

BACKGROUND

Human papillomavirus (HPV) vaccination rates fall far short of Healthy People 2020 objectives. A leading reason is that clinicians do not recommend the vaccine consistently and strongly to girls and boys in the age group recommended for vaccination. Although Web-based HPV vaccine educational interventions for clinicians have been created to promote vaccination recommendations, rigorous evaluations of these interventions have not been conducted. Such evaluations are important to maximize the efficacy of educational interventions in promoting clinician recommendations for HPV vaccination.

OBJECTIVE

The objectives of our study were (1) to expand previous research by systematically identifying HPV vaccine Web-based educational interventions developed for clinicians and (2) to evaluate the quality of these Web-based educational interventions as defined by access, content, design, user evaluation, interactivity, and use of theory or models to create the interventions.

METHODS

Current HPV vaccine Web-based educational interventions were identified from general search engines (ie, Google), continuing medical education search engines, health department websites, and professional organization websites. Web-based educational interventions were included if they were created for clinicians (defined as individuals qualified to deliver health care services, such as physicians, clinical nurses, and school nurses, to patients aged 9 to 26 years), delivered information about the HPV vaccine and how to increase vaccination rates, and provided continuing education credits. The interventions' content and usability were analyzed using 6 key indicators: access, content, design, evaluation, interactivity, and use of theory or models.

RESULTS

A total of 21 interventions were identified, out of which 7 (33%) were webinars, 7 (33%) were videos or lectures, and 7 (33%) were other (eg, text articles, website modules). Of the 21 interventions, 17 (81%) identified the purpose of the intervention, 12 (57%) provided the date that the information had been updated (7 of these were updated within the last 6 months), 14 (67%) provided the participants with the opportunity to provide feedback on the intervention, and 5 (24%) provided an interactive component. None of the educational interventions explicitly stated that a theory or model was used to develop the intervention.

CONCLUSIONS

This analysis demonstrates that a substantial proportion of Web-based HPV vaccine educational interventions has not been developed using established health education and design principles. Interventions designed using these principles may increase strong and consistent HPV vaccination recommendations by clinicians.

Variation in Human Papillomavirus Vaccine Uptake and Acceptability Between Female and Male Adolescents and Their Caregivers

HPV vaccination coverage is suboptimal. Previous research largely focused on vaccinating girls. This study aimed to identify factors associated with HPV vaccination among male and female adolescents. We conducted secondary analyses using the National Immunization Survey-Teen. We specified parallel logistic models to examine associations of adolescent, caregiver, and provider characteristics with vaccination status among boys and girls. The primary outcome was HPV vaccination status defined as unvaccinated, initiated, or completed. Additionally, we analyzed caregivers' intent to initiate or complete the three-dose series. The vaccination completion rate was 26 %. Among teens aged 13-17 years, 19 % initiated, but did not complete the vaccine. Additionally, 14 % of males completed the 3-dose series as compared to 38 % of females. Vaccination rates were higher among teens receiving a provider recommendation [girls: adjusted odds ratio (AOR) = 3.33, 95 % confidence interval (CI) (2.44, 4.55); boys: AOR = 10.0, 95 % CI (7.69, 12.5)]. Moreover, provider recommendation was associated with caregivers' intent to initiate vaccination [girls: AOR = 2.32, 95 % CI (1.77, 3.02); boys: AOR = 2.76, 95 % CI (2.22, 3.43)]. Other associations differed by gender. Higher vaccine initiation rates were associated with younger age and residing in the mid-west for girls and racial/ethnic minority and eligibility for the "Vaccine for Children" program for boys. Provider recommendation for vaccination was the strongest predictor for both genders; however, it is insufficient to achieve high coverage rates, especially among boys. Factors associated with HPV vaccination were different for males and females. These findings suggest providers should consider gender bias with regard to HPV vaccination.

Barriers, facilitators, and potential strategies for increasing HPV vaccination: A statewide assessment to inform action

OBJECTIVE

The objective was to investigate how state level strategies in South Carolina could maximize HPV vaccine uptake.

DESIGN

An environmental scan identified barriers, facilitators, and strategies for improving HPV vaccination in South Carolina. Interviews were conducted with state leaders from relevant organizations such as public health agencies, medical associations, K-12 schools, universities, insurers, and cancer advocacy organizations. A thematic content analysis design was used. Digital interview files were transcribed, a data dictionary was created and data were coded using the data dictionary.

RESULTS

Thirty four interviews were conducted with state leaders. Barriers to HPV vaccination included lack of HPV awareness, lack of provider recommendation, HPV vaccine concerns, lack of access and practice-level barriers. Facilitators included momentum for improving HPV vaccination, school-entry Tdap requirement, pharmacy-based HPV vaccination, state immunization registry, HEDIS measures and HPV vaccine funding. Strategies for improving HPV vaccination fell into three categories: 1) addressing lack of awareness about the importance of HPV vaccination among the public and providers; 2) advocating for policy changes around HPV vaccine coverage, vaccine education, and pharmacy-based vaccination; and 3) coordination of efforts.

DISCUSSION

A statewide environmental scan generated a blueprint for action to be used to improve HPV vaccination in the state.

The impact of access to immunization information on vaccine acceptance in three countries

Introduction

Vaccine acceptance is a critical component of sustainable immunization programs, yet rates of vaccine hesitancy are rising. Increased access to misinformation through media and anti-vaccine advocacy is an important contributor to hesitancy in the United States and other high-income nations with robust immunization programs. Little is known about the content and effect of information sources on attitudes toward vaccination in settings with rapidly changing or unstable immunization programs.

Objective

The objective of this study was to explore knowledge and attitudes regarding vaccines and vaccine-preventable diseases among caregivers and immunization providers in Botswana, the Dominican Republic, and Greece and examine how access to information impacts reported vaccine acceptance.

Methods

We conducted 37 focus groups and 14 semi-structured interviews with 96 providers and 153 caregivers in Botswana, the Dominican Republic, and Greece. Focus groups were conducted in Setswana, English, Spanish, or Greek; digitally recorded; and transcribed. Transcripts were translated into English, coded in qualitative data analysis software (NVivo 10, QSR International, Melbourne, Australia), and analyzed for common themes.

Results

Dominant themes in all three countries included identification of health care providers or medical literature as the primary source of vaccine information, yet participants reported insufficient communication about vaccines was available. Comments about level of trust in the health care system and government contrasted between sites, with the highest level of trust reported in Botswana but lower levels of trust in Greece.

Conclusions

In Botswana, the Dominican Republic, and Greece, participants expressed reliance on health care providers for information and demonstrated a need for more communication about vaccines. Trust in the government and health care system influenced vaccine acceptance differently in each country, demonstrating the need for country-specific data that focus on vaccine acceptance to fully understand which drivers can be leveraged to improve implementation of immunization programs.

Factors Associated With Parents' Intent to Vaccinate Adolescents for Human Papillomavirus: Findings From the 2014 National Immunization Survey-Teen

Introduction

While factors associated with receipt of human papillomavirus (HPV) vaccination have been well characterized, less is known about the characteristics associated with parents’ intent to have their adolescent children vaccinated. This study aimed to examine factors associated with parental intention toward HPV vaccination.

Methods

We analyzed data on 10,354 adolescents aged 13 to 17 years from the 2014 National Immunization Survey–Teen. Weighted multivariable logistic regression was used to examine associations between sociodemographic characteristics of mothers and adolescents, as well as a health care provider recommendation with parents’ intention to have their children receive HPV vaccine.

Results

Among unvaccinated adolescents, Hispanic ethnicity (boys adjusted odds ratio [AOR], 1.87, 95% confidence interval [CI], 1.34–2.61; and girls AOR, 1.57; 95% CI, 1.05–2.35), mothers with less than a high school diploma (boys AOR, 2.41; 95% CI, 1.58–3.67; and girls AOR, 1.86; 95% CI, 1.02–3.38), and having a health care provider recommend the vaccine (boys AOR, 1.87; 95% CI, 1.52–2.31; and girls AOR, 1.38; 95% CI, 1.05–1.82) were significantly associated with parents’ intention to have their adolescent child vaccinated within the next 12 months. In addition, non-Hispanic black race was a significant predictor of parents’ intent to vaccinate for boys (AOR, 1.89; 95% CI, 1.35–2.65).

Conclusion

Maternal education and Hispanic ethnicity were the strongest predictors of parental intent to vaccinate against HPV, followed by provider recommendation. As HPV vaccination rates in the United States remain below the Healthy People 2020 goal, messages may need to be targeted based on maternal education, race/ethnicity, and provider recommendation.

Practical Approaches to Optimize Adolescent Immunization

With the expansion of the adolescent immunization schedule during the past decade, immunization rates notably vary by vaccine and by state. Addressing barriers to improving adolescent vaccination rates is a priority. Every visit can be viewed as an opportunity to update and complete an adolescent's immunizations. It is essential to continue to focus and refine the appropriate techniques in approaching the adolescent patient and parent in the office setting. Health care providers must continuously strive to educate their patients and develop skills that can help parents and adolescents overcome vaccine hesitancy. Research on strategies to achieve higher vaccination rates is ongoing, and it is important to increase the knowledge and implementation of these strategies. This clinical report focuses on increasing adherence to the universally recommended vaccines in the annual adolescent immunization schedule of the American Academy of Pediatrics, the American Academy of Family Physicians, the Centers for Disease Control and Prevention, and the American Congress of Obstetricians and Gynecologists. This will be accomplished by (1) examining strategies that heighten confidence in immunizations and address patient and parental concerns to promote adolescent immunization and (2) exploring how best to approach the adolescent and family to improve immunization rates.

Factors associated with parental reasons for "no-intent" to vaccinate female adolescents with human papillomavirus vaccine: National Immunization Survey - Teen 2008-2012

Background

1) To identify socio-demographic factors associated with parental “no-intent” for their 13–17 year old unvaccinated daughter to receive the human papillomavirus (HPV) vaccine series within the next twelve months, 2) to describe patterns in “no-intent” by socio-demographic factors, and 3) to identify socio-demographic factors associated with parental reasons for “no-intent”.

Methods

Data from 2008–2012 National Immunization Survey - Teen (NIS - Teen) were examined in this study. Parents with “no-intent” to vaccinate their daughters were asked to identify reasons for their decision. All responses were categorized into five domains identified as barriers to receive the HPV vaccine series: 1) Safety and Effectiveness Concerns; 2) Systemic Barriers; 3) Vaccine Misinformation; 4) Lack of Knowledge about the Vaccine; and 5) Socio-cultural Barriers. Multivariable logistic regression models were performed to address the study objectives.

Results

Number of people in the household, household income, mother’s age, education, health insurance, recommendation of a health care provider, and the survey year were significantly associated with parental “no-intent”. Race/ethnicity, mother’s education, marital status, recommendation of a health care provider, household income, age of the unvaccinated daughter, and the survey year, were significantly associated with one or more domains identified as barriers to receive the HPV vaccine.

Conclusions

This study identified sub-groups of parents across different socio-demographic factors with “no-intent” for their adolescent daughters to receive the HPV vaccine. Developing strategies that target educational tools towards the identified sub-groups of parents about the purpose, safety, and efficacy of the HPV vaccine, and HPV infection, may help increase HPV vaccine acceptance, initiation and completion rates.

Mothers, Fathers, Sons, and Human Papillomavirus Immunization Practices

Despite the fact that human papillomavirus (HPV) infection and HPV-related cancers are on the rise in men, male HPV vaccine series completion is less than 10% in many areas. This study examined parental knowledge of the HPV vaccine and intent to vaccinate their sons. A cross-sectional study of 341 parents of boys was conducted in school settings in rural southeastern Georgia. Mothers were 2.07 times more likely than fathers to vaccinate their sons. Future research directions should include strategies to increase HPV vaccination in both genders and focus on parents' perceived severity and vulnerability of their sons to HPV infection.

Human papillomavirus vaccination among adolescents in Georgia

Human papillomavirus (HPV) vaccination coverage for adolescent females and males remains low in the United States. We conducted a 3-arm randomized controlled trial (RCT) conducted in middle and high schools in eastern Georgia from 2011-2013 to determine the effect of 2 educational interventions used to increase adolescent vaccination coverage for the 4 recommended adolescent vaccines: Tdap, MCV4, HPV and influenza. As part of this RCT, this article focuses on: 1) describing initiation and completion of HPV vaccine series among a diverse population of male and female adolescents; 2) assessing parental attitudes toward HPV vaccine; and 3) examining correlates of HPV vaccine series initiation and completion. Parental attitude score was the strongest predictor of HPV vaccine initiation among adolescents (adjusted odds ratio (aOR): 2.08; 95% confidence interval (CI): 1.80, 2.39). Other correlates that significantly predicted HPV series initiation were gender, study year, and intervention arm. Parental attitudes remained a significant predictor of receipt of 3 doses of HPV vaccine along with gender, race, school type and insurance type. This study demonstrates that positive parental attitudes are important predictors of HPV vaccination and critical to increasing coverage rates. Our findings suggest that more research is needed to understand how parental attitudes are developed and evolve over time.

Collaborative patient-provider communication and uptake of adolescent vaccines

RATIONALE

Recommendations from healthcare providers are one of the most consistent correlates of adolescent vaccination, but few studies have investigated other elements of patient-provider communication and their relevance to uptake.

OBJECTIVE

We examined competing hypotheses about the relationship of patient-driven versus provider-driven communication styles with vaccination.

METHODS

We gathered information about vaccine uptake from healthcare provider-verified data in the 2010 National Immunization Survey-Teen for tetanus, diphtheria, and pertussis (Tdap) booster, meningococcal vaccine, and human papillomavirus (HPV) vaccine (initiation among females) for adolescents ages 13-17. We categorized communication style in parents' conversations with healthcare providers about vaccines, based on parents' reports (of whether a provider recommended a vaccine and, if so, if conversations were informed, shared, or efficient) (N = 9021).

RESULTS

Most parents reported either no provider recommendation (Tdap booster: 35%; meningococcal vaccine: 46%; and HPV vaccine: 31%) or reported a provider recommendation and shared patient-provider communication (43%, 38%, and 49%, respectively). Provider recommendations were associated with increased odds of vaccination (all ps < 0.001). In addition, more provider-driven communication styles were associated with higher rates of uptake for meningococcal vaccine (efficient style: 82% vs. shared style: 77% vs. informed style: 68%; p < 0.001 for shared vs. informed) and HPV vaccine (efficient style: 90% vs. shared style: 70% vs. informed style: 33%; p < 0.05 for all comparisons).

CONCLUSION

Efficient communication styles were used rarely (≤2% across vaccines) but were highly effective for encouraging meningococcal and HPV vaccination. Intervention studies are needed to confirm that efficient communication approaches increase HPV vaccination among adolescents.

Comparing human papillomavirus vaccine knowledge and intentions among parents of boys and girls

BACKGROUND/OBJECTIVE

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. Previous research suggests some differences between male and female adolescents in correlates of vaccine receipt and reasons for non-vaccination; few studies examine both sexes together. This analysis assessed knowledge and attitudes related to HPV disease and vaccination, intention to vaccinate, and reasons for delayed vaccination or non-vaccination among parents of boys and girls 13-17 y old in 50 states, the District of Columbia, and selected local areas.

METHODS

National Immunization Survey-Teen 2013 data were analyzed and gender differences examined.

RESULTS

In this sample, adolescent boys were more likely than girls to be unvaccinated and less likely to have completed the HPV vaccination series (p < 0.005 for both). Parents of girls were more likely than parents of boys to report a provider recommendation for HPV vaccination (65.0% vs. 42.1%). Only 29% of girls' parents reported a provider recommendation to begin vaccination by 11-12 y old. Among unvaccinated teens, parental intention to vaccinate in the next 12 months did not differ by sex, but reasons for vaccination or non-vaccination did. Many parents do not know the recommended number of HPV doses.

CONCLUSIONS

Gender differences in provider vaccination recommendations and reasons for vaccination might partially explain differential HPV uptake by male and female adolescents. Clinicians should offer strong recommendations for HPV vaccination at 11-12 y old for both girls and boys. To reduce missed opportunities, HPV vaccination should be presented in the context of, and given concurrently with, other routinely administered vaccines.

Human Papillomavirus Infection and Vaccination

Human papillomavirus (HPV) is an infection that can be sexually transmitted and result in health consequences including genital warts and cancers. Two vaccines, Gardasil® [Human Papillomavirus Quadrivalent (Types 6, 11, 16, and 18) Vaccine, Recombinant] and Cervarix™ [Human Papillomavirus Bivalent (Types 16 and 18) Vaccine], have been approved for the prevention of HPV and HPV-related diseases.

OBJECTIVES

To explore facilitators and barriers associated with HPV vaccine utilization and compliance regarding vaccine series completion in school-aged, adolescent, and young adult females in the United States; to discuss HPV infection and highlight the safety and efficacy of the HPV vaccine; and to illustrate delivery strategies that can improve immunization rates and review implications for healthcare providers.

METHODS

A literature review was performed using health-related online databases (CINAHL, MEDLINE, PubMED, Web of Science, EBSCOHost and Google Scholar) and archival searching to identify current vaccination rates and factors associated with vaccine uptake.

RESULTS

Despite the availability of vaccines that prevent cancer, acceptance and utilization rates of both HPV vaccines are less than recommended by the Advisory Committee for Immunization Practices (ACIP). Some of the barriers to HPV vaccination include lack of provider recommendation, negative parent or patient attitudes and beliefs, cost, and missed clinical opportunities. The primary facilitator to HPV vaccination is a strong provider recommendation.

CONCLUSIONS

Healthcare providers can enhance HPV vaccine utilization by taking an active role with patients. Strategies include education and advocacy for receiving the vaccine, maximizing access to the HPV vaccine, and implementing new strategies for vaccine-delivery.

Disparities in collaborative patient-provider communication about human papillomavirus (HPV) vaccination

BACKGROUND

Healthcare providers may vary their communications with different patients, which could give rise to differences in vaccination coverage. We examined demographic disparities in parental report of collaborative provider communication and implications for human papillomavirus (HPV) vaccination.

METHODS

Participants were 4,124 parents who completed the National Immunization Survey-Teen about daughters ages 13-17. We analyzed disparities in collaborative communication (mutual information exchange, deliberation, and decision) and whether they mediated the relationship between demographic characteristics and HPV vaccine initiation.

RESULTS

Half of parents (53%) in the survey reported collaborative communication. Poor, less educated, Spanish-speaking, Southern, and rural parents, and parents of non-privately insured and Hispanic adolescents, were least likely to report collaborative communication (all p<.05). These disparities in communication accounted for geographic variation in HPV vaccination, specifically, the higher rates of uptake in the Northeast versus the South (mediation z=2.31, p<.01) and in urban/suburban vs. rural areas (mediation z=2.87, p<.01). These disparities were also associated with vaccination among subgroups with relatively high coverage, minimizing what could have been even higher uptake among Hispanic compared to non-Hispanic white adolescents (mediation z=-3.04, p<.01) and non-privately versus privately insured adolescents (mediation z=-3.67, p<.001). Controlling for provider recommendation attenuated some of these associations (but all p<.10).

CONCLUSIONS

Collaborative communication showed widespread disparities, being least common among underserved groups. Collaborative communication helped account for differences-and lack of differences-in HPV vaccination among some subgroups of adolescent girls. Leveraging patient-provider communication, especially for underserved demographic groups, could improve HPV vaccination coverage.

The Student Human Papillomavirus Survey: Nurse-Led Instrument Development and Psychometric Testing to Increase Human Papillomavirus Vaccine Series Completion in Young Adults

BACKGROUND AND PURPOSE

The Student Human Papillomavirus Survey (SHPVS) was developed to examine students' perceived benefits or barriers to human papillomavirus (HPV) vaccination.

METHODS

Survey development included (a) 2-phase integrative literature reviews; (b) draft of survey items based on the literature; (c) critique of survey items by young adults, nursing and psychology faculty, and health care providers; and (d) pilot testing. The psychometric properties of the SHPVS were evaluated using classical item analysis and exploratory factor analysis (EFA) among a sample of 527 university students' ages 18-24 years.

RESULTS

The estimated Cronbach's alpha for the SHPVS is .74.

CONCLUSIONS

The SHPVS is a measure of young adults HPV perceived vulnerability, perceived severity, perceived barriers, and perceived benefits of HPV vaccination.

The most effective and promising population health strategies to advance human papillomavirus vaccination

The US is failing to make substantive progress toward improving rates of human papillomavirus vaccine uptake. While the Healthy People 2020 goal for human papillomavirus (HPV) vaccination is 80%, the three-dose completion rate in the US in 2014 for 13- to 17-year-old females is less than 40%, and the rate for males is just above 20%. Experts point to a number of reasons for the poor HPV vaccination rates including parental concerns about safety, necessity, and timing. However, the evidence refuting these concerns is substantial. Efforts focusing on education and communication have not shown promise, but several population health strategies have reminder/recall systems; practice-focused strategies targeting staff, clinicians, and parents; assessment and feedback activities; and school-based HPV vaccination programs.

Timing of HPV vaccine intervals among United States teens with consideration to the current ACIP schedule and the WHO 2-dose schedule

The current recommendation for human papillomavirus (HPV) vaccination in the United States is for 3 doses to be administered over a 6 month period. In April 2014, the World Health Organization (WHO) recommended adoption of a 2-dose schedule, with doses spaced a minimum of 6 months apart, for teens who begin the series before age 15. We analyzed data from the 2013 National Immunization Survey-Teen to examine the timing of second and third dose receipt among US adolescents. All analyses were restricted to adolescents age 13-17 y who had adequate provider data. The Wilcoxon-Mann-Whitney test measured differences in time to receive vaccine doses among demographic and socioeconomic groups. Logistic regression identified socioeconomic characteristics associated with receiving the second dose of HPV vaccine at least 6 months after the first dose. The median time for teens to receive the second dose of HPV vaccine was 2.6 months after the first dose, and the median time to receive the third dose was 4.9 months after the second dose. Minority teens and teens living below the poverty level took significantly longer to receive doses. Among teens that initiated the HPV vaccine series before age 15 y, 28.6% received the second dose at least 6 months after the first dose. If these teens, who met the WHO criteria for up-to-date HPV vaccination, were classified as having completed the vaccination series, overall coverage in the US would increase 3.9 percentage points, with African American and Hispanic teens having the greatest increases in coverage.

Strategies for increasing adolescent immunizations in diverse ethnic communities

PURPOSE

We sought to identify attitudes and knowledge of adolescent vaccination recommendations for tetanus, diphtheria, and acellular pertussis (Tdap); quadrivalent meningococcal conjugate (MCV4); and human papillomavirus (HPV) vaccines among Hispanic, Somali, and Ethiopian/Eritrean communities in King County, Washington.

METHODS

In-person surveys of Hispanic, Somali, and Ethiopian/Eritrean adolescents (n = 45) and parents of adolescents (n = 157), and three focus groups with mothers of 11- to 18-year-olds were conducted to assess knowledge, attitudes, and barriers related to recommended adolescent vaccines. Bivariate analyses of parent survey responses were performed to evaluate possible differences between ethnic groups (chi-square test and Fisher exact test where possible). Findings were used to develop (1) culture-specific written brochures for community members, which addressed misperceptions about adolescent immunizations and related diseases, and (2) a presentation highlighting specific messages for health care providers (HCPs) in the target communities. HCPs were surveyed after delivery of the presentation (n = 20).

RESULTS

We identified barriers to adolescent immunization including: parents' and adolescents' limited awareness of, and misperceptions regarding, recommended adolescent vaccines and vaccine preventable diseases; lack of HCP recommendations for vaccination; and inability to access health information in native languages. Awareness of tetanus, diphtheria, and acellular pertussis, quadrivalent meningococcal conjugate, and human papillomavirus vaccines varied by vaccine and ethnic group. Lack of knowledge of adolescent vaccination recommendations was the main reason given by parents that their adolescents had not been vaccinated. Most parents in the focus groups identified doctors as a trusted source of health information and reported that they would vaccinate their teens if their doctor recommended it. All the surveyed HCPs routinely recommend adolescent vaccines at well-child visits, 55% at acute visits, and 35% at injury visits. Eighty percent reported that they would be more likely to recommend HPV vaccine after our on-site presentation.

CONCLUSIONS

A strong recommendation from the physician is a critical factor influencing parents' decision to vaccinate, even when hesitancy exists. Other factors (such as personal experiences with these diseases and religious and cultural beliefs) also influence parents' decisions regarding vaccination. Knowledge of beliefs, misperceptions, and concerns can help inform strategies to improve adolescent vaccine uptake among specific ethnic populations, including the availability of culturally tailored, translated information. Additionally, HCPs may benefit from guidance on communicating with ethnic populations to support meaningful dialogue with families about the risks and benefits of adolescent vaccines.

Identifying and addressing vaccine hesitancy

In the 20th century, the introduction of multiple vaccines significantly reduced childhood morbidity, mortality, and disease outbreaks. Despite, and perhaps because of, their public health impact, an increasing number of parents and patients are choosing to delay or refuse vaccines. These individuals are described as "vaccine hesitant." This phenomenon has developed due to the confluence of multiple social, cultural, political, and personal factors. As immunization programs continue to expand, understanding and addressing vaccine hesitancy will be crucial to their successful implementation. This review explores the history of vaccine hesitancy, its causes, and suggested approaches for reducing hesitancy and strengthening vaccine acceptance.

Why are U.S. girls getting meningococcal but not human papilloma virus vaccines? Comparison of factors associated with human papilloma virus and meningococcal vaccination among adolescent girls 2008 to 2012

BACKGROUND

Human papilloma virus (HPV) vaccination rates in the United States remain low, compared with other recommended adolescent vaccines. We compared factors associated with intention to receive and receipt of HPV and meningococcal vaccines and completion of the HPV vaccine series among U.S. adolescent girls.

METHODS

Secondary analysis of data from the National Immunization Survey-Teen for 2008 through 2012 was performed. Multivariable logistic modeling was used to determine factors associated with intent to receive and receipt of HPV and meningococcal vaccination, completion of the HPV vaccine series among girls who started the series, and receipt of HPV vaccination among girls who received meningococcal vaccination.

FINDINGS

Provider recommendation increased the odds of receipt and intention to receive both HPV and meningococcal vaccines. Provider recommendation was also associated with a three-fold increase in HPV vaccination among girls who received meningococcal vaccination (p<.001), indicating a relationship between provider recommendation and missed vaccine opportunities. However, White girls were 10% more likely to report provider recommendation than Black or Hispanic girls (p<.01), yet did not have higher vaccination rates, implying a role for parental refusal. No factors predicted consistently the completion of the HPV vaccine series among those who started.

CONCLUSION

Improving provider recommendation for co-administration of HPV and meningococcal vaccines would reduce missed opportunities for initiating the HPV vaccine series. However, different interventions may be necessary to improve series completion.