HPV Vaccination of Adolescents: Factors That Influence Caregiver and Adolescent Views and Practices

What factors influence caregivers and adolescents regarding whether adolescents will receive the human papillomavirus (HPV) vaccine?

Factors that influence caregivers and adolescents worldwide about adolescent receipt of the HPV vaccine fit into one of eight broad themes: (1) biomedical knowledge; (2) perceptions of the risks and benefits of HPV vaccination; (3) views of other vaccines or vaccination programs; (4) familial decision-making dynamics; (5) influence of social networks; (6) effect of cultural beliefs and practices; (7) level of trust in institutions or experts associated with vaccination; and (8) logistical concerns.¹

HPV vaccination of adolescents likely prevents cervical cancer in women and other HPV-associated diseases in people of any sex.² In the United States, despite a Healthy People 2030 goal of vaccinating more than 80% of adolescents, only 57.3% of patients aged 13 to 15 years received two or three doses of the HPV vaccine.³ US vaccination rates for other childhood vaccines remain higher than 90%.⁴ The authors of this Cochrane review sought to identify key factors to explain why some caregivers and adolescents may be less likely to accept the HPV vaccine.¹ This qualitative research synthesis can be used to develop more acceptable and effective interventions, ultimately increasing worldwide HPV vaccination of adolescents.

This review sampled 88 of 237 eligible articles describing 71 studies of qualitative data for analysis.¹ The studies encompassed all six World Health Organization regions and included studies from high-, middle-, and low-resource countries. Thirty-nine studies focused on caregivers only, eight on adolescents only, and 24 included both groups. Fifty studies focused on the HPV vaccine for females only, 11 for males only, and 10 included both. Thirty-nine of the studies conducted individual patient interviews, 20 conducted focus group discussions, and eight studies conducted both types.

Eight distinct themes impacting HPV vaccination decisions were identified in the systematic analysis: (1) biomedical knowledge; (2) perceptions of the risks and benefits of HPV vaccination; (3) views of other vaccines or vaccination programs; (4) familial decision-making dynamics; (5) influence of social networks; (6) effect of cultural beliefs and practices; (7) level of trust in institutions or experts associated with vaccination; and (8) logistical concerns.¹ It was acknowledged that the themes overlapped in complex ways. Each theme was further analyzed for specific findings and rated by level of confidence in the saliency of the finding based on study methodology, data quality, and coherence of results. In many instances, a theme could yield contradictory findings. For example, a lack of biomedical knowledge about HPV vaccination could decrease rates of acceptance when participants believed it would decrease fertility, but it could also increase acceptance when study participants believed it would prevent HIV infection.

The authors stated they had high confidence (GRADE [Grading of Recommendations, Assessment, Development, and Evaluation]) in several findings.¹ Biomedical knowledge about HPV in general and HPV vaccination was often limited among caregivers and adolescents, including misperceptions regarding short- and long-term adverse effects as well as vaccine effectiveness. Concerns about the relative newness of the vaccine and that it would “promote ‘inappropriate’ sexual practices” contributed to skepticism. Adolescent fear of needles also discouraged HPV vaccination. Attitudes about the HPV vaccine were influenced by views of and experiences with other vaccines or vaccination programs. The perception of HPV as a “feminine” vaccine decreased acceptance among male adolescents. In addition, associated costs and logistical convenience in accessing the vaccine influenced patients' decisions. Adolescents' peers played an important role in shaping their HPV vaccination views and practices; the influence of traditional or religious leaders, teachers and school leaders, government leaders, family members, and clinicians also contributed to caregiver acceptance and ultimately receipt of the vaccine.