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Goal 2: Increase Parents’, Caregivers’, and Adolescents’ Acceptance of HPV Vaccines

Parents' and other caregivers' knowledge, attitudes, and beliefs affect whether their children receive vaccines, including HPV vaccines. Most parents believe that vaccines protect their children from potentially life-threatening diseases, but some refuse one or more recommended vaccines based on concerns about safety and other factors.[1] One study found that parents were more likely to refuse HPV vaccines than other recommended vaccines.[1] Research has identified several reasons parents do not vaccinate their adolescents against HPV (see sidebar).[2-4]

Reasons Parents Did Not Intend to Vaccinate Their Adolescents Against HPV

  • Vaccination not needed, particularly for males
  • Vaccination not recommended by healthcare provider
  • Safety concerns
  • Lack of knowledge about the vaccines or diseases caused by HPV infections
  • Son or daughter not sexually active
  • Son or daughter too young to be vaccinated against HPV
  • Cost of vaccines

These reasons demonstrate both the failure of providers to recommend HPV vaccines strongly and parental lack of understanding about HPV vaccines and their safety profiles, especially for males.

Other studies have provided additional insight into parents' views. Surveyed pediatricians and family practice physicians reported that parents of young adolescents sometimes are upset by recommendations that their children receive vaccines against sexually transmitted infections. Providers also report more vaccine refusals among parents of younger versus older adolescents.[5] This trend is troubling in light of the fact that the vaccines are most effective when administered before initiation of sexual activity, and sexual debut for some adolescents may occur earlier than their parents expect.[6-8] Some parents have expressed concern that HPV vaccination would encourage sexual activity, although this does not appear to be a major barrier to HPV vaccination uptake. To date, studies have not shown a relationship between receipt of HPV vaccines and initiation of sexual activity[9-11] or sexual activity-related outcomes (e.g., pregnancy, sexually transmitted infection testing or diagnosis, contraceptive counseling).[12] One study noted a higher number of lifetime partners among sexually active girls who had received HPV vaccines compared with unvaccinated sexually active girls.[13] However, the correlation does not mean that HPV vaccines caused these adolescents to have more sexual partners. It is equally plausible that the physicians and/or parents of these adolescents anticipated their greater level of sexual activity and were more likely to encourage HPV vaccination for them than for girls who they viewed as less likely to have multiple sexual partners.

Objective 2.1: CDC should develop, test, and collaborate with partner organizations to deploy integrated, comprehensive communication strategies directed at parents and other caregivers, and also at adolescents.

CDC is a logical choice to lead development and implementation of communications strategies for parents and other caregivers, as well as adolescents. Other stakeholder groups also should provide accurate information to parents and caregivers. Research has indicated that parents and adolescents may distrust information from pharmaceutical companies.[14,15] This is one reason it is important that communications come from impartial sources.

HPV vaccines should be framed as vaccines that prevent cancers.

Communication strategies—including messages and modes of delivery—should incorporate lessons from qualitative and quantitative research and also should be sensitive to cultural, literacy/health literacy, and language differences of target populations. While recognizing that all messages should be tested through research, the following points should be considered as part of communications strategies:

  • Frame HPV vaccines as vaccines that prevent cancers.
  • Provide factual information about which adolescents should be vaccinated (routine vaccination of 11- to 12-year-olds, with catch-up vaccination of older adolescents and young adults), along with how-to information (e.g., which providers can administer vaccinations, where vaccines are available in different communities).
  • Address common myths, misconceptions, and misinformation about HPV vaccines.
  • Highlight the safety of HPV vaccines.
  • Emphasize the importance of vaccinating both males and females as part of the adolescent vaccine platform.
  • Address both initiation and completion of the HPV vaccine series.
  • Aim to resonate emotionally with parents, other caregivers, and adolescents.

The ways in which messages are delivered are important.[16] Modes of communication should be informed by research and tested with target audiences, but could include:

  • Websites, blogs, social media, and print and electronic media (e.g., mobile phones and text messages) accessible by and acceptable to parents.
  • Recruitment of vaccination champions who are influential for particular target audiences.
  • Development of companion communication tools for use with parents/caregivers and adolescents in healthcare providers' offices (e.g., posters, brochures, computer kiosks). Such tools may make it easier for physicians to convey strong recommendations regarding HPV vaccination.

References

  1. Freed GL, Clark SJ, Butchart AT, Singer DC, Davis MM. Parental vaccine safety concerns in 2009. Pediatrics. 2010;125(4):654-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20194286
  2. Centers for Disease Control and Prevention. Human papillomavirus vaccination coverage among adolescent girls, 2007-2012, and postlicensure vaccine safety monitoring, 2006-2013—United States. MMWR. 2013;62(29):591-5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23884346
  3. Reiter PL, Gilkey MB, Brewer NT. HPV vaccination among adolescent males: results from the National Immunization Survey-Teen. Vaccine. 2013;31(26):2816-21. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23602667
  4. Holman DM, Benard V, Roland KB, Watson M, Liddon N, Stokley S. Barriers to human papillomavirus vaccination among U.S. adolescents: a systematic review of the literature. JAMA Pediatr. 2014;168(1):76-82. Available from: http://www.ncbi.nlm.nih.gov/pubmed/24276343
  5. Daley MF, Crane LA, Markowitz LE, Black SR, Beaty BL, Barrow J, et al. Human papillomavirus vaccination practices: a survey of U.S. physicians 18 months after licensure. Pediatrics. 2010;126(3):425-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20679306
  6. Petäjä T, Pedersen C, Poder A, Strauss G, Catteau G, Thomas F, et al. Long-term persistence of systemic and mucosal immune response to HPV-16/18 AS04-adjuvanted vaccine in preteen/adolescent girls and young women. Int J Cancer. 2011;129(9):2147-57. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21190190
  7. Muñoz N, Kjaer SK, Sigurdsson K, Iversen OE, Hernandez-Avila M, Wheeler CM, et al. Impact of human papillomavirus (HPV)-6/11/16/18 vaccine on all HPV-associated genital diseases in young women. J Natl Cancer Inst. 2010;102(5):325-39. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20139221
  8. Lehtinen M, Paavonen J, Wheeler CM, Jaisamrarn U, Garland SM, Castellsague X, et al. Overall efficacy of HPV-16/18 AS04-adjuvanted vaccine against grade 3 or greater cervical intraepithelial neoplasia: 4-year end-of-study analysis of the randomised, double-blind PATRICIA trial. Lancet Oncol. 2012;13(1):89-99. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22075171
  9. Liddon NC, Leichliter JS, Markowitz LE. Human papillomavirus vaccine and sexual behavior among adolescent and young women. Am J Prev Med. 2012;42(1):44-52. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22176845
  10. Marchand E, Glenn BA, Bastani R. HPV vaccination and sexual behavior in a community college sample. J Community Health. 2013;38(6):1010-4. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23728823
  11. Forster AS, Marlow LA, Stephenson J, Wardle J, Waller J. Human papillomavirus vaccination and sexual behaviour: cross-sectional and longitudinal surveys conducted in England. Vaccine. 2012;30(33):4939-44. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22664223
  12. Bednarczyk RA, Davis R, Ault K, Orenstein W, Omer SB. Sexual activity-related outcomes after human papillomavirus vaccination of 11- to 12-year-olds. Pediatrics. 2012;130(5):798-805. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23071201
  13. Markowitz LE, Hariri S, Lin C, Dunne EF, Steinau M, McQuillan G, et al. Reduction in human papillomavirus (HPV) prevalence among young women following HPV vaccine introduction in the United States, National Health and Nutrition Examination Surveys, 2003-2010. J Infect Dis. 2013;208(3):385-93. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23785124
  14. Friedman AL, Shepeard H. Exploring the knowledge, attitudes, beliefs, and communication preferences of the general public regarding HPV: findings from CDC focus group research and implications for practice. Health Educ Behav. 2007;34(3):471-85. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17000622
  15. Pepper JK, Reiter PL, McRee AL, Brewer NT. Advertisements promoting human papillomavirus vaccine for adolescent boys: does source matter? Sex Transm Infect. 2012;88(4):264-5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22223814
  16. World Health Organization. HPV vaccine communication: special considerations for a unique vaccine. Geneva (CH): WHO; 2013. Available from: http://apps.who.int/iris/bitstream/10665/94549/1/WHO_IVB_13.12_eng.pdf