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Rates of Human papilloma virus (HPV) vaccination among pediatric survivors of cancer and patients with sickle cell disease are lower than the national average. While recent attention has focused on patient HPV vaccine hesitancy and refusal, less is known about provider-level and system-level barriers to vaccinations in pediatric hematology/oncology (PHO) populations. Applying thematic analysis to qualitative interviews with 20 pediatric hematology/oncology physicians and nurse practitioners, we examine their views regarding HPV vaccination, with a focus on access and barriers to providing HPV vaccination in PHO practices. Results demonstrated that despite 90% of interviewees supporting HPV vaccination in their population, the number of pediatric hematology/oncology providers who reported that they counsel about HPV or provide HPV vaccination was 45%, even in stem cell and sickle cell clinics, where other childhood vaccines are commonly provided. Clinicians identified provider-level, clinic-level, and system-level barriers to giving the HPV vaccination, including but not limited to time/flow constraints, lack of resources, and continued education regarding the HPV vaccine. These barriers impede the ability for pediatric hematology/oncology providers to counsel and provide HPV vaccination to this specialized population.

State vaccine requirements are a tool for improving child and adolescent vaccination immunization coverage, but to be effective, parental buy-in is needed. The objective of this study was to assess the demographic, healthcare characteristics, and health beliefs associated with parental acceptance of general and HPV-specific state vaccine requirements. Indiana parents (N = 601) with children ages 11-17 years old completed a survey during March 2020.Results showed that 47.2% and 43.1% of parents believed there should always be general and HPV-specific state vaccine requirements, respectively. In multivariable analysis, higher odds of parental support for general state vaccine requirements were associated with being unsure whether HPV-associated cancer is a problem in the participant's county and having higher perceived benefits of HPV vaccines. Lower odds were associated with private insurance, having less than a bachelor's degree, and having less confidence in vaccines. In comparison, parents had higher odds of agreeing with HPV-specific state vaccine requirements if they reported higher interpersonal altruism and higher perceived benefits of HPV vaccines; they had lower odds if they were non-Hispanic White. Findings indicate that while similar percentages of parents agreed with general and HPV-specific state vaccine requirements, there were different characteristics associated with acceptance of each. Results can inform the development of tailored interventions for improving parental support for general and HPV-specific state vaccine requirements., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Although the US Advisory Committee on Immunization Practices recommends vaccinating adolescents against the human papillomavirus (HPV) to prevent HPV-associated cancers, vaccine initiation and completion rates are suboptimal. Parental and provider hesitancy contributes significantly to low HPV vaccine uptake. This review describes sources of HPV vaccine hesitancy using a World Health Organization framework that categorizes determinants of vaccine hesitancy as follows: contextual factors (historical, sociocultural, environmental, or political factors), individual and group factors (personal perception or influences of the social/peer environment), and vaccine/vaccination-specific issues (directly related to vaccine or vaccination)., (Copyright © 2022 Elsevier Inc. All rights reserved.)

HPV vaccination rates remain suboptimal in the United States. While the current literature focuses on expressly hesitant parents, few studies have examined parents with "high intent", or those indicating they definitely will vaccinate and have had the opportunity but not yet vaccinated their adolescents. Our objective was to differentiate characteristics of mothers with high intent from those who already vaccinated their adolescents using various socioeconomic, previous vaccine decision-making, and healthcare provider relationship-related variables. English-speaking mothers or female guardians of adolescents ages 11-14 years living in low HPV vaccine uptake states within the U.S. in September 2018 were recruited from a national survey panel as part of a larger study. We assessed HPV vaccine status of their adolescents and categorized respondents into two categories: Already Vaccinated and High Intent. We assessed differences using a multivariable logistic regression model. Among 2406 mothers, 18% reported high intent vs. 82% already having vaccinated. Mothers with high intent were more likely to identify as non-Hispanic White (p = 0.01), to have a younger adolescent (p < 0.001), and to report not receiving a provider HPV vaccination recommendation (p < 0.001). Mothers who estimated that half/more (vs. less) of their child's friends have received/will receive the vaccine had higher odds of already vaccinating (p < 0.001). Our findings suggest that clinicians may be able to improve HPV vaccination uptake within their practices by giving repeated, high-quality recommendations to parents of children who are not yet vaccinated. Additionally, these findings indicate perceived social norms may play a large role in on-time vaccine uptake. Reassuring hesitant parents that most parents accept the vaccine may also improve uptake in clinical practice., Competing Interests: Declaration of Competing Interest Outside of the current work, Dr. Zimet has served as a paid consultant to Merck & Co., Inc. and Moderna, Inc. for work on HPV vaccine and COVID-19 vaccine, respectively. He also has received research funding from Merck, administered through Indiana University. Dr. Feemster is an employee of Merck & Co., Inc. (after study implementation). Dr. Panozzo is an employee of Moderna, Inc. (after study implementation). Outside of the current work, Dr. Head has received investigator-initiated research funding from Merck administered through Indiana University. The other authors have no conflicts of interest relevant to this article to disclose., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Purpose: The first vaccine against SARS-CoV-2 (COVID-19) for adolescents 16 years and older in the United States received Emergency Use Authorization in December 2020. Soon after its approval, parents expressed concerns about vaccine safety for adolescents. Similar concerns about vaccine safety partially explain suboptimal human papillomavirus (HPV) vaccine uptake. This qualitative study explores similarities and differences in parents' attitudes about these two vaccines., Methods: Parents were recruited through social media and at health centers in Alabama. Semi-structured interviews with parents of adolescents aged 9-17 years were conducted before and after Alabama expanded age eligibility to those 16 and older. Topics included knowledge about HPV and COVID-19 vaccines, and parents' intentions to have children vaccinated. Interviews were analyzed using thematic analysis., Results: From March 11, 2021 to April 24, 2021, 21 in-depth interviews were conducted. Parents discussed the importance of HPV and COVID-19 vaccines for protecting their children's health but differences between the two related to community protection. Parents were concerned about vaccine safety but media coverage about the COVID-19 vaccine led to more favorable attitudes about the benefits of vaccination, which was not observed for HPV vaccines. Instead for HPV vaccination, parents wanted their healthcare providers' opinions about the vaccine before making a vaccination decision., Discussion: Parents had similar concerns about HPV and COVID-19 vaccines. Although provider recommendations can improve vaccine uptake, local news reports were seen to have a positive impact on COVID-19 vaccine acceptance in lieu of provider recommendation. Disseminating information online could be beneficial to promote HPV and COVID-19 vaccines., (Copyright © 2022 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Men involvement in HPV vaccine advocacy is important in a patriarchal society. This study aimed to investigate the influence of men on HPV vaccination of adult women. An online cross-sectional survey was undertaken between June and August 2019. Participants were fathers of children enrolled in schools in Fujian Province. A total of 1953 participants responded to our survey. Just over 60% reported they would definitely or likely support their spouse/partner to receive HPV vaccine. Physician recommendation (adjusted odds ratio [aOR] = 5.68, 95%CI = 3.89-6.86) and spouse/partner communication about HPV vaccination (aOR = 5.30, 95%CI = 3.72-7.55) were significant covariates associated with higher willingness to support women's HPV vaccination. Perceiving HPV vaccination as only for women who have had multiple sex partners and HPV vaccination as a sensitive topic were significantly associated with lower willingness to support HPV vaccination. Over two-thirds (67.3%) reported joint HPV vaccination decision-making and 2.8% reported that it was entirely the man's decision. The role of men in HPV vaccine acceptance and hesitancy among adult women is evident in China and warrants educational interventions to target men to enhance women's HPV vaccination uptake.

Introduction: This study aimed to investigate HPV vaccination intention among adult married women aged 27 to 45 years and its associated factors, and their spouse/partner's influence on HPV vaccination decision-making., Methods: This is a cross-sectional, questionnaire-based study. Study participants were recruited through simple random sampling of patients attending obstetrics and gynecology outpatient clinics in a university teaching hospital. Participants were selected based on a computer-generated list of a random list of patients attending the clinic., Results: A total of 794 complete responses were received (response rate 88.2%). The mean age of the respondents was 32.2 years with a standard deviation (SD) of ±3.9 years.The vast majority (85.3%) would communicate with their spouse/partner with regard to HPV vaccination decision-making. Nearly 30% (over half were of the Malay ethnic group) perceived their spouse/partner would not consent to their HPV vaccination. Over half (54.9%) reported joint decision-making, and 9.1% (the majority of whom were Malay) reported that HPV vaccination was dependent on their spouse/partner's decision. Intention to vaccinate against HPV was high (74.5%). Factors influencing HPV vaccination intention were spouse/partner's consent to HPV vaccination (odds ratio [OR] = 4.51; 95% confidence interval [CI], 3.08-6.62), being a postgraduate student (OR = 4.55; 95% CI, 2.13-9.72 vs. unemployed/housewife), average household income MYR2000-4000 (OR = 2.09; 95%CI, 1.16-3.78 vs. below MYR2000), and an HPV-related knowledge score of 9-20 (OR = 1.60; 95% CI, 1.10-2.32 vs. score 0-8)., Conclusion: Findings highlight the importance of culture-centered interventions to enhance male partner's awareness and support for the HPV vaccination of married women.

Background: Chlamydia vaccination is a potentially important strategy to prevent infections and reduce the global burden of disease. Ideally, chlamydia immunization programs would require vaccinating adolescents before they engage in sexual activity. Communication by health care providers (HCPs) has been shown to have an impact on vaccine acceptance. Therefore, it is imperative to understand their opinions on chlamydia vaccines and factors that would promote strong vaccine recommendations to patients to promote uptake., Methods: Semi-structured interviews with adolescent HCPs were conducted and focused on perceived need for chlamydia vaccine. Additional topics included vaccine characteristics, such as efficacy, cost, and booster vaccines, and potential vaccine recommendation strategies., Results: From January to July 2021, 22 interviews were completed. Health care providers discussed how chlamydia vaccines are needed, especially in settings with high prevalence rates. Health care providers thought a chlamydia vaccine would need to be very efficacious in preventing infections and related sequalae and cost-effective. However, there were concerns about low completion rates if this vaccine required multiple doses or boosters. In addition, vaccine misinformation was prevalent among HCPs regarding potential benefits of vaccination., Conclusions: Health care providers' perceptions that an adolescent chlamydia vaccine would be beneficial offers great promise for future promotion. However, there is need for targeted education programs about chlamydia and the benefits of vaccination for HCPs. These programs will be especially important in order for HCPs to effectively communicate about the benefits of vaccination to parents and adolescents provide strong vaccine recommendations., Competing Interests: Conflict of Interest: L.M.N. has served as a scientific advisor for Merck, Moderna, and Janssen. G.D.Z. has served as a consultant and advisory committee member for Merck regarding HPV vaccination and as an advisory committee member for Moderna regarding COVID-19 vaccination. He has also received investigator-initiated research funding from Merck, administered through Indiana University. E.T.O. served as a consultant for ViiV. All other authors have no conflicts to disclose., (Copyright © 2022 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Chlamydia vaccines are currently under development and have the potential to lower the incidence of infection and disease, which are highest among adolescents and young adults. Ideally, a chlamydia vaccine would be administered to adolescents before sexual debut, a time when parents are the primary vaccine decision makers. This study explores parent opinions about an adolescent chlamydia vaccine to understand barriers and facilitators to uptake., Methods: Semistructured interviews were conducted with parents of adolescents. Topics included conversations parents have with their children about chlamydia, opinions on chlamydia vaccine development, and vaccine characteristics, such as efficacy and cost. Interviews were analyzed using a thematic analysis approach., Results: From March to April 2021, 21 interviews were completed. Few parents discuss chlamydia with their children and sex education was seen as limited. Overall, 16 parents indicated that a chlamydia vaccine is needed. However, there were mixed opinions about vaccinating their own children, related to the need to vaccinate at a young age, vaccine efficacy, and confusion about benefits of vaccination. Finally, healthcare provider recommendations were seen as important before deciding to vaccinate a child., Conclusions: Although parents think that chlamydia vaccines are needed, lack of awareness about infections and potential benefits of vaccination could serve as barriers to uptake. Healthcare provider recommendations can help to improve knowledge and vaccine uptake. However, there is a need for multilevel approaches to improve chlamydia awareness and ensure that vaccination initiation and completion rates remain high., Competing Interests: Conflict of Interest and Sources of Funding: Dr Niccolai has served as a scientific advisor for Merck, Moderna, and Janssen. Dr Zimet has served as a consultant and advisory committee member for Merck regarding human papillomavirus vaccination and as an advisory committee member for Moderna regarding COVID-19 vaccination. He has also received investigator-initiated research funding from Merck, administered through Indiana University. Dr Overton served as a consultant for ViiV. All other authors have no conflicts to disclose., (Copyright © 2022 American Sexually Transmitted Diseases Association. All rights reserved.)

This study examined associations between general attitudes toward seeking medical care, attitudes about vaccines/fear of shots, and human papillomavirus (HPV) vaccine uptake and intentions in college women. Hypothesized associations were framed by the Theory of Planned Behavior (TPB). Participants ( N  = 330, mean age = 18.9 years, 75% White) completed a one-time survey. The majority (61%; n  = 201) had received ≥1 HPV vaccine dose. Hierarchical logistic regression examined relationships between attitudes and vaccine uptake. Pearson correlation coefficients and Kruskal-Wallis tests examined associations between attitudes and vaccine intentions. Results were partially consistent with the TPB. In the final model, perceived benefits, but not fear of shots, were associated with vaccine uptake. Among the unvaccinated, perceived benefits, but not fear of shots, were associated with vaccine intentions. Provider recommendation was the strongest predictor of vaccine uptake. Findings suggest interventions incorporating discussion of perceived benefits and provider recommendation may improve HPV vaccine receipt among college women.

Vaccine hesitancy is a top ten global health threat that can negatively impact COVID-19 vaccine uptake. It is assumed that vaccine refusers hold deep, negative beliefs, while acceptors hold strong, positive beliefs. However, vaccine hesitancy exists along a continuum and is multidimensional, varying by time, place, vaccine, subgroup, and person. Guided by the Health Belief Model and vaccine hesitancy frameworks, the study purpose was to qualitatively explore maternal COVID-19 threat perceptions and willingness to accept a COVID-19 vaccine in light of their expressed vaccine hesitancy toward past school required and routinely recommended vaccines and the HPV vaccine for their children. Researchers conducted twenty-five interviews with US Midwestern mothers during the early COVID-19 pandemic months. Mothers were grouped by vaccine hesitancy categories and thematic analysis was used to analyze the data within and across categories. Results showed that prior vaccine hesitancy attitudes and behavior did not fully capture maternal acceptance of COVID-19 vaccine or perception of COVID-19 threat. Perceptions of COVID-19 threat did influence mothers' decisions about COVID-19 protective behaviors (e.g., handwashing, mask wearing, and distancing). However, mothers were hesitant to accept the COVID-19 vaccine across vaccine hesitancy categories, primarily citing concerns about safety, efficacy, and confusion over conflicting information as barriers to immediate COVID-19 vaccine acceptance. Findings indicate that mothers cannot be grouped together based on hesitancy about, or acceptance of, other vaccines for purposes of assuming COVID-19 preventive behavior adherence or anticipated COVID-19 vaccine acceptance.

Background: Many women see an obstetrician/gynecologist (OB/GYN) annually and receive their primary care from an OB/GYN. Understanding OB/GYNs' human papillomavirus (HPV) vaccination practices, including knowledge of and barriers to vaccination, is essential to design effective interventions to increase vaccination. This study evaluated OB/GYN knowledge, attitudes, and beliefs regarding vaccinating both younger (18-26 years) and mid-adult (27-45 years) women. Materials and Methods: Data were collected from OB/GYN providers in October 2019 through a nationwide web-based survey. Items included the following: HPV-related vaccination practices, recommendation strength, knowledge (seven items), benefits (four items), and barriers (eight items). Results: The sample ( n  = 224) was majority were White (69%), men (56%), and practice in suburban clinics (55%). Most (84%) reported they usually or always recommend HPV vaccine to eligible patients, but estimated only about half (51%) of other OB/GYNs did the same. Recommendation strength varied by patient age with 84% strongly recommending it to patients ≤18 years, compared with 79% and 25% strongly recommending to younger and mid-adult patients, respectively ( p  < 0.01). Participants reported lower benefits ( p  = 0.007) and higher barriers ( p  < 0.001) for 27- to 45-year-old patients compared with younger patients. Cost was the most frequently reported barrier, regardless of patient age. Overall knowledge was high ( m  = 5.2/7) but 33% of participants did not know the vaccine was safe while breastfeeding. Conclusions: Although providers reported strongly and consistently recommending the HPV vaccination to their adult patients, there were gaps in knowledge and attitudinal barriers that need to be addressed. Provider performance feedback may be important in improving HPV vaccination awareness among providers.

Human papillomavirus (HPV) vaccination can prevent six types of HPV-related cancers, and approximately, 54.2% of adolescents are up-to-date with the HPV vaccine in the United States. While moderate success has been achieved with provider- and parent-focused interventions, HPV vaccination in the U.S. lags well behind desired goals. In order to maximize HPV vaccination and prevention of HPV-related cancers, it may be prudent to consider state policy approaches, such as school-entry requirements as part of the patchwork of provider, parent, and structural interventions. In this paper, we reviewed the history of efforts to implement school-entry requirements for HPV vaccine, the challenges and benefits associated with implementing these requirements, and the evidence for the effectiveness of school-entry requirements. In addition, we presented new data from Rhode Island's Immunization Information System (IIS) showing how their school-entry requirement, implemented in 2015, has impacted HPV vaccination rates. These registry data indicate that HPV vaccination rates improved significantly after the 2014-2015 school year and policy implementation, and add to the ongoing evidence supporting the value of school-entry requirements for HPV vaccination. School-entry requirements should be considered alongside other initiatives and policies for promoting HPV vaccine uptake. Taking a comprehensive systems approach to HPV vaccination is needed.

We address ethical, legal, and practical issues related to adolescent self-consent for human papillomavirus (HPV) vaccination. HPV vaccination coverage continues to lag well behind the national goal of 80% series completion. Structural and behavioral interventions have improved vaccination rates, but attitudinal, behavioral, and access barriers remain. A potential approach for increasing access and improving vaccination coverage would be to permit adolescents to consent to HPV vaccination for themselves. We argue that adolescent self-consent is ethical, but that there are legal hurdles to be overcome in many states. In jurisdictions where self-consent is legal, there can still be barriers due to lack of awareness of the policy among healthcare providers and adolescents. Other barriers to implementation of self-consent include resistance from antivaccine and parent rights activists, reluctance of providers to agree to vaccinate even when self-consent is legally supported, and threats to confidentiality. Confidentiality can be undermined when an adolescent's self-consented HPV vaccination appears in an explanation of benefits communication sent to a parent or if a parent accesses an adolescent's vaccination record via state immunization information systems. In the context of the COVID-19 pandemic, which has led to a substantial drop in HPV vaccination, there may be even more reason to consider self-consent. The atmosphere of uncertainty and distrust surrounding future COVID-19 vaccines underscores the need for any vaccine policy change to be pursued with clear communication and consistent with ethical principles., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Little is known regarding Chinese mothers' intention to vaccinate their daughters against human papillomavirus (HPV) since the HPV vaccine was approved for use in China in 2016. The aim was to explore maternal HPV vaccination acceptance, preference for 2-, 4- or 9-valent HPV vaccine and acceptance of domestically manufactured HPV vaccines. Study participants were mothers of primary school children in Southeastern region of Fujian. An online cross-sectional survey was undertaken between June and August 2019. Among the total of 3,586 completed responses (response rate 28.5%), the intention to vaccinate daughter against HPV was high (83.3%). Higher maternal education and perceived benefit and barriers were associated with greater intention to vaccinate. Among mothers who did not intend to vaccinate their daughters, the three most common reasons were daughter being too young to receive HPV vaccination (40.6%), fear of side effects (31.9%) and vaccine price is too high (16.0%). The largest proportion (41.4%) preferred their daughter to be vaccinated with the 9-valent HPV vaccine (9vHPV). Greater preference for 9vHPVwas strongly associated with higher maternal education level and annual household income. The majority of mothers expressed a preference for imported HPV vaccine (56.3%). Our result indicates that lower intentions to vaccinate daughters against HPV among less educated and lower-income mothers may lead to significant social inequalities in HPV vaccine uptake in the country.

Background: While many clinicians encounter parents or adolescents who refuse HPV vaccine, little is known about the prevalence of hesitancy for HPV vaccine nationally or its association with vaccination., Methods: In April 2019, we surveyed families with adolescents 11-17 years using a national online panel (Knowledge Panel®) as the sampling frame. We assessed the prevalence of HPV vaccine hesitancy with the validated 9-item Vaccine Hesitancy Scale (VHS). We used multivariate analyses to assess demographic factors associated with HPV vaccine hesitancy. We also assessed practical barriers to receipt of HPV vaccine and the relationship between barriers and hesitancy. Finally, we evaluated the association between both HPV vaccine hesitancy and practical barriers on HPV vaccine receipt or refusal., Results: 2,177 parents out of 4,185 sampled (52%) completed the survey, 2,020 qualified (lived with adolescent). Using a VHS cut-off score > 3 out of 5 points, 23% of US parents were hesitant about HPV vaccine. Hesitancy was lower among those with Hispanic ethnicity. At least one out of five parents disagreed that the HPV vaccine is beneficial for their adolescent, that the vaccine is effective, protects against HPV-related cancers, or that they followed their adolescent's health-care provider's recommendation about the vaccine. Many were concerned about vaccine side effects and the novelty of the vaccine. Adolescents living with vaccine-hesitant parents were less than one-third as likely to have received the vaccine (RR = 0.29, 95% CI 0.24, 0.35) or completed the vaccine series (RR = 0.29, 95% CI 0.23, 0.36), and were 6-fold more likely to have refused the vaccine because of parental vaccine-related concerns (RR = 6.09, 95% CI = 5.26, 7.04). Most practical barriers were independently associated with vaccine receipt but not with vaccine refusal., Conclusions: HPV vaccine hesitancy is common nationally and strongly related to both under-vaccination and vaccine refusal., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: G. Zimet has received honoraria and travel support from Merck for consultations related to HPV vaccination and honoraria from Sanofi Pasteur for work on the Adolescent Immunization Initiative. S. Humiston has received an honorarium and travel support from Sanofi Pasteur for work on vaccine hesitancy but not specific to this study or manuscript., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Purpose: The aim of the study was to determine whether supplementing a bundled recommendation (recommendation for all 11- to 12-year-old platform vaccines) with tailored messaging that addressed one versus all parental concerns improved human papillomavirus (HPV) vaccination intent among mothers., Methods: We conducted a Web-based randomized controlled trial, randomizing mothers who did not intend to vaccinate their 11- to 14-year-old child against HPV to (1) bundled recommendation video ("control"); (2) control + video addressing the top HPV vaccine concern; or (3) control + ≥1 videos addressing all concerns. Outcomes were HPV vaccination intent (1 = extremely unlikely and 10 = extremely likely) and strength of main concern (1 = a little concerned and 10 = very concerned). We assessed differences in intervention effects using generalized linear models for vaccine intent and mixed models for the strength of main concern., Results: Of the 762 mothers, 51% had a female child, 82% of children were white, and 90% were non-Hispanic. The mean intent to vaccinate postintervention ranged from 3.5 (95% confidence interval [CI] = 3.1-3.8) in the control group to 4.2 (95% CI = 3.9-4.6) in the all-concerns group (p = .01). The mean strength of the concerns declined pre- to postintervention by .1 (95% CI = -.1 to .3) in the control group (p = .42), .6 (95% CI = .4-.9) in the top concern group (p < .001), and .7 (95% CI = .5-1.0) in the all-concerns group (p < .001). However, the mean strength of the main concerns postintervention remained high (≥7.0 for each group)., Conclusions: Tailored messages addressing all concerns improved HPV vaccination intent and reduced the strength of the main concern more than bundled messages alone, but intent remained low and strength of the main concerns remained high in this vaccine-hesitant population., (Copyright © 2020 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Human papillomavirus vaccine school entry requirements may be an opportunity to improve the low rates of human papillomavirus vaccination among adolescents. This study evaluates changes in provider-verified human papillomavirus vaccine uptake by age 13 years for adolescents in Rhode Island compared with all other states from 2011 to 2017., Methods: The National Immunization Survey-Teen 2011-2017, a population-based cross-sectional survey, was analyzed in 2019. The survey included telephone interviews and provider-verified reports of vaccination among U.S. adolescents aged 13-17 years. The sample was subset to participants with provider-verified human papillomavirus vaccination reports (n=145,153). A difference-in-differences approach evaluated the Rhode Island human papillomavirus vaccination school entry requirement enacted in 2015. The main outcome was provider-verified human papillomavirus vaccine uptake by age 13 years., Results: Compared with boys in other states, boys in Rhode Island had an increase of 14 percentage points in the probability of uptake of human papillomavirus vaccination by age 13 years (β=0.139, 95% CI=0.073, 0.205). No such differences were observed on comparing girls in Rhode Island with girls in other states (β=0.009, 95% CI= -0.068, 0.086)., Conclusions: The Rhode Island school entry requirement for human papillomavirus vaccination improved rates of vaccine uptake among boys and may be a useful option for improving human papillomavirus vaccination nationally., (Copyright © 2020 American Journal of Preventive Medicine. Published by Elsevier Inc. All rights reserved.)

HPV vaccine hesitancy in Asia is unique compared to Western countries due to multidimensional social-cultural norms that influence beliefs regarding vaccination. Reviews on HPV vaccine hesitancy in Asia lack of in-depth discussion regarding the traditional and social-cultural norms dimensions. This paper puts forward opinions in which culture, normative beliefs, and religion influence HPV vaccine hesitancy in Asian countries. Issues surrounding HPV hesitancy among parents, young adult women, adult women, men and the sexual and gender minority people in Asian countries were highlighted. The shortage of HPV vaccine supply would soon be reduced as some Asian countries are on the way to producing the HPV vaccine which production is currently dominated by Western European countries. The culture of favoring imported Western products among many in Asia and in addition to long-existing fake vaccine crisis pose a challenge for the newly emerging HPV vaccine produced in Asia. Some recommendations, research gaps, and future research needs were discussed.

Objective: This study aims to investigate acceptance and willingness to pay for HPV vaccination among adult women in China., Methods: An online survey was sent to mothers aged 27-45 years of primary school pupils in the Fujian province, China. Participants completed questions about HPV related knowledge and health beliefs, intention to take the HPV vaccine and the willingness to pay for bivalent vaccine (2vHPV), quadrivalent vaccine (4vHPV), and 9-valent HPV vaccine (9vHPV)., Results: Of a total of 2339 complete responses, 58.3% reported intent to obtain HPV vaccine. Mothers who were younger in age, residing in urban, working in managerial or professional occupations, who knew someone with cervical cancer and who were able to make independent decisions about the HPV vaccine (vs. joint decision with spouse) were more likely to express intent to have HPV vaccination. Perceived barriers, cues to action and self-efficacy were three of the constructs in the health belief model that significantly influenced HPV vaccination intent. A higher proportion of participants expressed willingness to pay for 2vHPV (81.2%) and 4vHPV (75.9%), as compared to 9vHPV (67.7%)., Conclusion: Adults women expressed moderate intention to receive the HPV vaccine. Intervention to address barriers to uptake of the HPV vaccine among adult women in China is warranted., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Dr. Zimet has served and has received honoraria from Sanofi Pasteur for his work on the Adolescent Immunization Initiative and travel support from Merck & Co., Inc. to present at an HPV vaccine symposium., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Little research has been conducted on the intention to obtain HPV vaccine now that the vaccine is approved for use in China. Acceptance of the three HPV vaccines, which differ in valency and price, has never been investigated., Methods: An online cross-sectional survey assessing female undergraduate students' intention to obtain the HPV vaccine and their acceptability of 2-, 4- and 9-valent HPV vaccines (2vHPV, 4vHPV, and 9vHPV, respectively)., Results: Of a total of 997 complete responses, 55.2% reported intent to obtain the HPV vaccine. Some of the significant factors exerting influence on intent to obtain HPV vaccination were high knowledge score (OR = 1.469, 95% CI:1.087-1.987), perceived high risk of HPV infection (OR = 1.466, 95%CI:1.017-2.114), perception of no serious side effects (OR = 1.562, 95%CI:1.150-2.121), and mass media exposure to HPV vaccination information (OR = 2.196, 95%CI: 1.625-2.966). Socioeconomic status indicators did not significantly influence intent to obtain the HPV vaccine. A higher proportion of respondents were willing to pay for 2vHPV (78.6%) and 4vHPV (68.0%) compared with 9vHPV (49.3%). Socioeconomic status indicators were the strongest correlates of acceptability for all the three vaccines. Exposure to mass media reporting about HPV vaccination is the factor which exerts the most influence on acceptance of 9vHPV after socioeconomic status indicators., Conclusions: It is important to improve knowledge and health beliefs, and to establish a mass media marketing strategy to promote HPV vaccination in order to enhance HPV vaccine uptake. Undergraduate female students should be provided with detailed information about the different valency vaccine choices to help them make informed decisions about immunization., (Copyright © 2019. Published by Elsevier Ltd.)

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.

Purpose: Despite that human papillomavirus (HPV) vaccination could prevent ∼90% of HPV-associated cancers, only 65.5% of American adolescents initiate vaccination. African Americans have the highest prevalence of morbidity and mortality from HPV-associated cancers. Mounting evidence suggests that advice from social contacts is associated with vaccine acceptance. The present study examines the associations of social processes with HPV vaccine refusal among African American parents., Methods: A cross-sectional survey was conducted among African American parents of children aged 10-12 years before a health-care visit at which HPV vaccine was offered by the health-care provider. Data from the 353 parents who named at least one social contact who advised them about vaccines were included in these analyses., Results: Only 54.4% of the participants consented to HPV vaccination for their children. On average, parents had 2 to 3 social contacts who provided vaccine advice. Vaccine advice networks were generally dense, family-centric, and homophilous. Slightly over 80% of all parents trusted family members and friends for vaccine advice "some" or "a lot." Controlling for sociodemographic characteristics and reason for the health-care visit, perceived high exposure to anti-HPV vaccine viewpoints and low exposure to pro-HPV vaccine viewpoints were both associated with HPV vaccine refusal (adjusted odds ratio = 1.5, 95% confidence interval = 1.01, 2.3, and adjusted odds ratio = 1.7, 95% confidence interval = 1.2, 2.6, respectively)., Conclusions: Social processes may be associated with HPV vaccine refusal among African American parents. Interventions designed to educate African American parents about HPV vaccine to increase uptake should consider leveraging vaccine advice networks for greater impact., (Copyright © 2019 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Study Objective: To assess the knowledge and beliefs regarding human papillomavirus (HPV) and the HPV vaccine among girls before and after vaccination in the Malaysian HPV Immunisation Programme., Design: A nationwide longitudinal survey., Setting: Thirty-two randomly selected schools from 13 states and 3 federal territories in Malaysia from February to March 2013, and October to November 2013., Participants: Form One female students (13 years old)., Interventions: None., Main Outcome Measures: Mean knowledge score of HPV infection., Results: A total of 2644 students responded to the prevaccination survey, of whom 2005 (70%) completed the postvaccination survey. The mean knowledge score was 2.72 (SD ± 2.20) of a maximum score of 10 in the prevaccination survey, which increased significantly to 3.33 (SD ± 1.73) after the 3 doses of HPV vaccine (P = .001). Many answered incorrectly that, "Only girls can get HPV infection" (91.5%, n = 1841 prevaccination vs 96.1%, n = 1927 postvaccination), and only a few were aware that, "Vaccinating boys helps to protect girls against HPV infection" (11.4%, n = 229 for prevaccination vs 10.2%, n = 206 for postvaccination). The mean knowledge score was significantly higher postvaccination among higher-income families and those with parents of a higher occupational status. Regarding beliefs about the HPV vaccine, 89.4% in the prevaccination survey held the view that they would not get a HPV infection, and the percentage remained similar in the postvaccination survey. Perceived severity of HPV infection also remained low in the pre- and postintervention groups. Only 21.5% reported receiving health information about HPV along with the provision of the HPV vaccine; those who received health information showed higher levels of knowledge., Conclusion: Findings revealed a general lack of knowledge and erroneous beliefs about HPV and the HPV vaccine even after receiving vaccination. This suggests that imparting accurate knowledge about HPV along with vaccine administration is essential. Specifically, girls from lower socioeconomic groups should be a target of educational intervention., (Copyright © 2018 North American Society for Pediatric and Adolescent Gynecology. All rights reserved.)

Objective: The objective of this study is to identify factors influencing the vaccine intention-behaviour relationship., Design: A total of 445 parents who received a brief intervention to promote HPV vaccination were categorized based on their intentions post-intervention (yes/unsure/eventually/never) and subsequent adolescents' vaccine status (yes/no). Fifty-one of these parents participated in qualitative interviews., Main Outcome Measures: Parents described their intentions, decision-making and planning processes towards vaccination. Framework analysis was used to analyse the data., Results: Parents in the 'Yes/Yes' category were knowledgeable about HPV/vaccine, described strong, stable intentions, considered themselves the primary decision-makers about vaccination and said they vaccinated immediately. 'Yes/No' parents described strong intentions and thought their adolescent was vaccinated OR described hesitant intentions, seeking advice/agreement from others and noting barriers to vaccination without solutions. 'Unsure/Yes' parents described their intentions as strengthening with information from credible sources and identified strategies for overcoming barriers. 'Unsure/No' and 'Eventually/No' parents had misinformation/negative beliefs regarding vaccination, described being ambivalent or non-supportive of vaccination and cited barriers to vaccination. 'Never/No' parents held negative beliefs about vaccination, described strong, stable intentions to NOT vaccinate, deferring the decision to others, and reported no planning towards vaccination., Conclusions: Intention characteristics and planning processes could moderate the vaccine intention-behaviour relationship, potentially serving as targets for future vaccine strategies.

Concerns have been raised that risk perceptions after human papillomavirus (HPV) vaccination may lead to riskier sexual behaviors or sexually transmitted infection (STI) diagnosis. The aims of this study were to determine whether risk perceptions immediately after HPV vaccination (perceived risk of HPV, perceived risk of STIs other than HPV, and perceived need for safer sexual behaviors, measured using 5-item scales) were associated with number of sexual partners, condom use at last sexual intercourse, or STI diagnosis over the subsequent 48 weeks in HIV-infected young women (N = 99, 17-24 years of age) participating in an HPV vaccine clinical trial. Generalized estimating equation models demonstrated that lower perceived need for safer sexual behaviors was associated subsequently with lower total number of sexual partners (adjusted odds ratio (AOR) = 1.05, 95% confidence interval (CI) = 1.01-1.09) and lower perceived risk of HPV was associated with subsequent report of having used condoms at last sex (AOR = 0.36, AOR = 0.14-0.92). Lower perceived risk of other STIs was not associated with subsequent sexual behaviors. None of the three risk perceptions was associated with subsequent risk of STIs. The findings suggest that inappropriate risk perceptions after HPV vaccination such as lower perceived need for safer sexual behaviors and lower perceived risk of HPV or other STIs were not subsequently associated with risky behaviors or STI diagnosis in HIV-infected young women.

The human papillomavirus (HPV) vaccine has been available in the United States for over a decade. We sought to examine the associations between self-reported receipt of HPV vaccination among women and their 11-14-year-old children in 27 low-coverage states. Among the 3,261 mothers we surveyed, 18% reported receiving ≥1 dose of HPV vaccine. A significantly higher proportion of vaccinated women reported vaccination of their children compared to unvaccinated women (83% vs. 56%, p < .001). In multivariable logistic regression, vaccinated women (vs. unvaccinated) had 3.58 (95% CI: 2.81-4.56) times the adjusted-odds of vaccinating their children (≥1 dose HPV vaccine). Among unvaccinated children, vaccinated mothers (vs. unvaccinated) had 3.32 (95% CI: 2.09-5.26) times the adjusted odds of high intention to vaccinate their children in the next 12 months. We did not observe associations between mothers' vaccination confidence and their vaccination status. We conclude that mothers who received ≥1 dose of HPV vaccine may be more likely to initiate or highly intend to initiate the HPV vaccine series for their children. This may have important implications for meeting population goals for HPV vaccination coverage as an increasing proportion of mothers are likely to be vaccinated over time.

: media-1vid110.1542/5849572217001PEDS-VA&#95;2018-1457 Video Abstract BACKGROUND: Human papillomavirus (HPV) infection can lead to serious health issues and remains the most common sexually transmitted infection. Despite availability of effective vaccines, HPV vaccination rates are suboptimal., Methods: In a cluster randomized trial, an intervention used to target parents of adolescents (11-17 years) eligible for a dose of HPV vaccine, was tested in pediatric clinics part of an urban health system. Parents watched a digital video outlining the risks and benefits of vaccine using a tablet in the examination room. The primary outcome was change in HPV vaccine status 2 weeks after the clinic visit. An intention-to-treat analysis for the primary outcome used generalized estimating equations to accommodate the potential cluster effect of clinics., Results: A total of 1596 eligible adolescents were observed during the 7-month trial. One-third of adolescents visited an intervention clinic. Adolescents who attended an intervention clinic were more likely to be younger (11-12 years) than those who attended a control clinic (72.4% vs 49.8%; P < .001). No differences in race or sex were observed. The proportion of adolescents with an observed change in vaccine status was higher for those attending an intervention clinic (64.8%) versus control clinic (50.1%; odds ratio, 1.82; 95% confidence interval, 1.47-2.25; P < .001). Adolescents whose parents watched the video had a 3-times greater odds of receiving a dose of the HPV vaccine (78.0%; odds ratio, 3.07; 95% confidence interval, 1.47-6.42; P = .003)., Conclusions: Educational interventions delivered within a clinical setting hold promise to improve vaccination behaviors., Competing Interests: POTENTIAL CONFLICT OF INTEREST: Dr Zimet has been an investigator on investigator-initiated research funded by Merck & Co, Inc, and Roche, received travel funding from Merck & Co, Inc, to present research at a scientific conference, and received an honorarium for participation in an adolescent immunization initiative meeting. Dr Lindsay is an employee of Merck & Co, Inc. Dr Downs is a cofounder of Digital Health Solutions, LLC, Indianapolis, Indiana, a company created to license and market the Child Health Improvement through Computer Automation system; the other authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

A cross-sectional analysis of human papillomavirus (HPV) vaccine statutes and regulations from states and the District of Columbia in the United States (U.S.) was conducted from September-November 2018 to advance analyses of policy impact on HPV vaccination uptake. A search was conducted using WestlawNext, a legal research database. Statutes and regulations relevant to the study were analyzed and coded based on their legal attributes into ten broad coding questions and several sub-questions. Of the 212 laws identified by the initial search string, 93 (43.9%) reference HPV vaccination in statute or regulation. An additional three laws were added following subsequent review. There was a total of 52 statutes and 44 regulations from 34 states and the District of Columbia. Most laws were related to developing and distributing HPV vaccination materials for parents, and mechanisms to fund and reimburse for the vaccination. This study can be used by policymakers in jurisdictions that are considering establishing HPV vaccination promotion interventions in state law and highlighting the limited statutory and regulatory efforts that have been implemented to promote HPV vaccination. Importantly, this study can also be used to conduct evaluations of the efficacy of statutory and regulatory strategies in increasing HPV vaccination rates.

The introduction of human papillomavirus (HPV) vaccination in China aims to prevent HPV infection in all women. The issues that China might face include high cost of vaccines made in other countries, shortage in HPV vaccine supply, negative events attributed to vaccination (whether justified or not) that jeopardizes the general public's confidence in the HPV vaccine, cultural and literacy barriers, and sensitivity to receiving a vaccine for a sexually transmitted disease. Ensuring the effective delivery of the HPV vaccine in China, a country with vast economic, geographical, and cultural complexities, will require a commitment of significant resources. In light of the high price of imported vaccines, the availability of locally manufactured HPV vaccines would greatly facilitate the national HPV vaccination program. New evidence supporting the efficacy of a two-dose regime in younger adolescents would also be advantageous in terms of affordability and logistical simplicity of vaccine administration. Furthermore, it would potentially enhance the compliance and uptake, especially for hard to reach women in remote regions.

HPV vaccination rates in Florida are low. To increase rates, the CDC recommends clinics adhere to components of their evidence-based quality improvement program, AFIX (Assessment, Feedback, Incentives, and eXchange of information). We explored factors associated with engaging in HPV-specific AFIX-related activities. In 2016, we conducted a cross-sectional survey of a representative sample of 770 pediatric and family medicine physicians in Florida and assessed vaccination practices, clinic characteristics, and HPV-related knowledge. Data were analyzed in 2017. The primary outcome was whether physicians' clinics engaged in ≥1 AFIX activity. We stratified by physician specialty and developed multivariable models using a backward selection approach. Of the participants in the analytic sample (n = 340), 52% were male, 60% were White of any ethnicity, and 55% were non-Hispanic. Pediatricians and family medicine physicians differed on: years practicing medicine (p < 0.001), HPV-related knowledge (p < 0.001), and VFC provider status (p < 0.001), among others. Only 39% of physicians reported engaging in ≥1 AFIX activity. In the stratified multivariable model for pediatricians, AFIX activity was significantly associated with HPV-related knowledge (aOR = 1.33;95%CI = 1.08-1.63) and provider use of vaccine reminder prompts (aOR = 3.61;95%CI = 1.02-12.77). For family medicine physicians, HPV-related knowledge was significant (aOR = 1.57;95%CI = 1.20-2.05) as was majority race of patient population (non-Hispanic White vs. Other: aOR = 3.02;95%CI = 1.08-8.43), daily patient load (<20 vs. 20-24: aOR = 9.05;95%CI = 2.72-30.10), and vaccine administration to male patients (aOR = 2.98;95%CI = 1.11-8.02). Fewer than half of Florida pediatric and family medicine physicians engaged in any AFIX activities. Future interventions to increase AFIX engagement should focus on implementing and evaluating AFIX activities in groups identified as having low engagement in AFIX activities., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Despite being an effective cancer prevention strategy, human papillomavirus (HPV) vaccination in Canada remain suboptimal. This study is the first to concurrently evaluate HPV vaccine knowledge, attitudes, and the decision-making stage of Canadian parents for their school-aged daughters and sons. Data were collected through an online survey from a nationally representative sample of Canadian parents of 9-16 year old children from August to September 2016. Measures included socio-demographics, validated scales to assess HPV vaccine knowledge and attitudes (using the Health Belief Model), and parents' HPV vaccination adoption stage using the Precaution Adoption Process Model (PAPM; six stages: unaware, unengaged, undecided, decided not, decided to, or vaccinated). 3779 parents' survey responses were analyzed (1826 parents of sons and 1953 parents of daughters). There was a significant association between child's gender and PAPM stage of decision-making, with parents of boys more likely to report being in earlier PAPM stages. In multinomial logistic regression analyses parents of daughters (compared to sons), parents of older children, and parents with a health care provider recommendation had decreased odds of being in any earlier PAPM stage as compared to the last PAPM stage (i.e. vaccinated). Parents who were in the 'decided not to vaccinate' stage had significantly greater odds of reporting perceived vaccine harms, lack of confidence, risks, and vaccine conspiracy beliefs. Future research could use these findings to investigate theoretically informed interventions to specifically target subsets of the population with particular attention towards addressing knowledge gaps, perceived barriers, and concerns of parents., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: To assess changes in human papillomavirus (HPV) vaccine initiation for adolescent girls and boys in Rhode Island compared with all other states., Methods: We estimated the gender-specific effects of Rhode Island's school-entry HPV vaccination policy on self-reported HPV vaccination initiation by using a difference-in-differences design with the National Immunization Survey-Teen from 2010 through 2016., Results: Compared with boys in other states, boys in Rhode Island increased their HPV vaccine initiation rate by 11% (b = 0.11; 95% confidence interval [CI] = 0.05, 0.18) after enactment of the requirement. No difference was seen in the probability of HPV vaccine initiation among girls in Rhode Island compared with girls in the multistate control (b = -0.01; 95% CI = -0.08, 0.05)., Conclusions: Our analysis identified an 11% increase in HPV vaccine initiation rate among boys in Rhode Island after the school-entry requirement was enacted, whereas no significant change was observed for girls. Public Health Implications. Given suboptimal vaccine uptake rates in the United States, continued pursuit of state-level public policy to improve HPV vaccination is needed. School-entry requirements for HPV vaccination may be a strategy for closing the gap in HPV vaccine uptake for boys and girls.

Over a decade has passed since the first human papillomavirus (HPV) vaccine was introduced. These vaccines have received unequivocal backing from the scientific and medical communities, yet continue to be debated in the media and within the general public. The current review is an updated examination that the authors made five years ago on some of the key sociocultural and behavioral issues associated with HPV vaccine uptake and acceptability, given the changing HPV vaccine policies and beliefs worldwide. We explore current worldwide HPV vaccination rates, outline HPV vaccine policies, and revisit critical issues associated with HPV vaccine uptake including: risk compensation, perceptions of vaccine safety and efficacy, age of vaccination, and healthcare provider (HCP) recommendation and communication. While public scrutiny of the vaccine has not subsided, empirical evidence supporting its safety and efficacy beyond preventing cervical cancer has amassed. There are conclusive findings showing no link that vaccinated individuals engage in riskier sexual behaviors as a result of being immunized (risk compensation) both at the individual and at the policy level. Finally, HCP recommendation continues to be a central factor in HPV vaccine uptake. Studies have illuminated how HCP practices and communication enhance uptake and alleviate misperceptions about HPV vaccination. Strategies such as bundling vaccinations, allowing nurses to vaccinate via "standing orders," and diversifying vaccination settings (e.g., pharmacies) may be effective steps to increase rates. The successes of HPV vaccination outweigh the controversy, but as the incidence of HPV-related cancers rises, it is imperative that future research on HPV vaccine acceptability continues to identify effective and targeted strategies to inform HPV vaccination programs and improve HPV coverage rates worldwide.

The HPV vaccine debuted more than ten years ago in the United States and many strategies have been evaluated to increase HPV vaccination rates, which include not only improving current vaccination behaviors but also sustaining these behaviors. Researchers and practitioners from a variety of backgrounds have engaged in this work, which has included efforts directed at public health and government policies, health education and health promotion programs, and clinical and patient-provider approaches, as well as work aimed to respond to and combat anti-HPV vaccination movements in society. Using a previously developed conceptual model to organize and summarize each of these areas, this paper also highlights the need for future HPV vaccine promotion work to adopt a multi-level and, when possible, integrated approach in order to maximize impact on vaccination rates.

Purpose: We examined longitudinally the relationship between human papillomavirus (HPV) vaccine-related risk perceptions and initiation of sexual activity among adolescent women over 30 months after HPV vaccination., Methods: Participants included 91 sexually inexperienced women aged 13-21 years receiving the HPV vaccine who completed at least three of five study visits. At every visit, participants completed surveys assessing HPV vaccine-related risk perceptions (perceived risk of sexually transmitted infections [STIs] other than HPV, perceived need for safer sexual behaviors), and sexual initiation. Outcomes were sexual initiation and age of sexual initiation. Associations between risk perceptions and outcomes were examined using ordered logistic regression models for sexual initiation and interval censored survival analyses for age of sexual initiation., Results: Mean age at baseline was 14.9 years (standard deviation [SD] 1.4). Most participants perceived themselves to be at risk of STIs other than HPV (mean scale score = 4.0/10; SD 2.1) and perceived a need for safer sexual behaviors (mean scale score = 1.5/10; SD 1.5). By 30 months, 65 participants (78%) initiated sex. Perceived risk of STIs and perceived need for safer sexual behaviors were not associated with sexual initiation or age of sexual initiation. Older age at baseline was associated with sooner sexual initiation (p = .02) and older age at sexual initiation (p < .001). Results of ordered logistic regression and survival analyses were unchanged when controlling for baseline age., Conclusions: HPV vaccine-related risk perceptions were not associated with sexual initiation or age of sexual initiation, providing further support that HPV vaccine-related risk perceptions are unlikely to lead to riskier sexual behaviors., (Copyright © 2017 The Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Introduction: Female sex workers (FSWs) are at risk for human papillomavirus (HPV)-induced diseases but are currently not targeted by the HPV vaccination program in the Netherlands. We explored determinants of their intention to get vaccinated against HPV in case vaccination would be offered to them., Methods: In 2016, FSWs 18 years and older having a sexually transmitted infection consultation with the Prostitution & Health Center (P&G292) in Amsterdam, either at the clinic or at their working location, were invited to complete a questionnaire assessing sociopsychological determinants of HPV vaccination intention (scale ranging from -3 to +3). Determinants of HPV vaccination intention were assessed with univariable and multivariable linear regression. In addition, we explored the effect of out-of-pocket payment on intention., Results: Between May and September 2016, 294 FSWs participated. The median age was 29 years (interquartile range, 25-37 years). Human papillomavirus vaccination intention was high (mean, 2.0; 95% confidence interval [CI], 1.8-2.2). In multivariable analysis, attitude (β = 0.6; 95% CI, 0.5-0.7), descriptive norm (β = 0.2; 95% CI, 0.1-0.3), self-efficacy (β = 0.2; 95% CI, 0.1-0.3), beliefs (β = 0.1; 95% CI, 0.0-0.2), and subjective norm (β = 0.1; 95% CI, 0.0-0.2) seemed to be the strongest predictors of HPV vaccination intention (R = 0.54). Human papillomavirus vaccination intention decreased significantly to a mean of 0.2 when vaccination would require out-of-pocket payment of &OV0556;350., Conclusions: The HPV vaccination intention among FSWs seems relatively high and is most strongly constituted in attitudinal, normative, and self-efficacy beliefs. Out-of-pocket payment will probably have a negative impact on their HPV vaccination acceptability.

Introduction: Human papillomavirus (HPV), a sexually transmitted infection, can cause anogenital warts and a number of cancers. To prevent morbidity and mortality, three vaccines have been licensed and are recommended by Canada's National Advisory Committee on Immunisation (for girls since 2007 and boys since 2012). Nevertheless, HPV vaccine coverage in Canada remains suboptimal in many regions. This study will be the first to concurrently examine the correlates of HPV vaccine decision-making in parents of school-aged girls and boys and evaluate changes in parental knowledge, attitudes and behaviours over time., Methods and Analysis: Using a national, online survey utilising theoretically driven constructs and validated measures, this study will identify HPV vaccine coverage rates and correlates of vaccine decision-making in Canada at two time points (August-September 2016 and June-July 2017). 4606 participants will be recruited to participate in an online survey through a market research and polling firm using email invitations. Data cleaning methods will identify inattentive or unmotivated participants., Ethics and Dissemination: The study received research ethics board approval from the Research Review Office, Integrated Health and Social Services University Network for West-Central Montreal (CODIM-FLP-16-219). The study will adopt a multimodal approach to disseminate the study's findings to researchers, clinicians, cancer and immunisation organisations and the public in Canada and internationally., Competing Interests: Competing interests: ZR reports grants from the Canadian Cancer Society Research Institute during the conduct of the study and personal fees from Merck outside the submitted work. GDZ reports grants from Merck and personal fees from Sanofi Pasteur, outside the submitted work. The remaining authors declare no conflict of interest., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Assessing physicians' experiences in HPV vaccine recommendation and delivery to adolescent boys is essential to providing an understanding of the issues of vaccine acceptance and an insight for policymakers to enhance HPV vaccinations among adolescent boys. Between January and April 2014 a mail survey was conducted using physicians in Malaysia known to provide either one or both HPV vaccine (Gardasil and Cervarix) immunisation services. A total of 357 completed questionnaires were received (response rate 22.5%). Of these, 335 physicians see adolescent boys aged 11 to 18 years old in their practice. Only 26.3% (n = 88) recommended the HPV vaccine to these boys. A total of 46.6% (n = 41) have successfully given the HPV vaccine to adolescent boys. A lack of proper guidelines from the health authorities regarding the recommendation of HPV vaccine to the boys (37.2%) and a lack of awareness of the availability of the vaccine for boys (32.8%) were the most commonly cited reasons for non-recommendation. Impact statement Recommending the HPV vaccine for adolescent boys remains a challenge for physicians. Our study provides evidence of challenges and barriers faced by Malaysian physicians who recommend the HPV vaccines (Gardasil and Cervarix) in their practices. In this study, physicians reported HPV vaccine uptake by adolescent boys was very poor. A lack of proper guidelines from the health authorities regarding the recommendation of HPV vaccine to boys and a lack of awareness of the availability of the vaccine for boys were the most commonly cited reasons for non-recommendation. Physicians viewed that support and encouragement from the health authorities are needed to promote the recommendation of the HPV vaccine to adolescent boys. Physicians were also of the opinion that the lay public should be educated about the availability of the HPV vaccine for boys, and its benefits, safety and efficacy, and the high susceptibility of boys to getting HPV infections. The findings provide insights that could be helpful to policymakers or high-level decision-makers of the potential strategies to enhance HPV uptake among adolescent boys.

Background: Human Papillomavirus (HPV) leads to serious health issues and remains the most common sexually transmitted infection. Despite availability of effective vaccines, HPV vaccination rates are suboptimal. Furthermore, providers recommend the HPV vaccine less than half the time for eligible patients. Prior informatics research has demonstrated the effectiveness of computer-based clinical decision support (CDS) in changing provider behavior, especially in the area of preventative services., Methods: Following a randomized clinical trial to test the effect of a CDS intervention on HPV vaccination rates, we conducted semi-structured interviews with health care providers to understand whether they noticed the CDS reminders and why providers did or did not respond to the prompts. Eighteen providers, a mix of medical doctors and nurse practitioners, were interviewed from five publicly-funded, urban health clinics. Interview data were qualitatively analyzed by two independent researchers using inductive content analysis., Results: While most providers recalled seeing the CDS reminders, few of them perceived the intervention as effective in changing their behavior. Providers stated many reasons for why they did not perceive a change in their behavior, yet the results of the trial showed HPV vaccination rates increased as a result of the intervention., Conclusions: CDS reminders may be effective at changing provider behavior even if providers perceive them to be of little use., Trial Registration: ClinicalTrials.gov Identifier: NCT02551887 Registered on September 15, 2015.

Purpose: We sought to establish which human papillomavirus (HPV) vaccine communication approaches by pediatricians were associated with same-day HPV vaccination of 11- to 12-year-olds by evaluating audio recordings of visits., Methods: Verilogue, a market research company maintaining a panel of primary care pediatricians, provided audio recordings and transcriptions of well-child visits for 11- to 12-year-old patients from January through June 2013. Seventy-five transcripts from 19 pediatricians were coded for use of presumptive language (i.e., words conveying assumption of vaccine delivery), offer of delay, recommendation strength, and information provision. Using logistic regression, we evaluated the association between pediatrician communication approaches and agreement to same-day HPV vaccination. Generalized estimating equations accounted for clustering of patients within pediatricians., Results: Same-day agreement to HPV vaccination occurred in 29% of encounters. Pediatricians in the sample often provided parents with inconsistent, mixed messages and sometimes offered information about HPV or HPV vaccination that was inaccurate. Pediatricians used presumptive language in only 11 of 75 encounters; when used, presumptive language was associated with higher odds of accepting HPV vaccine (73% vs. 22%; odds ratio = 8.96; 95% confidence interval = 2.32-34.70). Pediatricians offered or recommended delay in most encounters (65%). HPV vaccine acceptance occurred far more often when pediatricians did not mention delaying vaccination (82% vs. 6%; odds ratio = 80.84; 95% confidence interval = 15.72-415.67). Same-day vaccination was not associated with strength of recommendation or pediatrician reference to vaccinating their own children., Conclusions: Our findings highlight the need to develop and evaluate physician-focused trainings on using presumptive language for same-day HPV vaccination., (Copyright © 2017 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: Healthcare providers (HCPs) are advised to give all parents a strong recommendation for HPV vaccination. However, it is possible that strong recommendations could be less effective at promoting vaccination among African Americans who on average have greater mistrust in the healthcare system. This study examines the associations of parental trust in HCPs and strength of HCP vaccination recommendation on HPV vaccine acceptance among African American parents., Methods: Participants were recruited from an urban, academic medical center between July 2012 and July 2014. We surveyed 400 African American parents of children ages 10-12years who were offered HPV vaccine by their HCPs to assess sociodemographic factors, vaccine beliefs, trust in HCPs, and the HPV vaccine recommendation received. Medical records were reviewed to determine vaccination receipt., Results: In multivariable analysis, children whose parents were "very strongly" recommended the HPV vaccine had over four times higher odds of vaccine receipt compared with those whose parents were "not very strongly" recommended the vaccine. Having a parent with "a lot of" versus "none" or only "some" trust in HCPs was associated with over twice the odds of receiving HPV vaccine. Very strong HCP recommendations were associated with higher odds of vaccination among all subgroups, including those with more negative baseline attitudes toward HPV vaccine and those with lower levels of trust. Adding the variables strength of HCP recommendation and parental trust in HCPs to a multivariable model already adjusted for sociodemographic factors and parental vaccine beliefs improved the pseudo R 2 from 0.52 to 0.55., Conclusions: Among participants, receiving a strong vaccine recommendation and having a higher level of trust in HCPs were associated with higher odds of HPV vaccination, but did not add much to the predictive value of a model that already adjusted for baseline personal beliefs and sociodemographic factors., (Copyright © 2017 Elsevier Ltd. All rights reserved.)

Background: There is a disparity in HPV vaccination rates in particular among young men who have sex with men (YMSM) and until very recently there has been a dearth of research examining factors related to HPV vaccination for YMSM. The purpose of this study was to elicit YMSM's beliefs about HPV and the HPV vaccine as well as describe perceived barriers and facilitators of vaccine initiation and completion., Methods: A qualitative, descriptive study that utilized a focus group design was conducted among an urban and racially diverse sample of YMSM. Questionnaire data were analyzed using descriptive statistics, and focus group data were analyzed using content analysis., Findings: 34 YMSM with a mean age of 20.8years participated. The sample was diverse, with the largest proportion of youth identifying as Black (35.4%). Over 90% reported having an annual exam each year, 61.8% reported obtaining a flu vaccine during the past year, and 58.8% reported initiating the HPV vaccine 3-dose series. Themes identified included low HPV knowledge and awareness, positive vaccine beliefs, perceived stigmas, and HPV vaccine facilitators. Participants identified 3 ways health providers/ researchers could facilitate vaccination: creative use of mobile technology, bundling vaccination with other health services, and increasing HPV and HPV vaccine awareness., Conclusions: Our findings point to some clear avenues to pursue in research and practice to improve HPV vaccination rates among YMSM, including increased use of mobile health strategies, making HPV vaccination a co-occurring part of other health-related services (e.g., HIV testing), and providing information on the relevance of HPV and HPV vaccination to YMSM., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Background: Provider recommendation is a significant predictor of HPV vaccine uptake. Prior research suggests that concerns regarding risk compensation could cause some providers to hesitate recommending the HPV vaccine., Methods: During 15-30 minute semi-structured interviews in early 2015, 22 U.S. pediatric providers were asked about their beliefs regarding sexual risk compensation and cervical cancer screening following HPV vaccination. Providers were asked if these beliefs result in reservations recommending the vaccine. Interviews were audio-recorded, transcribed, and analyzed using inductive content analysis., Results: None of the providers believed the HPV vaccine would result in risky sexual behavior. Half indicated it was better to start vaccination early, before sexual activity was a worry. Others noted that patients' risky behavior decisions happen independently of vaccination. When providers were asked if they were concerned about decreased cervical cancer screening, half said they did not know and some stated they had never thought about it before. The main themes addressed were the significant time lapse between vaccination and screening and that women tend to get over-screened as opposed to under-screened., Conclusion: Providers were generally in favor of HPV vaccination and do not perceive risk compensation as a barrier to HPV recommendation.

We explored HPV vaccination intention and its determinants among male clients of the sexually transmitted infections (STI) clinic in Amsterdam. In 2015, male clients aged ≥18 years were invited to complete a web-based questionnaire regarding HPV vaccination intention and socio-psychological determinants. Determinants (scale -3 to +3) were assessed with linear regression, stratified for men who have sex with men (MSM) (including men who have sex with men and women) and men who only have sex with women (MSW). Additionally, we explored the effect of out-of-pocket payment on intention. Of 1490 participants (median age 33 years [IQR:25-44]), 1,053(71%) were MSM. HPV vaccination intention was high (mean 1.68, 95%CI:1.55-1.81 among MSW; mean 2.35, 95%CI:2.29-2.42 among MSM). In multivariable analyses, socio-psychological determinants had similar effects on intention in both groups (R 2 =0.70 among MSW; R 2 =0.68 among MSM), except for subjective norms, self-efficacy, and HPV knowledge (significantly stronger associations among MSW). HPV vaccination intention decreased significantly when vaccination would require out-of-pocket payment; intention was negative at the current list price (€350). HPV vaccination intention among male clients of the Amsterdam STI-clinic is high and variance in intention was mostly be explained by socio-psychological factors. Out-of-pocket payment had a strong negative effect on HPV vaccination intention., (Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Rates of routine human papillomavirus (HPV) vaccination of adolescent males in the United States are low. Leading health organizations advocate consistent and strong physician recommendations to improve HPV vaccine dissemination. This study describes the prevalence and correlates of consistent and strong physician recommendations for HPV vaccination of adolescent males., Methods: We surveyed pediatric and family medicine physicians in Florida about their HPV vaccine recommendations for male vaccine-eligible age groups (11-12, 13-17, 18-21 years). Descriptive statistics compared consistency and strength of HPV recommendations across age groups. Multivariable logistic regression examined factors associated with consistent and strong recommendations for 11- to 12-year-olds., Results: We received 367 completed surveys (51% response rate). Physicians most often consistently and strongly recommended HPV vaccine to males ages 13 to 17 (39%) compared with ages 11 to 12 (31%) and 18 to 21 (31%). Consistent and strong recommendation for 11- to 12-year-old males was more likely to be delivered by Vaccine for Children providers and less likely among physicians who reported more personal barriers to vaccination, particularly concerns about vaccine safety, concerns about adding vaccines to the vaccine schedule, and difficulty in remembering to discuss HPV vaccination., Conclusions: Physicians' current consistency and strength of HPV vaccine recommendations do not align with national recommendations. Interventions to improve HPV vaccine recommendations must also consider the influence of physicians' personal barriers to HPV vaccine delivery., Impact: As one of the first studies to examine both consistency and strength of physicians' HPV vaccine recommendations for males, our findings can inform future interventions focused on facilitating physicians' recommendations. Cancer Epidemiol Biomarkers Prev; 25(10); 1435-46. ©2016 AACR., Competing Interests: Statement Regarding potential conflicts of interest, A.R. Giuliano (co-author) has received funding from Merck for consultancy and lectures and receives grant funding from Merck; A. Casler from the Vaccine Division of Merck; J.A. Kahn and G.D. Zimet from Merck; and D. Salmon from Pfizer, Crucell, and Merck., (©2016 American Association for Cancer Research.)

Objective: To examine the association between risk perceptions after human papillomavirus (HPV) vaccination and sexual behaviors and sexually transmitted infection (STI) diagnosis over 30months following vaccination., Methods: Participants included 112 sexually experienced girls aged 13-21years who were enrolled at the time of first HPV vaccination and completed ⩾2 of 4 follow-up visits at 2, 6, 18, 30months and including 30months. At each visit, participants completed surveys assessing risk perceptions (perceived need for safer sexual behaviors, perceived risk of STIs other than HPV) and sexual behaviors. STI testing was done at 6, 18, and 30months. Outcomes were condom use at last intercourse with main male partner, number of sexual partners since last study visit, and STI diagnosis. Associations between risk perceptions and sexual behaviors/STIs were examined using generalized linear mixed models., Results: Mean age was 17.9years; 88% were Black; 49% had a history of STI at baseline. Scale scores for perceived need for safer sexual behaviors did not change significantly over time. Scale scores for perceived risk of STIs other than HPV significantly changed (p=0.027), indicating that girls perceived themselves to be more at risk of STIs other than HPV over 30months following vaccination. Multivariable models demonstrated that greater perceived need for safer sexual behaviors following vaccination was associated with condom use (p=0.002) but not with number of partners or STI diagnosis. Perceived risk of STIs other than HPV was not associated with the three outcomes., Conclusions: The finding that perceived risk for STIs other than HPV was not associated with subsequent sexual behaviors or STI diagnosis is reassuring. The association between perceived need for safer sexual behaviors and subsequent condom use suggests that the HPV vaccination visit is an important opportunity to reiterate the importance of safer sexual behaviors to sexually experienced girls., (Copyright © 2016 Elsevier Ltd. All rights reserved.)