The HPV infection rate is increasing worldwide and is expected to become more widespread than cervical cancer. A review of literature was conducted to explore HPV and its consequences, vaccination barriers, strategies (facilitators or tactics for HPV vaccine uptake) for increasing the HPV vaccine uptake in adolescents, and to identify any gaps in the literature.
Literature Search Strategy
In efforts to isolate evidenced-based elements or themes that identified barriers and facilitators to HPV uptake, a comprehensive literature search was performed using databases CINAHL and EBSCOhost. Several search strategies were also followed to review the literature on successful vaccine programs as well as literature relating to HPV. The dates searched were from January 2011 to August 2018 so as to include current information from only the past seven years. The search was not restricted to any geographical setting.
Initially using the search terms HPV, uptake, health, and cancer produced 5,823 hits. To reduce the number of articles, two additional searches were undertaken by adding key terms minority, adolescent, HPV vaccine, barriers, facilitators, and access. The barriers for the HPV vaccine uptake were identified as socioeconomic status, lack of communication between parents and providers, lack of knowledge regarding HPV, cost to treat cancers associated with HPV, parental concerns, and lack of resources. These searches revealed 753 articles, and several were relevant quantitative studies conducted in the U.S., Europe, and the UK. It was noteworthy that the types of research design varied considerably, ranging from a quasi-experiment pre/post design to an observational study.
Three categories of search terms were subsequently entered independently and combined to reveal 303 citations. To narrow the search even further, articles were screened for inclusion after reviews of the abstracts and full text, which produced a final selection of nine articles.
Inclusion criteria included articles in the English language, quasi-trials, randomized control trials, articles published between 2011-2018, and articles that included adolescents between the ages of 11 and 19. Exclusion criteria included unrelated content and objectives, articles not in English, studies with adults only, and studies that did not report segregated data for the age group of interest. For this review, the adolescent population was defined as those individuals between 11 and 19 years old.
Vaccination Coverage and its Importance
Vaccination coverage is the estimated percent of individuals who have been vaccinated with specific vaccines (CDC, 2016). In the United States, health departments monitor vaccination coverage. This allows the states to assess how well their communities are protected from diseases that are preventable through vaccines. To help protect people from vaccine-preventable diseases, vaccine coverage information is used to identify areas and groups with lower vaccination coverage (CDC, 2016). As a result, health care partners, public health departments, and schools can act to improve vaccination coverage (CDC, 2016).
Consequences of HPV
HPV infections are common with prevalence peaking among young adults (Dunne, Nielson, Stone, Markowitz, & Giuliano , 2006; Dunne et al., 2011). Although most HPV infections usually clear within a couple of years, persistent infections can progress to precancers or cancer (Holman et al., 2014). Bouvard et al. (2009) explained that HPV includes a group of more than 40 sexually transmitted types that are catergorized epidemiologically based on risk (oncogenic). High- risk or oncogenic HPV types not only cause cervical cancers, but are a factor in many other oropharyngeal and anogenital cancers (Markowitz et al., 2013).
HPV-16 and -18 are responsible for roughly 70% of cervical cancers and are considered the high risk type (de Sanjose et al., 2010). Low risk or nononcogenic HPV types such as HPV-6 and -11 cause anogenital warts and rescurrent respiratory papillomatosis (Lacy, Lowndes, & Shah, 2006). In fact, vulvar, penile, vaginal orapharyngeal, and anal cancers are all caused by persistent infection with oncogenic or high-risk HPV types (Holman et al., 2014). The genital warts caused by HPV are known to be painful and uncomfortable.
According to a study by Hariri et al. (2011), about 40% of females aged 14 to 59 years were HPV positive; in addition, about 30% of infections were with high-risk types. Approximately 26 200 cancers per year are attributable to HPV, many of which could be preventable with appropriate use of current or future vaccines (CDC, 2018).
The incidence of HPV positive oropharyngeal cancers has increased in males in the United States (Chaturvedi et al., 2018). However, the prevalence of oral HPV infections were reduced in vaccinated individuals when compared to unvaccinated individuals (Chaturvedi et al., 2018).
The medical cost attributable to HPV can be enormous. Annually, the direct medical cost burden of preventing and treating HPV-associated diseases was nearly $8 billion, and nearly $6 billion was expended for cervical cancer screenings and follow-up visits in 2012 (Chesson et al., 2012). In addition, the increased financial burden resulting from cancer diagnosis leads to a poor quality of life among cancer survivors (Fenn et al., 2014).
Barriers to HPV Vaccine Uptake
Minority populations and those categorized as low socioeconomic status in the United States are affected disproportionately and diagnosed with cervical cancer more frequently (Grant et al., 2015). Women classified as lower socioeconomic status are less likely to initiate and complete the HPV vaccine series (Fisher, Trotter, Audrey, MacDonald-Wallis, & Hickman, 2013; Laz et al., 2013). In fact, the differences may be more pronounced than previously imagined (Rositch, Nowak, & Gravitt, 2014).
Hispanic and black women are most likely to be diagnosed with cervical cancer (Rositch et al., 2014), but HPV seems to be more prevalent in black women when compared to other ethnicities (Steinau et al., 2013). Although both groups have seen an increase in the uptake of the HPV vaccine, both groups remain low? when it comes to receiving the total series of the vaccine thus, making low socioeconomic status a barrier for vaccination (Reagan-Steiner et al., 2014).
Lack of Knowledge.
Lack of knowledge of HPV is an additional barrier frequently discussed in the literature. Parents who questioned the safety or the effectiveness of the vaccine were less like to vaccinate (Roberts et al., 2015). Also, parents with a lower level of education, were less likely to vaccinate than parents with higher educational levels (Lefowitz, Kelly, Vasilenko, & Maggs, 2014).
Parents also delay vaccination for their younger children and choose to vaccinate them when they are between the ages of 13-15 years old and not at the recommended age of 11 years old (Steinau et al., 2013). Parents believe that delaying their adolescent child’s HPV vaccination will lessen risky sexual behavior (Perkins et al., 2014).
Lack of knowledge by the provider was also mentioned in the literature. A study by Saraiya, Rosser, and Cooper (2012) revealed a low knowledge existed with medical providers regarding the correlation between HPV infection and genital warts and the relationship between HPV and noncervical cancers in females.
Disconnect Between Providers and Parents
START Roughly 90% of parents with daughters and approximately 81% of parents with sons indicated awareness of the HPV vaccine. 58% of parents with daughters and 14.2% of parents with sons reported that their provider had recommended the HPV vaccine for their child (Rahman et al., 2015). On the other hand, it is the opinion of many physicians that parents simply ignore the recommendation to have their children vaccinated, thus providing one of the most persistent barriers to uptake (Rahman et al., 2015).
Despite this fact, as of 2011, HPV awareness among parents was found to be greater than 80 percent. The evident disconnect between providers and parents requires further investigative study to determine what can be done to communicate the need to parents and to ensure follow through on vaccinations.
In vaccinations of males, communication efforts are also needed to highlight the benefits and importance vaccination (Holman et al., 2014). Parents of males often report not vaccinating their sons because of the perceived lack of direct benefit (Holman et al., 2014).
Provider Recommendation/Physician Influence
Consequently, and based on study outcomes (Rahman et al., 2015), there appears to be a direct correlation between provider recommendations for HPV vaccination and increased vaccine uptake. According to Holman (2014), medical professionals may benefit from guidance on communicating HPV recommendations to their patients and parents during clinic visits. As an introspective influence in the process, physicians would seem to be in a position not only to recommend and prescribe, but also to educate parents as well as adolescents on the benefits of the HPV vaccine.
Additionally, lack of physician recommendation is frequently cited as a reason why parents do not vaccinate (Roberts et al., 2015). The results of a longitudinal study reported that of 388 vaccine-eligible girls, only 37% received an HPV vaccine recommendation by their physician over the course of a year (Brewer et al., 2011). Providers who self-reported low vaccination rates admitted that they refrained from offering the HPV vaccine to adolescents who they did not think were sexually active (Beavis & Levinson, 2016).
As a result, misconceptions stemmed from the healthcare provider who did not actively propose vaccination initiation (Beavis & Levinson, 2016). On the other hand, when providers or medical doctors recommended the vaccine, the rates for vaccination were increased significantly (Beavis & Levinson, 2016).
It appears that improving best practice guidelines that provide both a medical and legal framework for recommending vaccination offers a path to improved vaccination uptake. The Rahman et al. (2015) study indicates that just 14% of parents with adolescent sons reported ever having received a physician recommendation for the HPV vaccination. However, it is noted that much of the responsibility for this could be ascribed to the ACIP, which has not updated its recommendations for quadrivalent HPV vaccine in males since October 2011 (Du et al., 2015).
Cost.
Cost is also frequently cited as a barrier to HPV vaccine uptake, especially with individuals who are economically disadvantaged (Daley et al., 2010). In fact, cost was reported most frequently as a barrier in a number of studies (Rambout, Tashkandi, Hopkins, & Tricc, 2014). Lack of health insurance, which results in patients paying for the vaccine out of their pocket, is an important factor associated with the failure to start the HPV vaccination (Fisher et al., 2013). This information is vital as it plays an important role in deciphering strategies that could lead to HPV vaccination initiation and completion (Beavis & Levinson, 2016). Without a doubt, providing vaccinations at no cost could increase vaccination uptake (Ferrer, Trotter, Hickman & Audrey, 2013).
Parental Concerns
Parental concerns and preconceptions are influential in determining whether children receive vaccinations and are often at the root of decreased HPV vaccination uptake (Ferrer, Trotter, Hickman, & Audrey, 2016). As previously discussed, parents may ignore the advice of health care providers. Some, on the other hand, may have an ill-informed perspective despite being aware of the risk of cervical cancer and other health threats (Ferrer et al., 2016).
The 2015 English study that sought to identify the barrier and facilitators to the uptake of the HPV vaccine in an ethnically diverse group of young women used interview sessions with 23 young ethnic minority women. Seventeen had received the HPV vaccine (14 in school). Those who had not been vaccinated provided a variety of reasons for not having done so. One subject’s mother feared that getting the vaccine would encourage her daughter to become more sexually active, while another simply feared being injected with a needle. Another interview subject said her mother was too busy to be bothered with vaccination (Ferrer et al, 2016).
Thus, social and educational factors impacted the decision to be vaccinated. The English study revealed that consent procedures for young female students were not being followed. The Ferrer et al. (2016) study revealed that parental guidance and or approval affects the uptake of the HPV vaccine in the adolescent population. If parents are unsure about vaccinations, it is likely that they will not vaccinate their child.
Facilitators for Vaccination Uptake
For the purpose of this project, the term facilitator will describe actions or strategic tactics which may help increase the uptake of the HPV vaccination. Facilitators for vaccine uptake can influence vaccination rates in a positive way. Numerous studies have suggested that access to the HPV vaccine is governed by parental influences, organizational factors, health professional recommendations, social norms and values, and policy context (Ferrer et al., 2016).
An additional facilitator has been identified as perceived benefit of vaccination (Rambout et al., 2014). Endorsements from influential individuals such as parents and health care providers seem to be important factors in prompting vaccination use; however, communication with those individuals can often be unclear or suboptimal (Rambout et al., 2014). As a result, it is important for healthcare providers to clearly and concisely educate their patients on the benefits of vaccination (Rambout et al., 2014). Therefore, being able to interpret aspects, which arbitrate vaccination decisions among target groups such as minorities, can result in improving the success of health promotion interventions (Rambout et al., 2014).
Strategies for HPV Vaccination Uptake
A number of factors have been examined for their relationship with low uptake of the HPV virus. The key factors or themes that were extracted from the literature regarding HPV vaccination uptake include: (a) implementing school-based interventions to increase vaccination; (b) addressing disconnect between providers and parents; (c) addressing parental concerns and; (d) heterogeneous approaches. Increasing access to care and provider recommendation is also vital to HPV vaccination uptake (Beavis & Levinson, 2016).
