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Infect Dis Obstet Gynecol. 2006; 2006: 36797. Published online 2006. doi: 10.1155/IDOG/2006/36797. | PMCID: PMC1522063 |
Strategies for Fostering HPV Vaccine Acceptance Bernard Gonik* Department of Obstetrics and Gynecology, School of Medicine, Wayne State University, Detroit, MI 49201, USA Received August 18, 2005; Accepted September 20, 2005. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Vaccines that protect against infection with the types of human papillomavirus (HPV) commonly associated with cervical cancer
(HPV 16 and 18) and genital warts (HPV 6 and 11) are expected to become available in the near future. Because HPV vaccines are
prophylactic, they must be administered prior to exposure to the virus, ideally during preadolescence or adolescence. The young
age of the target vaccination population means that physicians, parents, and patients will all be involved in the decision-making
process. Research has shown that parents and patients are more likely to accept a vaccine if it is efficacious, safe, reasonably priced,
and recommended by a physician.Widespread education of physicians, patients, and parents about the risks and consequences of
HPV infection and the benefits of vaccination will be instrumental for fostering vaccine acceptance. Human papillomavirus (HPV) is the most common sexually
transmitted infection (STI) and a known risk factor for cervical
cancer [ 1, 2]. HPV is highly prevalent in younger populations,
with prevalence rates of approximately 50% in sexually
active adolescent girls and young women [ 3]. Early age of
first sexual intercourse is associated with greater susceptibility
to HPV infection, possibly due to cervical immaturity [ 4].
Current estimates suggest that approximately 15% of sexually
active adults in the United States have clinical or subclinical
infections [ 5]. Despite the fact that most sexually active individuals
will become exposed throughout their lives, knowledge
about HPV and the diseases that HPV causes is generally
very limited [ 6]. The average age of first sexual intercourse inNorth America
is approximately 16 years for both men and women [ 7].
To provide the greatest public health benefit, HPV vaccines
must be administered prior to initiating sexual activity and
hence would be most effective if offered during early adolescence.
Because gynecologists often serve as the sole health
care provider for many women, they are in an excellent position
to disseminate information about the risks and consequences
of HPV infection as well as provide information
about HPV vaccines that will soon become commercially
available. Population awareness of the risks associated with acquiring HPV and the consequences associated with infection is low. Numerous studies have demonstrated that most patients are
unaware of HPV and its association with genital warts and
cervical cancer [ 2, 6, 8, 9, 10,
11, 12, 13,
14]. Furthermore, awareness has not
improved in the past decade: approximately 33% of women
and half of men surveyed have never heard of HPV [ 9, 11].
Nonetheless, there is a desire for more information about
HPV [ 15]. Women want to know how HPV is transmitted,
including whether intercourse is required to transmit disease,
and how they and their sexual partners can prevent becoming
infected. Additional information of interest includes
whether condoms protect against the virus, how HPV is detected,
the likelihood of spontaneous resolution of infection,
and the risk of cervical cancer [ 16]. Vaccines designed to reduce the incidence of HPV infection
are in late stages of clinical development and studies to date
have demonstrated that these vaccines are safe and highly efficacious.
Widespread acceptance of HPV vaccines are likely
to lend enormous health benefits by decreasing morbidity
and mortality associated with cervical cancer and by reducing
the psychosocial burden of both genital warts and abnormal
Papanicolaou (Pap) test results. Savings in health care
expenditures, including treatments for genital warts, preinvasive
cervical lesions, and cervical cancer would also be considerable
[ 17]. Historically, however, vaccine availability has not always
translated to widespread use. Underestimates of both the
level of risk and the severity of HPV-associated disease may become barriers to vaccine acceptance
[ 18]. Hence, physician, parent, and patient education about HPV and HPV
vaccines will be crucial to effectively implement HPV vaccination
programs. Vaccine acceptability among individuals Attitudes regarding HPV vaccine acceptance can be assessed
based on acceptability of previous vaccines and through
questionnaires completed by patients, parents, and health
care providers. For example, Kahn et al presented questionnaires
to 52 young women regarding HPV vaccination, and
found that most viewed vaccination positively [ 19]. Furthermore,
most reported a high intention of receiving the
vaccine, both for themselves and their hypothetical daughters.
Knowledge about HPV and the vaccine, personal beliefs
about vaccination, beliefs that others would approve of vaccination,
higher number of sexual partners, and perceived support
of provider, partner, and parents were all significantly
associated with intention to receive the vaccine [ 19]. In a
separate study of 256 college students, 74% endorsed HPV
vaccination [ 20]. Of those surveyed, acceptance significantly
correlated with higher number of sexual partners, parental
support, endorsement of universal HPV vaccination, low
cost, and vaccine safety. Hoover et al evaluated knowledge
of HPV and attitudes toward HPV vaccination and clinical
trial participation among 60 female adolescents and young
adults [ 21]. Almost all of the participants expressed interest
in receiving a vaccine that would prevent cervical cancer and
genital warts. Another study examined the attitudes about
hypothetical HPV vaccines in adolescent (  ) and adult women (  ) attending two urban STI clinics [ 22]. Here,
the idea of an HPV vaccine was favorably received and several
factors affected potential acceptance, including vaccine
efficacy, physician endorsement, and cost. Vaccine acceptability among parents Vaccine acceptance among parents is not universal. Although,
in general, overall confidence in vaccines remains
high, many Americans distrust public health policy and
refuse vaccination on these grounds [ 23]. Concern over potential
side-effects from vaccines is a common barrier to vaccination
[ 24]. Parents may also object to vaccination for religious
or philosophical reasons [ 25]. To overcome these barriers, clinicians should informparents
of the prevalence of HPV among adolescents and discuss
the potential consequences of forgoing vaccination and becoming
infected. Although many childhood vaccines are for
diseases that are now rare, HPV is highly prevalent and educational
efforts should stress that most sexually active adolescents
will acquire HPV. The sexual nature of HPV infections may introduce
unique barriers to parental consent not previously encountered
with other vaccines. Parents may feel that consenting
to a vaccine for an STI may inadvertently encourage their
adolescent children to engage in sexual intercourse. Similarly,
parentsmay feel that vaccination at an early age will encourage
earlier sexual debut [ 26]. Acceptance of the vaccine represents an acknowledgment of risk of infection [ 27], and
some parents may have difficulty accepting the fact that their
children are approaching an age at which sexual activity is
often initiated. Contrary to these beliefs, several studies have suggested
that the sexually transmitted nature of HPV may not pose a
major obstacle toHPV vaccine acceptance. In one study, 70%
of parents approved of vaccination for STIs [ 18, 28]. Desire
to protect their children, concern about specific disease characteristics,
and personal experience with an STI were directly
correlated with vaccine acceptance. Rejection was associated
with the perception that their child was at low risk for infection
or with the parent having a low concern about severity
of the disease. In a similar study, Zimet et al questioned
278 parents about their attitudes toward adolescent vaccination,
incorporating nine hypothetical STI scenarios defined
along four different dimensions: mode of transmission
(STI vs non-STI), severity (curable/chronic/fatal), vaccine efficacy
(50%, 70%, 90%), and behavioral method for prevention
(available/not available) [ 27]. Interestingly, whether a
disease was sexually transmitted did not affect the parents'
decision. Instead, severity of the hypothetical disease and
vaccine efficacy predicted vaccine acceptance [ 27]. When parents who were undecided about HPV vaccination were provided with a basic information sheet about
HPV and HPV vaccines, they became significantly more likely to support HPV vaccination [ 26]. Physician endorsement and school requirements have also been identified
as important catalysts for parental vaccine acceptance [ 29].
Conversely, information acquired from friends, relatives, or
advertisements had a marginal impact. Vaccine acceptability among health care professionals Endorsement by professional organizations is a major predictor
of HPV vaccine acceptance. One study concluded that
a recommendation from the American College of Obstetricians
and Gynecologists would be the most important factor
influencing whether gynecologists would recommend vaccination
[ 29]. If the endorsements included a specific age for
vaccination, this would undoubtedly increase acceptance of
early-adolescent HPV vaccination. Educational initiatives targeting health care professionals
have demonstrated effectiveness in fostering vaccine acceptance.
A study to measure the effectiveness of a statewide
peer educational program on changes in clinician immunization
practice patterns and behaviors was conducted between
June 1999 and October 2000 (Figure 1) [ 30]. Interventions
included hospital grand rounds lectures and officebased
small group in-service sessions. Forty-two percent of
the 532 providers who attended the 16 grand rounds lectures
completed both the pre- and posttests; the response
rate was the same for the 368 physicians who attended the
15 office-based sessions. Knowledge (  ) and practice
attitudes (  ) pertaining to vaccine-preventable disease
and immunization improved after attending a lecture
or in-service session. Grand rounds were more effective than
in-service sessions at convincing physicians to change their vaccine-preventable disease office
practices (  ), but everyone
who participated in one or more interventions had
better knowledge recall, improved attitudes toward vaccinepreventable
disease, and practice patterns that were more
likely to improve patient vaccine awareness compared with
those who did not participate (  ). Thus, educational
interventions can positively influence immunization-related
practice patterns. Educational efforts aimed at health care professionals
should include physician assistants and nurse practitioners,
as well as physicians. Educating patients about HPV and
the HPV vaccine will be time consuming, and the assistance
these groups can provide will prove to be invaluable. Clinicians should provide information in an individualized
fashion, tailoring educational sessions according to the
patient's background, age, and literacy level [ 16]. An effort
should be made to provide needed information to parents
and adolescents without creating needless anxiety over the
situation [ 31]. Nonetheless, it is crucial that the high risk of
infection, the frequent negative consequences associated with
infection, and the importance of vaccinating in early adolescence,
before the individual has become sexually active, be
made clear to the parent. Prophylactic HPV vaccines may soon become available for
public distribution; however, general knowledge about HPV
and HPV-associated disease is limited and may affect vaccine
acceptability. Research suggests that vaccine acceptance will
be maximized by effectively communicating the risks associated
with HPV infection and the benefits of vaccination. Educational
initiatives targeted towards patients, parents, and
health care providers will play key roles in fostering positive
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