Annie Laurie McRee

Longitudinal predictors of human papillomavirus vaccine initiation among adolescent girls in a high-risk geographic area.

Background: Human papillomavirus (HPV) vaccine uptake is low among adolescent girls in the United States. We sought to identify longitudinal predictors of HPV vaccine initiation in populations at elevated risk for cervical cancer. Methods: We interviewed a population-based sample of parents of 10- to 18-year-old girls in areas of North Carolina with elevated cervical cancer rates. Baseline interviews occurred in summer 2007 and follow-up interviews in fall 2008. Measures included health belief model constructs. Results: Parents reported that 27% (149/567) of their daughters had initiated HPV vaccine between baseline and follow-up. Of parents who at baseline intended to get their daughters the vaccine in the next year, only 38% (126/348) had done so by follow-up. Of parents of daughters who remained unvaccinated at follow-up but had seen a doctor since baseline, only 37% (122/388) received an HPV vaccine recommendation. Rates of HPV vaccine initiation were higher among parents who at baseline perceived lower barriers to getting HPV vaccine, anticipated greater regret if their daughters got HPV because they were unvaccinated, did not report “needing more information” as the main reason they had not already vaccinated, intended to get their daughters the vaccine, or were not born-again Christians. Conclusions: Missed opportunities to increase HPV vaccine uptake included unrealized parent intentions and absent doctor recommendations. While several health belief model constructs identified in early acceptability studies (e.g., perceived risk, perceived vaccine effectiveness) were not longitudinally associated with HPV vaccine initiation, our findings suggest correlates of uptake (e.g., anticipated regret) that offer novel opportunities for intervention.

HPV vaccine and adolescent males

In 2009, the United States approved quadrivalent HPV vaccine for males 9-26 years old, but data on vaccine uptake are lacking. We determined HPV vaccine uptake among adolescent males, as well as stage of adoption and vaccine acceptability to parents and their sons. A national sample of parents of adolescent males ages 11-17 years (n=547) and their sons (n=421) completed online surveys during August and September 2010. Analyses used multivariate linear regression. Few sons (2%) had received any doses of HPV vaccine, and most parents and sons were unaware the vaccine can be given to males. Parents with unvaccinated sons were moderately willing to get their sons free HPV vaccine (mean=3.37, SD=1.21, possible range 1-5). Parents were more willing to get their sons vaccinated if they perceived higher levels of HPV vaccine effectiveness (β=0.20) or if they anticipated higher regret about their sons not getting vaccinated and later developing an HPV infection (β=0.32). Vaccine acceptability was also modest among unvaccinated sons (mean=2.98, SD=1.13, possible range 1-5). Sons were more willing to get vaccinated if they perceived higher peer acceptance of HPV vaccine (β=0.39) or anticipated higher regret about not getting vaccinated and later developing an HPV infection (β=0.22). HPV vaccine uptake was nearly nonexistent a year after permissive national recommendations were first issued for males. Vaccine acceptability was moderate among both parents and sons. Efforts to increase vaccine uptake among adolescent males should consider the important role of peer acceptance and anticipated regret.

Growing Up With a Chronic Illness: Social Success, Educational/Vocational Distress

OBJECTIVES We compared adult educational, vocational, and social outcomes among young adults with and without childhood-onset chronic illness in a nationally representative U.S. sample. METHODS We used data from Wave IV (2008) of the National Longitudinal Study of Adolescent Health. We compared respondents who reported childhood-onset cancer, heart disease, diabetes, or epilepsy with young adults without these chronic illnesses in terms of marriage, having children, living with parents, romantic relationship quality, educational attainment, income, and employment. Multivariate models controlled for sociodemographic factors and adult-onset chronic illness. RESULTS As compared with those without childhood chronic illness, respondents with childhood chronic illness had similar odds of marriage (odds ratios [OR] = .89, 95% CI: .65-1.24), having children (OR = .99, 95% CI: .70-1.42), and living with parents (OR = 1.49, 95% CI .94-2.33), and similar reports of romantic relationship quality. However, the chronic illness group had lower odds of graduating college (OR = .49, 95% CI: .31-.78) and being employed (OR = .56, 95% CI: .39-.80), and higher odds of receiving public assistance (OR = 2.13, 95% CI: 1.39-3.25), and lower mean income. CONCLUSIONS Young adults growing up with chronic illness succeed socially, but are at increased risk of poorer educational and vocational outcomes.

Acceptability of HPV Vaccine Among a National Sample of Gay and Bisexual Men

Objective: Due to higher rates of human papillomavirus (HPV) infection and anal cancer among gay and bisexual men, we aimed to characterize their willingness to get HPV vaccine and identify correlates of vaccine acceptability. Methods: We surveyed a national sample of men aged 18 to 59 who self-identified as either gay (n = 236) or bisexual (n = 70) during January 2009. We analyzed data using multivariate logistic regression. Results: Most men had heard of HPV vaccine (73%, 224/306) and were willing to get it (74%, 225/306). HPV vaccine acceptability was higher among men who believed their doctor would recommend getting the vaccine (OR = 12.87, 95% CI: 4.63–35.79) and those who were unsure (OR = 3.15, 95% CI: 1.47–6.76), as compared to men who believed their doctor would not recommend it. Acceptability was also higher among men who reported 5 or more lifetime sexual partners (OR = 3.39, 95% CI: 1.34–8.55), perceived greater severity of HPV-related disease (OR = 1.92, 95% CI: 1.18–3.14), perceived higher levels of HPV vaccine effectiveness (OR = 1.97, 95% CI: 1.27–3.06), or reported higher levels of anticipated regret if they did not get vaccinated and later developed an HPV infection (OR = 2.39, 95% CI: 1.57–3.61). Conclusions: HPV vaccine acceptability was high among gay and bisexual men. These findings identify potentially important beliefs and attitudes for future communication efforts about HPV and HPV vaccine among gay and bisexual men.

Longitudinal Predictors of Human Papillomavirus Vaccination Among a National Sample of Adolescent Males

OBJECTIVES We conducted a longitudinal study to examine human papillomavirus (HPV) vaccine uptake among male adolescents and to identify vaccination predictors. METHODS In fall 2010 and 2011, a national sample of parents with sons aged 11 to 17 years (n = 327) and their sons (n = 228) completed online surveys. We used logistic regression to identify predictors of HPV vaccination that occurred between baseline and follow-up. RESULTS Only 2% of sons had received any doses of HPV vaccine at baseline, with an increase to 8% by follow-up. About 55% of parents who had ever received a doctors recommendation to get their sons HPV vaccine did vaccinate between baseline and follow-up, compared with only 1% of parents without a recommendation. Fathers (odds ratio = 0.29; 95% confidence interval = 0.09, 0.80) and non-Hispanic White parents (odds ratio = 0.29; 95% confidence interval = 0.11, 0.76) were less likely to have vaccinated sons. Willingness to get sons HPV vaccine decreased from baseline to follow-up among parents (P < .001) and sons (P = .003). CONCLUSIONS Vaccination against HPV remained low in our study and willingness to vaccinate may be decreasing. Physician recommendation and education about HPV vaccine for males may be key strategies for improving vaccination.

Do correlates of HPV vaccine initiation differ between adolescent boys and girls

BACKGROUND Guidelines now recommend that adolescents routinely receive human papillomavirus (HPV) vaccine. Because little is known about uptake among boys, we assessed HPV vaccine initiation in a population-based sample of adolescent boys and girls. METHODS We analyzed weighted data from 751 parents who reported on an 11- to 17-year-old son or daughter for the 2010 North Carolina Child Health Assessment and Monitoring Program survey. Stratified multivariate logistic regression analyses identified correlates of HPV vaccine initiation separately for boys and girls. RESULTS Only 14% of sons had received one or more doses of HPV vaccine compared to 44% of daughters (p<0.01). For both sons and daughters, vaccine initiation correlated with age and having received meningococcal vaccine. Among sons, initiation of HPV vaccine was lower for those living in high income households (odds ratio [OR]=0.22, 95% CI, 0.09-0.53) and higher for those whose race was neither white nor black (OR=3.26, 95% CI, 1.06-10.04). When asked to give the main reason for not vaccinating their child against HPV, parents of unvaccinated sons were more likely than those of daughters to report not getting a providers recommendation or not being aware that the vaccine was available for their child, but less likely to report concern about safety (p<0.01). At least 86% of unvaccinated children had missed an opportunity to receive HPV vaccine. CONCLUSIONS HPV vaccine correlates and concerns varied for parents of boys and girls. To improve very low levels of uptake among boys, providers should recommend HPV vaccine concomitant with other adolescent vaccines.

Statewide HPV Vaccine Initiation Among Adolescent Females in North Carolina

Background: Cervical cancer incidence in the United States may be greatly reduced through widespread human papillomavirus (HPV) vaccination. We estimated the statewide level of HPV vaccine initiation among adolescent girls in North Carolina and identified correlates of vaccine initiation. Methods: We used data from 617 parents of adolescent females from North Carolina who completed the population-based 2008 Child Health Assessment and Monitoring Program survey. Analyses used weighted multivariate logistic regression. Results: Overall, 31.3% of parents reported their daughters had received at least 1 dose of HPV vaccine. Vaccine initiation was higher among daughters aged 13 to 15 years (odds ratio [OR] = 2.03, 95% CI, 1.12–3.67) or 16 to 17 years (OR = 3.21, 95% CI, 1.76–5.86) compared with those 10 to 12 years old. Additional correlates of HPV vaccine initiation included the daughter having a preventive check-up in the last 12 months (OR = 5.09, 95% CI, 2.43–10.67), having received meningococcal vaccine (OR = 2.50, 95% CI, 1.55–4.01), or being from an urban area (OR = 1.81, 95% CI, 1.02–3.21). Among parents of unvaccinated daughters, intent to vaccinate in the next year was higher among those with daughters aged 13 to 17 years. Parents of unvaccinated non-Hispanic white daughters reported lower levels of intent to vaccinate within the next year compared with parents of unvaccinated daughters of other races. Conclusions: HPV vaccine initiation in North Carolina is comparable with other US areas. Potential strategies for increasing HPV vaccination levels include reducing missed opportunities for HPV vaccination at preventive check-ups and increasing concomitant administration of HPV vaccine with other adolescent vaccines.

Does Framing Human Papillomavirus Vaccine as Preventing Cancer in Men Increase Vaccine Acceptability

Background: Human papillomavirus (HPV) vaccine is now approved for use in males in the United States to prevent genital warts. We conducted an experiment to see whether framing HPV vaccination as also preventing cancer in men would increase mens vaccination willingness. Methods: We conducted an online survey in January 2009 with a national sample of men ages 18 to 59 years who self-identified as gay/bisexual (n = 312) or heterosexual (n = 296). In the within-subjects experiment, men read four randomly ordered vignettes that described hypothetical vaccines that prevented either genital warts alone, or genital warts and either anal cancer, oral cancer, or penile cancer. We analyzed data using repeated measures ANOVA and tested whether perceived severity or perceived likelihood mediated the effect of disease outcome framing on mens HPV vaccination willingness. Results: Although only 42% of men were willing to receive HPV vaccine when it was framed as preventing genital warts alone, 60% were willing to get it when it was framed as preventing cancer in addition to genital warts (P < 0.001). The effect of outcome framing was the same for heterosexual and gay/bisexual men and for the three cancer types examined. Perceived severity of disease partially mediated the association between disease outcome and HPV vaccination willingness. Conclusions: Men may be more accepting of HPV vaccine when it is framed as preventing cancer, regardless which of the three most common HPV-related cancers in men is described. Impact: Study findings may be useful in developing health communication messages that maximize HPV vaccine acceptability among young men. Cancer Epidemiol Biomarkers Prev; 19(8); 1937–44. ©2010 AACR.

Vaccinating adolescent girls against human papillomavirus-Who decides?

Human papillomavirus (HPV) vaccination holds exceptional promise for preventing genital warts, cervical cancer and other HPV-related cancers (Markowitz et al., 2007). Most research on HPV vaccine acceptability has focused on parents (Brewer and Fazekas, 2007), potentially overlooking an important role that adolescents may have in making these vaccination decisions. While parents are likely to be the primary decision makers about their child’s healthcare, many individuals begin contributing to these decisions during adolescence (Dickey and Deatrick, 2000). Research conducted prior to availability of HPV vaccine suggests that many parents believe vaccination decisions should be made jointly between parents and their children (Brabin et al., 2006) making it plausible that adolescents are more central to HPV vaccination decisions than presently recognized. To address this question, we briefly characterize parent perceptions of adolescent involvement in decisions about whether they will get vaccinated against HPV. We describe the study design briefly here and in detail elsewhere (Hughes et al., 2009, Ziarnowski et al., 2009). At baseline, we contacted a probability sample of households in areas of North Carolina with elevated cervical cancer rates, over-sampling households likely to include a female child aged 10 to 18, African Americans, and rural telephone exchanges. Trained personnel used computer-assisted telephone interviewing equipment to conduct interviews. Data for our paper came from follow-up interviews with caregivers of adolescent girls, by then aged 11–20. Since the vast majority of caregivers interviewed (97%) reported being the child’s parent, hereafter, we refer to all participants as parents. Of 1220 eligible parents contacted, 889 (73%) completed baseline interviews between July and October 2007. Interviewers re-contacted 74% (650/873) of eligible baseline respondents by telephone during the fall of 2008. HPV vaccine decision-making data were available for 647 parents. Most parents were female (94%; Table 1), non-Hispanic White (74%) or African American (20%), married (86%), and had at least some college education (81%). The University of North Carolina Institutional Review Board approved the study. Table 1 Correlates of daughter involvement in HPV vaccination decision making (North Carolina, USA, 2008). The primary outcome was parents’ report of their daughters’ involvement in HPV vaccination decisions (1=“none”, 4=“a lot”). We also assessed the primary person who decided whether to vaccinate the daughter against HPV (self, spouse, daughter, other). We collected information on HPV vaccine uptake, whether a doctor had recommended HPV vaccine, and parent’s perception of their daughter’s sexual activity. The survey also assessed daughter’s age as well as a range of parent demographics. We examined correlates of adolescent involvement in HPV vaccination decisions with linear regression (reporting associations as standardized regression coefficients, β’s). We examined correlates of daughters being primary decision makers as well as associations between involvement and vaccine uptake with logistic regression (reporting associations as odds ratios, ORs). We entered statistically significant bivariate predictors (p<0.05) into multivariate models. Analyses used Stata SE version 10.0 (Statacorp, College Station, TX). Parents reported substantial involvement by their daughters in decisions about whether to get HPV vaccine (mean: 2.55, SD=1.21). About half (51%, 329/647) reported their daughters were involved a moderate amount or a lot in the decisions. Furthermore, while most parents reported either they or their spouses were the primary person who made HPV vaccination decisions (86%, 559/647), many parents identified their daughter as the primary decision maker (12%, 75/647). Adolescent involvement in HPV vaccination decisions was higher among daughters aged 15–17 (β=.24) or 18–20 (β=.41) than those aged 11–14 (both p<.001) in multivariate analyses. Parents who believed their daughters were sexually active (β=.11, p<.05) or who reported receiving a doctor recommendation to get their daughters HPV vaccine (β=.08, p<.05) also indicated their daughters were more involved. Daughter’s age was the only significant correlate of daughters being primary decision-makers. Daughters aged 15–17 (11%, OR=2.41, 95%CI: 1.16–5.02) or 18–20 (30%, OR=8.54, 95%CI: 4.30–16.97) were more likely than daughters aged 11–14 (5%) to be the primary decision-maker. At baseline and follow-up, 12% and 35% of parents had initiated HPV vaccine for their daughters. Initiation of HPV vaccine increased with higher adolescent involvement in vaccination decisions (OR=1.18, 95%CI: 1.03–1.35) in bivariate analyses. This relationship was no longer statistically significant after controlling for covariates that were significant in bivariate models (daughter’s age, perception of daughter’s sexual activity, doctor’s recommendation, race/ethnicity, and parental education level). In summary, many parents reported that their daughters were involved in HPV vaccination decisions. This level of involvement is consistent with a recent finding that 48% of adolescent girls said they participated in decisions about whether or not to receive HPV vaccine (Mathur et al., 2009). The gap in our understanding of adolescents’ role in decision making may hamper efforts to increase vaccine uptake. Adolescent involvement in vaccination decisions has the potential to both positively and negatively influence uptake of HPV vaccine. Our findings show that daughters are involved in decisions both to receive and to decline HPV vaccination, but the nature of their involvement is still unclear. Knowledge of how parents and their daughters jointly make HPV vaccination decisions may provide insight into ways of increasing current rates of HPV vaccination. Doctor recommendation of HPV vaccine predicts acceptability (Brewer and Fazekas, 2007) and uptake (Reiter et al., 2009). In our study, we found it was also associated with adolescent involvement in HPV vaccination decisions, though the reason for this relationship requires further investigation. Communication about HPV vaccine between adolescents, their parents, and their healthcare providers is also an area for future research. The main limitation of this study is that we understand adolescents’ participation only from the perspective of their parents. Interviewing daughters might give us a different impression of their involvement, potentially showing a larger role. We did not explicitly ask whether parents had made a decision, leaving open the possibility that some parents had not gone through a decision-making process and may have answered about who would likely decide. Our findings suggest that many female adolescents, even girls as young as age 11, play an important role in making decisions about HPV vaccine. While our study provides new information about the prevalence of daughters’ involvement in HPV vaccination decisions, further research is needed to help us better understand the nature of their participation and their role in influencing vaccine uptake.

Human papillomavirus vaccination among young adult gay and bisexual men in the United States

Objectives. We examined human papillomavirus (HPV) vaccination among gay and bisexual men, a population with high rates of HPV infection and HPV-related disease. Methods. A national sample of gay and bisexual men aged 18 to 26 years (n = 428) completed online surveys in fall 2013. We identified correlates of HPV vaccination using multivariate logistic regression. Results. Overall, 13% of participants had received any doses of the HPV vaccine. About 83% who had received a health care provider recommendation for vaccination were vaccinated, compared with only 5% without a recommendation (P < .001). Vaccination was lower among participants who perceived greater barriers to getting vaccinated (odds ratio [OR] = 0.46; 95% confidence interval [CI] = 0.27, 0.78). Vaccination was higher among participants with higher levels of worry about getting HPV-related disease (OR = 1.54; 95% CI =  1.05, 2.27) or perceived positive social norms of HPV vaccination (OR = 1.57; 95% CI =  1.02, 2.43). Conclusions. HPV vaccine coverage is low among gay and bisexual men in the United States. Future efforts should focus on increasing provider recommendation for vaccination and should target other modifiable factors.