Nicole Liddon

Barriers to human papillomavirus vaccination among US adolescents: a systematic review of the literature.

IMPORTANCE Since licensure of the human papillomavirus (HPV) vaccine in 2006, HPV vaccine coverage among US adolescents has increased but remains low compared with other recommended vaccines. OBJECTIVE To systematically review the literature on barriers to HPV vaccination among US adolescents to inform future efforts to increase HPV vaccine coverage. EVIDENCE REVIEW We searched PubMed and previous review articles to identify original research articles describing barriers to HPV vaccine initiation and completion among US adolescents. Only articles reporting data collected in 2009 or later were included. Findings from 55 relevant articles were summarized by target populations: health care professionals, parents, underserved and disadvantaged populations, and males. FINDINGS Health care professionals cited financial concerns and parental attitudes and concerns as barriers to providing the HPV vaccine to patients. Parents often reported needing more information before vaccinating their children. Concerns about the vaccines effect on sexual behavior, low perceived risk of HPV infection, social influences, irregular preventive care, and vaccine cost were also identified as potential barriers among parents. Some parents of sons reported not vaccinating their sons because of the perceived lack of direct benefit. Parents consistently cited health care professional recommendations as one of the most important factors in their decision to vaccinate their children. CONCLUSIONS AND RELEVANCE Continued efforts are needed to ensure that health care professionals and parents understand the importance of vaccinating adolescents before they become sexually active. Health care professionals may benefit from guidance on communicating HPV recommendations to patients and parents. Further efforts are also needed to reduce missed opportunities for HPV vaccination when adolescents interface with the health care system. Efforts to increase uptake should take into account the specific needs of subgroups within the population. Efforts that address system-level barriers to vaccination may help to increase overall HPV vaccine uptake.

Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.

OBJECTIVES: The objectives of this study were to assess, in a nationally representative network of pediatricians and family physicians, (1) human papillomavirus (HPV) vaccination practices, (2) perceived barriers to vaccination, and (3) factors associated with whether physicians strongly recommended HPV vaccine to 11- to 12-year-old female patients. METHODS: In January through March 2008, a survey was administered to 429 pediatricians and 419 family physicians. RESULTS: Response rates were 81% for pediatricians and 79% for family physicians. Ninety-eight percent of pediatricians and 88% of family physicians were administering HPV vaccine in their offices (P < .001). Among those physicians, fewer strongly recommended HPV vaccination for 11- to 12-year-old female patients than for older female patients (pediatricians: 57% for 11- to 12-year-old patients and 90% for 13- to 15-year-old patients; P < .001; family physicians: 50% and 86%, respectively; P < .001). The most-frequently reported barriers to HPV vaccination were financial, including vaccine costs and insurance coverage. Factors associated with not strongly recommending HPV vaccine to 11- to 12-year-old female patients included considering it necessary to discuss sexuality before recommending HPV vaccine (risk ratio: 1.27 [95% confidence interval: 1.07–1.51]) and reporting more vaccine refusals among parents of younger versus older adolescents (risk ratio: 2.09 [95% confidence interval: 1.66–2.81]). CONCLUSIONS: Eighteen months after licensure, the vast majority of pediatricians and family physicians reported offering HPV vaccine. Fewer physicians strongly recommended the vaccine for younger adolescents than for older adolescents, and physicians reported financial obstacles to vaccination.

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.

A National Survey of Pediatrician Knowledge and Attitudes Regarding Human Papillomavirus Vaccination

OBJECTIVE. A human papillomavirus vaccine was licensed in June 2006. The vaccine is quadrivalent, protecting against 2 human papillomavirus strains that cause cervical cancer and 2 that cause genital warts. The objective of this study was to determine physician characteristics, knowledge, and attitudes associated with an intention to recommend human papillomavirus vaccination. METHODS. Between August and October 2005, a cross-sectional survey was administered to a national network of 431 pediatricians. The network was developed from a random sample of American Academy of Pediatrics members and was designed to be representative of the organization’s membership with respect to urban/rural location, practice type, and region. The survey was conducted before human papillomavirus vaccine licensure and therefore focused on a candidate quadrivalent human papillomavirus vaccine and a range of potential vaccination recommendations. The main outcome measure was intention to recommend a quadrivalent human papillomavirus vaccine to young adolescent (10- to 12-year-old) females. RESULTS. Survey response rate was 68%. If endorsed by national health organizations, 46% of respondents would recommend vaccination for 10- to 12-year-old females, 77% for 13- to 15-year-old females, and 89% for 16- to 18-year-old females. Corresponding rates for males were 37%, 67%, and 82%, respectively. Whereas 60% of respondents thought that parents would be concerned that human papillomavirus vaccination may encourage risky sexual behaviors, 11% reported that they themselves had this concern. Respondents who believed that other new adolescent immunization recommendations (eg, meningococcal, pertussis) would facilitate human papillomavirus vaccine implementation were more likely to intend to recommend vaccination. CONCLUSIONS. Although a national sample of pediatricians expressed a high level of acceptance of human papillomavirus vaccination in older adolescent females, fewer than one half anticipated giving human papillomavirus vaccine to younger female patients. Provider concerns about parental vaccine acceptance will need to be addressed to optimize human papillomavirus vaccination implementation.

Prevalence and Correlates of Heterosexual Anal and Oral Sex in Adolescents and Adults in the United States

BACKGROUND Heterosexual anal and oral sex are related to the acquisition of sexually transmitted infections, including human immunodeficiency virus infection. We examined the correlates of heterosexual anal and oral sex in the general population, using data from the National Survey of Family Growth. METHODS The sample included 12,571 men and women aged 15-44 years (79% response rate). RESULTS One-third of men and women had ever had anal sex, and three-quarters had ever had oral sex. Condom use during last oral or anal sex was relatively uncommon. In separate models for men and women, having ever had anal sex was associated with white race, age of 20-44 years, and having had a non-monogamous sex partner. White race, age of 20-44 years, being married, and having higher numbers of lifetime sex partners were related to having ever given oral sex in men and women. Giving oral sex was associated with having a non-monogamous sex partner in men. Ever receiving oral sex was associated with white race and a non-monogamous sex partner in men and women. CONCLUSIONS It would be beneficial to track the prevalence of heterosexual anal and oral sex and associated condom use on a more frequent basis.

Human Papillomavirus Vaccine and Sexual Behavior Among Adolescent and Young Women

BACKGROUND Vaccines to prevent certain types of human papillomavirus (HPV) and associated cancers are recommended for routine use among young women. Nationally representative reports of vaccine uptake have not explored the relationship between HPV vaccine initiation and various sexual behaviors. PURPOSE Explore sexual behavior and demographic correlates of HPV vaccine initiation from a nationally representative survey of adolescent and young adult women. METHODS In 2007-2008, a total of 1243 girls/women aged 15-24 years responded to questions about receiving HPV vaccine in the National Survey of Family Growth (NSFG). In 2010, demographic and sexual behavior correlates were evaluated in bivariate and multivariate analyses by age. RESULTS HPV vaccine initiation was higher among those aged 15-19 years than those aged 20-24 years (30.3% vs 15.9%, p<0.001). No differences existed by race/ethnicity for those aged 15-19 years, but among women aged 20-24 years, non-Hispanic blacks were less likely than non-Hispanic whites to have received the HPV vaccine (AOR=0.15). HPV vaccine initiation was greater for those with insurance regardless of age. HPV vaccination was not associated with being sexually active or number of sex partners at either age. Among sexually active adolescents aged 15-19 years, those who received HPV vaccine were more likely to always wear a condom (AOR=3.0). CONCLUSIONS This study highlights disparities in HPV vaccine initiation by insurance status among girls/women aged 15-24 years and by race/ethnicity among women aged >19 years. No association was found between HPV vaccination and risky sexual behavior.

The HPV vaccine: a content analysis of online news stories.

PURPOSE Approximately 73 million adults in the United States report using the Internet as a source for health information. This study examines the quality, content, and scope of human papillomavirus (HPV) vaccine Internet news coverage starting on the day of its licensure. Information about the HPV vaccine in the media may influence personal attitudes and vaccine uptake. METHODS Using four search engines and six search terms, a sample of 250 Internet articles on the HPV vaccine were identified between June 8, 2006, and September 26, 2006. The coding instrument captured how the headline was depicted and how the vaccine was labeled in addition to information about HPV, cervical cancer, the HPV vaccine, and current social issues and concerns about the vaccine. RESULTS Analysis revealed balanced Internet news coverage; 52.4% of Internet news stories were coded as neutral toward the vaccine. Eighty-eight percent of articles labeled the vaccine as a cervical cancer vaccine; 73.5% explained the link between HPV and cervical cancer, although without providing background information on HPV or cervical cancer. Vaccine affordability was the most cited social concern (49.2%). Information about vaccine safety and side effects, duration of vaccine protection, and availability of the catchup vaccine for females aged 13-26 was repeatedly missing. CONCLUSIONS The HPV vaccine is being marketed as a vaccine to prevent cervical cancer. Comprehensive information on the vaccine, HPV, and cervical cancer continues to be missing from media coverage. Public health educators should monitor online media in an effort to respond to inaccurate information. Barriers to vaccine cost and funding mechanisms need to be addressed more effectively by states. Knowledge of particular media messages could provide a starting point for tackling opposition and uptake issues for future sexually transmitted infection (STI) vaccines.

Disinhibition and risk compensation: scope, definitions, and perspective.

WITH MANY CHANGES, INCLUDING advances in health, comes speculation about the possible damaging and unintended consequences of introducing change. In many preventive interventions, unintended consequences follow a particular form called disinhibition or risk compensation. As typically understood, these concepts are operationalized via individuals who, once feeling protected against 1 health risk, engage in other risky behavior that puts them at risk for the same or other health problems. For example, commentary from the 1960s and 1970s cited effective STD treatment as a risk for increased sexual behavior.1 As well, recent debate over mandatory human papillomavirus vaccinations for school entry has brought similar fear that young women might subsequently feel free from concern about the cancer-causing disease and have more unprotected sex with more partners at an earlier age.2–4 In this issue of Sexually Transmitted Diseases, Greg et al. present data from a HIV prevention trial testing the safety and efficacy of oral tenofivir for women in Ghana,5 which we will use to prompt some thoughts about the differences between disinhibition and risk compensation and their scope and relationship to intervention. First, we note there are important conceptual differences between disinhibition and risk compensation with different implications for intervention strategies. Disinhibition derives from psychological terminology; it occurs when people stop trying to avoid risk to themselves or others. Probably the most widely known examples in sexual behavior are centered around the disinhibiting effects of alcohol; an inebriated person may be sexually incautious or aggressive because he or she no longer “cares” about the risk of sexual exposure.6,7 Other examples are drawn from people who feel they cannot avoid a harm and then no longer even try to do so.8 In both examples, the outcome is behavioral disinhibition through lack of caring, although the causes (alcohol vs. perception of unavoidable risk) are very different. Risk compensation, on the other hand, is best understood from a more cognitive perspective. The term applies to those whose diminished susceptibility via a given preventive intervention permits them to increase other risk behaviors. Although both terms are often used interchangeably in the literature, what we have defined as risk compensation is the most common source of concern for those conducting interventions. Guest et al.’s analysis of HIV preexposure prophylaxis in this issue5 is a good starting point to examine these phenomena more closely because the women in the trial, largely sex workers, (a) had high potential for disinhibition via greatly elevated–“unavoidable”–risk of HIV acquisition and (b) high potential for risk compensation via their economic motive for sex. Specifically, the authors examined changes in risk behavior among HIV negative, sexually active women after enrollment in the trial, with data gathered across up to 12 visits over the course of 6 months. For the purposes of these analyses, Guest et al. stratified the sample by baseline sexual risk characteristics (most risky 25% vs. all others); as both control and intervention arm participants took a pill daily, changes in risk would not easily be attributed to knowing one was on antiretroviral prophylaxis. They found that participants reported decreases in unprotected sex, with the steepest declines among women categorized (via number of partners and proportion of unprotected sex acts) in the highest risk group. Through qualitative interviews with a subset of the women, the authors were able to attribute decreased risk behavior at least partly to counseling accompanying the drug regimen. All this is good news about “changes in sexual behavior.” The intervention provides another demonstration that most members of groups whose sexual health prospects have become more assured do not subsequently attempt to damage said prospects: that is, no widespread risk compensation was seen. Similarly, penicillin “preexposure prophylaxis” for syphilis, tested in Louisiana between 1997 and 1999, and a review of sexual behavior for HIV positive people on antiretroviral therapy yielded the same conclusions.9,10 Inference about disinhibition is more indirect, although the results are consistent with reduced disinhibition as the women’s protective behaviors increased with the advent of the preventive intervention. As with risk compensation, the qualitative data were supportive of such inferences but without ruling out alternative explanations. We do not suggest that risk compensation and disinhibition are always negligible effects in interventions. If one lesson seems to be that neither disinhibition nor risk compensation is a widespread, Correspondence: Matthew Hogben, PhD, Mail Stop E-44, Centers for Disease Control and Prevention, Atlanta, GA 30333. E-mail: mhogben@ cdc.gov. Received for publication August 1, 2008, and accepted September 19, 2008. From the Division of STD Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia Sexually Transmitted Diseases, December 2008, Vol. 35, No. 12, p.1009–1010 DOI: 10.1097/OLQ.0b013e31818eb752 Copyright

Intent to receive HPV vaccine and reasons for not vaccinating among unvaccinated adolescent and young women: findings from the 2006-2008 National Survey of Family Growth.

BACKGROUND AND PURPOSE HPV vaccine coverage for females has increased in the U.S., although challenges to achieving high coverage remain. HPV vaccine coverage continues to lag behind that of other routinely recommended adolescent vaccines and these gaps in coverage are widening. To inform strategies to improve uptake, we explore correlates of vaccine intention and describe reasons for refusing HPV vaccination among unvaccinated females in a nationally representative sample of adolescents and young adults during early stages of HPV vaccine availability. METHODS In 2007-2008, 1243 females aged 15-24 years were asked about HPV vaccination in the National Survey of Family Growth (NSFG). For unvaccinated women (n=955), we evaluated demographic and sexual behavior correlates of likelihood to receive the vaccine in the next 12 months in bivariate and multivariable analyses by age. Correlates to the main reasons for foregoing vaccination are described. RESULTS A minority (42.5%) of unvaccinated respondents said they intended to receive HPV vaccine in the next 12 months: 37.6% of adolescents (15-19 years) and 42.0% of young adults (20-24 years). Sexually experienced women were more than twice as likely as non-sexually experienced women to intend to receive HPV vaccine (15-19 years: aOR=2.39, 95% CI=1.15, 4.94; 20-24 years: aOR=2.17, 95% CI=1.08, 4.33). Having health insurance was associated with being likely to receive HPV vaccine among adolescents. Hispanic young adults were more likely than non-Hispanic Whites to be likely to receive HPV vaccine. The belief of not being at risk for HPV and institutional barriers were the two most commonly cited reasons for foregoing vaccination.Among unvaccinated women who did not intend to get vaccinated, respondents who never had sex were more likely to report not being at risk as the main reason for not needing the vaccine compared to women with sexual experience (44.5 vs. 24.4%) but this finding was only marginally significant in our limited sample. CONCLUSION In the first years immediately post-licensure of an HPV vaccine, the majority of unvaccinated women indicated that they were unlikely to seek vaccination. Intent to receive the HPV vaccine is tied to sexual experience and most women who do not intend to get vaccinated and have never had sex believe they are not at risk of HPV or do not need an HPV vaccine. These findings highlight the need to better communicate information regarding lifetime risk for HPV and the importance of receiving HPV vaccine prior to sexual initiation. These findings should inform strategies to increase vaccine uptake.

HIV/STI Risk behaviors among Latino migrant workers in New Orleans post-Hurricane Katrina disaster.

Objectives: A rapid influx of Latino migrant workers came to New Orleans after Hurricane-Katrina. Many of these men were unaccompanied by their primary sex partner potentially placing them at high-risk for HIV/STIs. The purpose of this study was to assess HIV/STI sexual risk behavior of these men. Methods: A venue-based sample of Latinos who came to New Orleans post-Hurricane Katrina were administered an anonymous, structured interview in Spanish in a mobile unit and urine tested for Chlamydia trachomatis (CT) and Neisseria gonorrhea (GC) using the nucleic acid amplification technique. Results: Participants (n = 180) had a mean age of 33 (range, 18–79), did not speak or understand English very well (93.9%), were undocumented (91.2%), were married (63.5%), and had children (67.4%), though the percent living with spouse and children was 6.1% and 4.9%, respectively. Although most men were born in Honduras (49.7%) and Mexico (25.4%), 61.9% came to New Orleans from another US state. The majority drank alcohol in the past week (75.5%), and of those, 68.7% engaged in binge drinking. A lower percentage used marijuana (16.6%) and cocaine (5.5%) at least once in the prior week. No men reported injection drug use. Self-reported history of HIV was 10%. No men tested positive for GC and 5 (2.8%) tested positive for CT. In the last month, 68.9% engaged in sex with high-risk sex partners, 30.0% were in potential bridge position, 50.0% used condoms inconsistently, 30.6% did not use a condom the last time they had sex, and 21.1% were abstinent. Since arriving, 9.4% reported leaving and returning to New Orleans. Conclusion: Latino migrant workers in New Orleans reported risky sexual behaviors and low condom use within a potential bridge position. Although a low prevalence of CT and GC was found, there was a high percent of self-reported HIV infection. The cultural and contextual factors that place these migrant workers and their sex partner(s) at risk for HIV/STI need further investigation.