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Introduction
Human papillomavirus (HPV) has continuously been implicated as the leading cause of sexually transmitted disease in the United States (Satterwhite et al., 2013). Studies have shown that approximately 6.2 million new cases of persons between ages 14 and 44 are recorded annually (Chesson et al., 2007). According to a report released by the Centre for Disease Control and Prevention (CDC), an estimated 74 % of these cases occur in persons between age 15 to 24 (CDC, 2017). It is also estimated that approximately 50 % of sexually active individuals in the United States will acquire HPV at some point in the course of their lives (Winer, 2003). This data is an indication that HPV infections disproportionately affect the younger compared with the older population. While a majority of HPV infection cases are usually asymptomatic and transient, several cases of the progression of persistent disease to carcinomas have been reported with cervical carcinoma being the most common. Other carcinomas linked to the disease include anorectal, valval, oropharyngeal, and penile carcinomas and genital warts.
However, HPV infections are currently preventable owing to the introduction of 2 vaccines (a bivalent HPV2 and a quadrivalent HPV4) which are both available in the United States. In 2006, the Food and Drug Administration licensed the use of the HPV vaccine (HPV4; Gardasil, Merck & Co. Inc.) by females. The vaccine is directed against several HPV subtypes including HPV types 6, 11, 16, and 18. In 2009, the FDA approved the use of the quadrivalent vaccine by males aged 9 to 26 for the prevention of genital warts. In 2011, the Advisory Committee on Immunization Practices (ACIP) approved the routine administration of the HPV vaccine at ages 11 or 12. The committee also recommended the administration of the vaccine to males through 21 who have not previously received the vaccine or those who did not complete the 3-dose series. Similar, females aged 13 through 26 with no history of a complete HPV vaccination are required to take the vaccine. Currently, a 2-dose schedule is recommended for both females and males taking the vaccine before they are 15 years old while a 3-dose schedule is recommended for those who start the series from ages 15 through 26.
These vaccines have proven to be highly safe and effective against high-grade cervical lesions which are frequently associated with HPV 16 and 11. The Healthy People 2020 aims to improve the current status of HPV vaccination and the completion of the series by females ages 13 to 15 to approximately 80 % come 2020 ("Sexually Transmitted Diseases | Healthy People 2020," n.d.). While the Healthy People 2020 does not mention HPV vaccination for males, it is recommended that the males are vaccinated as well in order to protect themselves and their partners (Chesson et al., 2007). While significant improvement has been seen over the years, the HPV vaccine coverage still is of great concern as it remains substantially lower than that of other adolescent vaccines such as diphtheria, tetanus, and the meningococcal conjugate vaccine. The vaccine coverage in the United States has also been shown to be significantly lower than that in other developed countries such as Australia, Denmark and the United Kingdom which all have more than 70% coverage.
BARRIERS TO HPV VACCINATION
Several factors have been implicated as major barriers to the acquisition of HPV vaccination that results in significantly low coverage. These factors include healthcare professional factors, parent and caregiver factors, underserved and disadvantaged groups, and the male population (Cole et al.,2017).
Health Care Practitioners
Health care practitioners have been reported as barriers to the vaccination of their patients. A study conducted by Perkins & Clark, 2012 showed that this is as a result of the continuing knowledge gap among professionals. Studies have shown that some of these practitioners lack knowledge on the link between HPV infections and genital warts and carcinomas. Other studies showed that most practitioners that offer their patients the HPV vaccine fail to provide adequate information about the vaccine with some even highlighting it as optional (Goff, Mazor, Gagne, Corey, & Blake, 2011). Studies have also shown that most of the contributions by health care practitioners to the low coverage are related to various financial constraints including the cost to parents and inadequate insurance.
Parents and Caregivers
Parental and caregiver factors contributing to the low HPV vaccination coverage have been addressed in several studies. Majority of these studies have attributed several of these factors to the lack of adequate knowledge with regards to the vaccine (Holman et al., 2014). A study conducted by Tsui et al., 2012 showed that while most parents are aware of the need for vaccination, they had several concerns about the safety and the efficacy of the vaccine especially on the adverse effects (Tsui et al., 2012). Other factors included the belief that the child was too young for HPV vaccination hence the need to delay the vaccine. However, most studies have shown that parents are more likely to accept the vaccine after receiving a recommendation from a health care practitioner (Holman et al., 2014).
Underserved and Disadvantaged Groups
While most of the barriers to the acquisition of the HPV vaccine have been observed to affect various ethnicities and races in equal measure, some studies have observed a variation in vaccine acceptance and initiation (Shrestha, Sudenga, Royse, & Royse, 2011). For instance, these studies have shown that vaccine completion rates among the black and Hispanic populations are much less than those among the white population (Dorell et. al, 2012). This has been attributed to the differences in the average household incomes and health insurance coverage (Walker et al., 2018). Other contributory factors include cultural differences and social norms, the distrust of healthcare facilities and the imposed immigrant status.
Males
Studies have over the years shown that the administration of the HPV among the male adolescent population if substantially lower than that among the female. This has been attributed to the fact that health care practitioners often recommend the vaccine more to the female adolescent. Furthermore, studies have shown that there is a general lack of knowledge about the need to vaccinate males as the consequences of HPV infection are considered to more pronounced in the females.
EDUCATIONAL INTERVENTIONS TO INCREASE HPV VACCINATION ACCEPTANCE
A majority of studies aimed at increasing the HPV acceptance, early initiation compliance have demonstrated the need for educational interventions as the lack of knowledge about the vaccine has been implicated as a major contributory factor to the low coverage levels. Some of these interventions include:
Health Care Provider Education Interventions
While studies have shown that parents are often skeptic of the vaccine due to lack of sufficient knowledge about it, it has been demonstrated that the acceptance is often improved following a recommendation from a health care professional. Promoting the vaccine as safe and efficacious against carcinomas rather than solely against sexually transmitted disease has been shown to improve acceptance rates (Bratic, Seyferth, & Bocchini, 2016). Therefore, clinicians are often recommended to educate their patients on the benefit of the vaccine. In fact, it is recommended that they offer it alongside other adolescent vaccines such as the meningococcal vaccine administered at 11 or 12 years (Sussman et al., 2015).
Other interventions have included the provision of provider-based training which has involved the sensitization of care providers on the need for the vaccine and to prepare them to recommend the vaccine consistently. These programs have proven to be highly effective. The CDC’s Assessment/Feedback/Incentive/exchange (AFIX) program offers web-based or one on one consults with care providers in a bid to improve the immunization rates. Aside from the program, the CDC provides a wide variety of educational materials including flyers, posters and videos in order to educate care providers, and parents about the HPV vaccine (CDC, 2017).
Adolescent and Young Adult Education Interventions
As evidenced in several studies, most adolescents and young women lack sufficient knowledge on the benefits of HPV vaccination. Several school-based interventions have been conducted with the aim of improving HPV vaccination among adolescents and young adults (Niccolai & Hansen, 2015). A study conducted to investigate the efficacy of these interventions provided students with health education programs conducted by school nurses. The study showed a significant improvement in the reduction of STI related cases in the school. Other school-based interventions include the introduction of web-based programs, PowerPoint presentations, videos, and even fact-sheets.
Conclusion
Taking into account the several studies that have been conducted to demonstrate the best ways of improving HPV vaccination coverage, it can be concluded that much focus should be drawn towards improving people’s knowledge on the link between HPV infections and HPV-related carcinomas and the benefits of HPV vaccination. To achieve this, there is a dire necessity to integrate efficient educational interventions with the aim of achieving the said goal. Attention should also be drawn towards the male adolescent as most studies have shown that they are often neglected with regards to the vaccination. A stance that is evidenced by the low coverage levels among the adolescent males in the United States. HPV is highly preventable and while the Healthy People 2020 goals of achieving an 80% HPV coverage may not be feasible due to the several barriers outlined in this paper, it is just a matter of time until the goal is attained.
Recommendations
Future Studies:
Despite the fact that several studies have been conducted with regards to HPV vaccination, the majority of these studies have focused on issuing informational handouts to the educated population thus limiting their reach. Future studies should focus on using culturally-competent interventions in order to reach a vast majority of the population.
Addressing Barriers:
Health care providers should educate their patients on the link between HPV infections and the occurrence of certain cancers and the role in which the HPV vaccine can play in preventing that.
Educational materials on HPV vaccination should provide a guideline of the vaccination schedule to encourage parents to conduct these vaccinations earlier. The materials should also contain information about the benefits, safety, adverse effects, and cost of the vaccine.
References
Bratic, J. S., Seyferth, E. R., & Bocchini, J. A. (2016). Update on barriers to human papillomavirus vaccination and effective strategies to promote vaccine acceptance. Current Opinion in Pediatrics, 28(3), 407-412. doi:10.1097/mop.0000000000000353
Chesson, Harrell. Dunne, Eileen F. Lawson, Herschel W. Markowitz, Lauri E. Saraiya, Mona. Unger, Elizabeth R., 1951-. (2007). Quadrivalent human papillomavirus vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP). Atlanta, GA: U.S. Dept. of Health & Human Services, Centers for Disease Control and Prevention.
Cole, T., Thomas, M. C., Straup, K., Savage, A. (2017). How to increase HPV vaccination rates. Clinician Reviews, 27(9), 40-46
Dorell CG, Yankey D, Santibanez TA, Markowitz LE. Human Papillomavirus Vaccination Series Initiation and Completion, 2008-2009. Pediatrics. 2011; 128(5):830-839. (2012). PEDIATRICS, 130(1), 166-168. doi:10.1542/peds.2012-1013
Goff, S. L., Mazor, K. M., Gagne, S. J., Corey, K. C., & Blake, D. R. (2011). Vaccine counseling: A content analysis of patient–physician discussions regarding human papilloma virus vaccine. Vaccine, 29(43), 7343-7349. doi:10.1016/j.vaccine.2011.07.082
Holman, D. M., Benard, V., Roland, K. B., Watson, M., Liddon, N., & Stokley, S. (2014). Barriers to Human Papillomavirus Vaccination Among US Adolescents. JAMA Pediatrics, 168(1), 76. doi:10.1001/jamapediatrics.2013.2752
Niccolai, L. M., & Hansen, C. E. (2015). Practice- and Community-Based Interventions to Increase Human Papillomavirus Vaccine Coverage. JAMA Pediatrics, 169(7), 686. doi:10.1001/jamapediatrics.2015.0310
Perkins, R. B., & Clark, J. A. (2012). Providers’ Attitudes Toward Human Papillomavirus Vaccination in Young Men. American Journal of Men's Health, 6(4), 320-323. doi:10.1177/1557988312438911
Products – Data Briefs – Number 280 – April 2017. (2017, April 6). Retrieved from https://www.cdc.gov/nchs/products/databriefs/db280.htm
Satterwhite, C. L., Torrone, E., Meites, E., Dunne, E. F., Mahajan, R., Ocfemia, M. C., … Weinstock, H. (2013). Sexually Transmitted Infections Among US Women and Men. Sexually Transmitted Diseases, 40(3), 187-193. doi:10.1097/olq.0b013e318286bb53
Sexually Transmitted Diseases | Healthy People 2020. (n.d.). Retrieved from https://www.healthypeople.gov/2020/topics-objectives/topic/sexually-transmitted-diseases/objectives
Shrestha, S., Sudenga, Royse, & Royse. (2011). Role and uptake of human papillomavirus vaccine in adolescent health in the United States. Adolescent Health, Medicine and Therapeutics, 63. doi:10.2147/ahmt.s15941
Sussman, A. L., Helitzer, D., Bennett, A., Solares, A., Lanoue, M., & Getrich, C. M. (2015). Catching Up with the HPV Vaccine: Challenges and Opportunities in Primary Care. The Annals of Family Medicine, 13(4), 354-360. doi:10.1370/afm.1821
Tsui, J., Gee, G. C., Rodriguez, H. P., Kominski, G. F., Glenn, B. A., Singhal, R., & Bastani, R. (2012). Exploring the Role of Neighborhood Socio-Demographic Factors on HPV Vaccine Initiation Among Low-Income, Ethnic Minority Girls. Journal of Immigrant and Minority Health, 15(4), 732-740. doi:10.1007/s10903-012-9736-x
Walker, T. Y., Elam-Evans, L. D., Yankey, D., Markowitz, L. E., Williams, C. L., Mbaeyi, S. A., … Stokley, S. (2018). National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents Aged 13–17 Years — United States, 2017. MMWR. Morbidity and Mortality Weekly Report, 67(33), 909-917. doi:10.15585/mmwr.mm6733a1
Winer, R. L. (2003). Genital Human Papillomavirus Infection: Incidence and Risk Factors in a Cohort of Female University Students. American Journal of Epidemiology, 157(3), 218-226. doi:10.1093/aje/kwf180
ACTION PLAN:
A CALL TO ACTION FOR THE IMPROVEMENT OF HPV VACCINATION COVERAGE THROUGH EDUCATIONAL INTERVENTIONS.
A collaborative project:
This project aimed at improving the coverage of HPV vaccination in the United States is a collaborative project between———————————————.The project was made possible by the Centre for Disease Control and Prevention.
WHY PRIORITIZE HPV VACCINATION?
Despite having been approved to be safe and efficacious in preventing HPV related diseases, HPV vaccination coverage has remained substantially low over the years compared to other routine vaccinations offered during the adolescent period. Only approximately 6 out of every 10 females aged 13 to 17 received at least a single dose of the HPV vaccine in 2014 while only 4 out of 10 completed the 3-dose series that same year. This phenomenon has largely been attributed to the general lack of sufficient knowledge with regards to the vaccine. Therefore, this has necessitated the prioritization of HPV vaccination through the introduction of various educational interventions. Other reasons to prioritize HPV vaccination include:
The need to lower costs:
HPV vaccines have been shown to offer approximately 90 % protection against some cancers. Treating HPV related cancers is much costlier than preventing it. Hence, the need for prevention.
The need to offer quality service and care:
Quality care embodies all aspects of disease prevention and treatment. By offering patients HPV vaccination, they can be guaranteed lifetime immunity against HPV related infections.
The need to improve the quality of life:
Administering the HPV vaccine to patients help prevent HPV related infection which can often have debilitating complications. Thus, by doing so, you improve the general quality of their lives.
RESISTANCE, BARRIERS AND OPPORTUNITIES:
Most of the barriers to administration of the HPV vaccine can be put into 3 major categories which include:
Parent hesitancy
Provider recommendation practices
Accessibility
Parent hesitancy:
Parents often question the safety and the efficacy of these vaccines and are often skeptic. Some parents have even reported to fear vaccinating their children as that is likely to condone sexual activity.
Parents often underestimate their children’s sexual experiences and have often reported their 11 to 18-year old’s as not being sexually active when they are. This often leads to the reluctance to get their children to be vaccinated.
Provider recommendation practices:
Health care practitioners have been shown to recommend HPV vaccines less than other adolescent vaccines often due to the lack of knowledge.
Some health practitioners often feel uncomfortable discussing sexual topic with their patients and their parents and thus always fail to educate the parents on the need for the HPV vaccine.
Physicians often vary the strength of their recommendation to their patients depending on their evaluation of the parents socioeconomic status.
Accessibility
Some teens without parents or regular guardians often lack the knowledge about HPV infections and the HPV vaccine hence end up missing out on the vaccinations.
These vaccines are often costly and that can deter some from access them especially for the uninsured or underinsured families.
BREAKING BARRIERS AND MINIMIZING RESISTANCE