Characterizing U.S. mothers with high human papillomavirus vaccine intent yet unvaccinated adolescents

Human papillomavirus (HPV) vaccination is effective in preventing 90% of cervical cancer,(Lei et al., 2020) reducing the risk of HPV infections that are a major cause of 70% of oropharyngeal cancers,(Nielsen et al., 2021) and preventing HPV infections associated with about 5% of all cancers worldwide.(National Cancer Institute, 2023) Evidence shows that effective immunization programs in the U.S. since 2006 for females and 2011 for males have reduced the incidence of cervical cancer for females,(Liao et al., 2022) reduced HPV-associated oral infections among vaccinated young adults,(Chaturvedi et al., 2018) and contributed to herd immunity against oral infections with high-risk HPV strains among the unvaccinated.(Chaturvedi et al., 2019) Given the strong cancer prevention benefits, the Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices (ACIP) recommends routine immunization with the HPV vaccine series for U.S. adolescents starting at ages 9–10 to protect against HPV-related cancers.(Centers for Disease Control and Prevention, 2023; Oshman and Davis, 2020) However, coverage rates among U.S. adolescents lag compared to all other routinely recommended adolescent vaccines.(Centers for Disease Control and Prevention, 2023; Pingali et al., 2022) In 2021, only 61.7% of 13–17 year-olds completed the series, with slightly more up-to-date girls (63.8%) than boys (59.8%).(Pingali et al., 2022) Additionally, the COVID-19 pandemic further exacerbated this deficit, with declining routine childhood immunization rates leading to over 150,000 missed HPV vaccine doses.(Desilva et al., 2022; Saxena et al., 2021)

To achieve maximum cancer prevention benefits by increasing immunization coverage, interventionists and clinicians need a better understanding of why coverage lags compared to other adolescent vaccines. Several factors are associated with increased or decreased HPV vaccination uptake, including a healthcare provider (HCP) recommendation and parental hesitancy.(Stout et al., 2020; Gilkey et al., 2017; Kornides et al., 2018a; Holman et al., 2014; Szilagyi et al., 2020) Specifically, a strong HCP recommendation is associated with series initiation and completion regardless of adolescent age or gender, highlighting the importance of HCPs in improving national HPV vaccination coverage.(Newman et al., 2018; Oh et al., 2021) Studies have found that hesitant parents with concerns are less likely to refuse or delay if they receive a strong HCP recommendation and are more likely to accept the vaccine at a subsequent visit if they do delay vaccination after receiving a strong HCP recommendation at the initial visit.(Kornides et al., 2018b)

While hesitant parents who expressly refuse or delay HPV vaccines have been extensively studied in terms of reasons for vaccine hesitancy and interventions to change their intent,(Gilkey et al., 2017) less is known about parents who report no concerns or hesitancy, indicate intent to vaccinate, but have not yet vaccinated their age-eligible children despite having opportunities. This gap between vaccine willingness or intent and uptake has been documented globally, but it is unknown how these high intent parents differ from parents who have already vaccinated their children with regards to having received a HCP recommendation, the strength of that recommendation, their vaccination attitudes, social norms and beliefs, and sociodemographic characteristics. Studying these factors are important because they can indicate where best to intervene to nudge parents into accepting HPV vaccines. The Theory of Reasoned Action and Theory of Planned Behavior posit that intention is a central determinant of a behavior.(Montã and Kasprzyk, 2015) However, as these behaviorally hesitant parents show high intention without action, we believe is important to further probe their behavioral beliefs, normative beliefs, and control beliefs to ultimately better understand and link their intentions with action.(Montã and Kasprzyk, 2015) Therefore, the objective of our study was to examine self-reported differences in vaccination attitudes, social influences, and HCP relationships among a sample of mothers who indicated high intent to vaccinate but had not yet vaccinated vs. those who had already vaccinated their 11–14-year-old child against HPV.

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