The human papillomavirus (HPV) is the most common sexually transmitted infection among men and women in the United States (U.S.), and is associated with 90% of cervical and anal cancers and 70% of vaginal, vulvar, penile and oral cancers. Nearly 38,800 new cases of HPV-associated cancers emerge each year in the U.S. Individuals aged 15-24 comprise roughly 50% of these newly diagnosed cases. The Advisory Committee on Immunization Practices (ACIP) recommends the three-dose vaccine, Gardasil, for administration in adolescent beginning at ages 11 and 12 to prevent infection from HPV. While HPV vaccine initiation rates (i.e., receive 1 dose) have steadily increased within the last seven years to 60% among adolescent girls and 42% among adolescent boys, completion rates (i.e., receive 3 doses) remain significantly low at 39.7% and 21.6% among adolescent girls and boys respectively. Therefore, the purpose of this literature review is to examine parental barriers and facilitators that contribute to low rates of HPV vaccination initiation and completion among adolescents in the United States.
To identify relevant literature on parental barriers and facilitators to HPV vaccination, several databases (PubMEd, CINAHL, ProQuest Central, and PsychINFO) were searched in September and October of 2016 using the following keywords: “HPV vaccination,” “adolescents,” “facilitators,” and “barriers.” Inclusion criteria were: English language; participants that were parents of adolescents ages 9-17 who had received at least one dose of the vaccine, completed vaccination requirements, or were unvaccinated, and; publication since 2006, as the HPV vaccine was approved for administration in 2006. Studies conducted outside the United States were excluded. Additionally, intervention-based studies were excluded to insure focus on understanding the barriers and facilitators to vaccination rather than increasing vaccination.
The initial search returned 1365 articles and 38 were retained for this review. Most of the studies used quantitative methodology using cross-sectional, survey designs (n = 27). Convenience, purposive, and probability sampling methods were used across all studies. Parents’ ages ranged from 30 to ≥ 50 years and the average adolescent’s age ranged from 11 to 17 years. Three major themes emerged for parental perceived barriers: vaccine concerns, age of vaccine administration, and adolescent sexual activity. Four themes emerged for parent perceived facilitators: provider recommendation, attitudes towards HPV and vaccination, HPV knowledge, and awareness and perceived risk for HPV.
Many of the studies in this review were limited by design and/or instrumentation choice. For example, cross-sectional designs preclude understanding of how parental perceptions may change over time, and how perceptions ultimately affect vaccination rates. Longitudinal designs would be well-suited to understanding how and whether perceptions are related to outcomes. Additionally, since parents’ perceived barriers and facilitators to HPV vaccination varied between different racial and ethnic groups, future work should focus on the unique experiences of groups traditionally underrepresented in research, with the recognition that variation exists within these groups that also warrants investigation. Finally, only three studies noted that parents included their children in the decision-making process for HPV vaccination. Future work may consider exploring whether family members’ experiences and vaccination rates differ based on whether or not children were participants in their health care decision making.