Elsevier

Preventive Medicine

Volume 131, February 2020, 105968
Preventive Medicine

Review Article
Factors associated with adolescent HPV vaccination in the U.S.: A systematic review of reviews and multilevel framework to inform intervention development

https://doi.org/10.1016/j.ypmed.2019.105968Get rights and content

Highlights

  • Provider recommendation consistently associated with adolescent HPV vaccine uptake

  • Provider- and clinic-level factors most important for series completion

  • Research needed to identify provider-level factors associated with recommendation

  • Research needed on implementation strategies for effective clinic-level systems

Abstract

Multilevel factors impact HPV vaccine series initiation and completion among adolescents in the U.S. Synthesis of these factors is needed to inform intervention development and to direct future research. Current frameworks synthesizing factors focus on females only and do not include both series initiation and completion outcomes. We conducted a systematic review of reviews to identify modifiable individual-, provider-, and clinic-level factors associated with HPV vaccination outcomes among U.S. adolescents and developed a multilevel framework illustrating relations between factors to inform intervention development. We searched Medline, PsychInfo, Pubmed, CINAHL, and ERIC databases and included reviews published 2006 to July 2, 2018 describing individual-, provider-, or clinic-level factors quantitatively associated with HPV vaccination among U.S. adolescents. Two coders independently screened reviews, extracted data, and determined quality ratings. Sixteen reviews containing 481 unique primary studies met criteria. Factors synthesized into the multilevel framework included parent psychosocial factors (knowledge, beliefs, outcome expectations, intentions) and behaviors, provider recommendation, and patient-targeted and provider-targeted clinic systems. The scope of our framework and review advances research in two key ways. First, the framework illustrates salient modifiable factors at multiple levels on which to intervene to increase HPV vaccination. Second, the review identified critical gaps in the literature at each level. Future research should link the body of literature on parental intentions to vaccination outcomes, identify provider psychosocial factors associated with recommendation behaviors and subsequent vaccine uptake in their patient population, and understand clinic factors associated with successful implementation of patient- and provider-targeted system-level interventions.

Introduction

The human papillomavirus (HPV) vaccine protects against oncogenic types of HPV that can lead to cancer and genital warts (Garland et al., 2007; Paavonen et al., 2007). HPV-related cancers include cervical, anal, vaginal, vulvar, penile, and oropharyngeal cancers, with the most common being cervical cancer among women and oropharyngeal cancers among men (Viens et al., 2016). The CDC Advisory Committee for Immunization Practices (ACIP) recommends the HPV vaccine be administered to adolescents aged 1112 years, although it is available for adolescents starting at age nine and adults up to age 45 (Meites et al., 2016; Meites et al., 2019). Current HPV vaccination coverage lags behind the Health People 2020 national goal that 80% of 13–15 year olds complete the multi-dose series (U.S. Department of Health and Human Services Office of Disease Prevention and Health Promotion, n.d.; Walker et al., 2019). National data show HPV vaccine initiation rates of 70% of females and 66% of males aged 13–17 years, and 54% of females and 49% of males aged 13–17 years are considered up to date on all doses (Walker et al., 2019).

To increase vaccination, it is important to understand the diverse multilevel factors associated with HPV vaccine series initiation and completion. Synthesizing these factors in a multilevel framework that illustrates their associations can inform future interventions aiming to increase HPV vaccination coverage. The National Cancer Institute (NCI) specifically calls for multilevel interventions across the cancer control continuum (National Cancer Institute, 2012). However, current frameworks and evidence syntheses of factors associated with HPV vaccination are limited in their scope, outcomes, and populations (Batista Ferrer et al., 2014; Batista Ferrer et al., 2015; Brewer and Fazekas, 2007; Fernández et al., 2010; Katz et al., 2010). Fernandez and colleagues were the first to develop a multilevel logic model illustrating the relations between parental-, provider-, clinic-, community-, and policy-level factors associated with HPV vaccination acceptance and willingness to vaccinate (Fernández et al., 2010). That model, however, has limited applicability to inform interventions focused on vaccine series initiation and completion. Although more recent frameworks illustrate relations between multilevel factors associated with behavioral outcomes, they were produced before the vaccine was recommended for males (Batista Ferrer et al., 2014; Katz et al., 2010; Tiro et al., 2012).

An updated framework integrating multilevel factors associated with HPV vaccine series initiation and completion for male and female adolescents in the U.S. is needed. Therefore, our systematic review or reviews consolidates the large body of literature describing multilevel factors associated with HPV vaccination outcomes among U.S. adolescents aged 11–17 years, and we illustrate the relations among these factors in an empirically-based and theoretically-informed multilevel framework. We limit the scope of our review and framework to the individual-, provider-, and clinic-levels and do not include population levels such as the community or policy levels. While policies such as mandatory HPV vaccination for school entry have been successful at increasing coverage, particularly outside of the U.S., states are slow to adopt such policies which often have limited support (Barraza et al., 2016; Brandt et al., 2016; Calo et al., 2016; Vercruysse et al., 2016). Instead, we focus on the individual-, provider-, and clinic-levels to inform the development of interventions targeting vaccination decision makers (parents and adolescents), vaccine administerers (providers), and clinic systems.

Section snippets

Methods

Methods are reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist (Moher et al., 2009).

Study selection

We identified 356 unique records from the database search and 10 additional records from reference lists. Seventeen met inclusion criteria after the two-step screening process (Fig. 1). Principal reasons for exclusion were not being a review and not assessing HPV vaccination outcomes. One meta-analysis was excluded post hoc because it included only demographic correlates of vaccination outcomes (Fisher et al., 2013). (Excluded citations are available from corresponding author.)

Characteristics of reviews

Most reviews (n

Discussion

We conducted a systematic review of 16 reviews to synthesize multilevel factors associated with HPV vaccination among U.S. adolescents. The scope of the review advances research in two key ways. First, we can use the empirical evidence of modifiable factors associated with HPV vaccination and draw upon health behavior theory to develop a multilevel framework that can inform intervention development and increase HPV vaccine initiation and completion. Second, the review provides an up-to-date

Conclusion

In summary, an updated synthesis of the multilevel factors associated with HPV vaccine initiation and completion among U.S. adolescents is needed. Our systematic review and multilevel framework depict salient factors including parent knowledge, beliefs, outcome expectations, and intentions; parent behaviors; provider recommendation; and patient- and provider-targeted systems that can be modified and targeted through interventions to increase HPV vaccination coverage and reach Healthy People

Acknowledgments

The authors thank Helena VonVille, MPH for her assistance in creating the systematic review search criteria and managing the search and screening processes. SAR thanks Drs. Paula Cuccaro and Alan Nyitray for their feedback on iterations of this manuscript.

Funding sources

SAR was supported by a predoctoral fellowship from The University of Texas Health Science Center at Houston (UTHealth) School of Public Health Cancer Education and Career Development Program – National Cancer Institute (NCI)/National Institutes of Health (NIH) Grant R25 CA57712. She received partial support from the UTHealth School of Public Health Department of Health Promotion and Behavioral Sciences. SAR and DLM received partial support from the Cancer Prevention & Research Institute of Texas

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