Review ArticleFactors associated with adolescent HPV vaccination in the U.S.: A systematic review of reviews and multilevel framework to inform intervention development
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
References (77)
- et al.
An appraisal of theoretical approaches to examining behaviours in relation to Human Papillomavirus (HPV) vaccination of young women
Prev Med (Baltim)
(2015) - et al.
Predictors of HPV vaccine acceptability: a theory-informed, systematic review
Prev Med (Baltim)
(2007) - et al.
A randomized intervention of reminder letter for human papillomavirus vaccine series completion
J. Adolesc. Health
(2015) - et al.
Barriers and enablers to adolescent self-consent for vaccination: a mixed-methods evidence synthesis
Vaccine
(2019) - et al.
Parental acceptance and uptake of the HPV vaccine among African-Americans and Latinos in the United States: a literature review
Soc. Sci. Med.
(2016) - et al.
Provider communication and HPV vaccination: the impact of recommendation quality
Vaccine
(2016) - et al.
Factors associated with HPV vaccine uptake in teenage girls: a systematic review
Vaccine
(2012) - et al.
Persuasive texts for prompting action: agency assignment in HPV vaccination reminders
Vaccine
(2017) - et al.
Efficacy of a prophylactic adjuvanted bivalent L1 virus-like-particle vaccine against infection with human papillomavirus types 16 and 18 in young women: an interim analysis of a phase III double-blind, randomised controlled trial
Lancet
(2007) - et al.
Characterizing safety-net providers HPV vaccine recommendations to undecided parents: a pilot study
Patient Educ. Couns.
(2016)
AMSTAR is a reliable and valid measurement tool to assess the methodological quality of systematic reviews
J. Clin. Epidemiol.
Multilevel correlates for human papillomavirus vaccination of adolescent girls attending safety net clinics
Vaccine
Human papillomavirus infection and vaccination
J. Pediatr. Nurs.
Meaningful methods for increasing human papillomavirus vaccination rates: an integrative literature review
J Pediatr Heal Care
Adoption of evidence-based interventions in local health departments
Am. J. Prev. Med.
Using the theory of planned behavior to predict mothers’ intentions to vaccinate their daughters against HPV
J. Sch. Nurs.
Implementation of HPV vaccination guidelines in a diverse population in Los Angeles: results from an environmental scan of local HPV resources and needs
Vaccine
Understanding how mothers of adolescent girls obtain information about the human papillomavirus vaccine: associations between mothers’ health beliefs, information seeking, and vaccination intentions in an ethnically diverse sample
J. Health Psychol.
Health promotion by social cognitive means
Heal Educ Behav
Human papillomavirus and mandatory immunization laws: what can we learn from early mandates?
Public Health Rep.
Planning Health Promotion Programs: An Intervention Mapping Approach
The uptake of human papillomavirus (HPV) vaccine among adolescent females in the United States: a review of the literature
J. Sch. Nurs.
Barriers and facilitators to HPV vaccination of young women in high-income countries: a qualitative systematic review and evidence synthesis
BMC Public Health
Increasing HPV vaccination through policy for public health benefit
Hum Vaccines Immunother
The National Cancer Institute’s Community Networks Program Initiative to reduce cancer health disparities: outcomes and lessons learned
Prog Community Heal Partnerships Res Educ Action
Parents’ support for school-entry requirements for human papillomavirus vaccination: a national study
Cancer Epidemiol. Biomark. Prev.
Factors associated with parental intentions for male human papillomavirus vaccination: results of a national survey
Sex. Transm. Dis.
Adolescent consent for vaccination: a position paper of the society for adolescent health and medicine
J. Adolesc. Health
Integrating clinical, community, and policy perspectives on human papillomavirus vaccination
Annu. Rev. Public Health
Inequalities in the uptake of human papillomavirus vaccination: a systematic review and meta-analysis
Int. J. Epidemiol.
Factors influencing completion of multi-dose vaccine schedules in adolescents: a systematic review
BMC Public Health
Quadrivalent vaccine against human papillomavirus to prevent anogenital diseases — NEJM
N Engl J Med.
Provider communication about HPV vaccination: a systematic review
Hum Vaccines Immunother
Disseminating effective cancer screening interventions
Cancer
Health Program Planning: An Educational and Ecological Approach
Eliminating parental consent for adolescents receiving human papillomavirus vaccination
R I Med J (2013)
Cited by (91)
“Why is it so necessary?”: African American Parents’ Perspectives on Delaying and Refusing HPV Vaccination
2023, Journal of Pediatric Health Care