ReviewPredictors of HPV vaccine acceptability: A theory-informed, systematic review
Introduction
The advent of new human papilloma virus (HPV) vaccines with the potential to prevent the majority of cases of invasive cervical cancer presents a remarkable public health achievement (Markowitz et al., 2007, Villa et al., 2006). However, much of the existing behavioral research on the vaccines appears to be missing important opportunities. Our review's primary aim is to inform HPV vaccination programs by synthesizing findings relevant to HPV vaccine acceptability using a theoretical framework. This review differs from previous ones (e.g., Waller et al., 2004, Zimet et al., 2006) by (1) systematically reviewing the literature, (2) using theory to identify predictors of HPV vaccine acceptability, and (3) placing special emphasis on the populations most affected by cervical cancer.
The epidemiology of cervical cancer is fundamental to its prevention (Green and Kreuter, 2004). Yet, acceptability has not been adequately characterized for the groups that may benefit most from the HPV vaccine. Invasive cervical cancer is one of the leading causes of cancer-related deaths among women in the world, killing an estimated 237,500 women a year, mostly in developing countries in Africa and Asia (Globocan, 2002). In the United States, about 3670 women will die of the cervical cancer in 2007 (American Cancer Society, 2007), but this number does not adequately describe the disease's many well-documented disparities.
Race and ethnicity play a central role in the epidemiology of cervical cancer in the United States. Twice as many African American women die from cervical cancer as white women (5.0 vs. 2.4 deaths, respectively, per 100,000 women annually); Hispanic women also have a higher cervical cancer mortality rate than white women (3.4 deaths per 100,000 women annually) (Ries et al., 2002). Cervical cancer is increasingly a disease of poor women in the United States, as socioeconomic deprivation is associated with cervical cancer screening, diagnosis, treatment, and survival differentials (Newmann and Garner, 2005). Cervical cancer mortality rates are higher among rural populations than urban populations, and factors that place women at high risk for developing or dying from cancer are concentrated disproportionately in rural areas of the United States (Newmann and Garner, 2005). Other risk factors for cervical cancer include smoking, HIV infection, and, possibly, multiple pregnancies and long-term oral contraceptive use (Gottlieb, 2002).
Theories of health behavior can offer a priori predictions about beliefs likely to increase adoption of the HPV vaccine. Our review emphasizes the health belief model because of its proven relevance to vaccination behavior. The constructs in the health belief model (Becker, 1974) – perceived risk, perceived effectiveness of the vaccine, perceived barriers to vaccination, and cues to action – are among the most important predictors of influenza vaccination (Brewer et al., 2007a, Chapman and Coups, 1999). Perceived likelihood, in the context of HPV vaccination, is the belief that HPV infection and cervical cancer are likely to happen. It is a statement of probability in numerical or non-numerical terms. Perceived severity, another dimension of perceived risk, is the belief that HPV infection or cervical cancer would have serious negative consequences for health or well being. Perceived effectiveness (i.e., a perceived benefit) is the belief that the HPV vaccine will reduce the likelihood or severity of HPV infection or cervical cancer. Perceived barriers to being vaccinated against HPV can be any perceived impediment to vaccination such as vaccine side effects and cost. Cues to action are situational factors that trigger one to get vaccinated.
We also review awareness of HPV and knowledge about HPV infection, cervical cancer, and the HPV vaccine, even though these commonly assessed constructs are not formally part of the health belief model. Because many consider them prerequisites for making informed decisions about vaccination, awareness and knowledge appear in other conceptual approaches to studying health behaviors (Weinstein, 1988). Lastly, we report other beliefs that do not neatly fit into the health belief model framework but that were examined in the studies. The review focuses on HPV vaccine acceptability among adolescents, young adults, and parents of adolescents in the United States.
Section snippets
Methods
Two investigators searched Medline, CINAHL, and PsycINFO from 1995 to January, 2007, the approximate time frame during which HPV was known to cause cervical cancer, for articles related to HPV vaccine acceptability and its likely predictors identified from behavioral theory, among adolescents, young adults, and parents. Although physicians are not the focus of our review, we acknowledge that they are likely to play a central role in prompting vaccination. All studies were conducted prior to the
Results
As shown in Fig. 1, the search identified 1682 articles. Of the 53 articles that met inclusion criteria, 22 reported data collected in Europe, Canada, or Australia, two in Latin America, and one in Africa. Twenty-eight studies were conducted in the United States. We review only studies conducted in the United States because of the many differences with health care systems in other countries and potential cross-cultural differences in beliefs and motivations related to HPV vaccination.
The United
Discussion
Parents in the United States have generally positive evaluations of HPV vaccination. The same theoretical constructs that have been pivotal in promoting uptake of other vaccines also influenced HPV vaccine acceptability. The studies had substantial limitations in their designs, study populations, and likely generalizability. Current literature on HPV acceptability is generally limited to cross-sectional studies based on small, largely Caucasian samples, with few studies of Hispanic women, and
Conclusions
Vaccine programs should consider that those lacking access to routine Pap screening and follow-up care can benefit most from HPV vaccination because of their high-risk. Research on HPV vaccine acceptability does not reflect those who are most in need of vaccination such as Hispanic adolescents and young adults, those living in rural areas, and those with low socioeconomic status. Future studies are urgently needed to address the dearth of HPV vaccine acceptability research in developing
Acknowledgments
The review was funded in part by grants from the American Cancer Society (MSRG-06-259-01-CPPB) and the University Research Council of the University of North Carolina at Chapel Hill. We thank Joan Cates, Talya Salz, Nina Sperber, and Karen Ziarnowski for their comments on an earlier draft of this paper. A portion of this work was presented at the 2007 meeting of the Society for Behavioral Medicine.
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