ABSTRACT
Objective: To determine parents' and providers' attitudes toward school-located provision and school-entry requirements for HPV vaccination. Methods: Parents/guardians of 11–17 y old girls and pediatric healthcare providers at one inner-city public clinic and three private practices completed semi-structured interviews in 2012-2013. Participants were asked open-ended questions regarding their attitudes toward school-located provision and school-entry requirements for HPV vaccination. Parents' answers were analyzed with relationship to whether their daughters had not initiated, initiated but not completed, or completed the HPV vaccine series. Qualitative analysis was used to identify themes related to shared views. Results: 129 parents/guardians and 34 providers participated. 61% of parents supported providing HPV vaccinations in schools, citing reasons of convenience, improved access, and positive peer pressure. Those who opposed school-located provision raised concerns related to privacy and the capacity of school nurses to manage vaccine-related reactions. Parents whose daughters had not completed the series were more likely to intend to vaccinate their daughters in schools (70%) and support requirements (64%) than parents who had not initiated vaccination (42% would vaccinate at school, 46% support requirements) or completed the series (42% would vaccinate at school, 32% support requirements; p < 0 .05 for all comparisons). 81% of providers supported offering vaccination in schools, wanting to take advantage of the captive audience, improve vaccine completion rates, and decrease the administrative burden on medical office staff, but were concerned about adequate information transfer between schools and medical offices. Only 32% of providers supported school-entry requirements, largely because they felt that a requirement might provoke a public backlash that could further hinder vaccination efforts. Conclusions: School-located provision of HPV vaccination was widely accepted by healthcare providers and parents whose children have not completed the series, indicating that this venue might be a valuable addition to improve completion rates. Support for school-entry requirements was limited among both parents and healthcare providers.
Introduction
HPV vaccination rates in the United States lag behind those of other industrialized nations. National data indicate that as of 2014, 60% of 13-17 y old girls and 42% of boys have initiated the HPV vaccination, and 40% and 22% have completed the series.Citation1 Vaccination in the United States is provided in medical offices, and is dependent upon adolescents visiting their healthcare providers three times to complete the series. However, in other countries such as Australia, Canada, and the United Kingdom, where HPV vaccination is provided within the school setting, rates of complete HPV vaccination exceed 70%.Citation2-4 Some countries with high vaccination rates have already documented population-wide declines in cervical dysplasia and genital warts.Citation5,6 School-located vaccination within the US has therefore been proposed as a means of improving vaccination coverage.Citation7 Most US parents express support for school-located adolescent vaccines,Citation8 though support for HPV vaccination specifically ranged widely from 6% to 72%.Citation9,10 Approximately 60% of providers support school-located vaccinations in general,Citation11 though data are lacking on acceptability of HPV vaccination specifically. School-entry requirements for vaccines, or mandates, have also demonstrated effectiveness for achieving high vaccine population coverage and have been suggested as a means of increasing the number of adolescents receiving HPV vaccination.Citation12-14 Parents' attitudes toward school-entry requirements for HPV vaccination are mixed, ranging from a low of 11% support to a high of 92% when opt-out provisions are included.Citation15-17 Data on providers' attitudes are limited, but indicate that fewer than half support school-entry requirements.Citation18,19 Policymakers are considering both school-located HPV vaccination and school-entry requirements for HPV vaccination to address persistently low coverage rates, yet the public response is difficult to predict as existing data are limited and parents' and providers' attitudes may have evolved over time. To address these limitations, we performed a qualitative interview study in 2012-2013 with parents/guardians and healthcare providers to understand their attitudes toward school-located provision and school-entry requirements related to HPV vaccination.
Results
Parents' demographics
One hundred and twenty-nine parents participated in the study. Participants were asked to recall the number of HPV vaccinations their daughters had received. Fifty-one parents reported that their daughters had not initiated vaccination (Not Initiated Group), 27 reported that their daughters had completed the series (Complete group), 37 reported that their daughters had received one or two doses, and 14 were unsure of the number of doses (Incomplete/Unsure Group). The percentage of respondents supporting school-located immunization and school-entry requirements were similar (±3 %) among parents who were unsure of their daughters' vaccination status and those whose daughters had not completed vaccination, so these groups were combined for statistical analyses. Demographics characteristics of parents differed between groups. Parents in the Incomplete/Unsure group were more often younger, non-White, foreign-born, had lower income and lower educational attainment, and received care in the public clinic than parents whose daughters had either not started or completed the vaccine series ().
Table 1. Demographic information of parents/guardians and daughters.
Parents' views on school-located vaccination
Most parents (61.6%) supported school-located provision of HPV vaccination, and no difference was noted between groups (). The primary reasons parents supported school-located vaccination () were the convenience (n = 21) and the improved access the site would offer (n = 9): “It would definitely be easier… than getting her out of school and driving her the 20 minutes each way.” Three parents cited the benefit of having a captive audience, and three others mentioned that vaccinating in school could create positive peer pressure: “Some kids if they see other kids do things, they'll do it too.”
Table 2. Parental support for school-based provision and school entry mandates for HPV vaccination.
Table 3. Parents' views supporting and opposing school-based provision of HPV vaccines.
Parents who opposed offering school-located vaccination voiced many different concerns (). Twenty-two parents expressed less trust in the competence of school nurses compared to their children's healthcare providers, and an additional seven voiced concerns about the safety of vaccination in non-medical settings: “I know the doctor more and I have more faith in the doctor… I trust him more. I mean school nurses I don't know how far her education has gone, and if she's ever given shots before.” Other parents felt that schools' roles should be limited to education, not medical care (n = 8), or that HPV vaccination was a private issue that should be kept between the parent and provider, not the school (n = 4). Ten parents were concerned that school-located HPV vaccination could promote promiscuity or stigmatize girls: “You don't want kids to be stigmatized like, ‘Oh she's going to get the sex shot.’” Four parents wanted to be present when their daughters were vaccinated, and three were concerned about information transfer between medical offices and schools.
Although the majority of parents in all groups supported providing HPV vaccines in schools, more parents in the Incomplete/Unsure group (70%) stated that they would utilize school-located provision if available compared with 42% of those in the Not Initiated group and 44.5% of those in the Complete group (p = 0.012; ). Most parents who said they would use school-located vaccination for their daughter mentioned improved access and convenience of the service as primary factors in their decision (n = 8). These factors hinted at reasons why some daughters had not completed the series: “[School-located vaccination is] more convenient. She's right there. They are right there. I don't have to set up an appointment. I don't have to take her out of school in order to do that it's right there…It's a lot easier to complete.” Some also pointed out that by vaccinating at school they would minimize missed opportunities (n = 2) and take advantage of positive peer pressure (n = 3).
Parents did voice concerns, however. The most common reason, cited by 15 parents who preferred not vaccinate their teenagers at school, was feeling uncomfortable with school nurses administering vaccinations and/or their capability of handling adverse reactions: “I still think it should be done at the doctor's office just because you never know if someone might have side effects.” Some parents who were willing to vaccinate their daughters in schools stated wanted assurance on the consent process for both the parent and the daughter, or wanted to be present at the time of vaccination (n = 4).
Parents views on other alternative sites
Parents were also asked whether they would feel comfortable with vaccination in other sites including pharmacies, community centers, and churches. Support for these sites was lower, with only 37% of parents feeling comfortable with the idea of their child receiving vaccination there. The most common concerns cited were lack of privacy, lack of medical expertise, and lack of cleanliness. Four parents expressed comfort with pharmacies but not churches or community centers, while two specifically opposed pharmacies. One parent felt comfortable only with vaccination received in church, but others felt that vaccination against a sexually transmitted infection was not appropriate for church.
Parents' views on school-entry requirements
Parents' views on school-entry requirements also differed by group, with 63.8% of parents in the Incomplete/Unsure group supporting requirements compared with 46% of parents in the Not Initiated group and 32% of parents in the Complete group (p = 0.028; ). Interestingly, support for school entry requirements did not correlate with personal decisions to vaccinate, as 68% of parents whose daughters were fully vaccinated opposed such requirements. All but two parents felt that school-entry requirements should apply to both boys and girls. Parents' most common reason to support school-entry requirements was an improvement in public health overall or their child's health specifically (n = 27 parents; ). Other parents supported requiring all medically recommended vaccines, and felt such requirements would protect girls whose parents might otherwise choose not to vaccinate (n = 7): “If it has to be mandatory for people to do the right thing then it has to be that way.” Parents also felt that the benefits of requirements outweighed their risks (n = 12) and that requirements would protect teens from sexually transmitted infections (n = 11): “I would be in favor of it. Because it sounds like from what I understand the vaccine is safe, efficacious and I'd be a fool and also have amnesia to believe that high schoolers do not engage in unwise sexual practices at times.” Three parents believed that requirements would normalize the HPV vaccine and reduce stigma associated with vaccinating.
Table 4. Parents' views supporting and opposing school-entry requirements for HPV vaccines.
Among parents who opposed school-entry requirements, the most common reason was the limitation on parental autonomy (43 parents; ): “Even though I believe you should get it… I don't think it should be forced on people if they do not agree.” Many of these parents felt that HPV vaccines were different than other required vaccines because HPV cannot be transmitted by casual contact (19 parents). Opponents to school-entry requirements also mentioned the newness of the vaccine (10 parents). Seven parents felt that HPV vaccine should not be required because some teens are not sexually active, and seven parents said the HPV requirement and the vaccine itself might stigmatize girls or result in a false sense of security related to sexual experimentation. Three parents felt that children should not be kept out of school for lack of HPV vaccination, and another three felt that HPV was not a severe enough disease to justify a school requirement.
Provider demographics
Thirty-four providers participated in qualitative interviews: 24 physicians, 5 nurse practitioners, and 5 registered nurses. Seventeen physicians, 5 nurse practitioners, and 4 nurses worked in private practices, the remainder worked in the public clinic. Seventeen physicians and all nurse practitioners and nurses were female; eight physicians were male. Providers had been practicing for an average of 15 years, with a range from a few months to more than 30 y.
Providers' views on school-located provision of HPV vaccination
Thirty-one providers responded to questions on school-located provision of vaccination, (MD, NP, RN). Twenty-five (81%) supported provision of HPV vaccination in schools. Several believed that vaccination rates would improve if vaccination were provided in schools (n = 12) while others stated that school-located vaccination would decrease the barriers associated with clinic-based vaccination (n = 4; ): “I think any way you can make it easier, you don't have to require an adolescent to make an appointment, show up, navigate the transportation system… I think school-based immunization makes a lot of sense.” Three providers echoed parents' feelings that adolescents are a “captive audience,” thus school-located vaccination would ensure high vaccine coverage. Two providers cited positive peer influence if many teens receive the vaccine in school, and two others welcomed the possibility of decreasing the burden of vaccinations on clinics.
Table 5. Provider's views supporting and opposing school-based provision of HPV vaccines.
Providers did express concerns about school-located vaccine provision, however (). One common concern was inadequate documentation (n = 5). The logistics of communication become especially challenging with the Family Educational Rights and Privacy Act (FERPA),Citation20 which prohibits schools from sharing information with physician offices under most circumstances. Five providers were concerned about waiting periods and backup in the case of a serious vaccine reaction: “It's a great idea as long as they can be monitored for the potential of the fainting.” Two providers felt providing vaccination would overburden already stressed school health systems, while two others felt that vaccinating in school might erode primary care. Two others felt that providing only HPV vaccine in schools could be detrimental by treating HPV vaccine differently than other recommended adolescent vaccines.
Providers' views on school-entry requirements for HPV vaccination
A minority of providers (n = 11, 32%) favored school entry requirements for HPV vaccination. An additional 21% (n = 7) said that they personally would favor a requirement, but thought that implementation would be difficult due to public resistance. Nearly 40% (n = 13) opposed a requirement, and two providers were unsure. Reasons given for supporting school requirements included improving vaccination rates (n = 6; ): “It's very clear that if you have a school mandate it will get done better than if you didn't,” and improving public health (n = 4): “I think I mean the more vaccines [that are required] I think the better really f it helps the common good that's the goal of a lot of vaccines anyways.”
Table 6. Provider' views supporting and opposing school-entry requirements for HPV vaccines.
However, twelve providers felt that society was not ready for HPV vaccine requirements, and seven shied away from the idea of school entry requirements due to the potential for provoking a public backlash (): “I wouldn't mind living in a country where that happened, but I can't see that happening in this country.” Nine providers felt that HPV did not warrant a requirement because it cannot be transmitted by casual contact: “There is a conscious choice to engage in sexual activity.” A physician who works closely with the public schools brought up an important point about educational funding being spent on vaccine compliance rather than other aspects of education: “So the issue for me is that we're paying educational dollars, two $50,000 salaries, so $100,000 of educational money to enter this data and it doesn't come easy.”
Discussion
HPV vaccination rates in the US lag far below national goals, especially for the recommended ages of 11-12.Citation21 Improvements in both vaccine initiation and completion of all three doses among those who start are current goals of the Centers for Disease Control and Prevention, American Academy of Pediatrics, and President's Cancer Panel.Citation22-26 Fewer than two thirds of adolescents who begin the HPV vaccine series complete all three doses, which may put adolescents at risk for HPV-related disease as three doses are associated with maximum effectiveness.Citation27 Because completing a three dose series has proven difficult for adolescents, policymakers are considering additional steps to raising vaccination rates, including vaccine provision at alternative sites and school-entry requirements. Our study with parents and providers found high levels of support for HPV vaccine provision in schools, especially among those who had difficulty completing the series. However support for school-entry requirements was limited.
Nearly two-thirds of parents and 81% of providers supported school-located HPV vaccination. Many parents felt that vaccination in school would be more convenient than vaccination in their providers' offices, and that school-located vaccination could improve vaccination rates for those with limited healthcare access. Providers felt that school-located vaccination would improve vaccination coverage and decrease logistical barriers to obtaining recommended vaccines. School-located vaccinations have a strong track record of success in other industrialized nations, as well as in the US. Australia, Canada, and the United Kingdom, have implemented school-located HPV vaccination programs and have documented complete vaccination rates exceeding 70% at the recommended ages.Citation2,28,29 These programs have demonstrated success in terms of decreasing genital warts and cervical dysplasia,Citation5,6,30 though have also noted that school-located vaccine provision can provoke anxiety among adolescents.Citation31 Though school-located immunization programs are relatively uncommon in the US at the present time, school-located immunization was commonly used to administer polio vaccination in the 1950s and Hepatitis B vaccination in the 1980s. Recent surveys addressing the acceptability of school-located immunization programs for HPV vaccination found that rates ranged 27%Citation32 among primarily Hispanic, urban parents of middleschoolers in Texas to 71% of a survey of primarily African-American parents in Georgia.Citation33 A national internet-based survey found that 67% of mothers were willing to vaccinate their children in school.Citation34 In this survey, parents who had not yet initiated vaccination demonstrated the highest intent to utilize school-located immunization programs. Similarly, we found that the majority of parents and providers supported school-located provision of HPV vaccination, and that intended program utilization was highest among parents whose daughters had not completed the vaccine series. Together these results indicate that expanding school-located immunization programs might be especially helpful to improve vaccine initiation and completion rates among adolescents most vulnerable to under-vaccination.
Only 37% of parents expressed support for vaccination at other community sites, such as pharmacies, compared with nearly 60% who supported school-located vaccination. Although pharmacy-located vaccination has been proposed as a mechanism to improve HPV vaccination ratesCitation35 and 61% of states have mechanisms by which pharmacies can provide vaccinations to adolescents ages 12 and older,Citation36 parental support for HPV vaccination in pharmacies is limited, with acceptance ranging from 5% to 21%.Citation32,37 Prior to expanding immunization into pharmacies, and other sites, several factors need to be considered including vaccine availability, clarification of vaccine administration to adolescents, retail commitment, vaccine storage and handling, and vaccine financing.Citation38
Only a minority of providers and parents supported school-entry requirements for HPV vaccination. Most parents felt that HPV vaccination should be a choice for parents and adolescents primarily because it could not be easily transmitted via casual contact. Providers felt that school-entry requirements would improve coverage rates, but were concerned about provoking an intense public backlash that could hinder vaccination efforts. These opinions are consistent with other US-based surveys,Citation15,17,39,40 and reflect the national debate on the issue of mandatory HPV vaccination. School-entry requirements are generally considered very effective policies for achieving widespread childhood vaccination.Citation13,14,41 In 2006, with intense lobbying by the pharmaceutical industry, 24 states and regions initiated legislation to require HPV vaccination for school attendance.Citation42 In the setting of modest parental support,Citation15,17 the legislation met with substantial public backlash.Citation39,43 Existing school-entry legislation in Virginia and the District of Columbia contains liberal opt-out provisions that apply only to HPV vaccination, and requirements have not led to higher coverage rates.Citation42 Now that the safety of HPV vaccination has been demonstrated over almost 10 y of use, and because vaccination rates remain stubbornly low, interest in school-entry requirements has resurfaced. Rhode Island was the first state to pass a school-entry requirement without exemptions; this regulation took effect in August of 2015. Although HPV vaccination rates in Rhode Island were high prior to the requirement, with 76% of girls and 69% of boys initiating HPV vaccination in 2014,Citation44 the legislation provoked some public backlash, even among parents who support vaccination and choose to vaccinate their own children.Citation45 The viability of school-entry requirements as a means to improve HPV vaccination coverage is an evolving story requiring careful consideration.
This study has several limitations. The study sample included a small number of participants and was recruited from an urban academic medical center serving primarily low-income and minority patients and three private practices treating more middle- and upper-income largely White parents in the Northeast, which may restrict the applicability of our results to the overall US population, especially those residing in rural areas or other geographic regions in the US. In addition, this study focused only on parents of daughters, and parents of sons could have different views. The results of this study use parental recall of shots administered, rather than the number verified by medical record review, which has limited accuracy.Citation46 Another limitation is that providers were not asked specifically about their support for provision of HPV vaccination in sites other than schools, such as pharmacies. A considerable proportion of parents born outside the US were from low resource countries, in which vaccinations in non-medical settings (e.g. schools) is common, which may have skewed the results obtained.
Conclusions
School-located provision of HPV vaccinations and school-entry requirements have been proposed as ways to raise vaccination rates. Interviews with parents and providers indicate relatively strong support for school-located vaccination, and only weak support for school-entry requirements. The highest intent to use school-located services was noted among parents whose daughters had not completed the vaccine series, indicating that expanding vaccination services into schools might be especially helpful to adolescents at risk for not completing the series.
Methods
Recruitment occurred from September 2012 to July 2013 at one public clinic located within a safety net hospital and three private practices. Parents/guardians presenting with their adolescent daughters between the ages of 11 and 17 were approached before and after their appointments to participate in the study. Trained research assistants reviewed appointment schedules to determine eligible patients and recruited parents in the waiting areas. Interviews were performed in English, Spanish, and Haitian Creole. Interviews were audio-recorded and transcribed verbatim by the research assistants. Bilingual researchers performed and translated interviews in Haitian Creole and Spanish verbatim. These interviews were back-translated to ensure accuracy. Parents received a $20 gift card as compensation for their participation. Interviews lasted 30 minutes on average. Physicians, nurse practitioners, and registered nurses who provided primary care including HPV vaccination at the inner-city public clinic and private practices were also recruited. At each clinical site, a physician involved in the study recruited additional providers. Providers did not receive compensation. Thirty-eight percent of eligible parents/guardians participated. More than 80% of providers at private practices participated, and recruitment at the public clinic was terminated when additional interviews provided no new ideas (7 of 20 primary care providers). This study was approved by the Boston University Medical Center's and Harvard Vanguard Medical Associates Institutional Review Boards. This study represents a subset of interviews previously analyzed to examine barriers to and facilitators to initiation of HPV vaccine series initiation.Citation25
The full interview guide used semi-structured, interview questions were designed to probe the constructs of the health belief and Transtheoretical models: background factors, health beliefs, cues to action, readiness to action (stage of change) perceptions of HPV, and logistical barriers related to vaccination. The components of the parent interviews that were analyzed for this study include parental demographic information, daughter's HPV vaccination status as recalled by the parent, and parental views about school entry requirements for HPV vaccination, school-located provision of HPV vaccination, and whether they would vaccinate their daughters in school if the service were available. The components of the provider interviews that were analyzed included provider views on school-entry requirements for and school-located provision of HPV vaccines. All interviews were coded by two to six researchers and discrepant codes were discussed to reach consensus. Codes were generated from the data collected, consistent with qualitative data analysis. Data analysis aimed to understand parents/guardians' and providers' views vis-à-vis HPV school-entry requirements, school-located provision of HPV vaccination and whether parents would vaccinate their daughters in school if the service were available.
Abbreviations
| HPV | = | Human Papillomavirus |
Disclosure of potential conflicts of interest
Dr. Pierre-Joseph received funding from Merck & Co after this work was completed. No other authors have conflicts of interest to declare.
Funding
This work is supported by American Cancer Society Mentored Research Scholar Grant (MRSG-09-151-01), and Centers for Disease Control and Prevention Cooperative Agreement (1UO1IP000636). No commercial support was obtained. After this study was completed, Dr. Pierre-Joseph received the following award: Integrating HPV vaccination Promotion Initiative with Cervical Cancer Screening and Preventive Initiatives in Primary Care, Award#: 53261, unrestricted educational grant from Merck & Co.
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