https://orcid.org/0000-0003-3088-1091
ABSTRACT
Introduction
The HPV vaccination rate in Japan has been dismally low. Our previous survey work found that mothers in Japan, who have a strong influence over their daughters, often are receptive to the fathers’ participation in the family’s decision-making process about getting their daughter HPV vaccinated.
Methods
We conducted a survey to investigate the nature of the influence of fathers’ participation on the mother’s decision-making process. From an internet survey panel, we selected a pool of 1,499 eligible mothers who had 12–18 years old daughters. The mothers were randomized into three Groups. To the mothers in Group A, we gave an educational leaflet regarding HPV vaccination and a second leaflet which recommended that they talk with their husbands about the vaccination. To Group B, we gave only the educational leaflet. No leaflets were sent to Group C. A structured survey questionnaire was then distributed through the internet to the mothers.
Results
In Groups A, B, and C, their intention to have their daughter receive the HPV vaccine was 21.6%, 20.7% and 8.2%, respectively. The percent of Group A mothers who thought their husband’s opinion was important for when they made the decision was significantly higher (70%) than in Group B (56.6%) or Group C (47.1%).
Conclusions
The fathers’ participation in the mothers’ decision-making does not increase the likelihood of HPV vaccination for their daughters. On the other hand, the educational leaflet proved to be effective for this cause.
Introduction
Cervical cancer is the fourth leading cause of women’s cancer death. Citation1 The predominant cause of cervical cancer is the sexually transmitted human papilloma virus (HPV).Citation2 The anti-HPV vaccine is such a universally accepted effective prophylactic for cervical cancer that it is currently conducted as a national immunization program in more than 130 countries.Citation3
Figure 1. Study design. 1499 Japanese mothers were randomized into three Group: A, B and C. To mothers of Group A, we provided both an educational leaflet regarding HPV vaccination and a leaflet which recommended them to talk with their husbands about their daughter’s vaccination. To mothers in Group B, only the educational leaflet for HPV vaccination was provided. To Group C’s mothers, no leaflets were sent.
Japan’s national vaccination program was started in 2010 and was so successful that by early 2013 the rate of HPV vaccination of adolescent girls approached 70%. However, reports of suspected side-effects of the HPV vaccine dominated the news cycle early in the spring of 2013. As a precaution, the Japanese Ministry of Health, Labor and Welfare (MHLW) ‘temporarily’ withdrew its recommendation for HPV vaccination. This caused the rate of HPV vaccination in Japan to plunge to nearly zero. Incredibly, MHLW’s recommendation ‘pause’ has persisted into 2019. Although the HPV vaccination program was not officially stopped, and 12–16 years old girls can still receive the HPV vaccine for free via governmental support, the rate of HPV vaccination in Japan hovers near extinction, while it soars in other industrialized countries around the world.Citation4
We have conducted several studies regarding how we can better promote HPV vaccination under Japan’s current circumstances, and in particular, after a theoretical restart of the government’s recommendation. In one such study, after reading an education leaflet, and under the hypothetical scenario of a restart of the governmental recommendation, 27% of the mothers answered that they would recommend to their daughters that they get the HPV vaccine.Citation5 Through our surveys, we have found that these mothers usually consulted with their husbands about their daughters’ health problems and that their husbands were involved with the decision-making process.
The first goal for this study was to determine whether their intention to make their daughters receive HPV vaccination would change after the mothers read a letter recommending talking with their husband about HPV vaccination, and a separate educational leaflet about HPV vaccination – relative to mothers who only read the educational leaflet, or to mothers who weren’t provided either leaflet. The secondary endpoint was to investigate how the mothers made decisions about the daughters’ HPV vaccination.
Methods
With approval from our Institutional Review Board, we conducted an online survey of 1,499 Japanese mothers by recruiting them from a large internet survey panel, which listed them as being married and having a 12-18-year-old daughter. Informed consent from the mothers for the survey was obtained via the internet. The mothers were randomized into three Groups: A, B, and C. To the 521 mothers of Group A, we provided both an educational leaflet regarding HPV vaccination and a leaflet which recommended them to talk with their husbands about their daughter’s vaccination. To the 528 mothers in Group B, only the educational leaflet for HPV vaccination was provided. To Group C’s 450 mothers, no leaflets were sent. The leaflets were sent to the mothers via the internet on March 30th of 2018, then our internet survey was conducted from 1 to 8 April.
Groups A and B were first asked if they had read the leaflets. The questionnaire was constructed to record their sociodemographic status, attitude toward HPV vaccination, how they made decisions based on a hypothetical restart of a governmental recommendation, if they talked to their husband about the vaccination, and what they thought was/or would be important when they made their decision about their daughters’ HPV vaccination status.
Statistical analysis
Characteristics of the participants were analyzed by the Kruskal-Wallis test followed by Dunn multiple comparison test (). Statistical analyses were conducted using MedCalc software, version 18.11.6 (Ostend, Belgium). Data in other tables were analyzed by the chi-square test. The difference was considered significant if p < .05/3 with the Bonferroni correction.
Table 1. Characteristics of the participants.
Results
We found no statistical differences between the three randomized Groups regarding their income and occupations. There were statistical differences between Group B and C regarding age and academic backgrounds (). With regards to the effectiveness of the leaflets, for Groups A, B, and C their intentions to make their daughter receive the HPV vaccine were: 20.7% (108/528, A vs. C, p < .0001, A vs. B, p < .9126), 21.6% (114/521 B vs C, p < .0001), and 8.2% (37/450), respectively. Intention was roughly equal in Groups A and B, where significantly more mothers answered that they had an intention to make their daughters inoculate than Group C, showing a beneficial effect of the educational material on their perceptions/memories and responses regarding their daughter’s vaccination. The mothers who responded that they wouldn’t inoculate their daughters was 30.5% (159/521), 30.9% (163/528), and 51.8% (233/450), respectively ().
Table 2. Intention to make their daughters receive the HPV vaccine under the hypothetical restart of a governmental recommendation.
In Group A, 80% (417/521) of the mothers responded that they had talked to their husbands as instructed, which was significantly higher than in the two groups who were not encouraged by our leaflet to talk to the husband; 36.7% of Group B did (194/528, p < .0001), and 20.5% (90/450, p < .0001) of Group C did. This showed that in Group A the leaflet recommending a discussion with their husbands had, at least, this desired effect (). The percentage of the mothers who changed their mind after talking with their husbands was 10.5% (55/521) in Group A (where they were encouraged by the leaflet to talk to their husband), and 6% (32/528) and 2% (9/441) in Groups B and C, respectfully. The percentage of Group A mothers who changed their mind after talking with their husband was significantly higher than for Groups B and C (p = .0115 and p < .0001). Also, Group B was significantly higher than Group C (p = .0027). This showed that the leaflet recommending discussion with the husband and the educational leaflet influenced the mothers ().
Table 3. Persons with whom the mothers discussed their daughters’ HPV vaccination.
Table 4. Changes in intention of the mothers to make their daughter receive vaccination, after a discussion about the HPV vaccine with the fathers.
The things that the mothers thought were most important for making decisions about their daughters’ HPV vaccination are listed in . The fraction of Group A mothers who thought their husband’s opinion was important when they make decisions was 70.1%, which was significantly higher than for Group B (56.6%) and Group C (47.1%) (p < .001 for both comparisons), showing a significant effect for the ‘talk-with-your-husband’ leaflet. After reading the leaflet(s), many other factors were thought to be significantly more important in Groups A and B than in Group C (which had no outside input), such as the risk of cervical cancer for their daughter, preventing the side-effects of the HPV vaccine, a return of the governmental recommendation for the vaccine, and the opinions of their doctors. By far, the greatest concern of the responding mothers was the potential for adverse side-effects from the HPV vaccine ().
Table 5. Points the mothers thought were important for making decisions about their daughters’ HPV vaccination.
Discussion
Our study revealed that a leaflet recommending mothers talking with their husband about HPV vaccination of their 12–16-year-old daughters does not significantly further increase the mother’s own intention to vaccinate their daughter. This suggests, in the culture of Japan, that if mothers do actually fulfill the recommendation to consult with the father, the fathers’ participation in the decision-making process about their daughters’ HPV vaccination will not significantly promote the rate of HPV vaccination.
There are now several reports that mothers in Japan still contribute far more to decisions regarding their daughters' HPV vaccination than do fathers;Citation6–Citation8 however, there are fewer studies focusing on the father’s role. Our previous survey showed the father’s participation in the decision-making process increased the mother’s intention to vaccinate their daughters (submitted). However, that outcome may have been dependent on the father’s level of awareness and knowledge concerning the vaccine and the risk of cervical cancer. The fathers who participated in our previous study were pre-selected based on knowing their daughters’ HPV vaccination status. Those pre-selected fathers were more likely to have already been more knowledgeable about the HPV vaccine and to have had a greater interest in their daughters’ health issues. In the current study, the respondents were the mothers, so we don’t know, across the Groups, how consistently informed or uninformed the fathers’ attitudes toward HPV vaccination and its role in cervical cancer prevention might have been, but, interestingly, this would be the same setting as in the ‘real world.’ Data regarding how many fathers read the leaflet was not available from the current study. It is presumed that if the fathers themselves are ill-informed or have negative feelings about the HPV vaccine, the mother’s intention to vaccinate their daughters would not be increased by talking with the fathers.
To better promote HPV vaccination in Japan, the culmination of our studies suggests that much more aggressive education for the fathers will be needed. We have also found that even when the fathers were willing to vaccinate their daughters, they could not change their wives’ negative feelings toward the HPV vaccine. Those feelings resulted from the widely covered reports of several possible adverse events occurring after HPV vaccination in 2013, and have persisted.
Unexpectedly, and unfortunately, the mothers’ willingness to make their daughter receive HPV vaccine was not improved by father’s participation in the HPV-vaccination decision-making process; however, the educational leaflet we provided was successful in raising the probable vaccination rates in Groups A and B – about two to three times higher than the baseline provided by the uninformed Control Group C. The mothers who answered that they changed their mind after discussion with their husband in Group A were higher than those in Group B (). Nevertheless, the rate of the mothers who answered that they were willing to make their daughter receive HPV vaccine was about the same in Groups A and B. That means the discussion with their husband worked both positively and negatively for HPV vaccination. Some mothers may have changed their mind from ‘not vaccinate’ to ‘vaccinate’, or from ‘vaccinate’ to ‘not vaccinate’, after a discussion with their husbands. How they changed their opinion is unknown because that question was not included in the survey.
About 20% of the mothers in this survey answered that they would vaccinate their daughters under a circumstance that included a restart of the Japanese government’s recommendation for the vaccine; this is the same percentage as we found in our previous study.Citation5 That study also found that 27% of mothers, after reading an educational leaflet, would vaccinate their children; the effect of the educational leaflet was reaffirmed in the current randomized group study.
In , only the significance of other children’s HPV vaccination status for altering decision-making was not significantly different in Groups A and B from Group C. In our previous study, after reading the educational leaflet, 50% of the mothers answered that they would change their mind and inoculate their daughter – but only if many children of the same age had safely received the HPV vaccine first. To begin to improve the HPV vaccination rate in Japan to >90%, where it should ultimately be, we first need to address this point. The educational leaflet we have been using does not yet contain data on the massive number of children in Japan that have already been safely inoculated with the HPV vaccine. From the start of HPV vaccination in Japan in 2010, to the cessation of the governmental recommendation in 2013, more than 8,910,000 inoculations safely occurred. Once there is a restart of the governmental recommendation for HPV vaccination, the number of the safe HPV vaccinations should be updated and reported regularly, to encourage parents that the vaccine is safe, so they will vaccinate their daughters. After they know how many other children have been vaccinated, their negative feeling about the HPV vaccine should be significantly diminished.
More than 90% of the mothers in Groups A and B, and 80% of Group C, answered that the potential for adverse effects from vaccination was important to them for their decision-making. The probable HPV vaccination rate was not increased with the fathers’ participation in the decision-making process; however, if the mothers fear the possible adverse effects of HPV vaccination, the fathers could support the mothers – if such rare adverse events did happen, lessening the impact on the family.
For 70% of the mothers in Group A, and 57% of the mothers in Group B, they wanted to talk with their husband when they made decisions for their daughters’ future vaccination (data not shown). The talk-to-the-father recommendation leaflet alone did not further promote the probable vaccination rate; however, the leaflet did make the mothers talk to their husbands about HPV vaccination. If the fathers can be better educated prior to those discussions perhaps that will improve the communication outcome.
The limitations of our study are several. The participants were chosen from an internet survey panel, which might select for certain types of respondents. The knowledge and attitudes toward HPV vaccination of the fathers were not simultaneously investigated. We did not survey the mothers in Groups A and B both before and after distributing the leaflets to them, we had assumed their responses would mirror the randomized parents in Group C, who also had not seen the leaflets at that point. It would have been useful to have that confirmation to add statistical power to our analysis. Another limitation is that there was only a seven-day window between the leaflet distribution and the survey, there may not have been enough time for the mothers to properly discuss the matter with their husbands. Another limitation is that the survey was conducted only in Japan – its cultural background, such as the relationship between mothers and fathers, is quite different from Western and Middle Eastern countries, etc.
Conclusions
Without proper educational pre-intervention, fathers’ participation in mothers’ decision-making process about their daughters’ HPV vaccination does not increase the probability of the daughters’ vaccination. It could work as both a positive effect and a negative effect on the daughters’ HPV vaccination. On the other hand, an HPV educational leaflet provided to the mother has proven to be effective for that purpose. Further investigation is needed to improve the HPV vaccination rate in Japan.
Abbreviations
| HPV | = | human papillomavirus |
| MHLW | = | Japanese Ministry of Health, Labor, and Welfare |
| WHO | = | World Health Organization |
Disclosure of potential conflicts of interest
No potential conflicts of interest were disclosed.
Supplemental Material
Download MS Word (3.8 MB)Acknowledgments
We would like to thank Dr. G. S. Buzard for his constructive critique and editing of our manuscript.
Supplementary material
Supplemental data for this article can be accessed online at http://dx.doi.org/10.1080/21645515.2019.1697107.
Additional information
Funding
References
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