Effect of the decision-making process in the family on HPV vaccination rates among adolescents 9–17 years of age

Abstract

The purpose of this study was to examine the relationship between human papillomavirus (HPV) vaccine uptake among adolescents aged 9–17 years and the decision-making process used by families in determining whether to vaccinate their children against HPV. A cross-sectional sample of women with at least one child aged 9–17 years (n = 1256) was recruited from 3 reproductive health clinics in Southeast Texas during 2011–2013. Self-administered survey included questions about the HPV vaccination decision-making process, HPV vaccine uptake (initiation and 3-dose series completion), and demographics. Among mothers with at least one 9 to 17-year-old daughter (n = 783), 40% independently decided whether or not to vaccinate their daughter against HPV, 22% involved their husbands/partners, and 31% their daughters. Only 7% of respondents reported other formats in the decision-making (husband/partner alone or daughter alone). Similarly, for women with at least one eligible son (n = 759), 39% decided alone, 30% with their husbands/partners, 24% with their sons, and 7% reported other formats. Among mothers with a daughter, those who made the decision independently were more likely to report that their daughters had initiated the HPV vaccine series (30%) compared with women who included their husbands/partners (10%) or daughters (20%) in the decision process or stated other types (18%) of decision making (P < 0.001). The respective figures for the completion of the entire series among daughters were 16%, 6%, 11%, and 11% (P = 0.012). Among mothers with a son, a similar scenario was observed for vaccine initiation (17%, 4%, 10%, and 0%, respectively) (P < 0.001) and completion (7%, 1%, 4%, and 0%, respectively) (P = 0.003). These associations remained significant after adjusting for confounder variables. Awareness programs to increase HPV vaccine uptake should include both parents and children, as all have an important role in deciding whether or not children will be vaccinated.

Keywords: :

• human papillomavirus
• HPV vaccine
• decision-making
• parents
• adolescents

Introduction

In 2006, the Advisory Committee on Immunization Practices (ACIP) recommended routine vaccination against human papillomavirus (HPV) for females 11–12 y of age and the “catch-up” vaccination recommended for females aged 13–26 y who have not been previously vaccinated or completed the full series.¹ In 2011, ACIP also began recommending routine HPV vaccination for 11–12 y old males and “catch up” vaccination for males 13–21 y old.² For both males and females, vaccination can begin as early as age 9.^1,2 Despite its proven efficacy,^3-6 only 33.4% of girls and 6.8% of boys aged 13–17 y completed the HPV vaccine series by 2012.⁷

In the US, HPV vaccination in children <18 y of age requires parental consent. Mothers have been shown to be highly involved in their children’s healthcare decisions, especially with regards to HPV vaccination.^8-12 Less is understood about the role that fathers or pediatric patients play in this process. It has been observed that Hispanic and black fathers prefer to defer decisions about HPV vaccination to female caretakers or trusted friends, while female Hispanics often prefer to make these decisions collaboratively.¹³ In contrast, fathers from other ethnic groups are more likely than mothers to believe that the decision should be made by both parents.¹⁴ Thus far, no studies have examined the association between the family’s decision-making patterns for adolescent HPV vaccination and current vaccination status of the child. Understanding this process is important as it needs to be considered when designing intervention programs. The purpose of this study was to examine whether familial decision-making processes are associated with HPV vaccine uptake and completion among US families with a 9–17 y old son or daughter.

Results

Of the 1256 mothers with a child aged 9–17 y, 484 (38.5%) had at least one daughter in the eligible age group, 452 (36.0%) had at least one son, and 320 (25.5%) had both a daughter and a son. The distribution by racial/ethnic groups was representative of the clinics’ patient population with Hispanic women comprising approximately half of the sample (Table 1). Most mothers 908 (72.3%) had heard of HPV previously and 619 (49.3%) were familiar with the vaccine.

Table 1. Sample characteristics of mothers with a 9–17-y-old child (n = 1256))

	n (%)^a
Age
<30	180 (14.3)
30–39	751 (59.8)
40 or above	325 (25.9)
Race/ethnicity
White	240 (19.1)
Black	357 (28.4)
Hispanic	642 (51.1)
Other	17 (1.4)
Marital status
Single, never married	249 (19.9)
Married or cohabitating	689 (55.1)
Separated/divorced/widowed	312 (25.0)
Education
Did not graduate high school	547 (43.6)
High school graduate or GED	392 (31.2)
College degree or some college	316 (25.2)
Education of partner
Did not graduate high school	435 (35.0)
High school graduate or GED	346 (27.9)
College degree or some college	188 (15.1)
Does not have a partner	273 (22.0)
Employment status
Does not work	689 (54.9)
Employed (full/part time)	566 (45.1)
Annual household income
Less than $15,000	496 (40.1)
$15,000-$29,999	542 (43.8)
$30,000 or above	200 (16.2)
Current smoker	282 (22.5)
Ever diagnosed with a STI	188 (15.1)
Ever diagnosed with HPV	93 (7.5)
Ever had abnormal pap smears	372 (29.8)
Ever diagnosed with precancerous cervical cells/cervical cancer	117 (9.4)

^a Numbers do not add up to 1256 due to missing data; GED, General Education Diploma; HPV, human papillomavirus; STI, sexually transmitted infection.

Among mothers with a daughter (n = 783), 40% were the sole decision maker regarding whether or not to vaccinate their daughter against HPV, 22% made/would make a joint decision with their husband/partner, and 31% with their daughter. Seven percent of mothers reported other types of decision-making (decision made by husband/partner alone, daughter alone, daughter with parents together, or daughter’s grandmother alone). Among women with a son (n = 759), 39% decided/would decide alone, 30% with their husband/partner, 24% with their son, and 7% other types of decision making.

Among mothers with a daughter, those who made (or will make) the decision independently were more likely to report that their daughters had initiated the HPV vaccine series (30%) compared with those who included their husbands/partners (10%) or daughters (20%) in decision process or stated other types (18%) of decision-making (P < 0.001; Table 2). A similar pattern was observed for vaccine series completion was among daughters (16%, 6%, 11% and 11%, respectively) (P = 0.012). Among mothers with a son, a similar scenario was also observed for vaccine initiation (17%, 4%, 10% and 0%, respectively) (P < 0.001) and completion (7%, 1%, 4%, and 0%, respectively) (P = 0.003). Among women who made the decision independently, HPV vaccine initiation and completion rates did not differ between women who were single and those who were living with their husbands/partners.

Table 2. The initiation and completion of HPV vaccine among 9–17 y old children by family decision making process^a

Decision making process as reported by mother	9–17 y old daughters (n = 783)				9–17 y old sons (n = 759)
	Received 1 dose n (%)	P value^b	Completed 3-dose series n (%)	P value^b	Received 1 dose n (%)	P value^b	Completed 3-dose series n (%)	P value^b
Decided/will decide jointly with partner/husband	18 (10.3)	<0.001	11 (6.3)	0.012	10 (4.3)	<0.001	3 (1.3)	0.003
Decided/will decide by mother herself	94 (30.1)		51 (16.4)		49 (16.7)		21 (7.1)
Decided/will decide jointly with daughter/son	49 (20.3)		27 (11.2)		18 (9.7)		8 (4.3)
Other formats^c	10 (18.2)		6 (10.9)		0 (0.0)		0 (0.0)

^a Number of women with daughter and son do not add up to 1256 as many of them had both daughter and son; ^bBased on chi square or the Fisher exact test; ^cHusband/partner alone, daughter/son alone, parents and daughter/son together, or grandmother alone

Multivariable logistic regression analysis adjusting for maternal age, education, and employment revealed that mothers who independently decided whether to vaccinate their daughters against HPV were more likely to initiate and complete the vaccination compared with mothers who involved their partners/husbands in the decision (Table 3). This association was also observed among mothers who independently decided to vaccinate their sons compared with mothers who reported sharing the decision with their partners/husbands. Mothers who made the decision alone were more likely to vaccinate their daughters (adjusted odds ratio [aOR] 2.05, confidence interval [CI] 1.35–3.11 for initiation; aOR 1.92, CI 1.14–3.25 for completion) and sons (aOR 2.21, CI 1.21–4.04 for initiation; aOR 1.97, CI 0.83–4.68 for completion) compared with mothers who reported that they made a joint decision with their daughters/sons (data not shown).

Table 3. Odds ratios (OR) of HPV vaccine initiation and completion among 9–17 y old children by family decision making process

Decision making process as reported by mother	Received 1 dose^a				Completed 3-dose series^a
	Unadjusted		Adjusted		Unadjusted		Adjusted
	OR (95% CI)	P value	OR (95% CI)	P value	OR (95% CI)	P value	OR (95% CI)	P value
For 9–17 y old daughters
Decided/will decide jointly with partner/husband	Reference		Reference		Reference		Reference
Decided/will decide by mother herself	3.74 (2.17–6.44)	<0.001	3.55 (2.00–6.31)	<0.001	2.90 (1.47–5.72)	0.002	2.34 (1.14–4.81)	0.020
Decided/will decide jointly with daughter	2.20 (1.23–3.93)	0.008	1.73 (0.94–3.21)	0.080	1.86 (0.90–3.86)	0.095	1.22 (0.56–2.65)	0.618
Other formats (e.g., daughter alone, husband alone)	1.93 (0.83–4.47)	0.127	1.73 (0.72–4.16)	0.219	1.81 (0.64–5.16)	0.264	1.46 (0.49–4.32)	0.493
For 9–17 y old sons
Decided/will decide jointly with partner/husband	Reference		Reference		Reference		Reference
Decided/will decide by mother herself	4.42 (2.19–8.94)	<0.001	3.93 (1.86–8.28)	<0.001	5.85 (1.72–19.85)	0.005	5.80 (1.64–20.58)	0.006
Decided/will decide jointly with son	2.38 (1.07–5.29)	0.033	1.78 (0.77–4.08)	0.279	3.423 (0.90–13.14)	0.071	2.94 (0.74–11.63)	0.125
Other formats (e.g., son alone, husband alone)	-^b		-^b		- ^b		-^b

^a Sociodemogrpahic variables (age category, race/ethnicity, education, partner’s education, work status, awareness about HPV vaccine, and history of abnormal Pap smears) with a P value < 0.1 based on bivariate logistic regression analysis where vaccine initiation and completion in daughters and sons were dependent variables in separate models were included in the multivariate models. However, variables with a P value > 0.1 in the initial multivariate model were removed from the final multivariate models (education, partner’s education, work status, and history of abnormal Pap smears). Age categories and race/ethnicity were forced in the models if the P value did not achieve significance at <0.1 level. ; ^bVaccine initiation or completion were not observed in this category of decision making.

Discussion

In this study, more than 90% of mothers were involved in the decision about whether to vaccinate their child and approximately 40% were the sole decision maker. This finding is in agreement with other studies, which have shown that mothers often have the primary decision-making authority regarding vaccinating their child against HPV.^10-13 Due to the high involvement of mothers in making vaccination decisions, it is critical that they have adequate knowledge about the risks and benefits of the HPV vaccine.^10,11,15-17 However, several studies have shown that a large proportion of women have never heard of HPV.^18-20 This is consistent with our finding, which found that 28% of mothers were not aware of HPV. These data demonstrate that further efforts are needed to ensure that all mothers of adolescents have adequate information on HPV to make an educated decision about vaccinating their child.

We found that the likelihood of adolescent HPV vaccination was lower when mothers involved their husbands/partners in the decision. This is in contrast to studies which have found that effective family and provider communication about the HPV vaccine was associated with improvements in vaccine acceptability and uptake.^21-23 However, little has been reported in these studies on the father’s perspective of HPV vaccination. Men have been shown to have low knowledge of HPV infection,^24,25 and are less likely to report HPV vaccination in their sons.²⁶ Given the shared role of fathers in the decision making process, they must be included in educational efforts designed to increase education and HPV vaccine awareness and uptake among adolescents. Moreover, qualitative studies are needed to examine factors influencing the decision in this population who involve their husbands/partners in the decision whether to obtain the HPV vaccination for their adolescent children.

We also found that mothers who involved their children in the decision were less likely to obtain the vaccine for their child. We did not have information, however, on the actual content of these discussions or the factors influencing the decision. Previous studies have suggested that HPV vaccine decision-making between parents and their children include interactive discussions about HPV infection and the vaccine.^15,27,28 Moreover, these discussions should also address other sex-related topics, as this has been associated with HPV vaccine uptake among older adolescents²¹ and may provide an opportunity to promote sexual health during early adolescence.²⁸ Mothers of young adolescents, however, may prefer to explain the HPV vaccine as a cancer prevention tool until the child is older.⁹

This study has several limitations. Due to the cross-sectional design, it is not possible to establish a causal relationship between family decision-making processes and adolescent HPV vaccine uptake. In addition, vaccination status was self-reported and subject to recall and social-desirability bias. Finally, this study was limited to low-income women seeking reproductive health care in a limited geographic area and may not be representative of the population as a whole.

While HPV vaccine uptake was highest among mothers who independently decided to vaccinate their children, more than half of mothers included their husbands/partners or children in the decision-making process. These findings underscore the importance of educating parents and adolescents on the benefits of vaccination for protection against HPV-related cancer and disease. Furthermore, parental guidance and active dialog about vaccination and health-promoting behaviors at a young age may encourage adolescents to take a more proactive role in their future health-related decisions.

Materials and Methods

Women presenting for care at 3 different reproductive health clinics operated by the University of Texas Medical Branch between September 2011 and February 2013 were invited to participate in a self-administered questionnaire about HPV vaccination. Women who agreed to participate were screened to determine that they had at least one child between 9 and 17 y of age. Of the 4020 women who attended the reproductive health clinics during that time, 1318 women met the eligibility criteria. Of these, 1276 (96.8%) women completed the survey questionnaire and 42 (3.2%) declined. Twenty (10 incomplete, 9 invalid, 1 missing) of the 1276 surveys were later excluded due to incomplete or invalid responses, leaving 1256 women. Those who participated were reimbursed $5 for their time and effort. Participants in this study provided informed consent to participate. The University of Texas Medical Branch Institutional Review Board approved all procedures for this study.

The self-administered questionnaire, which was available in English or Spanish, obtained information on the mother’s age, race/ethnicity, marital status, the education level of herself and her partner, employment status, and annual household income. It also included questions on current smoking status, awareness about HPV and the HPV vaccine, and prior history of sexually transmitted infections (STIs), abnormal Pap smears, and cervical cancer.

HPV vaccine uptake among the children was assessed by asking mothers, “Which of the following best describes your daughter’s current situation?” The response options included were (1) she has completed the series of 3 shots for the HPV vaccine; (2) she has started (but not completed) the series of 3 shots for the HPV vaccine; (3) she has already scheduled an appointment with a doctor to receive the HPV vaccine; and (4) she has not received the HPV vaccine or scheduled an appointment to receive the HPV vaccine. Mothers who responded that her child had completed or started the HPV vaccine series were considered HPV vaccine initiators. Those who answered that their child completed the series of 3 shots were considered vaccine completers. Similarly worded questions were asked for mothers who had a son.

To examine the involvement of other family members in the vaccine decision-making process, mothers were asked, “Who made/will make the decision to have your daughter(s) vaccinated with the HPV vaccine?” The response options were (1) only me; (2) only my husband/partner; (3) me and my husband/partner; (4) only my daughter; (5) me and my daughter; (6) me, my husband, and my daughter together; and (7) my mother. Mothers who had a son were asked similarly worded questions with similar response options. For the purpose of analysis, responses were placed in 4 categories: “decided/will decide by mother herself,” “mother decided/will decide in consultation with their husband/partner,” “mother decided/will decide in consultation with their daughter/son,” and “all other types together.” For those women who had multiple sons/daughters, information on only the oldest son or daughter in the eligible age group (9–17 y) was sought. When a woman had both a son and a daughter in the eligible age group, data was obtained on one son and one daughter.

Associations between the main exposure variable (familial decision-making patterns for adolescent HPV vaccination) and each of the outcome variables (HPV vaccine initiation and completion of the series) were examined using the chi-square test or the Fischer exact test. Bivariate logistic regression analyses were performed between demographic variables and outcome variables to identify potential confounding factors to be included in the multivariable models. Variables with a P value < 0.10 were included in the final multivariable logistic regression models. All analyses were performed using STATA 12 (Stata Corporation).

Abbreviations:
HPV	=	human papillomavirus
ACIP	=	Advisory Committee on Immunization Practices
OR	=	odds ratio

Disclosure of Potential Conflicts of Interest

No potential conflicts of interest were disclosed.

Funding Source

Federal support for this study was provided by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (K24 HD043659, Berenson). J.M.H. and C.J.M. are supported by a research career development award (K12HD052023: Building Interdisciplinary Research Careers in Women’s Health Program -BIRCWH) from the Office of Research on Women’s Health (ORWH), the Office of the Director (OD), the National Institute of Allergy and Infectious Diseases (NIAID), and NICHD at the National Institutes of Health. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NICHD or the National Institutes of Health.

End Note

10.4161/hv.28779