The Introduction of the HPV Vaccine

Parental Acceptance of a Mandatory Human Papillomavirus (HPV) Vaccination Program Daron Ferris, MD, Leslie Horn, BS, and Jennifer L. Waller, PhD

Objectives: The objective of this study was to determine factors that influence parent’s acceptance of a mandatory school-based human papillomavirus (HPV) vaccination program.

Methods: A convenience sample of 325 parents, with children aged 9 to 17 years old, completed a 53-item survey. Survey questions targeted their opinions about HPV, the HPV vaccine, and a mandatory HPV vaccination program. �2 tests were used to examine relationships between survey items.

Results: Characteristics of parents who believed the HPV vaccine should be mandated included lim- ited financial resources (P � .03), history of HPV-related disease (P � .04), understanding their child’s susceptibility (P � .03), interest in HPV vaccination for their child (P � .0001), and knowledge that the vaccine reduces the risk of cervical cancer (P � .001). Parents of children aged 12 to 14 years old (P � .02) or who knew the vaccine reduced their child’s risk of developing genital warts (P � .02) and cervi- cal cancer (P � .001) would be more likely to comply with a mandatory HPV vaccine program.

Conclusions: Certain characteristics define parents who support a mandatory HPV vaccination pro- gram. Greater education of parents and health care providers should improve vaccination uptake, which ultimately reduces morbidity and mortality from HPV related diseases. (J Am Board Fam Med 2010;23: 220–229.)

Keywords: Human Papillomavirus, Health Care Surveys, Attitude, Vaccination

Although the quadrivalent human papillomavirus (HPV) vaccine has demonstrated robust efficacy and reasonable safety, suboptimal vaccination rates raise concern and questions.1–6 A survey conducted in 2007 by the Centers for Disease Control and Prevention found that approximately 25% of 13- to 17-year-old girls had received at least one dose of the HPV vaccine.5 Moreover, far fewer 9- to 12-

year-old and 18- to 26-year-old girls and women have initiated the vaccination series. The poor rate of HPV vaccine coverage for 9- to 12-year-old girls is particularly worrisome because this has been deemed the ideal age to vaccinate.7 In comparison, coverage for school-entry vaccines during the 2007–2008 school year estimated by the Centers for Disease Control and Prevention varied between 94% (varicella) and 96% (hepatitis B).8 The differ- ences in these vastly contrasting rates of vaccina- tion are likely because of many factors, including cost, safety, knowledge, provider issues, access, and controversy.9–11 However, one simple explanation is that school-entry vaccines are mandated and the HPV vaccine is not.

Although discussion of mandating vaccines gen- erates conflicting opinions, this approach has proven very beneficial from a public health per- spective. School-mandated vaccination programs have increased coverage for other vaccines.12–15

However, such an approach for the HPV vaccine has met some resistance by the medical commu- nity.16 Further, only a minority of parents ap- prove mandating the quadrivalent HPV vac- cine.17,18 Loss of parental autonomy, cost, insufficient data from clinical trials, and too

This article was externally peer reviewed. Submitted 22 April 2009; revised 8 July 2009; accepted 13

July 2009. From the Gynecologic Cancer Prevention Center (DF);

the Departments of Family Medicine and Obstetrics and Gynecology (DF) and the Department of Biostatistics (JLW), Medical College of Georgia (LH), Augusta, Geor- gia.

Funding: Residual grant funds. Conflict of interest: Dr. Ferris is an investigator for Glaxo-

SmithKline vaccine studies. He is also a consultant, investi- gator, and speaker for Merck and Co., Inc. Ms. Horn and Dr. Waller have no potential conflicts.

Corresponding author: Dr. Daron G. Ferris, Department of Family Medicine, Medical College of Georgia, 1423 Harper Street, HH-105, Augusta, GA 30912 (E-mail: agerman@ mcg.edu).

See Related Commentary on Page 149.

220 JABFM March–April 2010 Vol. 23 No. 2 http://www.jabfm.org

many side effects are the main reasons for lack of parental support.17,18 In addition, critical ap- praisal of parental acceptance of a mandatory HPV vaccination program would be beneficial before promoting required HPV vaccination for children. The purpose of this study was to deter- mine factors that influence parental acceptance of a mandatory HPV vaccination program.

Materials and Methods We asked parents of 9- to 17-year-old children to participate in this study. A convenience sample of eligible parents was recruited from waiting rooms in family medicine, obstetrics and gynecology, and pediatric clinics at the Medical College of Georgia, Augusta, and from Women’s Health Associates, Atlanta, Georgia. Patients were also recruited from community sites, including Riverview Park, North Augusta, South Carolina; Suwanee Academy of the Arts, Suwanee, Georgia; and hair and nail salons in Augusta and Atlanta. We excluded parents who were unable to read English. This study was ap- proved by the Human Assurance Committee at the Medical College of Georgia.

The questionnaire has been described previ- ously, but it consisted of 53 questions that collected demographic data, opinions about HPV and vac- cines, attitudes about the HPV vaccine, and issues involving a mandatory HPV vaccination pro- gram.17 The main outcome questions determined parental reactions to a mandated HPV vaccination program. Specifically, these questions were (1) Do you think the HPV vaccine should be added to the list of school entry vaccine requirements? and (2) If the vaccine was mandatory for a child to attend school, which of the following statements most agrees with your view? (answer options for question 2 were “I would sign a waiver to prevent my child from receiving the vaccine”; “I would have my child vaccinated”; or “I would do whatever my doctor recommends.” Questions were structured as yes/no and multiple choice. Some pertinent questions from previously developed questionnaires were in- cluded.19–21

Parents were asked to participate in a study about their opinions of the HPV vaccine and man- datory vaccination programs. Eligible parents who agreed to participate were given a 1-page cover letter that described HPV and the HPV vaccine. Subjects then completed the self-administered,

anonymous survey and returned it in an envelope to the investigators.

Descriptive statistics, including means and standard deviations, frequencies, and percent- ages, were calculated for responses to each ques- tion. �2 tests were used to examine the relation- ship between various questionnaire items. All statistical analyses were performed using SAS software version 9.1.3 (SAS Institute, Inc., Cary, NC) and statistical significance was assessed us- ing an � level of 0.05.

Results We asked 365 parents to participate in the study; 325 parents enrolled in the fall of 2008. The re- sponse rate was 89%, with insufficient time and length of the questionnaire being the main reasons for parents’ refusal to participate. Complete demo- graphic data based on the 325 parents have been published previously.17 In summary, subjects tended to be female, 30 to 39 years old, white, protestant, have a family income between $20,000 and $50,000, have some college education, and have private health insurance. Personal history of HPV-related problems included 13% with a previ- ous HPV infection, 5% with condyloma, and 37% had a previous abnormal Papanicolaou test result.

Associations between demographic variables and agreement with adding the HPV vaccine to school entry requirements are seen in Table 1. Those with incomes �$20,000, those with no health insurance, Medicaid, or Tricare insurance, or those who have ever had HPV were more likely to agree that the HPV vaccine should be added to school entry re- quirements. Sex, race, and age of children did not predict support for an HPV vaccine mandate.

Associations between various other variables and agreement with mandating the HPV vaccine were also examined (Table 2). Subjects who were not familiar or very familiar with HPV felt it very likely that their child could contract HPV and thought it was very important for their child to receive the HPV vaccine; those who thought that the HPV vaccine reduced the risk of cervical cancer more frequently thought that the HPV vaccine should be added to school entry requirements. Parents who supported government-mandated vaccines thought a mandatory HPV vaccine program would be very helpful, and those who want the federal govern- ment to help pay for the HPV vaccine more often supported school entry requirements.

doi: 10.3122/jabfm.2010.02.090091 Parental Acceptance of a Mandatory HPV Vaccination Program 221

Table 1. Association between Demographic Variables and Parent’s Agreement with Adding the Human Papilloma Virus Vaccine to School Entry Requirements

Variable

Do you Think the HPV Vaccine should be Added to the List of School Entry Vaccine

Requirements?

P*No (n �%�) Yes (n �%�)

Gender .47

Male 19 (51.4) 18 (48.7)

Female 163 (57.6) 120 (42.4)

Age (years) .19

18–29 30 (53.6) 26 (46.4)

30–39 81 (55.9) 64 (44.1)

40–49 49 (54.4) 41 (45.6)

50� 22 (75.9) 7 (24.1)

Race .50

White 103 (56.6) 79 (43.4)

African American 67 (54.9) 55 (45.1)

Asian 1 (50.0) 1 (50.0)

Hispanic 9 (75.0) 3 (25.0)

Other 2 (100.0) 0 (0.0)

Ages of Children, 9–11 .91

No 75 (57.3) 56 (42.8)

Yes 107 (56.6) 82 (43.4)

Ages of Children, 12–14 .05

No 126 (60.9) 81 (39.1)

Yes 56 (49.6) 57 (50.4)

Ages of Children, 15–17 .80

No 112 (57.4) 83 (42.6)

Yes 70 (56.0) 55 (44.0)

Income .03

�$20,000 17 (37.8) 28 (62.2)

$20,001-$50,000 77 (57.9) 56 (42.1)

$50,001-$100,000 54 (64.3) 30 (35.7)

�$100,000 34 (58.6) 24 (41.4)

Education .09

�High school 5 (38.5) 8 (61.5)

High school or GED 63 (51.6) 59 (48.4)

�College 114 (61.6) 71 (38.4)

Health insurance .01

None 9 (50.0) 9 (50.0)

Private 135 (61.6) 84 (38.4)

Medicaid 26 (40.6) 38 (59.4)

Medicare 2 (100.0) 0 (0.0)

Other 9 (75.0) 3 (25.0)

Tricare 1 (20.0) 4 (80.0)

Ever had HPV .04

Yes 18 (42.9) 24 (57.1)

No 155 (60.3) 102 (39.7)

Not sure 9 (42.9) 12 (57.1)

Ever had genital warts .78

Yes 8 (53.3) 7 (46.7)

No 174 (57.1) 131 (43.0)

Abnormal Papanicolaou test (women only) .55

Yes 67 (56.8) 51 (43.2)

No 98 (58.7) 69 (41.3)

Not sure 17 (48.6) 18 (51.4)

*�2 test. HPV, human papillomavirus; GED, General Educational Development test.

222 JABFM March–April 2010 Vol. 23 No. 2 http://www.jabfm.org

Table 2. Association of Parental Attitudes, Beliefs, and Agreement with Adding the Human Papillomavirus Vaccine to School Entry Requirements

Variable

Do You Think the HPV Vaccine Should be Added to the List of School

Entry Vaccine Requirement?

P*No (n �%�) Yes (n �%�)

Support government-mandated vaccine requirements �.0001 No 33 (97.1) 1 (2.9) Yes 148 (51.9) 137 (48.1)

Familiar with HPV .02 Not familiar 20 (45.5) 24 (54.6) Somewhat familiar 117 (63.6) 67 (36.4) Very familiar 45 (48.9) 47 (51.1)

Likelihood of child to contract HPV .03 Not at all likely 85 (57.8) 62 (42.2) Somewhat likely 93 (59.6) 63 (40.4) Very likely 4 (25.0) 12 (75.0)

Important for child to receive HPV vaccine �.0001 Not at all important 42 (84.0) 8 (16.0) Somewhat important 96 (72.7) 36 (27.3) Very important 43 (31.6) 93 (68.4)

Concerned about side effects of HPV vaccine .56 Not at all concerned 20 (60.6) 13 (39.4) Somewhat concerned 75 (53.6) 65 (46.4) Very concerned 86 (59.3) 59 (40.7)

HPV vaccine reduces risk of cervical cancer .001 No 30 (83.3) 6 (16.7) Yes 117 (51.5) 110 (48.5) No girls 32 (60.4) 21 (39.6)

HPV vaccine reduces risk of genital warts .06 No 74 (63.8) 42 (36.2) Yes 104 (52.8) 93 (47.2)

Want child to receive HPV vaccine �.0001 No 55 (90.2) 6 (9.8) Yes 123 (48.2) 132 (51.8)

Child has received HPV vaccine .008 No 166 (59.7) 112 (40.3) Yes 16 (38.1) 26 (61.9)

Physician supports HPV vaccine .07 No 4 (50.0) 4 (50.0) Yes 43 (47.3) 48 (52.8) Not Discussed 135 (61.1) 86 (38.9)

Most influences decision to get HPV vaccine .006 Doctor 97 (51.1) 93 (49.0) Spouse 14 (82.4) 3 (17.7) Child 13 (48.2) 14 (51.9) Parent 2 (28.6) 5 (71.4) Mandatory school requirement 14 (70.0) 6 (30.0) None 41 (70.7) 17 (29.3)

Comfortable with mandated HPV vaccine �.0001 Not comfortable 87 (97.8) 2 (2.3) Somewhat comfortable 87 (53.4) 76 (46.7) Very comfortable 7 (10.5) 60 (89.6)

doi: 10.3122/jabfm.2010.02.090091 Parental Acceptance of a Mandatory HPV Vaccination Program 223

We then examined parents’ possible reactions to a mandatory HPV vaccine program: signing a waiver to prevent their child from receiving the HPV vaccine, having their child vaccinated, or do- ing what their doctor recommends (Table 3). Par- ents with a child aged 12 to 14 years who were not familiar or very familiar with HPV thought it was very likely their child could contract HPV and thought the HPV vaccine reduced the risk of cer- vical cancer and genital warts. Those whose physi- cian supported the HPV vaccine more frequently agreed with the statement that they would have their child vaccinated with the HPV vaccine. Sub- jects who were very comfortable with a mandatory HPV vaccine program thought the federal govern- ment should pay for a mandatory HPV vaccine program and were very interested in the HPV vac- cine for their child; these parents were more likely to have their child vaccinated.

Several associations with government interven- tion in HPV vaccination were also examined. Par- ents who wanted their child to receive the HPV vaccine (45.5%) were more likely than those who did not want their child to receive the vaccine (8.2%) to want their government representative to make a law requiring the HPV vaccine (P � .0001). Subjects who thought the HPV vaccine should be added to the list of school-entry vaccine require-

ments (84.1%) were more likely to want their gov- ernment representative to make a law requiring the HPV vaccine than those who do not think it should be added to the school-entry vaccine requirements (28%; P � .0001). Individuals with incomes �$20,000 were more likely to want the state of Georgia (P � .004) and the federal government (P � .003) to pay for the HPV vaccine for school children than parents at all other income levels (84.4% and 86.7%, respectively).

Conclusions Our study identified numerous factors that increase the likelihood of parents accepting a mandatory HPV vaccination program. Parents with a personal history of HPV-related disease (HPV infection or genital warts) were more likely to support such a mandated program. Parents who had greater famil- iarity with the adverse consequences of HPV infec- tion were also more apt to approve a school-based mandate. Interestingly, mothers with a history of a previous abnormal Papanicolaou test were not more inclined to support a mandatory program. Many women were unaware of the viral cause for abnormal cervical cytology. A greater number of parents with the lowest income would also comply with a mandatory vaccination program; because

Table 2. (Continued)

Variable

Do You Think the HPV Vaccine Should be Added to the List of School

Entry Vaccine Requirement?

P*No (n �%�) Yes (n �%�)

Mandatory HPV vaccine program helpful �.0001 Not helpful 45 (97.8) 1 (2.2) Somewhat helpful 125 (64.1) 70 (35.9) Very helpful 12 (15.2) 67 (84.8)

Mandatory HPV vaccine program important �.0001 Not important 47 (94.0) 3 (6.0) Somewhat important 123 (67.2) 60 (32.8) Very important 12 (13.8) 75 (86.2)

Federal government to pay for HPV vaccine �.0001 No 90 (82.6) 19 (17.4) Yes 91 (43.3) 119 (56.7)

Interested in HPV vaccination for child �.0001 Not interested 52 (91.2) 5 (8.8) Somewhat interested 100 (66.2) 51 (33.8) Very interested 30 (26.8) 82 (73.2)

*�2 test. HPV, human papillomavirus.

224 JABFM March–April 2010 Vol. 23 No. 2 http://www.jabfm.org

Table 3. Association of Parental Attitudes, Beliefs, and Possible Responses to a Mandatory Human Papillomavirus Vaccine

Variable

If the HPV Vaccine was Mandatory to Attend School, Which of the Following Statements Most Agrees with Your View?

P*

Would Sign a Waiver to Prevent my Child from Receiving the Vaccine

(n �%�) Would have My Child

Vaccinated (n �%�)

Would do Whatever My Doctor

Recommends (n �%�)

Gender .95 Male 6 (16.2) 25 (67.6) 6 (16.2) Female 52 (18.4) 186 (65.7) 45 (15.9)

Age (years) .84 18–29 11 (19.6) 36 (64.3) 9 (16.1) 30–39 23 (15.9) 95 (65.5) 27 (18.6) 40–49 17 (18.9) 61 (67.8) 12 (13.3) 50� 7 (24.1) 19 (65.5) 3 (10.3)

Race .40 White 40 (22.0) 114 (62.6) 28 (15.4) African American 18 (14.8) 84 (68.9) 20 (16.4) Asian 0 (0.0) 1 (50.0) 1 (50.0) Hispanic 0 (0.0) 10 (83.3) 2 (16.7) Other 0 (0.0) 2 (100.0) 0 (0.0)

Ages of children, 9–11 .91 No 25 (19.1) 86 (65.7) 20 (15.3) Yes 33 (17.5) 125 (66.1) 31 (16.4)

Ages of children, 12–14 .02 No 39 (18.8) 127 (61.4) 41 (19.8) Yes 19 (16.8) 84 (74.3) 10 (8.9)

Ages of children, 15–17 .23 No 41 (21.0) 123 (63.1) 31 (15.9) Yes 17 (13.6) 88 (70.4) 20 (16.0)

Income .54 �$20,000 6 (13.3) 33 (73.3) 6 (13.3)

$20,001-$50,000 22 (16.5) 88 (66.2) 23 (17.3) $50,001-$100,000 21 (25.0) 49 (58.3) 14 (16.7) �$100,000 9 (15.5) 41 (70.7) 8 (13.8)

Education .84 �High school 2 (15.4) 9 (69.2) 2 (15.4)

High school or GED 20 (16.4) 85 (69.7) 17 (13.9) �College or more 36 (19.5) 117 (63.2) 32 (17.3)

Health insurance .06 None 2 (11.1) 10 (55.6) 6 (33.3) Private 47 (21.5) 139 (63.5) 33 (15.1) Medicaid 5 (7.8) 51 (79.7) 8 (12.5) Medicare 0 (0.0) 2 (100.0) 0 (0.0) Other 3 (25.0) 5 (41.7) 4 (33.3) Tricare 1 (20.0) 4 (80.0) 0 (0.0)

Ever had HPV .19 Yes 10 (23.8) 30 (71.4) 2 (4.8) No 46 (17.9) 165 (64.2) 46 (17.9) Not sure 2 (9.5) 16 (76.2) 3 (14.3)

Ever had genital warts .22 Yes 3 (20.0) 12 (80.0) 0 (0.0) No 55 (18.0) 199 (65.3) 51 (16.7)

doi: 10.3122/jabfm.2010.02.090091 Parental Acceptance of a Mandatory HPV Vaccination Program 225

Table 3. (Continued)

Variable

If the HPV Vaccine was Mandatory to Attend School, Which of the Following Statements Most Agrees with Your View?

P*

Would Sign a Waiver to Prevent my Child from Receiving the Vaccine

(n �%�) Would have My Child

Vaccinated (n �%�)

Would do Whatever My Doctor

Recommends (n �%�)

Abnormal Papanicolaou test (women only)

.62

Yes 23 (19.5) 80 (67.8) 15 (12.7) No 31 (18.6) 106 (63.5) 30 (18.0) Not sure 4 (11.4) 25 (71.4) 6 (17.1)

Support government mandated vaccines requirements

�.0001

No 17 (50.0) 10 (29.4) 7 (20.6) Yes 40 (14.0) 201 (70.5) 44 (15.4)

Familiar with HPV .02 Not familiar 7 (15.9) 30 (68.2) 7 (15.9) Somewhat familiar 30 (16.3) 115 (62.5) 39 (21.2) Very familiar 21 (22.8) 66 (71.7) 5 (5.4)

Likelihood of child to contract HPV �.0001 Not at all likely 36 (24.5) 76 (51.7) 35 (23.8) Somewhat likely 20 (12.8) 120 (76.9) 16 (10.3) Very likely 2 (12.5) 14 (87.5) 0 (0.0)

Important for child to receive HPV vaccine

�.0001

Not at all important 29 (58.0) 10 (20.0) 11 (22.0) Somewhat important 23 (17.4) 81 (61.4) 28 (21.2) Very important 5 (3.7) 119 (87.5) 12 (8.8)

Concerned about side effects of HPV vaccine

.08

Not at all concerned 8 (24.2) 20 (60.6) 5 (15.2) Somewhat concerned 16 (11.4) 102 (72.9) 22 (15.7) Very concerned 34 (23.5) 87 (60.0) 24 (16.6)

HPV vaccine reduces risk of cervical cancer

�.0001

No 20 (55.6) 10 (27.8) 6 (16.7) Yes 25 (11.0) 169 (74.5) 33 (14.5) No girls 11 (20.8) 30 (56.6) 12 (22.6)

HPV vaccine reduces risk of genital warts

.02

No 30 (25.9) 70 (60.3) 16 (13.8) Yes 26 (13.2) 136 (69.0) 35 (17.8)

Want child to receive HPV vaccine �.0001 No 35 (57.4) 10 (16.4) 16 (26.2) Yes 21 (8.24) 199 (78.0) 35 (13.7)

Child has received HPV vaccine .001 No 57 (20.50) 173 (62.2) 48 (17.28) Yes 1 (2.4) 38 (90.5) 3 (7.1)

Physician supports HPV vaccine .0004 No 3 (37.5) 2 (25.0) 3 (37.5) Yes 7 (7.7) 75 (82.4) 9 (9.9) Not discussed 48 (21.7) 134 (60.6) 39 (17.7)

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this vaccine is fairly expensive, one could assume that mandating vaccination might have equaled free availability in their minds. In fact, the Vaccines for Children Program provides free HPV vaccines to indigent children 18 years old or younger. This is a voluntary federal vaccination program that is prob- ably underutilized. The sex, age, race, education, and type of health insurance parents had did not influence their opinion about the importance of a mandated vaccine program. In fact, fewer college-

educated parents thought a mandatory HPV vac- cine program should be implemented.

Parents who understood the true vulnerability of their child and the possibility of their contracting HPV supported a mandatory HPV vaccine pro- gram. Tragically, most parents do not know the ubiquitous nature of HPV21 and awareness of this principle is an important cornerstone for vaccine acceptance. Moreover, no one can advise parents about how their child’s immune system might re-

Table 3. (Continued)

Variable

If the HPV Vaccine was Mandatory to Attend School, Which of the Following Statements Most Agrees with Your View?

P*

Would Sign a Waiver to Prevent my Child from Receiving the Vaccine

(n �%�) Would have My Child

Vaccinated (n �%�)

Would do Whatever My Doctor

Recommends (n �%�)

Most influences decision to get HPV vaccine

�.0001

Doctor 20 (10.5) 137 (72.1) 33 (17.4) Spouse 5 (29.4) 8 (47.1) 4 (23.5) Child 2 (7.4) 21 (77.8) 4 (14.8) Parent 0 (0.0) 5 (71.4) 2 (28.6) Mandatory school requirement 4 (20.0) 15 (75.0) 1 (5.0) None 27 (46.6) 24 (41.4) 7 (12.1) Somewhat comfortable 8 (4.91) 128 (78.5) 27 (16.6) Very comfortable 0 (0.00) 64 (95.5) 3 (4.5)

Mandatory HPV vaccine program helpful

�.0001

Not helpful 31 (67.4) 9 (19.6) 6 (13.0) Somewhat helpful 27 (13.9) 127 (65.1) 41 (21.0) Very helpful 0 (0.0) 75 (94.9) 4 (5.1)

Mandatory HPV vaccine program important

�.0001

Not important 32 (64.0) 12 (24.0) 6 (12.0) Somewhat important 25 (13.7) 118 (64.5) 40 (21.9) Very important 1 (1.2) 81 (93.1) 5 (5.8)

Federal government to pay for HPV vaccine

�.0001

No 42 (38.5) 48 (44.0) 19 (17.4) Yes 16 (7.6) 162 (77.1) 32 (15.2)

Interested in HPV vaccination for child �.0001 Not interested 41 (71.9) 7 (12.3) 9 (15.8) Somewhat interested 16 (10.6) 102 (67.6) 33 (21.9) Very interested 1 (0.9) 102 (91.1) 9 (8.0)

HPV vaccine should be added to the list of school entry vaccine requirements

�.0001

No 57 (31.3) 86 (47.3) 39 (21.4) Yes 1 (0.7) 125 (90.6) 12 (8.7)

*�2 test. HPV, human papillomavirus; GED, General Educational Development test.

doi: 10.3122/jabfm.2010.02.090091 Parental Acceptance of a Mandatory HPV Vaccination Program 227

spond to HPV infection, eg, spontaneous clearance or persistence that may increase the risk for devel- oping a malignancy. Parents who knew that the HPV vaccine reduced the risk of their child devel- oping cervical cancer were more inclined to con- done a mandatory program. Further education about HPV and its potential consequences are needed to improve HPV vaccine uptake. Such ed- ucation could influence response to a mandated program.

Parents whose health care providers supported the HPV vaccine were not more likely to support a mandatory vaccination program. Yet other studies have demonstrated the value of medical advice with respect to HPV vaccine acceptance.19,21,22 The opinion of a trusted health care provider is partic- ularly important with respect to preventive medical care. The dialogue between parent and health care provider probably has centered around action (get- ting the vaccine) and not the particular process (voluntary vs mandatory).

Many other variables indicated that parents thought the HPV vaccine should be added to the list of school-entry vaccine requirements. Parents with no insurance or federally financed insurance more often agreed that the HPV vaccine should be required. Reliance on government-funded heath insurance may have an affect on parental auton- omy. These parents may be more willing to abdi- cate these health decisions to the medical legislative process. However, others caution that such a man- datory program for the HPV vaccine would place a financial burden on existing government health programs, thereby potentially reducing coverage rates for other vaccines.23

To parents we posed a realistic scenario: that the HPV vaccine was required for school. They could choose to sign a waiver to prevent their child from receiving the HPV vaccine, have their child vacci- nated, or follow the recommendation of their health care provider. Most parents (66%) would simply select to allow their child to receive the vaccination. Those parents who supported manda- tory vaccination programs knew the potential harms from HPV, realized their child was very susceptible to HPV infection, and wanted their child to receive the vaccine readily accepted com- pliance with an HPV vaccination mandate. Once again, knowledge about the problem seemed con- ducive to parents accepting mandatory health pro-

grams designed to prevent unnecessary morbidity and mortality.

The remaining parents were fairly divided be- tween the other 2 options. A certain number of parents want to retain the autonomy of making health decisions for their children. In our country and the state in which our study was conducted, opting out of vaccination for religious, medical, or philosophical reasons is allowed. However, some argue that society should protect innocent children who may be hurt by the choices of their parents.24

The issue has been conceptualized as conflict be- tween autonomy and utilitarianism.25 Other par- ents place the decision in the hands of their health care provider. Education of these influential people is critically necessary to assure proper guidance is given.

Our study was limited by regional sampling, greater participation by mothers, and limited Asian and Hispanic involvement. A national sample in- cluding more fathers and minorities may have al- tered our findings. Our study was also conducted immediately after unjust negative publicity from the national media. The HPV vaccine controversy is clouded by too many unproven assumptions and unknown factors.26 Although acceptance of a man- datory policy for the HPV vaccine may improve in the future, additional research may be beneficial to assess changing and evolving attitudes.

References 1. Villa LL, Costa RLR, Petta CA, et al. Prophylactic

quadrivalent human papillomavirus (types 6, 11, 16 and 18) L1 virus-like particle vaccine in young women: a randomized double-blind placebo-con- trolled multicentre phase II efficacy trial. Lancet Oncol 2005;6:271–8.

2. FUTURE II Study Group. Quadrivalent vaccine against human papillomavirus to prevent high-grade cervical lesions. N Engl J Med 2007;356:1915–27.

3. Ault KA, FUTURE II Study Group. Effect of pro- phylactic human papillomavirus L1 virus-like-parti- cle vaccine on risk of cervical intraepithelial neopla- sia grade 2, grade 3 and adenocarcinoma in situ: a combined analysis of four randomised clinical trials. Lancet 2007;369:1861–8.

4. Garland SM, Hernandez-Avila M, Wheeler CM, et al. Quadrivalent vaccine against human papillomavi- rus to prevent anogenital diseases. N Engl J Med 2007;356:1928–43.

5. Associated Press. 1 in 4 U.S. girls received HPV vaccine. October 9, 2008. Available at http://

228 JABFM March–April 2010 Vol. 23 No. 2 http://www.jabfm.org

www.msnbc.msn.com/id/27103121/ns/health-kids_ and_parenting/. Accessed 6 July 2009.

6. Springer K. Why are HPV vaccine rates so low? 25 February 2008. Available at http://www.newsweek. com/id/115329/output/print. Accessed 6 July 2009.

7. Markowitz LE, Dunne EF, Saraiya M, Lawson HW, Chesson H, Unger ER. Quadrivalent human papil- lomavirus vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2007;56:1–24.

8. CDC. Coverage estimates for school entry vaccina- tions, 2007–2008 school year. Available at http:// www2.cdc.gov/nip/schoolsurv/nationalavg.asp. Ac- cessed 6 July 2009.

9. Ford CA, English A, Davenport AF, Stinnett AJ. In- creasing adolescent vaccination: barriers and strate- gies in the context of policy, legal and financial is- sues. J Adolesc Health 2009;44:568–74.

10. Kahn JA, Rosenthal SL, Jin Y, Huang B, Namaky- doust A, Zimet GD. Rates of human papillomavirus vaccination, attitudes about vaccination, and human papillomavirus prevalence in young women. Obstet Gynecol 2008;111:1103–10.

11. Keating KM, Brewer NT, Gottlieb SL, Liddon N, Ludema C, Smith JS. Potential barriers to HPV vaccine provision among medical practices in an area with high rates of cervical cancer. J Adolesc Health 2008;43:S61–7.

12. Morita JY, Ramirez E, Trick WE. Effect of a school- entry vaccination requirement on racial and ethnic disparities in hepatitis B immunization coverage lev- els among public school students. Pediatrics 2008; 121:547–52.

13. Fogarty KJ, Massoudi MS, Gallo W, Averhoff FM, Yusuf H, Fishbein D. Vaccine coverage levels after implementation of a middle school vaccination re- quirement, Florida, 1997–2000. Public Health Rep 2004;119:163–9.

14. Olshen E, Mahon BE, Wang S, Woods ER. The impact of state policies on vaccine coverage by age 13 in an insured population. J Adolesc Health 2007; 40:405–11.

15. Wilson TR, Fishbein DB, Ellis PA, Edlavitch SA. The impact of a school entry law on adolescent immunization rates. J Adolesc Health 2005;37:511–6.

16. Gostin LO, DeAngelis CD. Mandatory HPV vacci- nation, public health vs private wealth. JAMA 2007; 297:1921–3.

17. Horn L, Howard C, Waller JL, Ferris DG. Opinions of parent’s about school-entry mandates for the hu- man papillomavirus vaccine. J Lower Genit Tract Dis 2010;14:53–8.

18. Hopson K. Majority of U.S. parents not in favor of HPV vaccine mandates. 22 May 2007. Available at http://www2.med.umich.edu/prmc/media/newsroom/ details.cfm?id�532. Accessed 12 January 2010.

19. Ferris DG, Waller JL, Miller J, et al. Variables as- sociated with human papillomavirus (HPV) vaccine acceptance by men. J Am Board Fam Med 2009;22: 34–42.

20. Ferris DG, Waller JC, Owen A, Smith J. Human papillomavirus vaccine acceptance among mid-adult women. J Am Board Fam Med 2008;21:31–7.

21. Davis K, Dickman ED, Ferris D, Dias JK. Human papillomavirus vaccine acceptability among parents of 10- to 15-year-old adolescents. J Lower Gen Tract Dis 2004;8:188–94.

22. Ferris DG, Waller JL, Miller J, et al. Men’s attitudes toward receiving the Human papillomavirus vaccine. J Lower Gen Tract Dis 2008;12:276–81.

23. Javitt G, Berkowitz D, Gostin LO. Assessing man- datory human papillomavirus vaccination: who should call the shots? J Law Med Ethics 2008;36: 384–95.

24. Colgrove J. The ethics and politics of compulsory human papillomavirus vaccination. N Engl J Med 2006;355:2389–91.

25. Field RI, Caplan AL. A proposed ethical framework for vaccine mandates: Competing values and the case of human papillomavirus. Kennedy Inst Ethics J 2008;18:111–24.

26. Haber G, Malow RM, Zimet GD. The human pap- illomavirus vaccine mandate controversy. J Pediatr Adolesc Gynecol 2007;20:325–31.

doi: 10.3122/jabfm.2010.02.090091 Parental Acceptance of a Mandatory HPV Vaccination Program 229