Significant others are noted to be remarkable influences in modelling children’s and young people’s health perceptions and their adoption of health behaviour. The vaccinations which a child receives are shown to be significantly influenced by his or her parents. However, there is a paucity of Chinese-based studies. When discussing the Human Papillomavirus (HPV) vaccine, very few studies examine the perceptions of Chinese parents regarding the vaccine as a preventive health measure, and even fewer examine how these perceptions of the vaccine and sexual values influence their motivations in encouraging their children to be vaccinated. In view of the literature gap, this article investigates the perceptions of Hong Kong mothers in regard to vaccinating their daughters against HPV in Hong Kong.A qualitative research approach with individual semi-structured interviews was conducted with 35 mothers aged 30 to 60 years old with daughter(s) between 9 and 17 years old.Six connected themes emerged. The participants commonly perceived the HPV vaccination as being unnecessary for their daughters in view of their young age. They worried that it would encourage their daughters to engage in premarital sex, and perceived the vaccination to be potentially harmful to health. Also, their low perceived risk of HPV in addition to the lack of reassurance from their health care providers failed to convince the participants that the vaccination was important for their daughters’ health. Finally, the participants found the vaccine to be expensive and perceived it to have little protection value in comparison to other optional vaccines.The sampled mothers did not have a positive perception of the HPV vaccine. The cultural association between receiving the vaccination and premarital sex was prevalent. Bounded by their cultural values, the participants also had many misconceptions regarding the vaccine and the transmission of HPV, which discouraged them from having their daughters vaccinated. Furthermore, a lack of support from health care providers and the government health authorities concerning HPV vaccination failed to provide confidence and reassurance to mothers, and conveyed a meaning to these mothers that HPV vaccine is relatively unimportant. Cervical cancer is the second most common cancer in women worldwide . In HongCervical cancer is caused by the genital infection Human Papillomavirus (HPV) , and HPVThe HPV vaccination has been clinically recognized as an effective preventive measure in decreasing the morbidity of cervical cancer -8. The vIn Hong Kong, HPV vaccines Gardasil® and Cervarix® have been available since 2006 . The vacStudies suggest that 75% of sexually active people will be infected with HPV at some point during their lives . HoweverSignificant others have notable influence in shaping the health perceptions of children and teenagers , who leaMany young adults are ignorant about the HPV vaccination as a preventive health measure , largelyA qualitative approach was adopted using individual semi-structured interviews. Thirty-five mothers were recruited through purposive sampling  in a heaPurposive sampling of the participants was conducted according to the following inclusion criteria: (a) women aged 30 to 60 years at the time of study, who (b) had at least one daughter aged 9 to 17 years old at the time of the study, (c) had not yet taken their daughter(s) to receive the HPV vaccine, (d) had no professional medical and/or health science training, (e) had the ability to understand and speak Cantonese, and (f) were Hong Kong Chinese by ethnicity. Because the HPV vaccine is mainly targeted at women who are not yet sexually active, and because mothers are noted to be among the most important significant others in influencing the health perceptions and behaviour of their children , mothersPrior to the interviews, the 35 participants were informed about the purpose and nature of the study with a participant information sheet written in their mother tongue. Written consent was obtained from each of the participants. They could seek clarifications before the interview, and were assured of their rights and freedom to withdraw from the study at any time. All interviews were conducted in a private room in the women’s social service centre, and were audio-recorded with the participants’ consent. Cantonese Chinese was used as the medium of conversation, and was the mother tongue of all the participants. To protect their privacy and confidentiality, no names or identities were mentioned throughout the interviews.The interviews were conducted between March and June 2013, and lasted between 1.75 and 2 hours. I conducted all the interviews to ensure interview consistency and quality. I developed an interview question guide  when sick. The remaining ten participants doctor-shopped whenever they needed medical consultation.Six themes were identified in relation to the participants’ perceptions of vaccinating their daughters. Overall, these perceptions intertwined to discourage the mothers from having their daughters receive the HPV vaccine.Because of the young ages of their daughters, all the participants perceived the HPV vaccination as being unnecessary. The vaccine was widely perceived to be mainly for women who were about to become sexually active, and therefore these mothers did not think that their daughters needed to be vaccinated. One participant said:My daughter is still very young. She is just 15 years old, and I assume she will only get married when she is in her late 20s or early 30s. The cervical cancer vaccine is for preventing cervical cancer, so it is for those who are about to start their sexual life. I have never thought about taking my daughter to be vaccinated. It is too early for her [P27].The effective duration of the vaccine remained unknown to the participants, and therefore they believed that their daughters could wait till just before marriage to receive the vaccination. This participant indicated a common perception:My daughter is still very young, so I think that there is no need for her to be vaccinated at the moment. It is too early for her; she is just 11 years old now! Also, I am not sure how long the vaccine efficacy can last. If the efficacy can just last for five years, then it is of no use to her to be vaccinated now. She will just turn 16 years old at that time and there are still many years ahead for her to get married. There will not be any point if she is vaccinated now; the vaccine will just be wasted [P6].The way in which participants perceived the HPV vaccine also influenced their motivations. All the participants referred to the vaccine as the “cervical cancer vaccine”. Because cervical cancer is a disease that affects adult women who are sexually active, this naming reinforced the participants’ perceptions that the HPV vaccine was for adult women rather than teenage girls:As far as I know, only adult women get cervical cancer, so I think the cervical cancer vaccine is mainly for adult women. I have never heard of young girls getting cervical cancer. If young girls do not get cervical cancer, then what is the point of taking my daughter to be vaccinated? She is just 13 years old [P5].Another common perception among the sampled mothers was that the vaccination had the potential to encourage premarital sexual behaviour. Almost all the participants worried that vaccinating their daughters could convey the message that they were allowed and approved to begin their sexual lives. This worry was particularly prevalent among participants with daughters in their teenage years. One participant expressed her concern:I do not think that it is good to vaccinate my daughter at the moment. The cervical cancer vaccine is mainly for women who are about to embark on their sexual life. She has just entered puberty, and taking her to have the vaccine may make her misunderstand that premarital sex is acceptable. My daughter is studying in a co-educational school; therefore she will see her male classmates every day, and she may be dating sooner or later. If I take my daughter to be vaccinated, I am afraid that this will send the wrong message to her that it is now safe to have premarital sex [P14].In many cases, the participants perceived that making their daughters fear contracting a disease could be effective in preventing them from having premarital sex. This reinforced the participants’ idea that their daughters should not be vaccinated, so they would be frightened of the health risks. As this participant explained:Taking my daughter to be vaccinated may make her perceive wrongly that she will not have any health consequences when considering premarital sex. Therefore I am very reluctant to take my daughter to be vaccinated. Not taking my daughter to be vaccinated will make her think more about the health consequences, such as getting cancer from having premarital sex. I think that this is more effective in educating my daughter about the bad consequences of having premarital sex. If she is vaccinated, then disease and cancer will no longer scare her away from thinking about having premarital sex [P19].More than half of the participants perceived the HPV vaccine as being harmful to one’s health. They thought that most vaccines are either manufactured from a virus or from artificial chemicals; therefore, they felt reluctant about taking their daughters to receive an additional but optional vaccine:Vaccines are made from viruses. Therefore, I believe it is not good to have too many vaccinations. After all, a vaccine is foreign material, and this material can make your body weak. You may get sick after the vaccination, and that’s why we often feel uncomfortable and have a fever after vaccination, because we get sick from the vaccine. If the vaccine is compulsory, then I have no choice. However, the cervical cancer vaccine is optional, so I do not want my daughter to get sick from the vaccine [P24].The HPV vaccine was a new vaccine to all the participants. They expressed doubt and hesitation about its safety. Most of them did not know much about this vaccine, except for the side-effects that had been reported in the newspapers. As this participant recalled:It seems that the cervical cancer vaccine is quite new. New things are always not good and always need adjustment and modification. I do not want my daughter to be a “white mouse”. Also, I remember that there have been some side-effects reported in the newspapers when this vaccine was just out on the market. I am not very confident about the safety of this vaccine at the moment, and so do not want my daughter to take the risk. Maybe after some more years, when the safety of this vaccine has been proved, then I may consider taking my daughter to be vaccinated, but definitely not at the moment [P18].Most of the participants had little understanding or knowledge about HPV and its potential danger to women’s health. Many of them had never heard of HPV, and were not aware of the close relationship between HPV and cervical cancer. One participant said:I do not know what HPV is, though I know about cervical cancer. Cervical cancer is caused by sex, so I do not think that receiving the vaccination can help you to prevent cervical cancer. I think that not having sex should be the best way to prevent cervical cancer rather than receiving the vaccination [P2].The low perceived risk about the dangers of HPV reduced the participants’ incentive to have their daughters receive the vaccination, and their daughters’ young ages lowered the perceived risk even further. As this participant indicated:Cervical cancer is caused by sex. My daughter is just 12 years old, and still has a long time before she gets married. Therefore I do not think that she will have any possibility of getting cervical cancer in these coming few years. I think that the vaccine is more useful to those women who will get married soon. In my daughter’s case, I cannot see what the vaccine can do for her, since she does not have any risk of getting cervical cancer [P20].The participants’ low perceived risk about the dangers of HPV was reflected in their own lack of regular cervical screening for themselves. Many of them did not think it necessary, since they believed the likelihood of suffering from cervical cancer was low. Such lack of awareness about the importance of this preventive health measure also affected their opinion about the HPV vaccine for their daughters. This participant indicated popular thinking:I know about pap smears, but I do not think that it is necessary for me. I only have my husband [as a sexual partner] and no other men. Only promiscuous women need to have pap smears, because they can more easily get cervical cancer. I believe that if a woman is moral and faithful, she does not need to worry about cervical cancer and having pap smears. It is just the same case for my daughters. If they are moral and faithful, then they do not need to worry about cervical cancer. Only those who are promiscuous need to be vaccinated. I trust that my daughters will be morally behaved and be good women when they grow up [P29].Health care providers’ lack of reassurance about the HPV vaccine is a significant barrier to the participants considering whether to vaccinate their daughters. Almost none of the participants’ health care providers encouraged the vaccination proactively. This lack of promotion often reinforced the perceptions of the participants that the HPV vaccine was unimportant and unnecessary:Every time I accompany my daughter to see our family doctor, he does not mention anything about the cervical cancer vaccine. However, he encourages us to receive the influenza vaccination and pneumonia vaccination [pneumococcal vaccine]. I trust our family doctor, and he will not ask us to have any unnecessary vaccination. It seems to me that the influenza and pneumonia vaccinations are more necessary to health than cervical cancer vaccination. That’s why I have never thought about taking my daughter to receive this vaccination [P11].Difficulty in obtaining information from health care providers is another significant barrier. In some cases, participants had asked about the vaccination for their daughters, but the non-enthusiastic responses from their health care providers further discouraged them:I once asked our family doctor about the cervical cancer vaccine. However, the doctor seemed to not know much about the vaccine. He just asked us to read the pamphlet outside. Perhaps my daughter was quite sick last time, so he focused more on treating her that time. After all, we see doctors only when we are sick. As a mother, when my daughter is sick, I will just focus on hoping that the doctor can treat my daughter, rather than thinking about a non-urgent vaccination [P25].These mothers commonly perceived the vaccination to be expensive. However, the expense was not a standalone factor in the participants’ decision not to have their daughters vaccinated; rather the financial issue had to be combined with other factors. Because the vaccine is not included in the government’s compulsory Childhood Immunization Programme, it conveys the impression that the HPV vaccination is unnecessary and unimportant for their daughters’ health. As this participant indicated:The cervical cancer vaccine seems to be not very necessary. Those necessary vaccines should be compulsory and included in the government’s child vaccination scheme. There are so many new vaccines nowadays, and they all cost money. If the vaccine is really necessary, I believe that the government’s child vaccination scheme will include it without charge. Those vaccines that need to be paid for should be unnecessary [P9].More than half the participants perceived the protection value of the HPV vaccine to be lower than other self-pay optional vaccines such as the seasonal influenza vaccine and pneumococcal vaccine. In their minds, influenza and pneumonia were more acute and more easily transmitted, and had the potential to impose an immediate life-threatening impact on their daughters’ health. In comparison to the more distant impacts caused by HPV, participants’ risk perception of HPV-related diseases was thus lower than these more acute diseases. This perception failed to motivate the participants to take their daughters for the HPV vaccination. As this participant shared:Unlike other vaccines that need to be paid for, the protection value of the cervical cancer vaccine seems to be the least. I am more motivated to take my daughter to receive the pneumonia [pneumococcal] vaccine, because pneumonia can kill and it can be easily transmitted through air. Even if it does not kill, still it can make my daughter be absent from school. Therefore it is more important to have the pneumonia vaccine. Cervical cancer is not that easily transmitted, unless you have sex. My daughter is still young, and still has a long time before getting married, so I do not think that she can get cervical cancer in the near future. I do not think that the protective value of the cervical cancer vaccine for my daughter is high enough to motivate me to take her to be vaccinated [P23].In contrast to other international examples which often show parents’ support for the HPV vaccine , in HongBecause of their daughters’ young ages, the participants commonly perceived the HPV vaccination to be unnecessary. Cervical cancer has been represented as a sex-induced cancer in Hong Kong , and is Language use can powerfully shape people’s cultural beliefs and perceptions . ParticiThe belief that their daughters’ had a low risk of contracting HPV impacted the participants’ perceived need for the vaccine. The risk perception correlated with sexual experience, and sexual experience was deemed to be positively related to age. Because their daughters were young, the participants assumed that they were sexually inactive, and thus had no need for the HPV vaccination ,42. HoweFor the sampled mothers, the HPV vaccination had a symbolic meaning. The vaccine was commonly perceived to be for sexually active  women; hence, receiving the vaccination was deemed to be almost a rite of passage for their daughters, conveying approval to begin their sexual lives. Concerned about the possibility of transmitting such a message to their daughters, this proved to be a prominent barrier to the participants against the HPV vaccination. Indeed, unfavourable perceptions about vaccinating women who are not sexually active are not uncommon in Hong Kong , and theIn patriarchal societies, women are under different forms of social control . MedicinCervical cancer was often perceived by the participants as closely associated with a woman’s promiscuity and immorality. These patriarchal values controlled the participants’ health values and health behaviour, not only leading them to believe that they did not need regular cervical screenings, but also leading to their lack of awareness about men’s role in HPV transmission and the importance of having their daughters vaccinated. Such patriarchal ideology was prevalent among the participants of all education levels. This represents a definite risk for women’s health and disease prevention. These mothers transmitted and executed these cultural beliefs as social control over their daughters. They perceived that the health consequences might scare their daughters away from premarital sexual activity, and as a result, the participants lacked incentive to encourage their daughters to be vaccinated.Consistent with previous studies showing that parents are concerned regarding the HPV vaccine’s effectiveness, safety and side-effects ,54, the Doctor recommendations are documented to be a significant incentive for women to receive the HPV vaccination ,55. ConsThe focus of vaccination promotion among primary care providers also supports the supposed triviality of the HPV vaccination. In addition to the HPV vaccine, the seasonal influenza vaccine and pneumococcal vaccine are also optional self-pay vaccines in Hong Kong. Doctors’ emphasis on promoting those vaccines over the HPV vaccine further reinforced the participants’ belief that the HPV vaccine is less vital than other optional vaccines. Primary care providers are an important agent in influencing people’s perceptions of a vaccine . Their eThe vaccination subsidy policy of the government health authorities also reinforced the participants’ perceptions about the relative insignificance of HPV vaccination. The government provides subsidies for the seasonal influenza and pneumococcal vaccines, but not the HPV vaccine. Superficially, the subsidies served as a financial incentive to the participants. However, the subsidies also convey a symbolic meaning, influencing perceptions about the importance of a vaccine. The lack of government subsidies for the HPV vaccine therefore reinforced the participants’ perception that this vaccine is unnecessary for their daughters’ health. Indeed, the government’s vaccination policy has a prominent role in influencing people’s vaccination behaviour , and theThe high cost of the HPV vaccine was another notable barrier for the participants. To some extent, this shows consistency with previous studies ,63. HoweParents are the role models for their children, and they play a significant role in constructing and modelling their children’s health perceptions and preventive health behaviour . The perThe sampled participants comprised only mothers aged 30 to 60 years at one centre of a women’s social service agency. Other mothers were not included. Future studies sampling mothers from more field sites can add more credibility to understanding the perceptions of mothers regarding the HPV vaccine in Hong Kong. Moreover, because many participants experienced a lack of support from their primary care providers, future study about primary care doctors’ knowledge and understanding of HPV, as well as their health promoting behaviour regarding HPV prevention, can allow for a deeper understanding of the experience and behaviour of the participants.Promoting HPV vaccination among adolescent girls and young women is an important public health measure in the prevention of cervical cancer and HPV-associated diseases. Yet adolescent girls do not have full independence in making decisions about their preventive health, and because they are still under the socialization of their parents, their parents’ perceptions and beliefs have a decisive role in constructing these adolescents’ health perceptions and shaping their preventive health behaviour. This article examines a number of perceptions among the sampled mothers about the HPV vaccine. These perceptions, combined together, served to prevent the participants from encouraging their daughters to receive the HPV vaccine. The participants did not have a positive perception of the HPV vaccine. The cultural association between receiving the vaccination and premarital sex was prevalent. Bounded by their cultural values, they also had many misconceptions regarding the vaccine and the transmission of HPV, which discouraged them from having their daughters vaccinated. Furthermore, a lack of support from health care providers and the government health authorities concerning HPV vaccination failed to provide confidence and reassurance to mothers, and conveyed a meaning to these mothers that HPV vaccine is relatively unimportant. The data show that the sampled mothers are in need of education about the risk of HPV and further assurance about the vaccine, so that they can transmit a more positive message to their daughters in regard to undertaking this preventive health measure.The author declares that she have no competing interests.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6874/14/73/prepubInterview question guide of the study.Click here for file


N = 2446) completed a 2014 Web-based survey assessing socio-demographic characteristics, child's HPV vaccination history, provider communication regarding the vaccine, and other attitudes and behaviors pertaining to vaccination and healthcare utilization. The main outcome measure was child's initiation of the HPV vaccine . Approximately 35% of the full sample and 27.5% of the 9–10-year-olds had initiated HPV vaccination. Females were more likely than males to have initiated HPV vaccination by the age of 13 but not by younger ages. Strength of health provider recommendation regarding HPV vaccination was a particularly salient predictor of vaccine initiation. Approximately a third of children may be initiating the HPV vaccine series before or during the targeted age range for routine administration of the vaccine. Because coverage remains below national targets, further research aimed at increasing vaccination during early adolescence is needed. Improving providers' communication with parents about the HPV vaccine may be one potential mechanism for increasing vaccine coverage.The quadrivalent and 9-valent human papillomavirus (HPV) vaccines are licensed for administration among 9–26-year-old males and females, with routine vaccination recommended for 11–12-year-olds. Despite the availability of the vaccine at younger ages, few studies have explored vaccine uptake prior to age 13, and national HPV vaccination surveillance data is limited to 13–17-year-olds. Our objective was to examine rates and predictors of HPV vaccine initiation among 9–13-year-olds in the United States. A national sample of mothers of 9–13-year-olds in the United States ( •Approximately 35% of 9–13-year-olds had initiated the HPV vaccine series.•A quarter of 9–10-year-olds had initiated the HPV vaccine series.•At age 13, females were more likely than males to have initiated HPV vaccination.•No gender difference in HPV vaccine initiation was found prior to age 13.•Provider recommendation was a particularly salient predictor of HPV vaccination Human papillomavirus (HPV) is a highly prevalent sexually transmitted infection affecting both males and females . HPV is In addition to socioeconomic status, race/ethnicity, and general and vaccine-specific healthcare utilization behaviors , healthcOur objective was to explore rates and predictors of HPV vaccine initiation among 9–13-year-old males and females in the United States. Because limited data are available regarding HPV vaccine initiation prior to age 13, one aim of the study was to estimate the vaccine initiation rate among 9–12-year-olds. We were also able to compare our observed rate of initiation by age 13 to that of previously published national estimates for 13-year-olds from the same time period. An additional aim of the study was to examine characteristics of “early” initiators  as well as predictors of initiation among children who had already reached the targeted age range for routine administration .Data were collected in August 2014 as part of a larger Web-based survey assessing attitudes and behaviors related to HPV and influenza vaccination in a national sample of mothers of 9–13-year-olds in the United States. The study was approved by the IRB at Indiana University. Data collection was facilitated by Survey Sampling International (SSI), a survey research company that maintains national panels of adults in 37 countries. Each panel member may participate in up to four surveys annually, and participants are entered into a lottery to win a monetary prize through SSI. E-mail invitations were sent at random to members of SSI's U.S. panel meeting the study's target demographic. Initially, 3208 panelists responded to a generic e-mail invitation to participate in a survey, with 2860 women (89%) agreeing to complete the survey after being presented with a brief description of the study. Of those agreeing to participate, 2446 (86%) met the eligibility criteria for participation . Participants with more than one 9–13-year-old child were prompted to answer questions about their youngest child in this age range. Although the participants were recruited nationally, the sample does not constitute a nationally representative sample.We assessed HPV vaccination history using mother report of the number of doses of the HPV vaccine received by the child. Children who had received at least 1 dose of the vaccine were categorized as HPV vaccine initiators.Additional items related to HPV vaccination included mother report of whether the child's healthcare provider had discussed with her that her child could receive the HPV vaccine, and, if so, the strength of recommendation , which was reported on a 5-point scale ranging from strongly discouraged to strongly recommended. These two items were combined and collapsed into four categories: “did not discuss,” “no recommendation” , “recommended,” and “strongly recommended.” Mothers also reported whether the target child had any older siblings and whether any of these siblings had received the HPV vaccine.Mothers responded to five items pertaining to general beliefs about the benefits of immunization  using a 5-point response scale  Chronba, with itMothers reported on multiple healthcare-utilization behaviors such as whether or not the child had visited a doctor, nurse, or other healthcare provider in the past year; whether the child has a regular healthcare provider , the type of location where the child typically visits a healthcare provider; and whether the child received the influenza vaccine during the most recent influenza season (approximately September 2013 to March 2014).Sociodemographic characteristics included child's age, gender, race/ethnicity, geographic region, and health insurance type, as these variables have previously been associated with disparities in adolescent HPV vaccination.n = 261) were excluded from analyses predicting vaccine HPV initiation, resulting in a total sample size of 2185, or 89.3% of eligible participants. HPV vaccination data were more likely to be missing among target children (n = 261) who were male, belonged to racial/ethnic minorities, and did not have private insurance, and also more likely to be missing among 9-year-olds and less likely among 13-year-olds. No differences were found with regard to geographic region.Children whose mothers reported uncertainty regarding the number of doses received or for whom vaccination history was missing  and 11–13-year-olds.Descriptive statistics for all variables are presented in α = .05. A significantly higher percentage of initiators were age 12 or 13, whereas a significantly higher percentage of non-initiators were age 9, 10, or 11. A significantly higher percentage of initiators were female, belonged to a racial/ethnic minority, had public health insurance or were uninsured, had an older sibling who received the HPV vaccine, received the flu vaccine during the most recent flu season, had visited a healthcare provider in the past year, and typically received healthcare services in a location other than a private office. Mothers of initiators reported significantly greater perceived general benefits of vaccination. A significantly higher percentage of initiators had mothers who reported that their child's healthcare provider had recommended or strongly recommended HPV vaccination, while a significantly higher percentage of non-initiators had mothers who reported that their child's healthcare provider had not discussed the possibility of vaccinating their child against HPV.All variables found to have significant bivariate associations with initiation were then included in a logistic regression model predicting vaccine initiation. Because observed data suggest a substantial gender difference in vaccination, with females more likely to initiate vaccination than males, we conducted additional exploratory analyses to clarify the negative effect of female gender in our multivariate logistic regression model. We found that this effect was likely due to the association between gender and provider communication—when included in the multivariate logistic regression model, a gender × communication interaction term was statistically significant. To illustrate the interaction between child gender and healthcare provider communication , we estiχ2 = 40.13, df = 3, p < .001). Among mothers of daughters, 41.2% (n = 503) reported that no discussion about HPV vaccination occurred; 8.6% (n = 105) reported that the HPV vaccine was discussed but either discouraged or not recommended; and 26.3% (n = 321) and 23.9% (n = 291) reported that their child's healthcare provider recommended or strongly recommended HPV vaccination, respectively. Among mothers of sons, 54.2% (n = 485) reported that no discussion about HPV vaccination occurred; 8.9% (n = 80) reported that the HPV vaccine was discussed but either discouraged or not recommended; and 20.4% (n = 183) and 16.4% (n = 147) reported that their child's healthcare provider recommended or strongly recommended HPV vaccination, respectively.Chi-square tests of independence also suggested significant differences in healthcare provider communication by gender , age 10 , age 11 , or age 12 . By age 13, a significantly higher proportion of females had initiated vaccination .Initiation was reported by 27.5% of 9–10-year-olds and 42.4% of 11–13-year-olds. We examined factors associated with HPV vaccine initiation vs. non-initiation by ages 9–10 as well as initiation vs. non-initiation by ages 11–13  using chChi-square tests of independence also indicated differences in health insurance type by initiation status among 9–10-year-olds, but not among 11–13-year-olds, with a significantly greater percentage of those who had initiated the vaccine by ages 9–10 either receiving publicly funded health insurance or being uninsured (45.8%) compared to non-initiated 9–10-year-olds (39.8%). A significantly higher percentage of those initiated by ages 11–13 had visited a healthcare provider in the past year (96.5%) compared to those not initiated by ages 11–13 (91.4%), while this difference was not observed among 9–10-year-olds. Those initiating by ages 11–13 also had mothers who reported significantly higher perceived benefits of vaccination than those not initiating by ages 11–13, M(SD) 3.68 (.75) vs. 3.45 (.81).We explored HPV vaccine initiation among 9–13-year-olds in the United States. To our knowledge, this is one of the first studies subsequent to the ACIP recommendation for routine immunization in early adolescence that assesses rates of HPV vaccine initiation among both males and females in this age range. This study adds to literature suggesting that provider communication and/or recommendation regarding HPV vaccination is a key factor in parents' vaccination decisions, suggesting that this may also be a key factor at earlier ages. We were also able to explore potential differences between children who initiated vaccination prior to and during the targeted ages for routine recommendation.Our multivariate analyses indicated that child age, provider communication regarding HPV vaccination, flu vaccine history, sibling receipt of the HPV vaccine, health insurance type, and typical location of provider visits were significant predictors of initiation among 9–13-year-olds. Older age was associated with increased likelihood of having initiated the vaccine series, which is in keeping with previous estimates of coverage across later adolescence . The resHealthcare provider communication regarding HPV vaccination was a particularly strong predictor of initiation across our sample. This finding regarding younger children is consistent with previous research among parents of older adolescents indicating the significant impact of provider recommendation on parents' decision making surrounding HPV vaccination .. UnfortOur finding that initiation among males may be more strongly affected by healthcare provider recommendation could reflect the relative recency of the ACIP's routine recommendation for males compared to females and the associated barriers to vaccination, such as less awareness of the importance of male vaccination among providers as well as among parents of sons. Such barriers are commonly reported by parents of sons, who may be willing to vaccinate once such barriers are addressed .Interestingly, the gender gap in initiation did not begin to emerge in our sample until around ages 12 to 13. Similarities in initiation rates among males and females at younger ages may reflect a trend toward increased availability and equality of administration of the vaccine for males, as licensure and routine recommendation of the vaccine for males  occurred more recently than for females .Although the rates were similar among both genders at ages 11–12, coverage remains discouragingly low given that this is the age range in which the vaccine should be routinely administered. Missed opportunities for vaccination are frequent—the Centers for Disease Control and Prevention estimates that 91.3% of females born in 2000 would have received at least one dose of the HPV vaccine by age 13 if it had been administered during healthcare visits when they received another immunization . In our The study has several limitations. First, data were not collected from a nationally representative sample. However, the demographics of our sample are comparable to the most recent available U.S. census estimates pertaining to the distribution of individuals across geographic regions  as well In one of the first studies to assess rates of HPV vaccine initiation among 9–13-year-olds following the ACIP recommendation for routine immunization in early adolescence, we found that one quarter of 9–10-year-olds had initiated the vaccine series, with coverage increasing across the age range, and no gender differences in initiation at younger ages. Strength of health provider recommendation to parents about HPV vaccination emerged as a key factor in parents' decision to vaccinate their children. Given the ubiquity of HPV and the vaccine's effectiveness against adverse health consequence, the frequency of initiation occurring prior to the targeted age for routine administration holds promise; however, vaccination coverage among early adolescents remains well below national health goals. Improvements in provider communication with patients and their parents could substantially contribute to HPV vaccination during early adolescence becoming truly routine.Gregory Zimet has been an investigator on investigator-initiated research funded by Merck, Inc., has served as a consultant to Merck, Inc., and has received an unrestricted program development grant from GlaxoSmithKline. The other authors have no conflicts of interest to disclose. The funding organizations did not play a direct role in the design and conduct of the study; management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication.


Knowledge on HPV prevalence and genotype distribution in HSIL and ICC is highly essential for the introduction of an effective vaccination program and appropriate epidemiological monitoring of viral ecology before and after vaccination in Congo. This study aimed to determine the specific-HPV genotypes in HSIL and ICC among women in southwestern Congo.125 archival paraffin-embedded biopsy collected between 2008 and 2012 and histologically diagnosed were investigated. DNA extraction was performed using the phenol/chloroform method. HPV search was performed by nested-PCR using MY09/MY11 and GP5+/GP6+ consensus primers followed by direct sequencing.The mean age of participants was 44.3 ± 8.2 years. Overall, HPV prevalence was 89.6% (112/125) with all high-risk genotypes. HPV-DNA was detected in 81.5% (53/65) of HSIL and 98.3% (59/60) of ICC. HPV 16 the most common genotype was detected in 47.1% (25/53) of HSIL and 52.5% (31/59) of ICC. Other types identified were: HPV 33 (22.6%), HPV 18 (15%), HPV 31 (11.3%) and HPV 69 (3.7%) in HSIL, and HPV 33 (28.8%), HPV 18 (11.8%), HPV 31 (5%) and HPV 35 (1.7%) in ICC. Knowing that the ADC accounted for 6.7% (4/60) of ICC cases, HPV 18 was identified in 25% (1/4) of these cases against 75% (3/4) for HPV 16.Our study showed that HPV 16, 33, 18 and 31 were the four most common genotypes in women with HSIL and ICC. These findings indicate that current vaccines against HPV could help to reduce the burden of cervical cancer in Congo. Cervical cancer (CC) is a major public health problem worldwide. Invasive cervical cancer (ICC) is the third most common carcinoma among women in the world, representing 8.8% of all cancers. Worldwide 560,505 new cases of CC are predicted to occur by 2015. More than 459,616 women aged less than 65 years will be affected. The number of deaths is estimated at 284 902 women a year with 191,833 women aged less than 65 years [In sub-Saharan Africa (SSA), 34.8 (around 75 141) new cases of cervical cancer are diagnosed per 100 000 women annually, and 22.5 (around 50 233) per 100 000 women die from the disease [The Republic of Congo holds also some of the highest incidence and mortality rates of CC in SSA. The Age-standardized incidence rate is 25.2 per 100 000 women . The Age-standardized mortality rate is 13.0 per 100 000 women each year in the Congo  [Human papillomavirus (HPV) infection has been identified as the primary cause of CC and the third most common cause of cancer-related death among women. HPV-DNA has been found in approximately 100% of CC cases . CurrentAlthough, most HPV infections are transient and disappear within 2 years without using any treatment , high-riMoreover, two HPV vaccines have been developed, a bivalent for HPV-16 and HPV-18 and a quadrivalent for HPV-16, HPV-18, HPV-6 and HPV-11, capable of protecting in an effective way against an infection caused by these types . AlthougAlthough the distribution of high-risk types in High-grade Squamous lesions (HSIL) and ICC shows little variation among regions of the world, –17, perfUntil now, no study has been conducted on this target population in the Republic of Congo. Thus, the aim of this study was to determine the prevalence and the HPV type’s distribution in HSIL and ICC among Congolese women in the southwestern part of the country.One hundred and thirty six formalin-fixed paraffin-embedded (FFPE) biopsy samples collected between 2008 and 2012 where HSIL and ICC diagnosis has been indicated were anonymously selected from tumor Registry files of Histopathological Unit of General Hospital of Loandjili (GHL) in Pointe-Noire. Altogether only 125 (91.9%) archival FFPE samples were found, 65 HSIL and 60 ICC (including 56 invasive squamous cell carcinomas (SCC) and 4 adenocarcinoma (ADC)) from women aged 28-74 years (mean age: 44.3 ± 8.2 years). The mention of diagnosis and especially the availability of biopsy to the laboratory were the two major inclusion criteria. For the purposes of scientific research, the study was approved by the local ethics committee in the Health Sciences  with an exemption from requiring consent from patients .Three to five sections of FFPE tissue were cut on a microtome and deparaffinized with xylenes and washed with 70% ethanol at ambient temperature. DNA extraction was performed using the manual technique of phenol/chloroform used in the laboratory of Virology, Microbiology and Quality/Eco-toxicology and Biodiversity (LVMQ/ETB) of the Faculty of Sciences and Techniques, University Hassan II Mohammedia-Casablanca in Morocco after enzymatic treatment with proteinase K. The DNA was precipitated with 2/5 volumes of 7.4M ammonium acetate and 2 volumes of 100% ethanol. DNA pellet was subsequently washed with 70% ethanol, air-dried and then suspended again in 30 or 50mL of Ultra-pure PCR water nuclease-free , thereafter stored at 20°C until further use.After extraction, DNA concentration was evaluated in NanoDrop 8000 Spectrophotometer . A 268-base-pair fragment of the housekeeping β-globin gene was amplified using the GH20/PCO4 primer set to evaluate quality and integrity of DNA extract as previously described . All amp® clean up system  whereas, the sequencing products was done with a Sephadex column 50G . Electrophoresis migration was performed in a 16 capillary automated sequencer 3131XL/Genetic HITACHI Analyzer  at a constant voltage of 12 KV.The samples were analyzed for HPV-DNA detection by nested-PCR using two consensus primer sets, i.e., MY09/MY11 and GP5/GP6 as previously described . To avoihttp://www.megasoftware.net) and results were analyzed using the BLAST algorithm (http://www.ncbi.nih.gov/BLAST). For each typing, we searched the hypervariable region from 34 to 50 bp downstream of the GP5+ binding site  software Version 4.0  samples tested (β-globin PCR). Our results showed that 112/125 (89.6%) of the total samples were positive for HPV-DNA. HPV-DNA was detected in 81.5% (53/65) of HSIL and 98.3% (59/60) of ICC (98.2% of SCC and 100% of ADC respectively).Six different genotypes have been identified, all were oncogenic high-risk types. HPV 16 the most common was detected in 47.1%  of HSIL and 52.5%  of ICC. Other types identified were in decreasing frequency: HPV 33 , HPV 18 , HPV 31 (11.3%) and HPV 69 (3.7%) in HSIL; HPV 33 , HPV 18 , HPV 31 (5%) and HPV 35 (1.7%) in ICC.Knowing that the ADC accounted for 6.7% (4/59) of positive ICC cases, only 1 of out 4 (1.7%) of them was identified as HPV 18 against 3 of out 4 (5%) for HPV 16. All the results are reported in Table The five most common individual oncogenic HPV types found in ICC in our study were compared with profiles found in the World, African regions; Europe and North America according to the WHO/ICO HPV information center Table .Table 3The study reported here is the first of its kind among Congolese women with high-grade lesions and invasive cervical cancer in the aim of understanding the HPV prevalence and genotypes distribution in this target population groups in the southwestern part of the Country. Study was conducted retrospectively, using FFPE biopsies diagnosed as HSIL or ICC taken from 2008 to 2012, from GHL in Pointe-Noire. The GHL is the only hospital of south of the country to have a pathological laboratory. The Patients received in this laboratory come from different regions of the country and represents wide social and economic strata. Therefore, the results of our study could have particular interest in the area.Worldwide, HPV prevalence in cervical cancer is reported to be 99.7% . This prIn our study, HPV 16 was the most common genotype found in HSIL (47.1%) and ICC (52.5%). These findings let appear a very high proportion of the infection by this genotype in our study population and are in keeping with other studies in the world –28. ThesWe found also HPV 33 was the second most common types in HSIL (22.6%) and ICC 28.8%) followed by HPV18, 15% and 11.8%; HPV31, 11.3% and 5% in HSIL and ICC respectively. This profile although slightly different from those reported in sub-Saharan Africa , 31, 32,.8% folloIn his study of women with HIV in Pointe-noire, Alidjinou using the Hybrid Capture II (HC2) method had found a prevalence of 70.9% of combined HPV16/18/45 . KnowingIn addition, although often diagnosed in the ADC, on 4 cases of our study, only a case was positive by HPV 18. This result indicates that the genotype 16 remains dominant whatever the histological type of the cancer. Frequently diagnosed among the first five genotypes in cervical cancer in the world, we found in our study a very high rate of HPV 33 in both HSIL (22.6%) than in ICC (28.8%), making it the second most prevalent type in our study population. This trend was also found with HPV 31 with frequencies of 11.3% and 5% in HSIL and ICC respectively. Admittedly lower degree, the high frequencies of these two types has been reported in several studies in Europe , 36. In In sum, the pattern of distribution of HPV in HSIL and ICC in southwestern Congo is as follows: HPV16, HPV33, HPV18, HPV31, HPV69 and HPV35. Note the notable absence of HPV45 which is among the five frequently identified worldwide genotypes. Our study showed for the first time a high prevalence of HPV in HSIL and ICC in women attending GHL in Congo. Early detection of infection for high-risk types could give physicians the possibility of more effective management of the disease . This stThe findings of this study are very significant because they provide, for the first time, baseline information on the HPV type’s distribution in HSIL and ICC in the Republic of Congo, which may guide the development of CC prevention and control programs in the country. These findings also indicate that HPV vaccination might be beneficial among Congolese population.


It has nearly been a decade since the introduction of the vaccine against human papillomavirus (HPV), yet vaccination rates in the United States have remained suboptimal, particularly among Hispanics. Culturally and linguistically relevant health education tools targeting Hispanics are needed to increase the current rate of HPV vaccination. This article evaluates a theory-informed, evidence-guided fotonovela (photographic short story) intervention to improve HPV vaccination knowledge, attitudes, and intention among young adults.Young adults  in a low-income primary care clinic in Southern California were administered pre- and post-intervention surveys to measure changes in perceived susceptibility to HPV, perceived benefit of vaccination in committed relationship, intention to vaccinate, intention to encourage social networks to vaccinate, and attitude towards vaccination. Post-intervention survey also examined attitudes towards fotonovela. Relationships between attitudes towards fotonovela and demographic characteristics were assessed with Fisher’s exact test. Self-reported gains in knowledge were categorized and tabulated. Changes in perceptions and intentions were analyzed with the marginal homogeneity test.p = 0.03), benefit of vaccination , intent to vaccinate , intent to encourage others to vaccinate  and attitude towards vaccination . Improvements in perceived susceptibility and attitude towards vaccination reached statistical significance (p < 0.05). The most frequent gains in knowledge were the risk of HPV infection despite condom use (N = 16) and relationship status (N = 8), three-dose vaccine administration schedule (N = 13), and burden of HPV infection among males (N = 9).The majority of participants were female (78.0 %), Latino/Hispanic (92.7 %), single (70.7 %), and had at least a college education (61.0 %). The mean age was 21.9 years (SD 0.4). The fotonovela was viewed as entertaining (95.1 %), educational (97.6 %), and easy to read (100 %). Following the intervention, Hispanic participants improved in all five variables of interest measured in the survey, including perceived susceptibility (+10.5 %, Results are promising because they demonstrate that health messages delivered through a narrative format can promote positive changes in knowledge, attitudes, and intentions. The fotonovela may be a powerful vehicle for HPV education, particularly among Hispanics. Approximately 14 million Americans are newly infected by human papillomavirus (HPV) each year, making it the most common sexually transmitted infection in the United States –4. HowevLack of knowledge regarding HPV and HPV vaccination may contribute to the high rate of non-vaccination among Hispanics –17, in pAlthough Hispanics are a priority group for HPV prevention, few educational interventions have been targeted specifically to this population. In a systematic review that examined resources designed to improve HPV vaccine knowledge and acceptance, 33 studies were evaluated and only a single study was culturally adapted to Hispanics . This stOne type of intervention that shows promise as a health education tool in Spanish-speaking communities is the fotonovela –36. FormIn the present study, we addressed the gap in HPV vaccine uptake among Hispanics by creating a culturally and linguistically tailored educational intervention in the form of a fotonovela that aimed to increase HPV vaccine knowledge, attitudes, and intentions in young adults. We first presented the theory that informed the design of the fotonovela. Then, we described a quantitative summative evaluation of the fotonovela in a low-income Hispanic community in Southern California. We hypothesized that the fotonovela will not only improve knowledge, attitudes and intentions regarding vaccination, but also encourage dialogue about HPV prevention within the community.The Health Belief Model (HBM) was used to guide the design of the fotonovela because of its proven relevance to vaccination behavior –40. The Low perceived HPV susceptibility, severity, and benefits of vaccination were addressed by organizing educational messages around common knowledge gaps  and misconceptions . Self-efficacy was promoted through story protagonists, who served as role models for healthy behavior; it was believed that readers could learn from and emulate the characters’ actions. Lastly, the fotonovela itself served as a cue to action. Reading the story should motivate readers to initiate a dialogue about HPV prevention with their healthcare provider, family, and friends. Healthcare providers could reduce the perceived barriers of vaccine safety and cost through reassurance and referral to public programs that pay for the vaccine.During a 6-month period in 2012–2013, the research team developed the script, photographed scenes, and designed the layout of the fotonovela. The fotonovela was piloted with community members prior to finalization to ensure cultural and linguistic appropriateness of plot, dialogue, characters, educational messaging, and visual content.The final product was an 18-page fotonovela entitled “What You Don’t Know” about a young Hispanic female who learned the importance of being vaccinated against HPV while in a committed relationship  were recruited to participate in the study. UCI-FHC is a community-based, federally qualified health center in Southern California that serves a predominantly low-income Hispanic/Latino medically underserved population. Hispanics comprise 70 % of the overall clinic population, and 90 % of patients fall below 200 % of the federal poverty life. The majority of patients either lack insurance or have insurance through Medicaid, a federal- and state-funded social health care program for individuals with low income and limited resources, or Medical Services Initiative, a health care program for low-income citizens in Orange County, California. Male and female adult patients were recruited into the study if they were aged 18–26 years old.Upon presentation to the clinic, participants were approached by our bilingual research personnel and asked to partake in a study about HPV. Participants who agreed to participate were screened for eligibility. After providing verbal informed consent, participants were handed a pretest survey, fotonovela, and posttest survey, in either Spanish or English. They were instructed to first complete the pretest survey, then read the fotonovela intervention, and subsequently complete the posttest survey. All questionnaires were anonymous in order to protect participant privacy. The study took place in the UCI-FHC waiting room and lasted 25 min. As compensation, participants were given the fotonovela. All study materials and procedures were approved by the UCI Institutional Review Board.This study used a pre-experimental study design to compare individual attitudes and intentions related to HPV and HPV vaccine pre- versus post-intervention. The questionnaire was divided into pretest (14 questions) and posttest Sects. (19 questions). The pretest section collected basic demographic information (9 questions) and preliminary attitudes and intentions towards HPV vaccination (5 questions). The same 5 variables of interest were administered again in the posttest section to assess for changes caused by the intervention (5 questions). The posttest section additionally evaluated attitudes about fotonovela content (13 questions) and gains in knowledge (1 question).Attitudes and intentions towards HPV vaccination were assessed with 5 items on a 5-item Likert scale with an “Undecided” option. The items measured perceived susceptibility to HPV (“How likely are you to be infected with HPV?”), perceived benefit of vaccination in a committed relationship (“Is it necessary to vaccinate against HPV even if you are in a committed relationship?”), intention to vaccinate (“How likely will you get the HPV vaccine?”), intention to encourage family and friends to vaccinate (“How likely will you to encourage family and friends to get the HPV vaccine?”), and attitude towards vaccination (“How will getting the HPV vaccine make you feel”?).The content of the fotonovela was assessed with 13 items on a dichotomous scale (yes/no). The items measured included entertainment value, educational quality, readability of text, cultural relevance, importance of presented information, relevance of information to personal life, familiarity of characters, and identification with characters. Additionally, there were items about willingness to disseminate the information with family and friends, willingness to share the fotonovela with family and friends, desire to learn more, and ability to use the learned information in everyday life. Gains in knowledge were evaluated with an open-ended question (“List 3 things that you learned after reading the booklet”). A research assistant, native in the source language and fluent in the target language, translated the questionnaire from English to Spanish. A second research assistant assessed the clarity, appropriateness of wording and acceptability of the translated questionnaire. The English and Spanish versions of the questionnaire were pretested prior to administration.All quantitative analyses were performed using Stata 12.0 . Frequencies and percentages were computed for all variables. Due to small sample size, some responses answered on the Likert scale were collapsed for analyses: “Very likely,” “Likely,” and “Somewhat Likely” were combined into the category “Likely.” Responses about attitudes towards vaccination were also collapsed: “Empowered” and “Safe” were combined into the category “Positive” and “Anxious” and “Embarrassed” into “Negative.” Relationships between variables of interest and demographic characteristics of participants were assessed with Fisher’s exact test. Changes from pretest to posttest were analyzed with marginal homogeneity test. Self-reported gains in knowledge were analyzed for any patterns in responses and subsequently organized into distinct categories and tabulated. Since the purpose of this study was to develop a culturally and linguistically relevant health literacy tool targeting Hispanics, non-Hispanics (N = 3) were excluded from analyses and tables.Of the 67 participants approached, 22 % refused to participate (N = 15), of which 80 % were men (N = 12). In total, 52 participants participated in the study, but 11 were excluded from analysis due to incomplete survey information. The 41 remaining participants were included in the analysis.p < 0.05), to read in English (p < 0.02), and to speak in English (p < 0.01). The average age of participants was 21.9 years (SD 0.4). Participants under 21 years and those over 23 years were more likely to identify with the story characters (p < 0.05); no differences were found for other demographic characteristics with character identification , Latino/Hispanic (92.7 %), single (70.7 %), and had at least a college education 61.0 %). As the majority of patients were born in the United States (73.2 %), most preferred to read in English (90.2 %) and approximately half spoke Spanish and English equally (53.7 %). Four participants (9.8 %) viewed the fotonovela and completed the questionnaires in Spanish. Hispanic participants with a higher education were more likely to have spent more years in the US . Furthermore, there were no differences between participants who completed the study in Spanish compared to those who completed it in English (p > 0.5).Nearly all participants viewed the fotonovela as entertaining (95.1 %), educational (97.6 %), and easy to read (100 %). More than half identified with the characters (63.4 %) and related to the story (63.4 %). Most participants (95.1 %) agreed that the information conveyed in the fotonovela was important. Among them, 94.9 % said they would be able to use the information in their lives. Fisher’s exact test did not show any differences between Hispanics and non-Hispanics (p = 0.03), to perceive benefit of vaccination in a committed relationship , to intend to vaccinate , to encourage others to vaccinate , and to have a positive attitude towards vaccination ; however, only improvements in perceived susceptibility and attitude towards vaccination reached statistical significance. Hispanic participants in marriages or domestic partnerships reported higher susceptibility to HPV post-intervention compared to those who were single (p < 0.01). A positive attitude towards the HPV vaccine increased from 71.1 % at baseline to 84.2 % post-intervention (p < 0.05); and of the participants initially ambivalent towards the vaccine, 50 % later reported that they would feel safer with it. The only demographic characteristic significantly associated with intentions was age. Participants under 24-years old expressed a greater willingness to self-vaccinate (p = 0.02) and to encourage others to vaccinate (p = 0.02).The majority of Hispanic participants (63 %) perceived the vaccine to be beneficial in committed relationships, intended to self-vaccinate and to encourage their friends and family to vaccinate, and had positive attitudes towards the vaccine at baseline. Only 21.1 % of Hispanic participants perceived themselves to be susceptible to HPV at baseline  and being married or committed relationship (N = 8), the 3-dose HPV immunization schedule at 0, 2, and 6 months (N = 13), and the burden of HPV infection among males (N = 9) (Box 6 and beiResults from this study are promising because they demonstrate that health messages delivered through a narrative format can promote positive changes in knowledge, attitudes, and intentions. Specifically, the fotonovela increased people’s knowledge about the three-dose immunization schedule and the possibility of contracting HPV regardless of gender, relationship status and condom use. Additionally, the fotonovela improved people’s perceptions of their susceptibility to HPV, perceptions of the benefits of vaccination, attitude of vaccination, and intention to self-vaccinate and to prompt others to vaccinate.Over 21 % of participants initially perceived themselves to being at risk of HPV. This coincides with previous studies that suggest between 21 and 46 % of adolescents and young adults believe they are at some risk of being infected with HPV . Such loAfter the fotonovela intervention, perceived susceptibility increased. Also, participants who were married or involved in a domestic partnership reported significantly higher susceptibility than those who were single. Overall, these findings are encouraging because studies have shown that higher perceived susceptibility to HPV infection is related to higher vaccine acceptability , 40.While the effectiveness of educational interventions on HPV vaccine acceptability has not been evaluated in the Hispanic young adult population, our study led to changes in vaccination intention that are comparable to research with other populations. In a Hong Kong study involving a 1-h educational slide presentation, the authors reported an 11.3 % increase in intention to vaccinate among Chinese adolescent girls . AnotherAlthough it is reassuring that 82 % of the people intended to vaccinate after reading the fotonovela, intentions have not historically translated to uptake within the Hispanic population. Previous studies have demonstrated similar acceptance rates among Hispanic parents, ranging from 73 to 97 % –45, yet Character identification has previously been described as a mechanism by which narratives influence behavior. In a narrative-based sexual health intervention, Moyer-Gusé et al. showed that identification with role model characters motivated participants to engage in sexual health discussions by increasing self-efficacy . In anotTo our knowledge, there is no other narrative-based HPV vaccination educational intervention that target Hispanic young adults; existing interventions have focused on Hispanic parents –29. The The results of this study should be interpreted in light of several limitations. This study used a pre-experimental design as a cost-effective and exploratory approach to examine the effectiveness of our fotonovela intervention. An important drawback is the potential threat to internal validity due to the lack of a control group. Another limitation was the small sample size. Due to constraints in resources, the study was underpowered, and thus, may not have detected the actual effects of the fotonovela. Some participant responses were collapsed into a broader category in order to correct for the relatively small sample size. While this allows for more meaningful analyses, some data was inevitably lost during this process.Whether or not participants were vaccinated may influence their knowledge, attitudes and intentions to the vaccine. Unfortunately, HPV vaccination status was not collected in this study, although such information would have been particularly informative for interpreting their perceptions to HPV susceptibility. We do not know whether the low reported perceived susceptibility of HPV was due to feeling protected from already having received the vaccine or truly believing they were not at risk of HPV. During data collection, three participants voluntarily reported that they received the vaccine, and evidently, perceived themselves to be at low risk of infection. However, without knowledge of other participants’ vaccination status, we cannot infer whether or not the low perceived susceptibility was related to prior vaccination. All participants, regardless of reported vaccination status, were included in analyses because this information should not influence their attitudes towards the fotonovela.A major advantage of the study was the inclusion of Hispanics and non-Hispanics, males and females. However, the overwhelming majority of participants were Hispanic women due to the women’s health clinic at UCI-FHC. Of the men who refused to participate, the predominant reasons were lack of interest in research topic and in incentive offered. The fotonovela was written at a sixth-grade reading level and intended for readers with minimal health literacy. However, most of the participants achieved at least a high school education and thus, may be more health literate than Hispanics who did not complete high school. While the 13 % of participants who did not attain a high school diploma still found the fotonovela easy to understand, it cannot be known with certainty whether this particular intervention would be suitable for everyone. Future research is needed to demonstrate generalizability and corroborate the appropriateness of the fotonovela within a larger sample of individuals across various cultures, educational levels, socioeconomics, and age groups, including adolescents. Lastly, because this study only examined changes in knowledge, attitudes and intentions related to vaccination immediately post-intervention, it would be worthwhile to study the fotonovela’s long-term impact, particularly in vaccination behavior.The fotonovela “What You Don’t Know” distinguishes itself as a unique educational tool. It is one of the first culturally tailored educational interventions designed to promote HPV vaccine acceptance among Hispanic young adults. Findings from this study demonstrated the utility of the fotonovela in impacting HPV vaccine knowledge, attitudes, and intentions. Implications of the fotonovela are enormous. The fotonovela can be used by healthcare providers to engage patients into dialogues about HPV vaccination, distributed within social networks to reach people who may not be seeking this information, incorporated into school curricula as an educational tool for sexual health, and used to empower individuals to take preventive actions in their personal health as well as their children’s health. Future efforts should examine the effectiveness of the fotonovela in conjunction with other educational interventions and explore alternative avenues and media outlets to disseminate the fotonovela to broaden its reach to new audiences.


However in-vitro evidence, seems to underline a possible negative effect of HPV in increasing blastocyst apoptosis and in reducing the endometrial implantation of trophoblastic cells. On these bases we believe that a new scientific approach is necessary to better understand the real role of male and female HPV infection in infertility and early pregnancy development.Current evidence about in-vivo and in-vitro studies regarding this topic.English literature review of manuscripts focused on HPV infection and human reproduction was conducted. We performed a critical analysis of evidence and possible bias affecting both in-vivo studies is due to the inappropriate timing of HPV effects evaluation since evidence about in-vitro studies strongly suggests that a large part of HPV negative effects occurs during a very early stage of embryo development. All the efforts of the scientific community to investigate the real role of HPV in human reproduction disorders cannot underestimate the severe BIAS of actual evidence in postulating new hypothesis and research projects which are fundamental to clarify if HPV may be associated with unexplained couples infertility and early miscarriages.The biggest limitation of the If the relationship between HPV gametes infection and early human reproduction step impairment will be confirmed, the HPV male and couple vaccination may represent a reliable option to improve fertility in some couples affected by infertility actually classified as “idiopathic” but maybe linked to HPV infection. Currentelopment -6. Howevic cells -15. Despic cells , in our ic cells . The higAnyway the interesting results of Perino et al. should be interpreted with caution since several Authors reported approximately 24% of cervical HPV-DNA detection in women with ongoing pregnancy ,18.Other 3 available studies  failed in-vivo studies conducted till now  are affected by different BIAS which probably led to confusion in considering the final results. The first possible BIAS is related to the HPV types detected: all the cited studies focused in particular on high-risk (Hr) genotype 16 and 18 extending the search only to few other Hr-genotypes or low risk HPV 6/11. The second BIAS is related to the sample detection methods of HPV presence which did not permit to rule out the possible contaminations derived by the passage through the genital tract. Adjunctively the study by Conde-Ferraez et al. and Ticconi et al., focusing only on cervical HPV detection, did not consider the possible BIAS related to the viral clearance  which can lead to an underestimation of the problem [in-vitro evidence which demonstrated that HPV sperm infection seems to have a possible role in adverse blastocyst development [We believe that all the  problem . The thielopment ,14. In pelopment ,13,20.in-vitro evidence on this field represents a good starting point to plan new perspective studies and to avoid the above mentioned BIAS.On these bases we believe that a new scientific approach is necessary to better understand the real role of male and female HPV infection in early pregnancy development and infertility. We think that the recent in-vitro studies, that HPV-31 infection and HPV-16 E6 and E7 oncogenes caused both a decrease in 3A trophoblastic cells number and a low trophoblast-endometrial cells adhesion in the first week after the exposure [Yet in 1996 Cabrera et al. in a murine experimental study demonstrated that spermatozoa carrying HPV-16 and −18 viral genome can be transfected into a mouse blastocyst with viral DNA localization both in the inner cells mass and trophoblastic cells . The conexposure ,13. The exposure . These fThese effects were also confirmed by Gomez et al. who found a 3- to 6- fold greater rate of apoptosis in trophoblastic cells transfected with a plasmid containing the entire HPV-16 genome and a progressive decrease of trophoblast invasion ability 25.2-57.6%) from day 3 until day 15 after transfection compared to negative controls . Also Ho.6% from The reasons which could explain the reduction of invasiveness of trophoblastic cells were suggested by Boulenouar et al. who found a down-regulation of E-cadherin  in trophoblastic cells expressing HPV-16 viral genome .Although all the considered studies have important limitations (which should not be underestimated) linked to the in-vitro artificial and experimental conditions, most of the analyzed data suggested a possible adverse effect of HPV infection in early pregnancy development and maybe in idiopathic couple infertility. The demonstration that also the spermatozoa can act as a vector of HPV viral genome into oocyte  force thThis fact acquires an even greater importance since the recent estimated prevalence of HPV sperm infection is about 10% (95% CI:7–14%) in general male population and 16% (95% CI:10–23%) in men affected by unexplained infertility [So, focusing the investigations on HPV implications in human reproduction, it is mandatory to shift the older concept of infection with female gender target (i.e. oncologic risk in infected women respect to men) and to start in considering the HPV infection as a couple or, even better, a men problem.in-vivo studies are not useful to completely understand the HPV exact role in human infertility because study methods, patients selection and idea conception seem to be inadequate.In agreement with this new conception, it is intuitive that all the available in-vivo studies is due to the inappropriate timing of HPV effects evaluation since evidence about in-vitro studies strongly suggests that a large part of HPV negative effects are carried out during a very early stage of embryo development (within the first two weeks after conception). These effects are very difficult to be demonstrated by clinical studies since it is possible to detect a causal-effects ratio on human reproduction only starting from the third week after conception (five week of amenorrhea). In this way all clinical studies lose a large part of negative effects demonstrated by in-vitro experimental studies.The biggest limitation of the Anyway clinical evidence can elucidate the consequences of HPV in late embryos development and pregnancy evolution. The detection of HPV in the placental tissue  lead to in-vitro and in-vivo further studies.In conclusion all the efforts of the scientific community to investigate the real role of HPV in human reproduction disorders cannot underestimate the severe BIAS of previous evidence in postulating new hypothesis and research projects. Even if the choice of more appropriate laboratory techniques (ISH rather than PCR) could partially solve the BIAS linked to potential contamination of specimen, shifting the attention on men and couples rather than only on women represent a first step to solve the dilemma. As suggestion to Clinicians interested in the topic we invite to focus the attention on idiopathic infertile couples undergoing ART cycles, theoretically the most appropriate cohort to plan both We must definitively understand if the hypothesized adverse effects of HPV in human reproduction is only a supposition derived from a “inconclusive” scientific speculation or if we are faced to a new important discovery which can potentially clarify the exact mechanism of some cases of unexplained couples infertility and of early miscarriages linked to HPV infection.So If the suspected HPV role in early human reproduction impairment will be confirmed by well conducted further studies, the couple vaccination before attempting both spontaneous and assisted pregnancy could be a reliable and effective tool .The rationale for proposing the use of HPV vaccination (Gardasil® or Cervarix®) in couple attempting ART cycle is based on the evidence that in man the HPV sperm infection seems associated with some spermatic parameters impairment  and in win-vitro and epidemiological studies on this field.If in infertile couple the fertility rate will result increased after vaccination, this can be considered an indirect confirmation of our hypothesis and a suggestion to start more appropriate Improvement in the knowledge of HPV-DNA sperm infection mechanisms, timing, and link to fertility impairment may explain some of the actual “idiopathic” male and couple infertility.The authors declare that they have no competing interests.MN & SG carried out literature search, critical analysis of data and written the manuscript. AA carried out language revision and critical comment. GBN and GA participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.


Human papillomavirus (HPV) causes roughly 1.6% of the plus 1.6 million cases of cancer that are diagnosed in the United States each year. Despite the proven safety and efficacy of available vaccines, HPV remains the most common sexually transmitted infection. Underlying the high prevalence of HPV infection is the poor adherence to the Centers for Disease Control recommendation to vaccinate all 11- to 12-year-old males and females. In fact, only about 38 and 14% of eligible females and males, respectively, receive the complete, three-dose immunization. The many factors associated with missed HPV vaccination opportunities – including race, age, family income, and patient education – contribute to widespread disparities in vaccine completion and related health outcomes. Beyond patient circumstance, however, research indicates that the rigor and consistency of recommendation by primary care providers also plays a significant role in uptake of HPV immunization. Health disparities data are of vital importance to HPV vaccination campaigns because they can provide insight into how to address current problems and allocate limited resources where they are most needed. Furthermore, even modest gains in populations with low vaccination rates may yield great benefits because HPV immunization has been shown to provide herd immunity, indirect protection for non-immunized individuals achieved by limiting the spread of an infectious agent through a population. However, the impact of current HPV vaccination campaigns is hindered by stagnant immunization rates, which remain far below target levels despite a slow overall increase. Furthermore, gains in immunization are not equally distributed across gender, age, demographic, and socioeconomic divisions within the recommended group of vaccine recipients. To achieve the greatest impact, public health campaigns should focus on improving immunization coverage where it is weakest. They should also explore more subtle but potentially significant determinants of HPV vaccine initiation and completion, such as the attitudes of parents and healthcare providers and factors that exacerbate HPV-related health outcomes, including smoking and human immunodeficiency virus-mediated immunosuppression. Optimizing the efficacy of vaccination campaigns will require a health disparities approach that both identifies and remedies the underlying causes of population differences in HPV vaccination. The human papillomavirus (HPV) is the most prevalent sexually transmitted infection (STI) in the United States. Epidemiological calculations project that the majority of sexually active heterosexual males (90%) and females (85%) will be infected with HPV in their lifetimes . HPV infAlthough more than 90% of HPV infections are eventually cleared , HPV canIn the United States, the incidence of cervical cancer varies by factors, such as race, ethnicity, and age. Women who are of Hispanic or Black heritage are 1.5–2 times more likely to develop cervical cancer than American women from other ethnic and racial backgrounds . The aveFortunately, protection from HPV-related STIs and cancers is available through immunization by one of three HPV vaccines that have been approved by the federal Food and Drug Administration (FDA). All three vaccines – Cervarix, Gardasil, and Gardasil 9 – are manufactured as a three-shot series administered at months 0, 1–2, and 8 . In geneThe risk for post-vaccine injury or illness is generally a major concern for parents in their willingness to consent to the immunization of their children. Therefore, it is worthwhile to explore how the adverse effects that parents associate with HPV vaccination impact HPV vaccine uptake in adolescents. According to a Centers for Disease Control (CDC)-endorsed report by the Vaccine Adverse Event Reporting System (VAERS), a total of 25,176 adverse events were linked to HPV immunization between June 2006 and March 2014 . Of thesIn light of the fact that 50% of adolescents become sexually active at some point during high school (ages 13–18) , the CDCHowever, only 38% of females and 14% of males in the recommended age group receive the complete, three-dose immunization . This inIn the United States, the federal agency responsible for protecting the health and wellbeing of citizens is the Department of Health and Human Services (USDHHS). In assuming the task of national health promotion and disease prevention, the USDHHS has developed a public health surveillance program called Healthy People 2020 (HP2020) . The proTwo aspects of population health that are outlined in the HP2020 mission include the promotion of reproductive health and the prevention of STIs through effective immunization , 35. TheUnfortunately, improvements in HPV vaccine completion rates do not align with the HP2020 goal. In fact, an increase of only 3.3% was noted for females in 2014 with little to no gains between 2011 and 2013 , 10, 19.Researchers have also found alarming geographic differences in vaccine completion rates for females, which are lowest in the American South, particularly in Mississippi 24.6%), Arkansas (23.4%), and Tennessee (20.1%) . These s.6%, ArkaUnfortunately, there is clear evidence that parental resistance is a barrier to HPV vaccination for children in the recommended age range of 11–12 years. One study found that parents are increasingly hesitant about vaccinating young daughters; parents are three times more likely to initiate vaccination in daughters between ages 16 and 18 than in daughters between ages 10 and 12 . Among aOne reason for the reluctance in vaccinating preteens and younger adolescents is that parents do not want to subject their children to multiple shots during a single doctor visit . DespiteThe inclination to delay vaccination of young adolescents is worrisome because there is evidence that this often results in parents completely neglecting to vaccinate their children against HPV . FurtherAlthough the HP2020 objectives focus on the completion of the full three-dose HPV vaccination series, it is important to understand disparities in the awareness and initiation of HPV vaccination as they directly influence series completion. In addition to patient age at the time of vaccine initiation, other factors that influence parental consent to HPV immunization of their children include lack of knowledge about the necessity of HPV immunization, concerns about safety and side effects, lack of recommendation by a healthcare professional, and absence of sexual activity , 45. UndThese findings highlight the need to customize the focus of HPV vaccine campaigns to differences in the misconceptions about the reasons for vaccination of both genders. Whereas the focus for adolescent girls should clarify the safety and efficacy of HPV vaccines in the protection against HPV infection and cervical cancer, educational materials for the parents of adolescent boys should highlight the relevancy of HPV immunization of males as a means to protect both genders from HPV infection and the many different malignancies associated with this virus.A handful of observational studies have been conducted to dissect the underlying causes of negative parental attitudes toward HPV immunization. One study by the CDC revealed that lack of vaccine recommendation by a healthcare provider is the primary reason why 13 and 23% parents do not have their daughters and sons vaccinated .Clearly, the absence of a healthcare provider’s recommendation of HPV vaccination is a leading cause for missed immunization opportunities in both genders.Another study compared parental attitudes with vaccine uptake and found that the three main reasons  why parents fail to immunize their adolescents against HPV are tied to uncertainties that could be clarified by a healthcare provider . The samYet, another study cross-analyzed the concerns that prevent physicians from recommending vaccines with the psychosocial assumptions that prevent parents from immunizing their adolescent daughters . This stAnother study specifically explored the efficacy of HPV education by analyzing how the content, design, and distribution channels of patient education materials influences parental attitudes toward vaccine uptake. This study finds that although half of the parents prefer written material in addition to speak with their physicians, a quarter reported difficulty in understanding written material, and the majority (88%) favored verbal communication as the ideal means of obtaining vaccine information . AdditioThe conclusions from these studies suggest that encouraging physicians to be clear and consistent in recommending HPV vaccination can significantly increase the prevalence of favorable parental attitudes toward HPV immunization. More specifically, these recommendations should be communicated in an “ongoing discussion” that is prefaced with sufficient information about HPV and the vaccine in the two to three visits before the scheduled immunization . EstabliGiven the aforementioned points about parental attitudes toward the HPV vaccine, it is evident that the role of healthcare providers as key influencers in the uptake of HPV immunization cannot be ignored in the process of redesigning the HPV education experience for parents. Practical measures for eliminating barriers and inconsistencies in the effective communication of HPV vaccine recommendation include incorporating a clear rationale for early vaccination and standardizing the content and distribution of patient education material during routine pediatric visits. If physicians feel uncomfortable prioritizing and presenting HPV immunization in front of younger adolescents, allied health personnel can be assigned to deliver this information in a private and sensitive manner. Another solution may be to present HPV vaccine information to the general patient population  in the form of making video PSAs, posters, and pamphlets available to patients in waiting rooms.The good news is that public health authorities are responding to the miscommunication of HPV and HPV vaccine education by creating effective campaigns that target adolescents, parents, and providers as key players in the uptake of HPV immunization. The impact of community-based health facilities is highlighted by the finding that despite an equal willingness to vaccinate male adolescents, parents who visited community health centers for vaccines were 3.5 times more likely (69 vs. 20%) to have vaccinated their sons than those who attended hospital for the same service . These dThe first of a few examples of community-based HPV immunization campaigns that will be explored in this section is “Third Time’s A Charm,” a campaign launched in 2013 by the Alabama Department of Public Health . The Cam“Protect Me with 3” is a second contemporary HPV vaccine campaign. The program, pioneered by The Arizona Partnership for Immunization (TAPI), focuses on the normalization of HPV vaccination  by integrating it with routine vaccine recommendations . The Cam“You are the Key to Cancer Prevention” is a third HPV immunization campaign that places emphasis on the role of health care providers (HCPs) as key influencers on the incidence of HPV-related cancers among young Americans. The program expands HCPs’ understanding of HPV’s burden of disease by speaking to both the clinical and financial implications of missed opportunities for HPV prevention; it quantifies the morbidity and mortality of cervical cancer with compelling statistics, and attributes $7 billion to the costs of treating genital HPV among non-vaccinated American women . The proThe reviewed literature has revealed that patient education is one of the most significant determinants of HPV vaccine uptake, and a leading cause for missed immunization opportunities among both males and females is the lack of vaccine recommendation by a HCP. Making sure that primary care physicians are equipped with the knowledge, cultural sensitivity, and practical guides to inform their patients about HPV immunization is essential to increase the ability of parents to make informed decisions about this vaccine and their willingness to accept it for their children. Realizing that primary care physicians are often tasked with covering an overwhelming amount of information during physical exams, it may be optimal to incorporate patient-led education initiatives in the form of virtual media  and take-home material .Health disparities in the HPV vaccination coverage are a serious public health concern but can be looked as an opportunity to make significant progress in the United States population as a whole. HPV vaccination should be carefully approached from a health disparities perspective because some disparities are not detectable at the level of vaccine initiation and are only evident when data on the completion of immunization are considered . The latHowever, the demonstrated herd immunity effect in HPV vaccination –29 suggeParallels can be drawn between modern HPV vaccination efforts and previous work that led to the eradication of polio in the United States in 1979. Similar to HPV vaccine development, the poliovirus vaccine was also improved in a stepwise manner with the increasing valency of new iterations , 65. AnoAll authors contributed to the writing of this literature review. All authors reviewed and approved the final version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.