HPV Vaccine Acceptability Among Adolescent Boys' and Parents: A Meta-Ethnography of Qualitative Studies

Introduction: HPV vaccines (HPV4, HPV9) reduce the risk of HPV infection, genital warts and HPV-associated cancers among men. Despite HPV vaccine safety, efficacy, and recommendations for routine use in preadolescent boys, uptake among boys remains low (~13.9%). Systematic reviews indicate parents’ crucial role in HPV vaccine uptake among their children (e.g. Holman et al, 2015), however these reviews focus predominantly on girls. This meta-ethnography draws on qualitative studies to understand, in-depth, perceptions, attitudes and beliefs about HPV vaccination for boys, and social and systemic barriers and facilitators to HPV vaccine uptake. 

Methods: Meta-ethnography is a systematic qualitative synthesis technique that enables building an interpretive layer beyond results of the original studies. We undertook a systematic process of searching 11 databases and use of snowballing techniques to identify qualitative studies examining HPV vaccines from the perspectives of boys and parents of boys. The Consolidated Criteria for Reporting Qualitative Research (COREQ) 32-item checklist was used to assess quality of reporting of each study. We used a structured and iterative process of data analysis in which we coded included studies, and developed descriptive and analytic themes. 

Results: Eight articles representing seven studies (n=256 parents, n=39 boys) were included in analysis. The process of synthesis revealed multilevel factors that influence HPV vaccine uptake among boys and their parents: 1) personal factors (e.g. perceived HPV vaccine benefits for boys), 2) interpersonal factors (e.g. key relationships between parents, sons, peers, and healthcare providers [HCP]), 3) community/societal factors (e.g. parental duty to protect), and 4) systemic factors (e.g. access barriers due to out-of-pocket cost). Overall, parents were positively predisposed to HPV vaccination of their sons as part of their perceived core duty to protect their children from harm. However, in depth exploration of contexts of parental and preadolescent decision-making reveals a confusing array of competing beliefs and mixed messages, a HCP influence gap, and health-system factors that inhibit translating this ‘duty to protect’ into vaccine uptake. The HCP influence gap was particularly detrimental to uptake for families in which parents and sons were unlikely to discuss sexual health.

Conclusions: This synthesis suggests that interventions targeting factors at the individual (e.g. clarifying mixed messages about for whom [both boys and girls] and against what [genital warts and cancer] the vaccine protects), interpersonal (e.g. promoting HCP recommendations for boys), and systemic level (e.g. providing HPV vaccine insurance coverage for boys) may support HPV vaccine uptake for boys.