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US Health Care Clinicians' Knowledge, Attitudes, and Practices Regarding Human Papillomavirus Vaccination: A Qualitative Systematic Review

      Abstract

      Clinicians' recommendation for the human papillomavirus (HPV) vaccine appears to be an important driver of parental decisions about vaccination. Our aim was to synthesize the best available evidence exploring the perceptions and experiences regarding HPV vaccination, from the perspective of the US clinician. We conducted a comprehensive literature search of Academic Search Complete, CINAHL Plus, Communication & Mass Media Complete, Consumer Health Complete (EBSCOhost), ERIC, Health and Psychosocial Instruments, MEDLINE with full text, and PsycINFO databases. We identified 60 eligible articles: 48 quantitative and 12 qualitative. We extracted the following information: study purpose, use of theory, location, inclusion criteria, and health care provider classification. Results were organized into 5 categories: 1) clinicians' knowledge and beliefs about HPV and the HPV vaccine, 2) clinicians' attitudes and beliefs about recommending HPV vaccines, 3) clinicians' intention to recommend HPV vaccines, 4) clinicians' professional practices regarding HPV vaccination, and 5) patient HPV vaccination rates. Although clinicians were generally supportive of HPV vaccination, there was a discrepancy between clinicians' intentions, recommendation practices, and patient vaccination rates. Studies reported that clinicians tended not to provide strong, consistent recommendations, and were more likely to recommend HPV vaccines to girls versus boys and to older versus younger adolescents. Analyses revealed a number of facilitating factors and barriers to HPV vaccination at the clinician, parent/patient, and systems levels, including clinician knowledge, clinician beliefs, and office procedures that promote vaccination. This review provides an evidence base for multilevel interventions to improve clinician HPV vaccine recommendations and vaccination rates.

      Keywords

      Human papillomavirus (HPV) is the most common sexually transmitted infection, with a prevalence rate of 43% among US adults.
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      Prevalence of HPV in Adults Aged 18-69: United States, 2011-2014.
      HPV might have serious health consequences for men as well as women, including anogenital cancers (cervical, vaginal, vulvar, penile, and anal), oropharyngeal cancers, and anogenital warts.
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      Chapter 1: human papillomavirus and cervical cancer–burden and assessment of causality.
      To prevent the potential health consequences, 3 HPV vaccines (2-valent, 4-valent, and 9-valent) have been licensed in the United States. Data from clinical trials have shown that these vaccines are almost 100% effective in preventing infection and precancers caused by the targeted HPV types, if given before HPV acquisition,
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      HPV vaccine against anal HPV infection and anal intraepithelial neoplasia.
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      A 9-valent HPV vaccine against infection and intraepithelial neoplasia in women.
      and that the 4-valent and 9-valent vaccines are highly effective in preventing anogenital warts.
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      • Sigurdsson K.
      • Iversen O.
      • et al.
      A pooled analysis of continued prophylactic efficacy of quadrivalent human papillomavirus (types 6/11/16/18) vaccine against high-grade cervical and external genital lesions.
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      • Leodolter S.
      • Hernandez-Avila M.
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      Efficacy of a quadrivalent prophylactic human papillomavirus (types 6, 11, 16, and 18) L1 virus-like-particle vaccine against high-grade vulval and vaginal lesions: a combined analysis of three randomised clinical trials.
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      HPV vaccine against anal HPV infection and anal intraepithelial neoplasia.
      HPV vaccine introduction in real-world settings has led to dramatic declines in vaccine-type HPV prevalence and anogenital warts.
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      Population-level impact and herd effects following human papillomavirus vaccination programmes: a systematic review and meta-analysis.
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      Substantial decline in vaccine-type human papillomavirus (HPV) among vaccinated young women during the first 8 years after HPV vaccine introduction in a community.
      Despite the potential for HPV vaccines to decrease morbidity and mortality associated with these outcomes, vaccine uptake remains below the Healthy People 2020 objective of 80% coverage. In the United States during 2014 to 2015, only 43% of 13- to 17-year-old girls and 32% of 13- to 17-year-old boys had completed the HPV vaccine series.
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      National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years — United States, 2016.
      Health care clinicians play a key role in HPV vaccine uptake, and clinicians' recommendation for the vaccine appears to be an important driver of parental decisions to vaccinate their child.
      • Hyun H.K.
      • Washburn T.
      • Marceau K.
      • et al.
      Human papillomavirus (HPV) vaccination coverage among Rhode Island adolescents, 2008-2014.
      However, research has shown that there are considerable missed clinical opportunities to recommend and administer the HPV vaccine. Furthermore, higher quality and strength of HPV vaccine recommendations predict a higher odds of initiation and vaccine series completion.
      • Gilkey M.B.
      • Calo W.A.
      • Moss J.L.
      • et al.
      Provider communication and HPV vaccination: the impact of recommendation quality.
      However, the strength and consistency of clinician recommendations for HPV vaccine is lower than for other adolescent vaccines: in 1 study, two-thirds of 11- and 12-year-old girls did not receive an HPV vaccine at a visit during which they received at least 1 other vaccine.
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      Missed opportunities to vaccinate have been cited as the primary reason the United States has not achieved high HPV vaccination rates.
      Centers for Disease Control and Prevention
      Human papillomavirus vaccination coverage among adolescent girls, 2007-2012, and postlicensure vaccine safety monitoring, 2006-2013-United States.
      Because of relatively low rates of HPV vaccination, the importance of clinicians' vaccine recommendation, and missed opportunities to vaccinate, understanding health care clinicians' knowledge, attitudes, and professional practices regarding the HPV vaccine is important for developing evidence-based interventions to improve the consistency and strength of HPV vaccine recommendations. Therefore, our aim was to synthesize the best available evidence on the perceptions and experiences regarding HPV vaccination, from the perspective of the US clinician.

      Methods

      For the purpose of this review, health care clinician was defined as an individual qualified to deliver health care services (eg, physicians, clinical nurses, school nurses) to patients within the recommended age group for vaccination (9–26 years of age). A comprehensive literature search of Academic Search Complete, CINAHL Plus with Full Text, Communication & Mass Media Complete, Consumer Health Complete (EBSCOhost), ERIC, Health and Psychosocial Instruments, MEDLINE with Full Text, and PsycINFO databases was conducted, using variations and Boolean connectors with the following terms: human papillomavirus, vaccine, immunization, vaccine, health care provider, perception, and practice. In addition to the electronic searches, each article was scanned in Scopus for potentially missed citations that cited the article produced in the initial search.
      The following criteria were used for inclusion of articles in this review: 1) original empirical reports (including quantitative and qualitative studies) published in a peer-reviewed, English language journal, 2) studies conducted in the United States, 3) data collection took place after the US Food and Drug Administration approval of the vaccine (2006), and 4) methodology included examination of the knowledge, perceptions, and/or professional practices of health care professionals regarding the HPV vaccine. Articles were excluded if they were commentaries, editorials, or personal perspectives. All articles published through August 2016 were retrieved (the date in which searching began). Information concerning the time frame the data were collected, purpose of the study, use of theory, location of study, inclusion criteria, classification of health care provider, study design, and sample size were extracted from eligible studies. Additionally, information about clinicians' knowledge about, perceptions of, and practices regarding the HPV vaccine were extracted. Data were abstracted and entered into a database by Dr Rosen and Ms Shepard. Dr Rosen independently abstracted the data from the first 35 articles (all articles published from 2008 to 2014), and Ms Shepard independently abstracted the data from the remaining 22 articles (published from 2015 to 2016). Dr Rosen and Ms Shepard also identified themes and subthemes through content analysis on the basis of the data in the articles. Dr Kahn conducted an independent review of the themes and subthemes providing validation of data classification, as well as reviewing the abstracted data to ensure the data were aligned with the themes and subthemes. Any discrepancies in classification were resolved through discussion between Dr Rosen, Ms Shepard, and Dr Kahn.

      Results

      Sixty articles were identified for this review, including 48 quantitative and 12 qualitative studies. The range of publication dates included 2008 through 2016: most studies (n = 15) were published in 2016, and most of these (n = 13) were conducted in 2010. Five studies did not provide information about the geographic area where the research was conducted. In 25 studies, data were derived from a national data set. The remainder of the studies reported data collected from states in the Northeast (n = 6), Midwest (n = 10), South (n = 12), and West (n = 2) as defined by the US Census Bureau. Participants in the studies included pediatricians (n = 29), family practitioners (n = 26), obstetricians and gynecologists (n = 12), physicians not otherwise classified (n = 13), nurse practitioners (n = 13), general practitioners (n = 8), internal medicine physicians (n = 7), registered nurses (n = 6), physician assistants (n = 5), preventive medicine physicians (n = 2), and school nurses (n = 2). Of the 48 quantitative studies, the sample size ranged from 50 to 2119 clinician participants. The sample size in the 12 qualitative studies ranged from 8 to 61 participants. Twelve of the 48 quantitative studies explicitly stated using a theory or model to collect and/or analyze data, including theory of planned behavior (n = 5), competing demands model (n = 4), diffusion of innovations (n = 3), health belief model (n = 2), shared decision-making framework (n = 1), and transtheoretical model (n = 1). Four of the studies reported using more than 1 theory or model. Analytic methods included grounded theory/constant comparison methods in 6 of the qualitative studies. Study characteristics are shown in Table 1.
      Table 1Study Characteristics
      ReferenceStudy DesignNStudy PopulationMeasure
      HPV and Vaccine KnowledgeRecommending AttitudesIntentions to RecommendProfessional PracticePatient Vaccine Rates
      Feemster et al
      • Feemster K.A.
      • Winters S.E.
      • Fiks A.G.
      • et al.
      Pediatricians' intention to recommend human papillomavirus (HPV) vaccines to 11- to 12-year-old girls postlicensing.
      Quantitative, cross-sectional101Pediatrics
      Ishibashi et al
      • Ishibashi K.L.
      • Koopmans J.
      • Curlin F.A.
      • et al.
      Pediatricians are more supportive of the human papillomavirus vaccine than the general public.
      Quantitative, cross-sectional373Pediatrics
      Ishibashi et al
      • Ishibashi K.L.
      • Koopmans J.
      • Curlin F.A.
      • et al.
      Paediatricians' attitudes and practices towards HPV vaccination.
      Quantitative, cross-sectional373Pediatrics
      Jensen et al
      • Jensen M.E.
      • Hartenbach E.
      • McElroy J.A.
      • et al.
      Brief report: measuring the attitudes of health care professionals in Dane county toward adolescent immunization with HPV vaccine.
      Quantitative, cross-sectional204Pediatrics, NP, FM, and gynecology
      Kahn et al
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      Quantitative, cross-sectional1122Pediatrics, OBGYN, FM, IM, and other
      Askelson et al
      • Askelson N.M.
      • Campo S.
      • Lowe J.B.
      • et al.
      Factors related to physicians' willingness to vaccinate girls against HPV: the importance of subjective norms and perceived behavioral control.
      Quantitative, cross-sectional207Physicians (FM, IM, and pediatrics)
      Barnack et al
      • Barnack J.L.
      • Reddy D.M.
      • Swain C.
      Predictors of parents' willingness to vaccinate for human papillomavirus and physicians' intentions to recommend the vaccine.
      Quantitative, cross-sectional100Pediatrics, OBGYN, FM, IM, and other
      Cook et al
      • Cook R.L.
      • Zhang J.
      • Mullins J.
      • et al.
      Factors associated with initiation and completion of human papillomavirus vaccine series among young women enrolled in Medicaid.
      Quantitative, cross-sectional550,048Girls aged 9–20 years
      Study included girls aged 9 to 20 years of age enrolled in Medicaid for ≥6 months to identify claims for HPV vaccination along with individual, provider, and practice characteristics linked to vaccination.
      Daley et al
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      Quantitative, cross-sectional680Pediatrics and FM
      Ko et al
      • Ko E.M.
      • Missmer S.
      • Johnson N.R.
      Physician attitudes and practice toward human papillomavirus vaccination.
      Quantitative, cross-sectional424Pediatrics, OBGYN, and IM
      McCave
      • McCave E.L.
      Influential factors in HPV vaccination uptake among providers in four states.
      Quantitative, cross-sectional227Pediatrics, physicians, OBGYN, PA, and NP
      Weiss et al
      • Weiss T.W.
      • Zimet G.D.
      • Rosenthal S.L.
      • et al.
      Human papillomavirus vaccination of males: attitudes and perceptions of physicians who vaccinate females.
      Quantitative, cross-sectional1094Pediatrics and FM
      Hughes et al
      • Hughes C.C.
      • Jones A.L.
      • Feemster K.A.
      • et al.
      HPV vaccine decision making in pediatric primary care: a semi-structured interview study.
      Qualitative, individual interviews20Physicians
      Roberto et al
      • Roberto A.J.
      • Krieger J.L.
      • Katz M.L.
      • et al.
      Predicting pediatricians' communication with parents about the human papillomavirus (HPV) vaccine: an application of the theory of reasoned action.
      Quantitative, cross-sectional406Pediatrics
      Tan et al
      • Tan T.Q.
      • Bhattacharya L.
      • Gerbie M.V.
      Awareness, perceptions and knowledge of recommended adult vaccines among a nationwide sample of adult primary care providers.
      Quantitative, cross-sectional733OBGYN, FM, and IM
      Vadaparampil et al
      • Vadaparampil S.T.
      • Kahn J.A.
      • Salmon D.
      • et al.
      Missed clinical opportunities: provider recommendations for HPV vaccination for 11-12 year old girls are limited.
      Quantitative, cross-sectional1013Pediatrics, OBGYN, and FM
      Young et al
      • Young J.L.
      • Bernheim R.G.
      • Korte J.E.
      • et al.
      Human papillomavirus vaccination recommendation may be linked to reimbursement: a survey of Virginia family practitioners and gynecologists.
      Quantitative, cross-sectional385OBGYN and FM
      Zimet et al
      • Zimet G.D.
      • Stupiansky N.W.
      • Weiss T.W.
      • et al.
      Influence of patient's relationship status and HPV history on physicians' decisions to recommend HPV vaccination.
      Quantitative, cross-sectional271OBGYN, FM, and IM
      Javanbakht et al
      • Javanbakht M.
      • Stahlman S.
      • Walker S.
      • et al.
      Provider perceptions of barriers and facilitators of HPV vaccination in a high-risk community.
      Qualitative, in-person interviews21Physicians, PA, medical assistants, and case managers
      Perkins and Clark
      • Perkins R.B.
      • Clark J.A.
      What affects human papillomavirus vaccination rates? A qualitative analysis of providers' perceptions.
      Qualitative, in-depth interviews34Physicians and NP
      Aragones et al
      • Aragones A.
      • Bruno D.
      • Gany F.
      Attitudes surrounding implementation of the HPV vaccine for males among primary care providers serving large minority populations.
      Quantitative, cross-sectional93Pediatrics, FM, and IM
      Head et al
      • Head K.J.
      • Vanderpool R.C.
      • Mills L.A.
      Health care providers' perspectives on low HPV vaccine uptake and adherence in Appalachian Kentucky.
      Qualitative, semistructured interviews8Physicians, NP, and licensed practical nurses
      Holder et al
      • Holder N.A.
      • Katzenellenbogen R.
      • Middleman A.B.
      Human papillomavirus vaccines: factors that affect vaccine knowledge and delivery.
      Quantitative, cross-sectional254Doctors of medicine, pediatrics, adolescent medicine sub-boarded, RN, certified NP
      Malo et al
      • Malo T.L.
      • Staras S.A.
      • Bynum S.A.
      • et al.
      Human papillomavirus vaccine administration among Medicaid providers who consistently recommended vaccination.
      Quantitative, cross-sectional433Pediatrics, OBGYN, FM, IM, and preventive medicine
      Perkins et al
      • Perkins R.B.
      • Anderson B.L.
      • Sheinfeld Gorin S.
      • et al.
      Challenges in cervical cancer prevention.
      Quantitative, cross-sectional366OBGYN
      Perkins and Clark
      • Perkins R.B.
      • Clark J.A.
      Providers' perceptions of parental concerns about HPV vaccination.
      Qualitative, semistructured interviews34Pediatrics, FM, and NP
      Post et al
      • Post R.E.
      • Carek P.J.
      • Mainous A.G.
      • et al.
      Factors affecting HPV vaccine use among recent family medicine residency graduates.
      Quantitative, cross-sectional112Recent graduates from FM residencies
      Hill and Okugo
      • Hill M.
      • Okugo G.
      Emergency medicine physician attitudes toward HPV vaccine uptake in an emergency department setting.
      Quantitative, cross-sectional50Emergency medicine physicians and residents
      Malo et al
      • Malo T.L.
      • Giuliano A.R.
      • Kahn J.A.
      • et al.
      Physicians' human papillomavirus vaccine recommendations in the context of permissive guidelines for male patients: a national study.
      Quantitative, cross-sectional728FM and pediatrics
      McRee et al
      • McRee A.
      • Gilkey M.B.
      • Dempsey A.F.
      HPV vaccine hesitancy: findings from a statewide survey of health care providers.
      Quantitative, cross-sectional575Physicians and NP
      Roland et al
      • Roland K.B.
      • Benard V.B.
      • Greek A.
      • et al.
      Primary care providers' human papillomavirus vaccine recommendations for the medically underserved: a pilot study in U.S. federally qualified health centers.
      Quantitative, cross-sectional98Physicians, NP, certified nurse midwives, and physicians
      Vadaparampil et al
      • Vadaparampil S.T.
      • Zhao X.
      • Halsey N.A.
      • et al.
      Physicians' human papillomavirus vaccine recommendations, 2009 and 2011.
      Quantitative, 2 cross-sectional surveys1013 (2009), 928 (2011)FM, pediatrics, and OBGYN
      Alexander et al
      • Alexander A.B.
      • Best C.
      • Stupiansky N.
      • et al.
      A model of health care provider decision making about HPV vaccination in adolescent males.
      Qualitative, semistructured interviews20Pediatrics (IM and adolescent)
      Berkowitz et al
      • Berkowitz Z.
      • Malone M.
      • Rodriguez J.
      • et al.
      Providers' beliefs about the effectiveness of the HPV vaccine in preventing cancer and their recommended age groups for vaccination: findings from a provider survey, 2012.
      Quantitative, cross-sectional1753FM, IM, NP, pediatrics, and OBGYN
      Gilkey et al
      • Gilkey M.B.
      • Malo T.L.
      • Shah P.D.
      • et al.
      Quality of physician communication about human papillomavirus vaccine: findings from a national survey.
      Quantitative, cross-sectional1022Pediatrics and FM
      Gilkey et al
      • Gilkey M.B.
      • Moss J.L.
      • Coyne-Beasley T.
      • et al.
      Physician communication about adolescent vaccination: how is human papillomavirus vaccine different?.
      Quantitative, cross-sectional1022Pediatrics and FM
      Katz and Paskett
      • Katz M.L.
      • Paskett E.D.
      The process of engaging members from two underserved populations in the development of interventions to promote the uptake of the HPV vaccine.
      Qualitative, cross-sectionalNot statedPhysicians, nurses, and medical assistants
      Rahman et al
      • Rahman M.
      • Laz T.H.
      • McGrath C.J.
      • et al.
      Provider recommendation mediates the relationship between parental human papillomavirus (HPV) vaccine awareness and HPV vaccine initiation and completion among 13- to 17-year-old U.S. adolescent children.
      Quantitative, cross-sectional23,564Unspecified medical providers
      Rosen et al
      • Rosen B.L.
      • Goodson P.
      • Thompson B.
      • et al.
      School nurses' knowledge, attitudes, perceptions, and professional practice regarding HPV vaccine for youth.
      Quantitative, cross-sectional413School nurses
      Suryadevara et al
      • Suryadevara M.
      • Handel A.
      • Bonville C.A.
      • et al.
      Pediatric provider vaccine hesitancy: an under-recognized obstacle to immunizing children.
      Quantitative, cross-sectional680Nurse, midlevel provider, and physician
      Allison et al
      • Allison M.A.
      • Hurley L.P.
      • Markowitz L.
      • et al.
      Primary care physicians' perspective about HPV vaccine.
      Quantitative, cross-sectional582Pediatrics and FM
      Askelson et al
      • Askelson N.M.
      • Edmonds S.W.
      • Momany E.T.
      • et al.
      Understanding clinic practices for human papilloma virus vaccination series completion in clinics that provide primary care: survey of clinic managers in Iowa.
      Quantitative, cross-sectional127Clinic managers
      Berkowitz et al
      • Berkowitz Z.
      • Nair N.
      • Saraiya M.
      Providers' practice, recommendations and beliefs about HPV vaccination and their adherence to guidelines about the use of HPV testing, 2007 to 2010.
      Quantitative, cross-sectional2119OBGYN and primary care providers (IM, FM, and midlevel providers)
      Dempsey et al
      • Dempsey A.F.
      • Pyrzanowski J.
      • Lockhart S.
      • et al.
      Parents' perceptions of provider communication regarding adolescent vaccines.
      Quantitative, cross-sectional356Parents of adolescent children
      Study included parents of adolescent children at 16 primary care practices to assess current provider communication practices and influence on HPV vaccine uptake.
      Gilkey et al
      • Gilkey M.B.
      • Calo W.A.
      • Moss J.L.
      • et al.
      Provider communication and HPV vaccination: the impact of recommendation quality.
      Quantitative, cross-sectional1495Parents of 11- to 17-year-old adolescents
      Study included parents of adolescents between the ages of 11 and 17 years of age assessing the quality of recommendations parents received for the HPV vaccine from health care providers.
      Grout et al
      • Grout R.L.
      • Beal S.J.
      • Kahn J.A.
      • et al.
      Provider-level characteristics associated with adolescent varicella, meningococcal, and human papillomavirus immunization initiation.
      Quantitative, retrospective study293213- to 18-year-old patients
      Study included electronic medical records of 13- to 18-year-old patients to assess patient and provider characteristics associated with initiating the HPV vaccine.
      Henrikson et al
      • Henrikson N.B.
      • Tuzzio L.
      • Gilkey M.B.
      • et al.
      “You're never really off time”: healthcare providers' interpretations of optimal timing for HPV vaccination.
      Qualitative, semistructured face-to-face interviews and telephone interviews44Physicians, NP, and PA
      Hudson et al
      • Hudson S.M.
      • Rondinelli J.
      • Glenn B.A.
      • et al.
      Human papillomavirus vaccine series completion: qualitative information from providers within an integrated healthcare organization.
      Qualitative, semistructured interview61Immunization Nurses, FM, and Pediatrics
      Hyun et al
      • Hyun H.K.
      • Washburn T.
      • Marceau K.
      • et al.
      Human papillomavirus (HPV) vaccination coverage among Rhode Island adolescents, 2008-2014.
      Quantitative, cross-sectionalNot statedParents of adolescents
      Study included parents of adolescents to assess vaccination rates, missed opportunities for vaccination, and role of health care provider recommendations in vaccine uptake.
      Javaid et al
      • Javaid M.
      • Ashrawi D.
      • Landgren R.
      • et al.
      Human papillomavirus vaccine uptake in Texas pediatric care settings: a statewide survey of healthcare professionals.
      Quantitative, cross-sectional1132Pediatrics, Nurse, FM, OBGYN, and PA
      Kasting et al
      • Kasting M.L.
      • Wilson S.
      • Dixon B.E.
      • et al.
      Healthcare providers' beliefs and attitudes regarding risk compensation following HPV vaccination.
      Qualitative, semistructured interviews22Physicians and NP with Pediatric Specialty
      Kulczycki et al
      • Kulczycki A.
      • Qu H.
      • Shewchuk R.
      Primary care physicians' adherence to guidelines and their likelihood to prescribe the human papillomavirus vaccine for 11- and 12-year-old girls.
      Quantitative, cross-sectional301FM and Pediatrics
      Malo et al
      • Malo T.L.
      • Ali K.N.
      • Sutton S.K.
      • et al.
      The content and context of physicians' communication with males about human papillomavirus vaccination.
      Quantitative, cross-sectional367Pediatrics and FM
      Perkins et al
      • Perkins R.B.
      • Chigurupati N.L.
      • Apte G.
      • et al.
      Why don't adolescents finish the HPV vaccine series? A qualitative study of parents and providers.
      Qualitative, semistructured interviews33Physicians, NP, and RN
      Rosen et al
      • Rosen B.L.
      • Ashwood D.
      • Richardson G.
      School nurses' professional practice in the HPV vaccine decision making process.
      Quantitative, cross-sectional137School nurses
      Ylitalo et al
      • Ylitalo K.R.
      • Lee H.
      • Mehta N.K.
      Health care provider recommendation, human papillomavirus vaccination, and race/ethnicity in the US National Immunization Survey.
      Quantitative, cross-sectional9274Girls aged 13-17 years
      Study included female adolescent patients with provider-verified vaccination records.
      FM indicates family medicine; HPV, human papillomavirus; IM, internal medicine; NP, nurse practitioner; OBGYN, obstetrics-gynecology; PA, physician's assistant; and RN, registered nurse.
      Study included female adolescent patients with provider-verified vaccination records.
      Study included girls aged 9 to 20 years of age enrolled in Medicaid for ≥6 months to identify claims for HPV vaccination along with individual, provider, and practice characteristics linked to vaccination.
      Study included parents of adolescent children at 16 primary care practices to assess current provider communication practices and influence on HPV vaccine uptake.
      § Study included parents of adolescents between the ages of 11 and 17 years of age assessing the quality of recommendations parents received for the HPV vaccine from health care providers.
      Study included electronic medical records of 13- to 18-year-old patients to assess patient and provider characteristics associated with initiating the HPV vaccine.
      Study included parents of adolescents to assess vaccination rates, missed opportunities for vaccination, and role of health care provider recommendations in vaccine uptake.
      We organized study results into the following primary categories: 1) clinicians' knowledge and beliefs about HPV and the HPV vaccine, 2) clinicians' attitudes and beliefs about recommending HPV vaccines, 3) clinicians' intention to recommend HPV vaccines, 4) clinicians' professional practices regarding HPV vaccination, and 5) patient HPV vaccination rates. For the last 3 categories (intention to recommend HPV vaccines, professional practices regarding HPV vaccination, patient HPV vaccination rates) we also included factors associated with each of these outcomes if the data were available. Within each category, themes were identified and subthemes classified through content analysis. For results that are summarized in the following sections and also presented in tables, citations are included in each table.

      Clinicians' Knowledge and Beliefs About HPV and the HPV Vaccine

      Studies assessing clinicians' knowledge of HPV and HPV vaccine showed that knowledge varied widely. Correct responses to items assessing HPV knowledge ranged from 22% to 95%
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      • Weiss T.W.
      • Zimet G.D.
      • Rosenthal S.L.
      • et al.
      Human papillomavirus vaccination of males: attitudes and perceptions of physicians who vaccinate females.
      • Rosen B.L.
      • Ashwood D.
      • Richardson G.
      School nurses' professional practice in the HPV vaccine decision making process.
      and correct responses to items assessing HPV vaccine knowledge ranged from 17% to 91%.
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      • Berkowitz Z.
      • Malone M.
      • Rodriguez J.
      • et al.
      Providers' beliefs about the effectiveness of the HPV vaccine in preventing cancer and their recommended age groups for vaccination: findings from a provider survey, 2012.
      • Rosen B.L.
      • Goodson P.
      • Thompson B.
      • et al.
      School nurses' knowledge, attitudes, perceptions, and professional practice regarding HPV vaccine for youth.
      • Rosen B.L.
      • Ashwood D.
      • Richardson G.
      School nurses' professional practice in the HPV vaccine decision making process.
      Clinicians' knowledge level about HPV in men was generally lower than their knowledge level for women, and was particularly low with respect to understanding of vaccine recommendations for men, such as the upper age limit of the recommendation and which male HPV-related cancers the vaccines prevents.
      • Holder N.A.
      • Katzenellenbogen R.
      • Middleman A.B.
      Human papillomavirus vaccines: factors that affect vaccine knowledge and delivery.
      • Alexander A.B.
      • Best C.
      • Stupiansky N.
      • et al.
      A model of health care provider decision making about HPV vaccination in adolescent males.
      In 1 study, knowledge level about the vaccine's effectiveness in preventing cervical cancer was higher than for knowledge about the prevention of anal, oropharyngeal, vulvar, and vaginal cancers.
      • Berkowitz Z.
      • Malone M.
      • Rodriguez J.
      • et al.
      Providers' beliefs about the effectiveness of the HPV vaccine in preventing cancer and their recommended age groups for vaccination: findings from a provider survey, 2012.
      Clinicians also reported deficits in knowledge about the risk of HPV infection in gay and bisexual men.
      • Gilkey M.B.
      • Malo T.L.
      • Shah P.D.
      • et al.
      Quality of physician communication about human papillomavirus vaccine: findings from a national survey.
      Clinicians generally believed that HPV infection caused serious health complications (eg, cervical cancer) and warranted a vaccine.
      • Aragones A.
      • Bruno D.
      • Gany F.
      Attitudes surrounding implementation of the HPV vaccine for males among primary care providers serving large minority populations.
      • Rosen B.L.
      • Goodson P.
      • Thompson B.
      • et al.
      School nurses' knowledge, attitudes, perceptions, and professional practice regarding HPV vaccine for youth.
      • Bruno D.M.
      • Wilson T.E.
      • Gany F.
      • et al.
      Identifying human papillomavirus vaccination practices among primary care providers of minority, low-income and immigrant patient populations.

      Clinicians' Attitudes and Beliefs About Recommending HPV Vaccines

      Clinicians' attitudes and beliefs about recommending HPV vaccines are summarized in Table 2. We identified 2 main themes: facilitating factors and barriers to recommending HPV vaccines. Within each of these themes, study findings were classified into the following subthemes: personal, parent/patient-related, and systems-level facilitating factors or barriers. Personal facilitating factors for recommending HPV vaccines included personal beliefs about vaccine benefits (eg, prevention of cancer,
      • Askelson N.M.
      • Campo S.
      • Lowe J.B.
      • et al.
      Factors related to physicians' willingness to vaccinate girls against HPV: the importance of subjective norms and perceived behavioral control.
      • Weiss T.W.
      • Zimet G.D.
      • Rosenthal S.L.
      • et al.
      Human papillomavirus vaccination of males: attitudes and perceptions of physicians who vaccinate females.
      • Young J.L.
      • Bernheim R.G.
      • Korte J.E.
      • et al.
      Human papillomavirus vaccination recommendation may be linked to reimbursement: a survey of Virginia family practitioners and gynecologists.
      • Perkins R.B.
      • Clark J.A.
      Providers' perceptions of parental concerns about HPV vaccination.
      • Roland K.B.
      • Benard V.B.
      • Greek A.
      • et al.
      Primary care providers' human papillomavirus vaccine recommendations for the medically underserved: a pilot study in U.S. federally qualified health centers.
      • Alexander A.B.
      • Best C.
      • Stupiansky N.
      • et al.
      A model of health care provider decision making about HPV vaccination in adolescent males.
      • Berkowitz Z.
      • Malone M.
      • Rodriguez J.
      • et al.
      Providers' beliefs about the effectiveness of the HPV vaccine in preventing cancer and their recommended age groups for vaccination: findings from a provider survey, 2012.
      • Berkowitz Z.
      • Nair N.
      • Saraiya M.
      Providers' practice, recommendations and beliefs about HPV vaccination and their adherence to guidelines about the use of HPV testing, 2007 to 2010.
      • Hudson S.M.
      • Rondinelli J.
      • Glenn B.A.
      • et al.
      Human papillomavirus vaccine series completion: qualitative information from providers within an integrated healthcare organization.
      prevention of HPV transmission,
      • Weiss T.W.
      • Zimet G.D.
      • Rosenthal S.L.
      • et al.
      Human papillomavirus vaccination of males: attitudes and perceptions of physicians who vaccinate females.
      decreased health care costs,
      • Alexander A.B.
      • Best C.
      • Stupiansky N.
      • et al.
      A model of health care provider decision making about HPV vaccination in adolescent males.
      and benefits specific to men
      • Weiss T.W.
      • Zimet G.D.
      • Rosenthal S.L.
      • et al.
      Human papillomavirus vaccination of males: attitudes and perceptions of physicians who vaccinate females.
      • Alexander A.B.
      • Best C.
      • Stupiansky N.
      • et al.
      A model of health care provider decision making about HPV vaccination in adolescent males.
      and vaccine safety
      • Young J.L.
      • Bernheim R.G.
      • Korte J.E.
      • et al.
      Human papillomavirus vaccination recommendation may be linked to reimbursement: a survey of Virginia family practitioners and gynecologists.
      • Alexander A.B.
      • Best C.
      • Stupiansky N.
      • et al.
      A model of health care provider decision making about HPV vaccination in adolescent males.
      • Rosen B.L.
      • Ashwood D.
      • Richardson G.
      School nurses' professional practice in the HPV vaccine decision making process.
      ). Parent and patient-related facilitating factors included cultural beliefs
      • Perkins R.B.
      • Clark J.A.
      Providers' perceptions of parental concerns about HPV vaccination.
      and vaccine education for patients and families.
      • Head K.J.
      • Vanderpool R.C.
      • Mills L.A.
      Health care providers' perspectives on low HPV vaccine uptake and adherence in Appalachian Kentucky.
      • Perkins R.B.
      • Clark J.A.
      Providers' perceptions of parental concerns about HPV vaccination.
      Systems-level facilitating factors included office procedures that reduce missed opportunities to vaccinate,
      • Head K.J.
      • Vanderpool R.C.
      • Mills L.A.
      Health care providers' perspectives on low HPV vaccine uptake and adherence in Appalachian Kentucky.
      financial support for vaccination (eg, the Vaccines for Children program),
      • McCave E.L.
      Influential factors in HPV vaccination uptake among providers in four states.
      and policies that promote vaccination.
      • McCave E.L.
      Influential factors in HPV vaccination uptake among providers in four states.
      • Zimet G.D.
      • Stupiansky N.W.
      • Weiss T.W.
      • et al.
      Influence of patient's relationship status and HPV history on physicians' decisions to recommend HPV vaccination.
      Barriers to recommending HPV vaccines related to personal knowledge and beliefs included insufficient knowledge about HPV and HPV vaccines
      • McCave E.L.
      Influential factors in HPV vaccination uptake among providers in four states.
      and a number of concerns about HPV vaccines. Parent and patient-related barriers included a lack of parental interest,
      • Ko E.M.
      • Missmer S.
      • Johnson N.R.
      Physician attitudes and practice toward human papillomavirus vaccination.
      • Head K.J.
      • Vanderpool R.C.
      • Mills L.A.
      Health care providers' perspectives on low HPV vaccine uptake and adherence in Appalachian Kentucky.
      lack of parental understanding about the vaccines,
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      • Tan T.Q.
      • Bhattacharya L.
      • Gerbie M.V.
      Awareness, perceptions and knowledge of recommended adult vaccines among a nationwide sample of adult primary care providers.
      • Head K.J.
      • Vanderpool R.C.
      • Mills L.A.
      Health care providers' perspectives on low HPV vaccine uptake and adherence in Appalachian Kentucky.
      • Javaid M.
      • Ashrawi D.
      • Landgren R.
      • et al.
      Human papillomavirus vaccine uptake in Texas pediatric care settings: a statewide survey of healthcare professionals.
      and a number of parental concerns that clinicians either anticipated or had experienced. These included concerns about vaccine safety,
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      • Ko E.M.
      • Missmer S.
      • Johnson N.R.
      Physician attitudes and practice toward human papillomavirus vaccination.
      • Tan T.Q.
      • Bhattacharya L.
      • Gerbie M.V.
      Awareness, perceptions and knowledge of recommended adult vaccines among a nationwide sample of adult primary care providers.
      • Javanbakht M.
      • Stahlman S.
      • Walker S.
      • et al.
      Provider perceptions of barriers and facilitators of HPV vaccination in a high-risk community.
      • Post R.E.
      • Carek P.J.
      • Mainous A.G.
      • et al.
      Factors affecting HPV vaccine use among recent family medicine residency graduates.
      • Katz M.L.
      • Paskett E.D.
      The process of engaging members from two underserved populations in the development of interventions to promote the uptake of the HPV vaccine.
      • Javaid M.
      • Ashrawi D.
      • Landgren R.
      • et al.
      Human papillomavirus vaccine uptake in Texas pediatric care settings: a statewide survey of healthcare professionals.
      • Bruno D.M.
      • Wilson T.E.
      • Gany F.
      • et al.
      Identifying human papillomavirus vaccination practices among primary care providers of minority, low-income and immigrant patient populations.
      vaccine efficacy,
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      • Post R.E.
      • Carek P.J.
      • Mainous A.G.
      • et al.
      Factors affecting HPV vaccine use among recent family medicine residency graduates.
      negative media reports,
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      behavioral consequences of vaccination,
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      • Ko E.M.
      • Missmer S.
      • Johnson N.R.
      Physician attitudes and practice toward human papillomavirus vaccination.
      • Javanbakht M.
      • Stahlman S.
      • Walker S.
      • et al.
      Provider perceptions of barriers and facilitators of HPV vaccination in a high-risk community.
      discussions about sexual topics,
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      • Javanbakht M.
      • Stahlman S.
      • Walker S.
      • et al.
      Provider perceptions of barriers and facilitators of HPV vaccination in a high-risk community.
      • McRee A.
      • Gilkey M.B.
      • Dempsey A.F.
      HPV vaccine hesitancy: findings from a statewide survey of health care providers.
      • Katz M.L.
      • Paskett E.D.
      The process of engaging members from two underserved populations in the development of interventions to promote the uptake of the HPV vaccine.
      child being too young or not yet sexually active,
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      • Javanbakht M.
      • Stahlman S.
      • Walker S.
      • et al.
      Provider perceptions of barriers and facilitators of HPV vaccination in a high-risk community.
      • Post R.E.
      • Carek P.J.
      • Mainous A.G.
      • et al.
      Factors affecting HPV vaccine use among recent family medicine residency graduates.
      • McRee A.
      • Gilkey M.B.
      • Dempsey A.F.
      HPV vaccine hesitancy: findings from a statewide survey of health care providers.
      • Katz M.L.
      • Paskett E.D.
      The process of engaging members from two underserved populations in the development of interventions to promote the uptake of the HPV vaccine.
      • Javaid M.
      • Ashrawi D.
      • Landgren R.
      • et al.
      Human papillomavirus vaccine uptake in Texas pediatric care settings: a statewide survey of healthcare professionals.
      and vaccine cost.
      • Askelson N.M.
      • Campo S.
      • Lowe J.B.
      • et al.
      Factors related to physicians' willingness to vaccinate girls against HPV: the importance of subjective norms and perceived behavioral control.
      • Tan T.Q.
      • Bhattacharya L.
      • Gerbie M.V.
      Awareness, perceptions and knowledge of recommended adult vaccines among a nationwide sample of adult primary care providers.
      Systems-level barriers included lack of clinic procedures to support vaccination,
      • Ko E.M.
      • Missmer S.
      • Johnson N.R.
      Physician attitudes and practice toward human papillomavirus vaccination.
      insufficient vaccine supply,
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      • Young J.L.
      • Bernheim R.G.
      • Korte J.E.
      • et al.
      Human papillomavirus vaccination recommendation may be linked to reimbursement: a survey of Virginia family practitioners and gynecologists.
      insufficient reimbursement
      • Ishibashi K.L.
      • Koopmans J.
      • Curlin F.A.
      • et al.
      Paediatricians' attitudes and practices towards HPV vaccination.
      • Askelson N.M.
      • Campo S.
      • Lowe J.B.
      • et al.
      Factors related to physicians' willingness to vaccinate girls against HPV: the importance of subjective norms and perceived behavioral control.
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      • Ko E.M.
      • Missmer S.
      • Johnson N.R.
      Physician attitudes and practice toward human papillomavirus vaccination.
      • McCave E.L.
      Influential factors in HPV vaccination uptake among providers in four states.
      • Young J.L.
      • Bernheim R.G.
      • Korte J.E.
      • et al.
      Human papillomavirus vaccination recommendation may be linked to reimbursement: a survey of Virginia family practitioners and gynecologists.
      • Aragones A.
      • Bruno D.
      • Gany F.
      Attitudes surrounding implementation of the HPV vaccine for males among primary care providers serving large minority populations.
      • Perkins R.B.
      • Anderson B.L.
      • Sheinfeld Gorin S.
      • et al.
      Challenges in cervical cancer prevention.
      • Hill M.
      • Okugo G.
      Emergency medicine physician attitudes toward HPV vaccine uptake in an emergency department setting.
      • Javaid M.
      • Ashrawi D.
      • Landgren R.
      • et al.
      Human papillomavirus vaccine uptake in Texas pediatric care settings: a statewide survey of healthcare professionals.
      or insurance coverage,
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      • Barnack J.L.
      • Reddy D.M.
      • Swain C.
      Predictors of parents' willingness to vaccinate for human papillomavirus and physicians' intentions to recommend the vaccine.
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      • Alexander A.B.
      • Best C.
      • Stupiansky N.
      • et al.
      A model of health care provider decision making about HPV vaccination in adolescent males.
      and difficulty getting patients to return for subsequent vaccine doses.
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      • Javanbakht M.
      • Stahlman S.
      • Walker S.
      • et al.
      Provider perceptions of barriers and facilitators of HPV vaccination in a high-risk community.
      • Head K.J.
      • Vanderpool R.C.
      • Mills L.A.
      Health care providers' perspectives on low HPV vaccine uptake and adherence in Appalachian Kentucky.
      • Post R.E.
      • Carek P.J.
      • Mainous A.G.
      • et al.
      Factors affecting HPV vaccine use among recent family medicine residency graduates.
      • Javaid M.
      • Ashrawi D.
      • Landgren R.
      • et al.
      Human papillomavirus vaccine uptake in Texas pediatric care settings: a statewide survey of healthcare professionals.
      Table 2Clinicians' Attitudes and Beliefs About Recommending HPV Vaccines
      ThemeResults
      Facilitating factors to recommending HPV vaccines
       Personal beliefs
      Vaccine benefits
       Prevention of cancer
      • Askelson N.M.
      • Campo S.
      • Lowe J.B.
      • et al.
      Factors related to physicians' willingness to vaccinate girls against HPV: the importance of subjective norms and perceived behavioral control.
      • Weiss T.W.
      • Zimet G.D.
      • Rosenthal S.L.
      • et al.
      Human papillomavirus vaccination of males: attitudes and perceptions of physicians who vaccinate females.
      • Young J.L.
      • Bernheim R.G.
      • Korte J.E.
      • et al.
      Human papillomavirus vaccination recommendation may be linked to reimbursement: a survey of Virginia family practitioners and gynecologists.
      • Perkins R.B.
      • Clark J.A.
      Providers' perceptions of parental concerns about HPV vaccination.
      • Roland K.B.
      • Benard V.B.
      • Greek A.
      • et al.
      Primary care providers' human papillomavirus vaccine recommendations for the medically underserved: a pilot study in U.S. federally qualified health centers.
      • Alexander A.B.
      • Best C.
      • Stupiansky N.
      • et al.
      A model of health care provider decision making about HPV vaccination in adolescent males.
      • Berkowitz Z.
      • Malone M.
      • Rodriguez J.
      • et al.
      Providers' beliefs about the effectiveness of the HPV vaccine in preventing cancer and their recommended age groups for vaccination: findings from a provider survey, 2012.
      • Berkowitz Z.
      • Nair N.
      • Saraiya M.
      Providers' practice, recommendations and beliefs about HPV vaccination and their adherence to guidelines about the use of HPV testing, 2007 to 2010.
      • Hudson S.M.
      • Rondinelli J.
      • Glenn B.A.
      • et al.
      Human papillomavirus vaccine series completion: qualitative information from providers within an integrated healthcare organization.
       Prevention of genital warts
      • Weiss T.W.
      • Zimet G.D.
      • Rosenthal S.L.
      • et al.
      Human papillomavirus vaccination of males: attitudes and perceptions of physicians who vaccinate females.
       Prevention of transmission to and disease in future partners
      • Weiss T.W.
      • Zimet G.D.
      • Rosenthal S.L.
      • et al.
      Human papillomavirus vaccination of males: attitudes and perceptions of physicians who vaccinate females.
       Decreased health care costs
      • Alexander A.B.
      • Best C.
      • Stupiansky N.
      • et al.
      A model of health care provider decision making about HPV vaccination in adolescent males.
       Better method of cervical cancer prevention than Papanicolaou test
      • Ishibashi K.L.
      • Koopmans J.
      • Curlin F.A.
      • et al.
      Pediatricians are more supportive of the human papillomavirus vaccine than the general public.
      Vaccine benefits specific to young men
       Prevents genital/anal warts
      • Alexander A.B.
      • Best C.
      • Stupiansky N.
      • et al.
      A model of health care provider decision making about HPV vaccination in adolescent males.
       Protect future partners from HPV infection and cervical cancer
      • Weiss T.W.
      • Zimet G.D.
      • Rosenthal S.L.
      • et al.
      Human papillomavirus vaccination of males: attitudes and perceptions of physicians who vaccinate females.
      • Alexander A.B.
      • Best C.
      • Stupiansky N.
      • et al.
      A model of health care provider decision making about HPV vaccination in adolescent males.
       Herd immunity
      • Alexander A.B.
      • Best C.
      • Stupiansky N.
      • et al.
      A model of health care provider decision making about HPV vaccination in adolescent males.
      Vaccine safety
      • Young J.L.
      • Bernheim R.G.
      • Korte J.E.
      • et al.
      Human papillomavirus vaccination recommendation may be linked to reimbursement: a survey of Virginia family practitioners and gynecologists.
      • Alexander A.B.
      • Best C.
      • Stupiansky N.
      • et al.
      A model of health care provider decision making about HPV vaccination in adolescent males.
      • Rosen B.L.
      • Ashwood D.
      • Richardson G.
      School nurses' professional practice in the HPV vaccine decision making process.
       Parent-/patient-related
      Cultural beliefs
       Latino families, immigrants more accepting
      • Perkins R.B.
      • Clark J.A.
      Providers' perceptions of parental concerns about HPV vaccination.
      Education of patients/families
       Sheets exploring parental concerns, focus on cancer prevention
      • Perkins R.B.
      • Clark J.A.
      Providers' perceptions of parental concerns about HPV vaccination.
       Communication about clinic vaccine appointment protocol
      • Head K.J.
      • Vanderpool R.C.
      • Mills L.A.
      Health care providers' perspectives on low HPV vaccine uptake and adherence in Appalachian Kentucky.
       Systems-level
      Office-level
       Reducing missed opportunities through recall/reminder systems
      • Head K.J.
      • Vanderpool R.C.
      • Mills L.A.
      Health care providers' perspectives on low HPV vaccine uptake and adherence in Appalachian Kentucky.
      Financial support for vaccination (eg, VFC)
      • McCave E.L.
      Influential factors in HPV vaccination uptake among providers in four states.
      Policies
       State-level policies
      • McCave E.L.
      Influential factors in HPV vaccination uptake among providers in four states.
      • Zimet G.D.
      • Stupiansky N.W.
      • Weiss T.W.
      • et al.
      Influence of patient's relationship status and HPV history on physicians' decisions to recommend HPV vaccination.
       Mandated vaccination
      • Javanbakht M.
      • Stahlman S.
      • Walker S.
      • et al.
      Provider perceptions of barriers and facilitators of HPV vaccination in a high-risk community.
      • Perkins R.B.
      • Clark J.A.
      What affects human papillomavirus vaccination rates? A qualitative analysis of providers' perceptions.
      • Alexander A.B.
      • Best C.
      • Stupiansky N.
      • et al.
      A model of health care provider decision making about HPV vaccination in adolescent males.
      • Gilkey M.B.
      • Moss J.L.
      • Coyne-Beasley T.
      • et al.
      Physician communication about adolescent vaccination: how is human papillomavirus vaccine different?.
      Barriers to recommending HPV vaccines
       Personal knowledge and beliefs
      Knowledge
       Insufficient knowledge of HPV and HPV vaccines
      • McCave E.L.
      Influential factors in HPV vaccination uptake among providers in four states.
      Beliefs and attitudes about HPV vaccines
       Concerns about vaccine safety,
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      • McCave E.L.
      Influential factors in HPV vaccination uptake among providers in four states.
      • Suryadevara M.
      • Handel A.
      • Bonville C.A.
      • et al.
      Pediatric provider vaccine hesitancy: an under-recognized obstacle to immunizing children.
      efficacy,
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      • McCave E.L.
      Influential factors in HPV vaccination uptake among providers in four states.
      • Suryadevara M.
      • Handel A.
      • Bonville C.A.
      • et al.
      Pediatric provider vaccine hesitancy: an under-recognized obstacle to immunizing children.
      duration of immunity
      • Ko E.M.
      • Missmer S.
      • Johnson N.R.
      Physician attitudes and practice toward human papillomavirus vaccination.
      • Aragones A.
      • Bruno D.
      • Gany F.
      Attitudes surrounding implementation of the HPV vaccine for males among primary care providers serving large minority populations.
       Low perceived risk of HPV-related diseases in one's patients and belief HPV-related disease can be prevented in other ways (eg, Papanicolaou screening)
      • Perkins R.B.
      • Clark J.A.
      What affects human papillomavirus vaccination rates? A qualitative analysis of providers' perceptions.
       Perception that HPV vaccine is “less important” than other vaccines
      • Hughes C.C.
      • Jones A.L.
      • Feemster K.A.
      • et al.
      HPV vaccine decision making in pediatric primary care: a semi-structured interview study.
      • Perkins R.B.
      • Clark J.A.
      What affects human papillomavirus vaccination rates? A qualitative analysis of providers' perceptions.
       Hesitancy to recommend multiple vaccines at once
      • Perkins R.B.
      • Clark J.A.
      What affects human papillomavirus vaccination rates? A qualitative analysis of providers' perceptions.
       Discomfort communicating about sexual topics
      • Perkins R.B.
      • Clark J.A.
      What affects human papillomavirus vaccination rates? A qualitative analysis of providers' perceptions.
      • Gilkey M.B.
      • Malo T.L.
      • Shah P.D.
      • et al.
      Quality of physician communication about human papillomavirus vaccine: findings from a national survey.
       Concerns about behavioral consequences of vaccination (sexual behaviors,
      • Kasting M.L.
      • Wilson S.
      • Dixon B.E.
      • et al.
      Healthcare providers' beliefs and attitudes regarding risk compensation following HPV vaccination.
      decreased Papanicolaou screening)
      • Ishibashi K.L.
      • Koopmans J.
      • Curlin F.A.
      • et al.
      Paediatricians' attitudes and practices towards HPV vaccination.
      • McCave E.L.
      Influential factors in HPV vaccination uptake among providers in four states.
      • Young J.L.
      • Bernheim R.G.
      • Korte J.E.
      • et al.
      Human papillomavirus vaccination recommendation may be linked to reimbursement: a survey of Virginia family practitioners and gynecologists.
      • Katz M.L.
      • Paskett E.D.
      The process of engaging members from two underserved populations in the development of interventions to promote the uptake of the HPV vaccine.
      • Rosen B.L.
      • Ashwood D.
      • Richardson G.
      School nurses' professional practice in the HPV vaccine decision making process.
       Low perceived control over recommending
      • Askelson N.M.
      • Campo S.
      • Lowe J.B.
      • et al.
      Factors related to physicians' willingness to vaccinate girls against HPV: the importance of subjective norms and perceived behavioral control.
       Mistrust because of the emphasis on marketing of the vaccine in the media and by industry
      • Perkins R.B.
      • Clark J.A.
      What affects human papillomavirus vaccination rates? A qualitative analysis of providers' perceptions.
       Beliefs and attitudes specific to young men: discomfort vaccinating young boys,
      • Alexander A.B.
      • Best C.
      • Stupiansky N.
      • et al.
      A model of health care provider decision making about HPV vaccination in adolescent males.
      lack of direct benefit/causes too few cancers in men,
      • Weiss T.W.
      • Zimet G.D.
      • Rosenthal S.L.
      • et al.
      Human papillomavirus vaccination of males: attitudes and perceptions of physicians who vaccinate females.
      genital/anal warts can be managed in other ways,
      • Weiss T.W.
      • Zimet G.D.
      • Rosenthal S.L.
      • et al.
      Human papillomavirus vaccination of males: attitudes and perceptions of physicians who vaccinate females.
      too late to vaccinate if already sexually active,
      • Weiss T.W.
      • Zimet G.D.
      • Rosenthal S.L.
      • et al.
      Human papillomavirus vaccination of males: attitudes and perceptions of physicians who vaccinate females.
      no need to vaccinate men if women already being vaccinated
      • Weiss T.W.
      • Zimet G.D.
      • Rosenthal S.L.
      • et al.
      Human papillomavirus vaccination of males: attitudes and perceptions of physicians who vaccinate females.
      • Javaid M.
      • Ashrawi D.
      • Landgren R.
      • et al.
      Human papillomavirus vaccine uptake in Texas pediatric care settings: a statewide survey of healthcare professionals.
       Parent/patient-related
      Lack of interest/parents not requesting
      • Ko E.M.
      • Missmer S.
      • Johnson N.R.
      Physician attitudes and practice toward human papillomavirus vaccination.
      • Head K.J.
      • Vanderpool R.C.
      • Mills L.A.
      Health care providers' perspectives on low HPV vaccine uptake and adherence in Appalachian Kentucky.
      Parental lack of education/understanding
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      • Tan T.Q.
      • Bhattacharya L.
      • Gerbie M.V.
      Awareness, perceptions and knowledge of recommended adult vaccines among a nationwide sample of adult primary care providers.
      • Head K.J.
      • Vanderpool R.C.
      • Mills L.A.
      Health care providers' perspectives on low HPV vaccine uptake and adherence in Appalachian Kentucky.
      • Javaid M.
      • Ashrawi D.
      • Landgren R.
      • et al.
      Human papillomavirus vaccine uptake in Texas pediatric care settings: a statewide survey of healthcare professionals.
       Belief that adolescents do not need vaccines
      • Javanbakht M.
      • Stahlman S.
      • Walker S.
      • et al.
      Provider perceptions of barriers and facilitators of HPV vaccination in a high-risk community.
      Anticipated/experienced parental concerns
       Vaccine safety/adverse effects,
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      • Ko E.M.
      • Missmer S.
      • Johnson N.R.
      Physician attitudes and practice toward human papillomavirus vaccination.
      • Tan T.Q.
      • Bhattacharya L.
      • Gerbie M.V.
      Awareness, perceptions and knowledge of recommended adult vaccines among a nationwide sample of adult primary care providers.
      • Javanbakht M.
      • Stahlman S.
      • Walker S.
      • et al.
      Provider perceptions of barriers and facilitators of HPV vaccination in a high-risk community.
      • Post R.E.
      • Carek P.J.
      • Mainous A.G.
      • et al.
      Factors affecting HPV vaccine use among recent family medicine residency graduates.
      • Katz M.L.
      • Paskett E.D.
      The process of engaging members from two underserved populations in the development of interventions to promote the uptake of the HPV vaccine.
      • Javaid M.
      • Ashrawi D.
      • Landgren R.
      • et al.
      Human papillomavirus vaccine uptake in Texas pediatric care settings: a statewide survey of healthcare professionals.
      • Bruno D.M.
      • Wilson T.E.
      • Gany F.
      • et al.
      Identifying human papillomavirus vaccination practices among primary care providers of minority, low-income and immigrant patient populations.
      concern about “new” vaccine
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      • Javanbakht M.
      • Stahlman S.
      • Walker S.
      • et al.
      Provider perceptions of barriers and facilitators of HPV vaccination in a high-risk community.
      • Perkins R.B.
      • Clark J.A.
      Providers' perceptions of parental concerns about HPV vaccination.
      • Katz M.L.
      • Paskett E.D.
      The process of engaging members from two underserved populations in the development of interventions to promote the uptake of the HPV vaccine.
       Lack of vaccine efficacy
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      • Post R.E.
      • Carek P.J.
      • Mainous A.G.
      • et al.
      Factors affecting HPV vaccine use among recent family medicine residency graduates.
       Concern that parent will think clinician is implying their child is sexually active
      • Alexander A.B.
      • Best C.
      • Stupiansky N.
      • et al.
      A model of health care provider decision making about HPV vaccination in adolescent males.
       Parental refusal because of negative media reports
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
       Parental request to delay vaccination
      • Perkins R.B.
      • Anderson B.L.
      • Sheinfeld Gorin S.
      • et al.
      Challenges in cervical cancer prevention.
      • McRee A.
      • Gilkey M.B.
      • Dempsey A.F.
      HPV vaccine hesitancy: findings from a statewide survey of health care providers.
      (especially for patients 11–12 years old
      • Perkins R.B.
      • Clark J.A.
      Providers' perceptions of parental concerns about HPV vaccination.
      )
       Parental concerns about behavioral consequences of vaccination
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      • Ko E.M.
      • Missmer S.
      • Johnson N.R.
      Physician attitudes and practice toward human papillomavirus vaccination.
      • Javanbakht M.
      • Stahlman S.
      • Walker S.
      • et al.
      Provider perceptions of barriers and facilitators of HPV vaccination in a high-risk community.
       Parental mistrust of vaccines in general
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      • Tan T.Q.
      • Bhattacharya L.
      • Gerbie M.V.
      Awareness, perceptions and knowledge of recommended adult vaccines among a nationwide sample of adult primary care providers.
       Parental reluctance for clinician to discuss sex, STI, or STI vaccine with their child
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      • Javanbakht M.
      • Stahlman S.
      • Walker S.
      • et al.
      Provider perceptions of barriers and facilitators of HPV vaccination in a high-risk community.
      • McRee A.
      • Gilkey M.B.
      • Dempsey A.F.
      HPV vaccine hesitancy: findings from a statewide survey of health care providers.
      • Katz M.L.
      • Paskett E.D.
      The process of engaging members from two underserved populations in the development of interventions to promote the uptake of the HPV vaccine.
       Parental beliefs their child is not at risk
      • Perkins R.B.
      • Clark J.A.
      Providers' perceptions of parental concerns about HPV vaccination.
      (too young,
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      not sexually active
      • Javanbakht M.
      • Stahlman S.
      • Walker S.
      • et al.
      Provider perceptions of barriers and facilitators of HPV vaccination in a high-risk community.
      • Post R.E.
      • Carek P.J.
      • Mainous A.G.
      • et al.
      Factors affecting HPV vaccine use among recent family medicine residency graduates.
      • McRee A.
      • Gilkey M.B.
      • Dempsey A.F.
      HPV vaccine hesitancy: findings from a statewide survey of health care providers.
      • Katz M.L.
      • Paskett E.D.
      The process of engaging members from two underserved populations in the development of interventions to promote the uptake of the HPV vaccine.
      • Javaid M.
      • Ashrawi D.
      • Landgren R.
      • et al.
      Human papillomavirus vaccine uptake in Texas pediatric care settings: a statewide survey of healthcare professionals.
      )
       Parental concerns about cost,
      • Askelson N.M.
      • Campo S.
      • Lowe J.B.
      • et al.
      Factors related to physicians' willingness to vaccinate girls against HPV: the importance of subjective norms and perceived behavioral control.
      • Tan T.Q.
      • Bhattacharya L.
      • Gerbie M.V.
      Awareness, perceptions and knowledge of recommended adult vaccines among a nationwide sample of adult primary care providers.
      HPV vaccine not covered by VFC
      • Javanbakht M.
      • Stahlman S.
      • Walker S.
      • et al.
      Provider perceptions of barriers and facilitators of HPV vaccination in a high-risk community.
       Lack of a mandate leads parents to think HPV vaccine less important than other vaccines
      • Gilkey M.B.
      • Malo T.L.
      • Shah P.D.
      • et al.
      Quality of physician communication about human papillomavirus vaccine: findings from a national survey.
       Systems-level
      Clinic-related
       Lack of staff to administer vaccines,
      • Ko E.M.
      • Missmer S.
      • Johnson N.R.
      Physician attitudes and practice toward human papillomavirus vaccination.
      lack of space to store vaccine,
      • Ko E.M.
      • Missmer S.
      • Johnson N.R.
      Physician attitudes and practice toward human papillomavirus vaccination.
      lack of system to track vaccines,
      • Ko E.M.
      • Missmer S.
      • Johnson N.R.
      Physician attitudes and practice toward human papillomavirus vaccination.
      lack of vaccination records in Emergency Department
      • Hill M.
      • Okugo G.
      Emergency medicine physician attitudes toward HPV vaccine uptake in an emergency department setting.
      Insufficient vaccine supply
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      • Young J.L.
      • Bernheim R.G.
      • Korte J.E.
      • et al.
      Human papillomavirus vaccination recommendation may be linked to reimbursement: a survey of Virginia family practitioners and gynecologists.
      Financial
       Cost to provide vaccination/low reimbursement,
      • Ishibashi K.L.
      • Koopmans J.
      • Curlin F.A.
      • et al.
      Paediatricians' attitudes and practices towards HPV vaccination.
      • Askelson N.M.
      • Campo S.
      • Lowe J.B.
      • et al.
      Factors related to physicians' willingness to vaccinate girls against HPV: the importance of subjective norms and perceived behavioral control.
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      • Ko E.M.
      • Missmer S.
      • Johnson N.R.
      Physician attitudes and practice toward human papillomavirus vaccination.
      • McCave E.L.
      Influential factors in HPV vaccination uptake among providers in four states.
      • Young J.L.
      • Bernheim R.G.
      • Korte J.E.
      • et al.
      Human papillomavirus vaccination recommendation may be linked to reimbursement: a survey of Virginia family practitioners and gynecologists.
      • Aragones A.
      • Bruno D.
      • Gany F.
      Attitudes surrounding implementation of the HPV vaccine for males among primary care providers serving large minority populations.
      • Perkins R.B.
      • Anderson B.L.
      • Sheinfeld Gorin S.
      • et al.
      Challenges in cervical cancer prevention.
      • Hill M.
      • Okugo G.
      Emergency medicine physician attitudes toward HPV vaccine uptake in an emergency department setting.
      • Javaid M.
      • Ashrawi D.
      • Landgren R.
      • et al.
      Human papillomavirus vaccine uptake in Texas pediatric care settings: a statewide survey of healthcare professionals.
      lack of insurance coverage
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      • Barnack J.L.
      • Reddy D.M.
      • Swain C.
      Predictors of parents' willingness to vaccinate for human papillomavirus and physicians' intentions to recommend the vaccine.
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      • Alexander A.B.
      • Best C.
      • Stupiansky N.
      • et al.
      A model of health care provider decision making about HPV vaccination in adolescent males.
      Insufficient time to recommend vaccine
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      • Young J.L.
      • Bernheim R.G.
      • Korte J.E.
      • et al.
      Human papillomavirus vaccination recommendation may be linked to reimbursement: a survey of Virginia family practitioners and gynecologists.
      • Aragones A.
      • Bruno D.
      • Gany F.
      Attitudes surrounding implementation of the HPV vaccine for males among primary care providers serving large minority populations.
      • Hill M.
      • Okugo G.
      Emergency medicine physician attitudes toward HPV vaccine uptake in an emergency department setting.
      • McRee A.
      • Gilkey M.B.
      • Dempsey A.F.
      HPV vaccine hesitancy: findings from a statewide survey of health care providers.
      • Hudson S.M.
      • Rondinelli J.
      • Glenn B.A.
      • et al.
      Human papillomavirus vaccine series completion: qualitative information from providers within an integrated healthcare organization.
      Competing priorities
      • Aragones A.
      • Bruno D.
      • Gany F.
      Attitudes surrounding implementation of the HPV vaccine for males among primary care providers serving large minority populations.
      Multidose vaccine
       Difficulty getting patients to return for subsequent doses
      • Daley M.F.
      • Crane L.A.
      • Markowitz L.E.
      • et al.
      Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure.
      • Javanbakht M.
      • Stahlman S.
      • Walker S.
      • et al.
      Provider perceptions of barriers and facilitators of HPV vaccination in a high-risk community.
      • Head K.J.
      • Vanderpool R.C.
      • Mills L.A.
      Health care providers' perspectives on low HPV vaccine uptake and adherence in Appalachian Kentucky.
      • Post R.E.
      • Carek P.J.
      • Mainous A.G.
      • et al.
      Factors affecting HPV vaccine use among recent family medicine residency graduates.
      • Javaid M.
      • Ashrawi D.
      • Landgren R.
      • et al.
      Human papillomavirus vaccine uptake in Texas pediatric care settings: a statewide survey of healthcare professionals.
      HPV indicates human papillomavirus; STI, sexually transmitted infection; and VFC, Vaccines for Children program.

      Clinicians' Intention to Recommend HPV Vaccines

      Data summarizing clinicians' intention to recommend HPV vaccines, as well as factors associated with intention, are shown in Table 3. In studies that examined intention among clinicians, rates varied widely, from 16% to 96%.
      • Feemster K.A.
      • Winters S.E.
      • Fiks A.G.
      • et al.
      Pediatricians' intention to recommend human papillomavirus (HPV) vaccines to 11- to 12-year-old girls postlicensing.
      • Ishibashi K.L.
      • Koopmans J.
      • Curlin F.A.
      • et al.
      Paediatricians' attitudes and practices towards HPV vaccination.
      • Jensen M.E.
      • Hartenbach E.
      • McElroy J.A.
      • et al.
      Brief report: measuring the attitudes of health care professionals in Dane county toward adolescent immunization with HPV vaccine.
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      • Askelson N.M.
      • Campo S.
      • Lowe J.B.
      • et al.
      Factors related to physicians' willingness to vaccinate girls against HPV: the importance of subjective norms and perceived behavioral control.
      • Barnack J.L.
      • Reddy D.M.
      • Swain C.
      Predictors of parents' willingness to vaccinate for human papillomavirus and physicians' intentions to recommend the vaccine.
      • Young J.L.
      • Bernheim R.G.
      • Korte J.E.
      • et al.
      Human papillomavirus vaccination recommendation may be linked to reimbursement: a survey of Virginia family practitioners and gynecologists.
      • Aragones A.
      • Bruno D.
      • Gany F.
      Attitudes surrounding implementation of the HPV vaccine for males among primary care providers serving large minority populations.
      • Perkins R.B.
      • Anderson B.L.
      • Sheinfeld Gorin S.
      • et al.
      Challenges in cervical cancer prevention.
      • Hill M.
      • Okugo G.
      Emergency medicine physician attitudes toward HPV vaccine uptake in an emergency department setting.
      • Allison M.A.
      • Hurley L.P.
      • Markowitz L.
      • et al.
      Primary care physicians' perspective about HPV vaccine.
      • Rosen B.L.
      • Ashwood D.
      • Richardson G.
      School nurses' professional practice in the HPV vaccine decision making process.
      • Feemster K.A.
      • Middleton M.
      • Fiks A.G.
      • et al.
      Does intention to recommend HPV vaccines impact HPV vaccination rates?.
      The mean for intention rates was 66.9 (SD = 23) and the median was 73; the 16% intention rate was an outlier. In 2 studies that examined intention according to patient age, intention was higher for 13- to 18-year-olds (92%–96%) than 11- to 12-year-olds (73%–78%).
      • Perkins R.B.
      • Anderson B.L.
      • Sheinfeld Gorin S.
      • et al.
      Challenges in cervical cancer prevention.
      • Feemster K.A.
      • Middleton M.
      • Fiks A.G.
      • et al.
      Does intention to recommend HPV vaccines impact HPV vaccination rates?.
      In a study on clinicians' intention to recommend the HPV vaccine according to patient gender, 67% of clinicians intended to recommend HPV vaccines only to female patients, whereas 14% intended to recommend the vaccine to girls and boys equally.
      • Jensen M.E.
      • Hartenbach E.
      • McElroy J.A.
      • et al.
      Brief report: measuring the attitudes of health care professionals in Dane county toward adolescent immunization with HPV vaccine.
      In another study on implementation of the HPV vaccine for boys, 62% of clinicians reported intending to recommend the vaccine to boys.
      • Aragones A.
      • Bruno D.
      • Gany F.
      Attitudes surrounding implementation of the HPV vaccine for males among primary care providers serving large minority populations.
      Intention to recommend to boys varied according to age in 1 study, with the highest intention rates (61%) reported for boys 13 to 17 years of age.
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      Clinician-related factors included higher knowledge levels about HPV,
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      professional factors (eg, specialty
      • Jensen M.E.
      • Hartenbach E.
      • McElroy J.A.
      • et al.
      Brief report: measuring the attitudes of health care professionals in Dane county toward adolescent immunization with HPV vaccine.
      • Barnack J.L.
      • Reddy D.M.
      • Swain C.
      Predictors of parents' willingness to vaccinate for human papillomavirus and physicians' intentions to recommend the vaccine.
      • Allison M.A.
      • Hurley L.P.
      • Markowitz L.
      • et al.
      Primary care physicians' perspective about HPV vaccine.
      and national or professional society recommendations
      • Jensen M.E.
      • Hartenbach E.
      • McElroy J.A.
      • et al.
      Brief report: measuring the attitudes of health care professionals in Dane county toward adolescent immunization with HPV vaccine.
      ), and beliefs and attitudes about HPV vaccines (eg, beliefs about vaccine safety and efficacy,
      • Askelson N.M.
      • Campo S.
      • Lowe J.B.
      • et al.
      Factors related to physicians' willingness to vaccinate girls against HPV: the importance of subjective norms and perceived behavioral control.
      about early vs late adoption of new vaccines,
      • Feemster K.A.
      • Winters S.E.
      • Fiks A.G.
      • et al.
      Pediatricians' intention to recommend human papillomavirus (HPV) vaccines to 11- to 12-year-old girls postlicensing.
      • Young J.L.
      • Bernheim R.G.
      • Korte J.E.
      • et al.
      Human papillomavirus vaccination recommendation may be linked to reimbursement: a survey of Virginia family practitioners and gynecologists.
      and about behavioral effects of vaccination
      • Suryadevara M.
      • Handel A.
      • Bonville C.A.
      • et al.
      Pediatric provider vaccine hesitancy: an under-recognized obstacle to immunizing children.
      ). Parent/patient-related factors associated with intention included perception that the patient was at high risk for HPV infection.
      • Hill M.
      • Okugo G.
      Emergency medicine physician attitudes toward HPV vaccine uptake in an emergency department setting.
      Systems-level factors negatively associated with intention included insufficient staff time
      • Young J.L.
      • Bernheim R.G.
      • Korte J.E.
      • et al.
      Human papillomavirus vaccination recommendation may be linked to reimbursement: a survey of Virginia family practitioners and gynecologists.
      and lack of reimbursement for vaccination.
      • Young J.L.
      • Bernheim R.G.
      • Korte J.E.
      • et al.
      Human papillomavirus vaccination recommendation may be linked to reimbursement: a survey of Virginia family practitioners and gynecologists.
      • Hill M.
      • Okugo G.
      Emergency medicine physician attitudes toward HPV vaccine uptake in an emergency department setting.
      Table 3Clinicians' Intentions to Recommend HPV Vaccination
      ThemeResults
      Intention rates
      Overall range
       16% to 96%
      • Feemster K.A.
      • Winters S.E.
      • Fiks A.G.
      • et al.
      Pediatricians' intention to recommend human papillomavirus (HPV) vaccines to 11- to 12-year-old girls postlicensing.
      • Ishibashi K.L.
      • Koopmans J.
      • Curlin F.A.
      • et al.
      Paediatricians' attitudes and practices towards HPV vaccination.
      • Jensen M.E.
      • Hartenbach E.
      • McElroy J.A.
      • et al.
      Brief report: measuring the attitudes of health care professionals in Dane county toward adolescent immunization with HPV vaccine.
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      • Askelson N.M.
      • Campo S.
      • Lowe J.B.
      • et al.
      Factors related to physicians' willingness to vaccinate girls against HPV: the importance of subjective norms and perceived behavioral control.
      • Barnack J.L.
      • Reddy D.M.
      • Swain C.
      Predictors of parents' willingness to vaccinate for human papillomavirus and physicians' intentions to recommend the vaccine.
      • Young J.L.
      • Bernheim R.G.
      • Korte J.E.
      • et al.
      Human papillomavirus vaccination recommendation may be linked to reimbursement: a survey of Virginia family practitioners and gynecologists.
      • Aragones A.
      • Bruno D.
      • Gany F.
      Attitudes surrounding implementation of the HPV vaccine for males among primary care providers serving large minority populations.
      • Perkins R.B.
      • Anderson B.L.
      • Sheinfeld Gorin S.
      • et al.
      Challenges in cervical cancer prevention.
      • Hill M.
      • Okugo G.
      Emergency medicine physician attitudes toward HPV vaccine uptake in an emergency department setting.
      • Allison M.A.
      • Hurley L.P.
      • Markowitz L.
      • et al.
      Primary care physicians' perspective about HPV vaccine.
      • Rosen B.L.
      • Ashwood D.
      • Richardson G.
      School nurses' professional practice in the HPV vaccine decision making process.
      • Feemster K.A.
      • Middleton M.
      • Fiks A.G.
      • et al.
      Does intention to recommend HPV vaccines impact HPV vaccination rates?.
      Intention by patient age
       11–12 years: 73%
      • Perkins R.B.
      • Anderson B.L.
      • Sheinfeld Gorin S.
      • et al.
      Challenges in cervical cancer prevention.
      to 78%
      • Feemster K.A.
      • Middleton M.
      • Fiks A.G.
      • et al.
      Does intention to recommend HPV vaccines impact HPV vaccination rates?.
       13–18 years: 92%
      • Feemster K.A.
      • Middleton M.
      • Fiks A.G.
      • et al.
      Does intention to recommend HPV vaccines impact HPV vaccination rates?.
      to 96%
      • Perkins R.B.
      • Anderson B.L.
      • Sheinfeld Gorin S.
      • et al.
      Challenges in cervical cancer prevention.
      Intention by patient gender
       67% intended to recommend only to female patients
      • Jensen M.E.
      • Hartenbach E.
      • McElroy J.A.
      • et al.
      Brief report: measuring the attitudes of health care professionals in Dane county toward adolescent immunization with HPV vaccine.
       14% intended to recommend to both boys and girls equally
      • Jensen M.E.
      • Hartenbach E.
      • McElroy J.A.
      • et al.
      Brief report: measuring the attitudes of health care professionals in Dane county toward adolescent immunization with HPV vaccine.
       Overall intention to recommend to boys: 62%
      • Aragones A.
      • Bruno D.
      • Gany F.
      Attitudes surrounding implementation of the HPV vaccine for males among primary care providers serving large minority populations.
       Boys 9–10 years: 22%
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
       Boys 11–12 years 42%
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
       Boys 13–17 years: 61%
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
       Boys 18–26 years: 60%
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      Factors associated with intention to recommend
       Clinician-related
      Knowledge
       Higher knowledge about HPV
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
      Professional factors
       Specialty (pediatricians more likely to report intention to recommend vs other specialties)
      • Jensen M.E.
      • Hartenbach E.
      • McElroy J.A.
      • et al.
      Brief report: measuring the attitudes of health care professionals in Dane county toward adolescent immunization with HPV vaccine.
      • Barnack J.L.
      • Reddy D.M.
      • Swain C.
      Predictors of parents' willingness to vaccinate for human papillomavirus and physicians' intentions to recommend the vaccine.
      • Allison M.A.
      • Hurley L.P.
      • Markowitz L.
      • et al.
      Primary care physicians' perspective about HPV vaccine.
       National recommendations (Food and Drug Administration
      • Jensen M.E.
      • Hartenbach E.
      • McElroy J.A.
      • et al.
      Brief report: measuring the attitudes of health care professionals in Dane county toward adolescent immunization with HPV vaccine.
      ) and professional society recommendations
      • Jensen M.E.
      • Hartenbach E.
      • McElroy J.A.
      • et al.
      Brief report: measuring the attitudes of health care professionals in Dane county toward adolescent immunization with HPV vaccine.
       Clear recommendation guidelines
      • Kulczycki A.
      • Qu H.
      • Shewchuk R.
      Primary care physicians' adherence to guidelines and their likelihood to prescribe the human papillomavirus vaccine for 11- and 12-year-old girls.
      Beliefs and attitudes
       Beliefs that vaccines are safe and effective
      • Askelson N.M.
      • Campo S.
      • Lowe J.B.
      • et al.
      Factors related to physicians' willingness to vaccinate girls against HPV: the importance of subjective norms and perceived behavioral control.
       Being an early adopter versus late adopter
      • Feemster K.A.
      • Winters S.E.
      • Fiks A.G.
      • et al.
      Pediatricians' intention to recommend human papillomavirus (HPV) vaccines to 11- to 12-year-old girls postlicensing.
      • Young J.L.
      • Bernheim R.G.
      • Korte J.E.
      • et al.
      Human papillomavirus vaccination recommendation may be linked to reimbursement: a survey of Virginia family practitioners and gynecologists.
       Anticipating parental concerns
      • Feemster K.A.
      • Winters S.E.
      • Fiks A.G.
      • et al.
      Pediatricians' intention to recommend human papillomavirus (HPV) vaccines to 11- to 12-year-old girls postlicensing.
       Belief that vaccination would increase riskier behaviors (negative association)
      • Suryadevara M.
      • Handel A.
      • Bonville C.A.
      • et al.
      Pediatric provider vaccine hesitancy: an under-recognized obstacle to immunizing children.
       Belief that vaccines should be mandated
      • Kahn J.A.
      • Cooper H.P.
      • Vadaparampil S.T.
      • et al.
      Human papillomavirus vaccine recommendations and agreement with mandated human papillomavirus vaccination for 11-to-12-year-old girls: a statewide survey of Texas physicians.
       Subjective norms (ie, willingness to adhere to the Advisory Committee on Immunization Practices recommendations, and perceived people they thought were important expected them to vaccinate patients) and perceived behavioral control (ie, if the clinician believed it was within their control to vaccinate the patient)
      • Askelson N.M.
      • Campo S.
      • Lowe J.B.
      • et al.
      Factors related to physicians' willingness to vaccinate girls against HPV: the importance of subjective norms and perceived behavioral control.
       Parent/patient-related
      Perceived patient to be at high risk
      • Hill M.
      • Okugo G.
      Emergency medicine physician attitudes toward HPV vaccine uptake in an emergency department setting.
       Systems-level
      Insufficient staff time (negative association)
      • Young J.L.
      • Bernheim R.G.
      • Korte J.E.
      • et al.
      Human papillomavirus vaccination recommendation may be linked to reimbursement: a survey of Virginia family practitioners and gynecologists.
      Lack of reimbursement (negative association),
      • Young J.L.
      • Bernheim R.G.
      • Korte J.E.
      • et al.
      Human papillomavirus vaccination recommendation may be linked to reimbursement: a survey of Virginia family practitioners and gynecologists.
      • Hill M.
      • Okugo G.
      Emergency medicine physician attitudes toward HPV vaccine uptake in an emergency department setting.
      cost (negative association)
      • Askelson N.M.
      • Campo S.
      • Lowe J.B.
      • et al.
      Factors related to physicians' willingness to vaccinate girls against HPV: the importance of subjective norms and perceived behavioral control.
      Lack of time to discuss HPV vaccine during visit (negative association)