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

Background and Purpose: HPV vaccines are safe and highly effective in preventing HPV infections associated with the majority of genital warts, oral, anal and penile cancers. HPV vaccination is recommended for all preadolescent boys in the U.S. and Canada, yet coverage remains vastly lower than among girls. Given the recommended age of vaccination, parents play a crucial role in HPV vaccine uptake; however, the majority of studies focus predominantly on girls. To address this important gap, we systematically reviewed published qualitative studies to understand in-depth, perceptions, attitudes, and beliefs towards HPV vaccination for boys, and social and systemic barriers and facilitators to HPV vaccine acceptability and uptake.

Methods: Meta-ethnography is a systematic qualitative synthesis technique that enables building an interpretive layer beyond the interpretations provided in original studies. We undertook a systematic process of searching 11 databases and used snowballing techniques to identify qualitative studies examining HPV vaccination from the perspective of boys and parents of boys. Quality of reporting of each study was assessed using the Consolidated Criteria for Reporting Qualitative Research 32-item checklist. We used a structured and iterative process of data analysis whereby we coded the original studies and developed descriptive and analytic themes. 

Results: Eight articles representing seven studies (n=256 parents, n=39 boys) were analyzed. The results highlighted multilevel factors that influence HPV vaccine acceptability and uptake among adolescent boys and their parents: 1) personal factors: perceived HPV vaccine benefits for boys; beliefs about adolescent male sexuality, 2) interpersonal factors: relationships between parents and sons, parents and their peers, and both parents and sons and their healthcare provider (HCP); decision-making processes), 3) community/societal factors: parental duty to protect; stigma), and 4) systemic factors: barriers to healthcare access, including transportation and out-of-pocket cost; HPV vaccine messaging from HCP and media). Overall, parents were receptive to HPV vaccination for their sons as part of their perceived core duty to protect their children from harm. However, in-depth exploration of contexts of parental and adolescent decision-making reveals a confusing array of competing beliefs and mixed messages, as well as the influence of HCP and health-system factors in translating this ‘duty to protect’ into vaccine uptake. An overall HCP influence gap appeared to have a particularly detrimental impact on vaccine uptake in families in which parents and sons were unlikely to discuss sexual health, and in families who would not only welcome HCP-initiated HPV vaccine discussion, but may rely on HCPs to address boys’ sexual health in the relatively neutral context of a healthcare visit. 

Conclusions and Implications: Given a predominant focus heretofore on HPV as a ‘women’s disease’, social workers should clarify mixed messages about for whom (both boys and girls) and against what (genital warts and multiple cancers) the HPV vaccine protects, assist parents in discussing sexual health with their sons and HCPs, and advocate for broadened public insurance coverage of HPV vaccination for boys as well as girls. Tailored and integrated social-medical interventions may support HPV vaccine acceptability and uptake for boys, ensuring healthy development for all youth.