Acceptability of Human Papillomavirus Vaccine for Males: A Review of the Literature

Article Outline

• Abstract
• Methods
• Results
  • HPV Vaccine acceptance among adult males
    • Acceptance Rates and Important Findings from U.S. Studies
    • Acceptance rates and important findings from studies conducted outside the United States
  • HPV vaccine acceptance among parents
    • Acceptance rates and important findings from U.S. studies
    • Acceptance rates and important findings from studies conducted outside the United States
  • Health providers' intention to recommend HPV vaccine to male patients
    • Acceptance rates and important findings from U.S. Studies
    • Acceptance rates and important findings from studies conducted outside the United States
• Discussion
• References
• Copyright

Abstract 

The quadrivalent human papillomavirus virus vaccine was recently licensed for use in males in the United States. This study reviews available published literature on acceptability among parents, health care providers, and young males. Among 23 published articles, half were conducted in the United States. The majority (87%) used quantitative survey methodology, and 13% used more explorative qualitative techniques. Convenience samples were used in most cases (74%) and 26% relied on nationally representative samples. Acceptability of a human papillomavirus virus (HPV) vaccine that protects against cervical cancer and genital warts was high in studies conducted among male college students (74%–78%) but lower in a community sample of males (33%). Among mothers of sons, support of HPV vaccination varied widely from 12% to 100%, depending on the mother's ethnicity and type of vaccine, but was generally high for a vaccine that would protect against both genital warts and cervical cancer. Health providers' intention to recommend HPV vaccine to male patients varied by patient age but was high (82%–92%) for older adolescent patients. A preference to vaccinate females over males was reported in a majority of studies among parents and health care providers. Messages about cervical cancer prevention for female partners did not resonate among adult males or parents. Future acceptability studies might incorporate more recent data on HPV-related disease, HPV vaccines, and cost-effectiveness data to provide more current information on vaccine acceptability.

Keywords: HPV vaccine, Vaccine acceptability, Males

HPV is the most common sexually transmitted infection in the United States, with an estimated 6.2 million new infections diagnosed annually [1]. Prevalence and incidence in males are estimated to be similar to that in females but vary depending on the study population and methods used to detect infection [2]. High-risk HPV types are perhaps better known for their association with various cancers affecting females including cervical, vaginal, and vulvar, but are also associated with cancers affecting males. Oncogenic HPV types (including types 16 and 18) are estimated to be responsible for 25%–35% of oral cancers, 90% of anal cancers, and 40% of penile cancers in the United States (US) [3], [4]. Low-risk HPV types, (e.g., HPV 6 and 11) cause genital warts, which affect both males and females, and impact quality of life and often require recurring and extensive treatment [5].

In 2006, the U.S. Food and Drug Administration (FDA) approved a prophylactic quadrivalent HPV vaccine for females aged 9–26 years that protects against four HPV types associated with >90% of genital warts and 70% of cervical cancers. The Advisory Committee on Immunization Practices (ACIP) recommended routine vaccination of females aged 11–12 years with a catch up of females through age 26. Interim results from a clinical trial in males aged 16–26 years found that the same vaccine had 90% efficacy for prevention of external genital lesions caused by HPV 6,11,16, or 18 [6]. The quadrivalent HPV vaccine was licensed for males by FDA in October 2009 and ACIP made a permissive recommendation for use in males aged 9–26 years.

Current research on the attitudes about and acceptance of an HPV vaccine has largely focused on females [7], [8], [9]. Considerably less is known about acceptance of HPV vaccine for males. The purpose of this study is to review the available published data on the acceptance of HPV vaccine for males among parents, health care providers, and young males.

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Methods 

We sought published manuscripts presenting qualitative or quantitative data of HPV vaccine intention and/or acceptability regarding male vaccination. Two trained researchers conducted a literature search using the PubMed database for articles on HPV vaccine in males published between 2000 and June 2009. Because little published research focuses specifically on this population, broad search terms were used to capture an initial comprehensive literature base on HPV vaccine in males that was then reviewed for specific focus on and reporting of acceptability data. To achieve this wide sampling frame, search terms were entered one by one to complete the phrase “HPV vaccine and _________” and included (a) universal, (b) acceptability, (c) intention, (d) males, (e) sons, (f) boys, (g) men who have sex with men, (h) parents, (i) providers, (j) physicians, (k) pediatricians, (l) doctors, (m) nurses, (n) pediatric, and (o) health personnel. These searches yielded an initial set of citations (n = 1347) and included studies that varied from commentaries and editorials to clinical trial results. Abstracts, and in some cases complete text of the articles, were reviewed for inclusion criteria. Included studies had to be published in English and report findings from adult males, parents, or health care providers on intention or acceptability data for vaccinating males. A total of 23 articles met inclusion criteria and are included in the review.

A standardized abstraction form was created to capture information about participant characteristics, study design, question frame, acceptability or intention rates, and other important findings. Four researchers independently reviewed and summarized each study. Any discrepancies were discussed and reconciled by the entire research team. Studies based in the United States and those conducted in other countries were reviewed separately in order to recognize the role of cultures, policies, and healthcare systems in shaping the acceptability of HPV vaccination. Overall results are presented in Table 1, Table 2, Table 3, but additional detail about other key findings is discussed in the text that follows.

Table 1. HPV vaccine acceptability among adult males

Authors	Participants/setting	Study design	Information provided to participants, question frame, and response options	Acceptability/results
U.S. studies
Boehner et al[10]a	College students n=256 (127 males) Midwestern public university	Self-administered survey	Information provided: Relationship between HPV and penile cancer (in 2 of 3 messages)	74% responded yes overall; gender specific responses not reported but no statistically significant difference in acceptability by gender or message
		Convenience sample	Question Frame: “If an HPV vaccine is made available to you, do you think you will decide to get the vaccine?”
		Randomized to receive 1 of 3 messages:	Response options: Yes, no
		STD message
		Reproductive health message
		Combined STD and reproductive health message
Jones and Cook [11]a	College students n=340 (138 males) Northeastern university	Self-administered survey	Information provided: Not reported	Males
		Convenience sample
		4 questions asked of all respondents	Question frame: “Assuming the HPV vaccine was available now, how likely would you be to get the vaccine if it prevented:”	Cervical cancer: 34%
				Cervical cancer and genital warts: 78%b
			HPV, Cervical cancer, Genital warts	Females
				Cervical cancer and genital warts: 88.6%b
			Cervical cancer and genital warts
			Response options: 5-point Likert recoded to indicate “extremely or somewhat likely”
Ferris et al[12], [13]	18–45-yr-old males recruited in community settings n=571	Self-administered survey	Information provided: HPV risk factors, prevention, infection consequences, and the vaccine “for male gender use”. Exact wording not provided	Yes 33%
		Convenience sample		No 27%
			Question frame: “Do you want to receive the HPV vaccine?	Undecided 40%
			Response options: Yes, no, undecided
Gerend and Barley [14]	Male college students n=356 Southern public university	Survey	Information provided: Vaccine likely to be available for men and would protect men from genital warts and anogenital cancers	Acceptability was “moderately high” and did not vary by experimental condition
		Convenience sample		Self protection M=3.93, SD=1.40
		Randomized to receive 1 of 2 messages	Question frame/response options: Composite average of 5-items with 6-point Likert response options (1=very unlikely and 6=very likely) measuring if respondent would	Self and partner protection M=3.78, SD=1.52
		Self-protection
		Self-protection and partner protection	Try to get more information about
			Consider getting
			Make it a priority to get
			Actually get
			Get if provider offered in the next 3yr
Studies conducted outside the U.S.
Lenselink et al[15] Netherlands	College students n=600 (223 males)	Self-administered survey	Information Provided: Survey was not preceded by any information	Reporting yes
				Males: 48%b
		Convenience sample	Question frame: Acceptability of HPV vaccine. Exact wording not reported	Females: 61%
			Response options: Yes, no
Simatherai et al[16] Australia	Men who have sex with men recruited from sexual health center;	Survey	Information provided: Vaccine would protect most cases of anal and genital warts and 80% of anal cancer	47% would pay A$450 for the HPV vaccine
	n=200	Convenience sample	Question frame: Would respondent get the HPV vaccine depending on cost and other circumstances. Exact wording not reported	93% would disclose sexuality to obtain the vaccine for free
			Response options: Not reported

Table 2. The acceptability of HPV vaccination of males among parents

Study	Participants/setting	Study design	Information provided to participants, question frame, and response options	Acceptability/results
U.S. studies
Olshen et al[17]a	Parents recruited in clinics in MA with at least one child 10–15yr n=25	Qualitative focus groups or in-depth interviews	Information provided: HPV prevalence, infection consequences, and potential benefits of vaccine. Exact wording not provided	The belief that vaccine has less direct benefit for boys was important
			Question frame: Open ended questions: “What issues would you think about when deciding whether or not to vaccinate your daughter (your son)?”	Some participants who had only sons did not think that the HPV vaccine should be given to boys, but most indicated both boys and girls should be given the vaccine
Slomovitz et al[18]a	Mothers recruited in clinics in Texas with at least one child 8–14yr n=200	Survey Convenience sample	Information provided: HPV, cervical cancer, HPV vaccine developments. Did not provide information directly relevant to men	67% of mothers of daughters and 66% of mothers of sons would consent for their child to be vaccinated
			Question frame: “Would you consent for your son or daughter to receive the HPV vaccine?”
			Response options: Not reported
Watts et al[19]	Mothers recruited in clinics with at least one child 10–15yr n=227 (mothers of sons=75)	Self-administered survey	Information provided: Not reported	Mothers of sons
		Convenience sample	Question frame: “Would you vaccinate your son (or daughter) to protect him (her) against:”	Latina
		Multiple acceptance questions asked of all respondents	HPV	HPV 92%b
			Genital warts (GW)	GW 94%b
			Anogenital cancer (AC)	AC 100%b
			“Would you vaccinate your son to protect women from cervical cancer (CC)?”	CC 18%
			Response options: Yes, no	Non-Latina
				HPV 77%
				GW 78%
				AC 89%
				CC 12%
				Mothers of daughters
				Latina
				HPV 97%b
				GW 91%
				CC 97%
				Non-Latina
				HPV 68%b
				GW 84%
				CC 96%
				Statistically higher acceptability among Latinas (p < .05)b
Studies conducted outside the U.S.
Brabin et al[20] United Kingdom	Parents of 11–12-yr-old students in the city of Manchester n=317	Mailed survey	Information provided: HPV and cervical cancer; did not provide information directly relevant to men	74% agreed it is preferable to vaccinate every child
		Random sample	Question frame:	3% agreed that all boys should be vaccinated
			“Do you agree that it is preferable to vaccinate every child?”
			“Do you think all boys should be vaccinated?”
			Response options: 5-point Likert recoded to indicate “agreed or strongly agreed”
Dursun et al[21] Turkey	Women attending hospital-based gynecology clinics n=1434	Survey	Information provided: Not reported	59% would consent for sons and 64% for daughters
		Convenience sample	Question frame: “Would you consent for your son/daughter to receive the [HPV] vaccine?”
			Response options: Not reported
Lenehan et al[22] Canada	Women attending a hospital-based obstetrics and gynecology clinic n=98	Self-administered survey	Information provided: Not reported	71% would vaccinate sons and 78% would vaccinate daughters in their early teensb
		Convenience sample	Question frame: “Would you consider having your daughter(s) and/or son(s) vaccinated against HPV in their early teens or as early as age 9 or 10?”	38% would vaccinate sons and 42% would vaccinate daughters at age 9 or 10yr
			Responses options: Not reported
Lenselink et al[15], [23] Netherlands	Parents of 10–12yr old children who attended participating schools n=356	Telephone survey	Information provided: Cervical cancer, HPV, and HPV vaccine developments. Exact wording not provided	88% of parents said both boys and girls should be vaccinated
		Convenience sample	Question frame: “Should both boys and girls be vaccinated?”
			Response options: Not reported
Noakes et al[24] United Kingdom	Parents of 8–10yr old children	Qualitative focus group discussions	Information provided: HPV, cancers, genital warts, and HPV vaccine. Discussed vaccine's relevance to males in terms of genital warts and penile cancer	The majority of parents had no objections to vaccinating both girls and boys in order to protect girls against cervical cancer
			Question frame: Open ended question
Ogilvie et al[25] Canada	Parents of 8–18yr old children n=2083 (n=1381 parents of sons)	Telephone survey (RDD)	Information provided: HPV, HPV vaccine, cervical cancer, genital warts, HPV transmission, and efficacy of vaccine. Exact wording not provided	68% of parents with sons and 74% of parents with daughtersbintended to vaccinate their child against HPV
		National random sample	Question frame: “I intend to have my daughter(s)/son(s) receive the HPV vaccine (once it becomes available)”	There was some variation by province
			Response options: 7-point Likert scale recoded to indicate “agreed or strongly agreed”
Sauvageau et al[26] Canada	Adults (18–69yr olds) recruited from outpatient clinics n=471 (33% male)	Telephone survey	Information provided: HPV, cervical cancer; did not provide information directly relevant to men	89% agreed or strongly agreed
		Convenience sample	Question frame: “Should the HPV vaccine be given to females and males?”
			Response options: 5-point Likert recoded to indicate “agreed or strongly agreed”
de Visser and McDonnell [27] United Kingdom	Parents of children under 16yr who responded to leaflets and announcements distributed by 18 schools n=353	Survey (online or mailed)	Information provided: Cervical cancer, HPV, vaccine developments, and potential benefit of vaccinating boys to achieve herd immunity	HPV vaccination of sons
		Convenience sample	Question frame: “I would have my son (daughter) vaccinated against HPV”	Agree: 73%
			Response options: 7-point Likert scale of agreement with “unsure” category = 4. Reponses recoded to any agreement/disagreement	Unsure: 17%
				Disagree: 10%
				HPV vaccination of daughters
				Agree: 75%
				Unsure: 15%
				Disagree: 10%

Table 3. Health providers' intention to recommend HPV vaccine to male patients

Study	Participants/setting	Study design	Information provided to participants, question frame, and response options	Acceptability/results
U.S. studies
Daley et al[28]a	Pediatricians n=294	Mailed or emailed survey	Information provided: HPV vaccine. Exact wording not provided	Participants were more likely to recommend vaccination to (p < .0001):
		National random sample	Question frame: “If endorsed by national health organizations, would (you) recommend vaccination for”	Girls (vs. boys)
			Males and females	Older children (vs. younger children)
			At each of the following ages 10–12, 13–15, and 16–18?	10–12-yr-olds
			Response options: Very/somewhat likely vs. very/somewhat unlikely and unsure	Females: 46%
				Males: 37%
				13–15-yr-olds
				Females: 77%
				Males: 67%
				16–18-yr-olds
				Females: 89%
				Males: 82%
Kahn et al[29]a	Pediatricians n=513	Mailed survey	Information provided: Not reported	Participants were more likely to recommend vaccination to (p < .0001):
		National random sample	Question frame: Intention to recommend for: (specific wording not reported)	Girls (vs. boys)
			Males and females	Older children (vs. younger children)
			At each age (11,14, and 17)	Cervical cancer/genital wart vaccine (vs. cervical cancer vaccine)
			Vaccine for cervical cancer and a vaccine for cervical cancer and genital warts	11yr old females
				Cervical cancer: 62%; cervical cancer and warts: 68%
				11yr old males
				Cervical cancer: 37%; cervical cancer and warts: 61%
				14yr old females
				Cervical cancer: 86%; cervical cancer and warts: 92%
				14yr old males
				Cervical cancer: 54%: cervical cancer and warts: 83%
				17yr old females
				Cervical cancer: 96%; cervical cancer and warts: 98%
				17yr old males
				Cervical cancer: 64%; cervical cancer and warts: 92%
Kahn et al[30]a	Pediatricians in mid-West U.S. region n=31	Qualitative, in-depth interviews	Information provided: HPV vaccine developments, HPV types, and infection consequences. Exact wording not provided	33% stated they would be more likely to recommend the vaccine to girls than boys if national guidelines supported vaccination of both genders
			Question frame: Closed ended about recommending a cervical cancer vaccine or a cervical cancer/genital warts vaccine (specific wording not reported)	67% stated that they would be equally likely to recommend the vaccine to both girls and boys
			Response options: Likert scale ranging from “extremely likely” to “extremely unlikely” (specific options not reported)
Riedesel et al[31]a	Family physicians n=145	Mailed survey	Information provided: Not reported	Participants were more likely to recommend vaccination to (p < .0001):
		National random sample	Question frame: Intention to recommend to (specific wording not reported)	Girls (vs. boys)
			Males and females	Older children (vs. younger children)
			At each age (11,14, and 17)	Cervical cancer/genital wart vaccine (vs. cervical cancer vaccine)
			Vaccine for cervical cancer and a vaccine cervical cancer and genital warts	11yr olds females
				Cervical cancer: 53%; cervical cancer and warts: 66%
				11yr old males
				Cervical cancer: 40%; cervical cancer and warts: 59%
				14yr old Females
				Cervical cancer: 91%; cervical cancer and warts: 91%
				14yr old males
				Cervical cancer: 56%; cervical cancer and warts: 80%
				17yr old females
				Cervical cancer: 97%; cervical cancer and warts: 97%
				17yr old males
				Cervical cancer: 65%; cervical cancer and warts: 90%
Studies conducted outside the U.S.
Duval et al[32] Canada	Nurses n=946	Mailed survey	Information provided: Not reported	Proportion who strongly or somewhat agreed that the HPV vaccine should be given to
		National random sample	Question frame: Agreement to statement “HPV vaccine should be given to:” girls and boys based on sexual activity (see results)	Girls before they become sexually active: 91%
			Response options: 4-point Likert scale (no undecided options) dichotomized into any agreement/disagreement	Boys before they become sexually active: 77%
				All sexually active females: 82%
				All sexually active males: 70%
Esposito et al[33] Italy	Pediatricians n=311	Mailed survey	Information provided: Not reported	Primary care pediatricians
		National random sample	Question frame: “If you recommend HPV vaccination, which of your patients should receive it?”	Both males and females: 56%
			Response options:	All females: 36%
			All females	Hospital pediatricians:
			Both males and females	Both males and females: 63%
			Only females with a family history of cervical cancer	All females: 26%
			Both males and females with a family history of cervical cancer	Pediatric residents:
				Both males and females: 69%
				All females: 18%

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Results 

Among 23 published articles, half were conducted in the United States (11/23). The majority (87%) used quantitative survey methodology but 13% used more explorative qualitative techniques such as focus groups and in-depth interviews. Convenience samples were used in most studies (74%) and only 26% relied on nationally representative samples. Five of the six published reports from national samples were of data from healthcare providers and one was of parents. Among the national studies of parents or young adult and/or adult males, none were performed on a U.S. sample.

HPV Vaccine acceptance among adult males 

Five published articles on HPV vaccine acceptance among potential male recipients were included in this review, two of which come from the same survey of adult males and three of which were conducted among college students (see Table 1). Acceptability of an HPV vaccine that protects against both cervical cancer and genital warts was high in studies conducted among college students (74%–78%) [10], [11]. Acceptability was lower in a sample taken from males aged 18–45 years recruited from various locations in two Georgia communities. In this sample, only 33% of men said that they would get vaccinated and 40% were undecided [12], [13].

Several studies evaluated differences in acceptability based on how the vaccine was framed and found a general preference for a vaccine that protected against more types of HPV and that provided some direct protection for males. For instance, only 34% of college males would accept a vaccine that protected against cervical cancer alone, whereas 78% would accept a vaccine that protected against both cervical cancer and genital warts. In this study, informing men about the benefits of male HPV vaccination for reducing cervical cancer risk in their female partner(s) did not increase their interest in receiving the vaccine beyond informing them of the benefits to their own health [11].

The behavioral correlates of vaccine acceptance and refusal were relatively similar across the studies. In every study, having more lifetime sex partners was significantly correlated with vaccine acceptance. Some studies reported that males who were currently dating, had a current sex partner, were sexually active, or had ever had an STD test were more likely to accept HPV vaccine [11], [14]. Three of the four studies reported that knowledge and awareness about HPV was associated with vaccine acceptability [13], [14], [15]. Males who perceived themselves at greater risk for HPV acquisition were more willing to be vaccinated [10], [11]. HPV vaccine acceptance was higher among males who believed that their parents, partners, or physicians would encourage them to receive HPV vaccine, as well as males who believed that their friends would seek vaccination [10], [13], [14]. Concern about vaccine safety and side effects as well as a fear of shots was associated with HPV vaccine refusal [10], [13]. Believing in the general importance of vaccines and vaccine cost were associated with HPV vaccine acceptance [10], [13], [14].

In one study, the most frequently cited reasons for wanting HPV vaccine included the desire to stay healthy (67%); prevention of cancer in sexual partner(s) (53%); prevention of anal, penile, and head and neck cancer (41%); fear of cancer (33%); and prevention of genital warts (33%). The most common reasons for not wanting to receive the vaccine included being in a monogamous relationship and not at risk (19%), not generally interested (14%), and insufficient evidence to prove benefit of the vaccine to men (8%) [12].

Two published articles from outside the United States that studied HPV vaccine acceptance among potential male recipients were included in this review. A survey of college students in the Netherlands revealed that 48% of male respondents indicated that they would accept HPV vaccination [15]. Although this acceptance rate is lower than that found in similar studies conducted in the United States, the survey design differed in one important aspect: the participants did not receive any information about HPV vaccine before completing the survey.

The second article documented HPV vaccine acceptance among men who have sex with men (MSMs) in Australia. Although general acceptance rates were not provided, the article reported that 47% of the participants were willing to pay $450AU for HPV vaccine and 93% were willing to disclose their sexuality to obtain the vaccine if by so doing they could obtain the vaccine for free [16].

HPV vaccine acceptance among parents 

HPV vaccine acceptance rates were relatively high in the two quantitative studies of parents and did not differ substantially by gender of child [18], [19]. Among mothers of sons, support of HPV vaccination of males varied from 66% to 100%, depending on the mother's ethnicity and type of vaccine. Overall, Latina mothers were significantly more willing to vaccinate sons than non-Latina mothers and differences in acceptance rates between ethnic groups persisted after controlling for participants' age, literacy, and language. Among mothers with sons, acceptance of an HPV vaccine, genital warts vaccine, and anogenital cancer vaccine ranged from 92% to 100% among Latina mothers and from 77% to 89% among non-Latina mothers. Acceptance of a cervical cancer vaccine was considerably lower; only 12% of non-Latina mothers and 18% of their Latina counterparts said they would accept a vaccine for cervical cancer prevention for their sons [19].

The perception that male children would not directly benefit from HPV vaccine was a main reason to refuse HPV vaccine for sons in both quantitative [18] and qualitative findings [17]. For instance, one parent in a focus group stated “I think that if I had daughters instead of boys, then I might be a little more concerned (about the disease)” [17].

Studies conducted outside the United States found varied parental acceptance of HPV vaccination for male adolescents that did not significantly differ from acceptance for females. Of the eight non-US studies, three were from Canada, three from the United Kingdom, one from the Netherlands, and one from Turkey. When the same question frame was employed, the studies yielded similar results. For example, in response to the statement “the HPV vaccine should be given to females and males,” 89% of the respondents in Canada and 91% of the respondents in the Netherlands agreed or strongly agreed [23], [26]. Four studies asked parents whether they intended to vaccinate their sons in his early teens. The percentages of respondents who responded yes ranged from 59% in Turkey, to 68% and 71% in Canada, to 73% in the United Kingdom [21], [22], [25], [27]. Parents were asked specifically about their intention to vaccinate their sons and daughters in four studies, and although not all differences were statistically significant, there was a slight preference among parents to vaccinate their daughters in each study [21], [22], [25], [27].

Health providers' intention to recommend HPV vaccine to male patients 

Health providers' intention to recommend HPV vaccine to male patients varied by age and ranged from 82% to 92% for older adolescent patients [28] (see Table 3). However, in all the surveys, health care providers indicated that they were more likely to recommend HPV vaccine to older adolescents and females [28], [29], [31]. There was also a preference for vaccine that protected against both genital warts and cervical cancer as opposed to a vaccine that protected only against cervical cancer; this relationship was markedly stronger for male patients than female patients and was statistically significant [29], [31]. Providers also indicated preference for recommending vaccine to older rather than younger patients, regardless of patient gender.

Although investigation of the impact of patients' gender on providers' intention to recommend HPV vaccine was not the primary objective of the studies in Table 3, the studies do provide some information on this topic. The qualitative study found that the preference among pediatricians to vaccinate girls is rooted in the belief that HPV vaccine has a greater benefit for girls and would be difficult to market to male patients and their families [30]. One of the quantitative studies discussed how patients' gender affected providers' intention to vaccinate in greater depth [28]. Intention to vaccinate male patients was lower among pediatricians who were concerned about parental reactions to an “STD vaccine” and participants indicated they anticipated parental refusal to be higher among male patients than female patients.

Only two studies conducted outside the United States that examined health providers' intention to recommend HPV vaccine to males met inclusion criteria. One measured the willingness among nurses in Canada to recommend HPV vaccine to girls and boys. This large, national survey found that 77% of the nurses would recommend HPV vaccine to boys before they became sexually active and 70% of the nurses would recommend the vaccine to sexually active males. The nurses' intention to recommend the vaccine girls was higher: 91% indicated that they would recommend the vaccine to girls before they became sexually active, and 82% would recommend the vaccine to sexually active females [32].

In a study of Italian pediatricians, the question was framed as “If you recommend HPV vaccination, which of your patients should receive it?” and results were stratified by type of pediatrician (primary care, hospital, or pediatric resident). The percentage of respondents indicating that both males and females should receive HPV vaccine ranged from 56% among primary care pediatricians to 69% among pediatric residents. The percentage indicating that HPV vaccine should be given to females only was much lower: 36% of primary care pediatricians, 26% of hospital pediatricians, and 18% of pediatric residents [33].

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Discussion 

Overall, findings from studies in this review indicate that acceptability of HPV vaccination for males would likely be generally high; most studies in the United States and elsewhere have found that majority of adult males, parents of boys, and healthcare providers would support vaccination of males. Acceptability of an HPV vaccine that protects against cervical cancer and genital warts was high in studies conducted among male college students (74%–78%) but lower in a community sample of males (33%). Among mothers of sons, support of HPV vaccination varied widely from 12% to 100%, depending on the mother's ethnicity and type of vaccine, but was generally high for a vaccine that would protect against both genital warts and cervical cancer. Health providers' intention to recommend HPV vaccine to male patients varied by patient age but was high (82%–92%) for older adolescent patients. Health care providers were less likely to recommend for younger adolescents, a finding similar to that from prelicensure data on females. It should be noted that government and professional organization recommendations postlicensure can likely affect provider practices.

A preference to vaccinate females over males was reported in a majority of studies that surveyed parents and health care providers. It is likely that the individual decisional process and issues regarding vaccinating a male will differ from those for vaccinating a female. For instance, we found that acceptance would be higher for vaccine that protects against genital warts as well as cervical cancer. However, in most studies, the direct benefit to men of protection against types 16 and 18 was not communicated. The belief that the vaccine would not directly benefit males was repeatedly cited as the primary reason why adult males, parents, and providers would decline HPV vaccination. Also, the message of cervical cancer prevention in female partners did not resonate among adult males or parents and was not a motivating reason for vaccination.

There may be great interest in using HPV vaccine among MSM who have higher rates of HPV infection and HPV-associated anal cancers [34], [35]. As noted in one Australian study in our review, the acceptability of male vaccination among MSM is likely to be high [16]. However, HPV vaccine would offer greatest benefit when administered before onset of exposure to HPV through sexual activity. It may prove difficult to target men identifying as gay and bisexual before they become sexually active.

There are limitations in the majority of articles included in this review. Studies were based on a hypothetical availability of an HPV vaccine for men, and results may not indicate actual acceptance should licensure occur. Furthermore, acceptance is also affected by professional and government recommendations. It is likely that acceptability among providers would be affected by recommendations (either for or against male vaccination) by ACIP and medical associations. Many articles also offered little explanation of outcome measures used and these varied greatly across studies, thus limiting the extent to which comparisons can be made.

Studies did not uniformly report whether information about the vaccine was provided, which could have affected vaccine acceptability among study participants. Eight of the articles included in our sample did not report whether information was provided to participants. Of the 15 articles that indicated that information was provided, six did not describe the information given in sufficient detail to determine whether participants were informed of the vaccine's benefits to males; five provided information unrelated to the vaccine's benefits to males; and four provided information in varying degrees of detail about the vaccine's benefits to males. Given the variability regarding how this aspect of the study designs was reported, it was impossible for the reviewers to draw any conclusions regarding how the provision of previous information affected vaccine acceptability. As well, information was often framed in terms of outcomes linked to infections rather than the different types of HPV [6], [11], [16], [19] that cause those outcomes. It is not clear what effect such information may have on results. For example, some studies mentioned only cervical cancer prevention and did not provide information on other HPV-related cancers that affect males. This information might have made the vaccine more acceptable. On the other hand, providers were not given information on the expected effect or cost-effectiveness of male vaccination, which might decrease the interest in male vaccination.

The majority of studies relied on convenience samples and findings cannot be generalized to the broader population nor focus in on particularly vulnerable subpopulations. For example, two-thirds of the articles that measured the acceptability of HPV vaccine among adult US males surveyed male college students, which may not accurately represent the primary target age group for vaccination.

This review found variability across studies regarding the assessment of HPV vaccine acceptance for males. Although there is a need for a more systematic review of the methodological techniques and measures used to date in published literature, we do make some informal observations here. For instance, samples were often too broad and included parents who did not have sons; findings from these populations may not prove relevant to vaccine uptake. Future research could focus on those populations either targeted for vaccination or influential to those populations including parents of boys in the age range being discussed for vaccination and healthcare providers who serve these populations. Few studies use a guiding theoretical framework and future research could benefit from the use of a broad conceptual framework that considers individual as well as cultural, institutional, policy, and health-system factors. As well, studies could benefit from inclusion of more detail about measurement and information provided to respondents.

In summary, we found most studies on adult males; healthcare providers and parents reported high acceptability of HPV vaccine for males. As more information becomes available on the efficacy of the vaccine in males, the burden of HPV-related disease in males, and cost-effectiveness, acceptability of the vaccine among health care providers, parents, and males will be affected. Future studies can evaluate acceptability in the context of a licensed vaccine and not hypothetical situations.

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