Factors Associated with HPV Vaccine Refusal among Young Adult Women after Ten Years of Vaccine Implementation

In Italy, human papillomavirus (HPV) vaccination is free and has been actively offered to all 12-year-old girls since 2007, and the National Health Department established a target vaccination coverage of 95% within 5 years of the start of the campaign. However, despite several promotional activities, vaccination coverage ranges from 27% to 83% among administrative regions. The Health Belief Model (HBM) attempts to explain and predict health behaviours, and is used in assessing health-behaviour interventions by focusing on the attitudes and beliefs of individuals. The aim of the study was to investigate factors associated with the refusal of HPV vaccination using HBM among young adult women of Palermo, Italy, after 10 years of vaccine implementation.

A cross-sectional study was conducted through the administration of a telephone questionnaire, consisting of 23 items on HPV infection and vaccination knowledge based on the HBM framework. Overall, 141 young women (18-21 years old) were enrolled (response rate 22%). Among them, 84.4% were unvaccinated, and 15.6% had at least one dose of the HPV vaccine.

The main sources of information about HPV vaccination were paediatrician/general practitioners (42.5%, n = 60), followed by gynaecologists (33.3%, n = 47) and parents (24.8%, n = 35). The HBM answers on benefits of all vaccines had a mean score of 2.5 (standard deviation (SD) = 0.1), benefits of HPV vaccine 2.5 (SD = 0.1), barriers of all vaccines 2.6 (SD = 0.1), barriers of HPV vaccine 2.0 (SD = 0.1), susceptibility of disease 4.3 (SD = 0.1), and disease severity 3.2 (SD = 0.1). Young women refusing vaccination had lower scores on HBM questions of perceived HPV vaccination benefits (odds ratio (OR) = 0.42, p = 0.002), perceived HPV vaccination barriers (OR = 0.46, p = 0.008), and perceived severity (OR = 0.50, p = 0.022), compared to women with at least one vaccination dose received.

In multivariate analysis, the factors associated with the refusal of the HPV vaccination were a bachelor's degree as the education level (OR = 10.2, p = 0.041), lower participation at school seminar on HPV (OR = 0.2, p = 0.047), and lower perception of HPV vaccine benefits (OR = 0.4, p = 0.048). The main reasons for vaccination refusal of HPV vaccine were lack of information (39.5% n = 47), followed by fear of vaccine adverse events (33.6% n = 40), belief that the vaccine was not efficacious (15.1% n = 18), and logistical reasons (11.8% n = 14).

In explaining these findings, the researchers note that it was possible that young women with a higher educational level were more skeptical about trusting or accepting information about vaccination at face value. The results also suggest the possible key role of schools in the promotion of correct information about HPV vaccination. In addition, to achieve a higher uptake of the vaccine, it could be offered in the context of school-based voluntary vaccination and information campaigns, as already implemented in other countries. Furthermore, evaluation of the perceptions about benefits, barriers, severity, and susceptibility of HPV vaccines could play a key role in the development of targeted educational campaigns that would increase the intention to get the HPV vaccine. The researchers propose that public health professionals provide tailored information to reinforce strength of recommendations regarding HPV vaccination, especially with parents of young women.

In conclusion: "educational interventions focused on sexual transmitted diseases and conducted in a school setting may be necessary to enhance HPV vaccination rates among Sicilian girls. Therefore, supplying correct and unambiguous information to young women about vaccine efficacy and safety, and the value of vaccinations in preventing cervical cancer may be needed in order to increase HPV vaccination coverage in the future."