https://orcid.org/0000-0002-2099-4562
ABSTRACT
Objective
This study aimed to investigate environmental factors influencing mothers’ decision-making regarding vaccination of the human papillomavirus (HPV) for their daughters.
Methods
This was a cross-sectional study, with data collected using online surveys from July to September 2018. Participants were 230 mothers of second-year female middle-school students in South Korea. The proportional stratification sampling method was used to reflect the difference in medical level between regions. Independent variables consisted of individual (demographic characteristics, HPV-related characteristics, knowledge, attitude, and subjective norms) and environmental factors (the influence of healthcare providers, school, and community environments) were examined. The potential factors influencing vaccination uptake were determined using hierarchical logistic regression.
Results
The factors influencing mothers’ decision-making about the HPV vaccine for their daughters were their attitude toward HPV vaccination (OR = 0.78 p < .001), whether a healthcare provider provided HPV-vaccine-related information (OR = 2.42, p = .030), and presenting positive-framed information (OR = 4.21, p = .020).
Conclusions
To increase HPV vaccination among the target population, it is necessary to consider environmental factors identified in this study. Healthcare providers should provide accurate information regarding the vaccination. Information emphasizing the vaccination’s benefits is particularly important.
Introduction
Human papillomavirus (HPV) vaccines have been confirmed as an effective means of preventing the contraction of HPV and associated diseases.Citation1 Since the HPV vaccine was first recommended in the United States in 2006, more than 65 countries have been recommending HPV vaccinations to people of the recommended age of 12 years.Citation2 The HPV vaccine was introduced as part of the national immunization program in June 2016 in South Korea, and two free vaccinations are provided for girls aged 12 years, for whom the vaccine is considered highly effective.Citation3 Despite the effectiveness of the HPV vaccine, the worldwide HPV vaccination rate in the target population is only 54.9% that it is still less than 80%, suggests that it dose not forms herd immunity.Citation4
There are many barriers to decision-making about immunization. In countries without universal healthcare coverage, the costs of the vaccine were identified as an important barrier to provision of, and access to, the HPV vaccine.Citation5,Citation6 In South Korea, in a study conducted before HPV was included as a national immunization program, 96.5% of mothers said that they would vaccinate their daughters if the HPV vaccination were covered by medical insurance.Citation7 However, in 2017, after free vaccination was implemented as a national vaccination initiative in South Korea, 71.1% and 60.6% of girls born in 2004 and 2005, respectively, received the first dose of the vaccination.Citation8 These proportions are low relative to those recorded in other countries, which have HPV-vaccination rates between 86.2%Citation9 and 87.3%.Citation10 Furthermore, these rates are below the 80% threshold, which is the level at which herd immunity can be expected.Citation4 Therefore, it is necessary to formulate a plan to increase the HPV-vaccination rate in countries that include HPV as a national vaccination.
The administration of the HPV vaccine to children requires the consent and approval of their parents. In many families, mothers are the primary decision-makers regarding their children’s health including the receipt of vaccination.Citation11 Most studies concerning mothers’ decision-making regarding the administration of the HPV vaccination to their children focused on individual factors such as mothers’ knowledge of the HPV vaccine, attitudes toward vaccination,Citation12,Citation13 and subjective norm.Citation5,Citation12 The individual interacts with the environment, and healthcare providers can change the individual’s health-related behavior through changes in the environment surrounding the individual.Citation14 Therefore, it is necessary to comprehensively identify environmental influencing factors for vaccination to establish an effective vaccination strategy.
Studies examining environmental impacts show that vaccine decisions are influenced by the physical environment, such as cost and geographic barriers of vaccines.Citation5,Citation6,Citation15 Communication media environment and influential leaders are considered important in contextual influences for vaccination decision-making.Citation16 Therefore, it is necessary to understand various environmental factors, such as healthcare providers, school, and community factors, excluding the cost. In particular, in today’s era where information can be obtained from various sources,Citation17 it is necessary to closely understand where and what type of information influences vaccine decision-making.
Therefore, this study aimed to identify environmental factors that affect mothers’ decision-making regarding HPV vaccination for their middle-school-aged daughters, representing the recommended age for receipt of the HPV vaccination.
Patients and methods
Study design and sample
The study was a cross-sectional survey of mothers with middle-school-aged daughters. Research participants were recruited from July to September 2018 with approval from the institutional review board at the university with which the researcher is affiliated (PNU IRB/2018_57_HR).
In South Korea, free HPV vaccination is recommended for adolescent girls in the sixth grade of elementary school and the first grade of middle school since June 2016.Citation3 As a result, this study made use of online surveys, which were completed by the mothers of girls attending their second year of middle school, as the decision regarding whether to vaccinate their children would have been made at this time. The ideal sample size was calculated using the G*power 3.1.9.2 program, with a significance level of .05 for the logistic regression analysis, a power value of 80%, and an odds ratio of 1.61.Citation12 The probability value (H0) was determined to be 0.711, based on the first-dose HPV-vaccination rate for target population.Citation3
The proportional stratification sampling method was used to reflect the difference in medical level between regions. Recruitment was conducted in one metropolis and one province, South Korea, using a recruitment ratio of 5:3:2, corresponding to the populations of students in the large cities, small-midsize cities, and rural areas. Initially, schools in the metropolis and the province were classified in terms of city size: metropolitan cities, mid-sized cities, and rural areas. The participants’ schools were selected using a random number sampling method, based on the proportions of students in the cities.
Following approval by thirty-three schools, 4,059 mothers were informed of this study through the students. Online questionnaires were made available to 346 mothers who wanted to participate in the study. This produced a total of 250 respondents, providing a response rate of 72.3%. Twenty surveys were excluded, as they contained incomplete responses; therefore, 230 surveys were used in the final analyses.
Measures
Dependent variables
The dependent variable was the daughter’s HPV vaccination status. Participants were asked the following question: “How many injections of the HPV vaccine has your daughter received?” Response categories were 0, 1, and 2. Out of a total of a potential two doses of HPV vaccinations, the mothers whose daughters were vaccinated at least once were categorized as the vaccination-decision group, and the mothers whose daughters were not vaccinated were categorized as the non-vaccination-decision group. Participants in the non-vaccination-decision group were asked for their reasons for not acquiring the vaccination and whether they intended to do so in the future.
Individual factors
The demographic characteristics collected included age, residential area, education level, employment, religion, financial status, and marital status. Participants’ HPV-vaccine-related characteristics were measured using three items: whether the respondents had been tested for cervical cancer; whether there was a family history of cervical cancer; and whether they had been vaccinated for HPV. Participants’ HPV-related knowledge was measured using selected items from the HPV Knowledge Scale,Citation18 which was developed using item-response theory and classical test theory. From the total of 29 items, those pertaining to understanding the test results and knowledge of the validity of the HPV test (seven items) were excluded because they did not suit the purpose of this study. Thus, 23 items were used in the study, including the items related to HPV knowledge (16 items) and HPV-vaccine-related knowledge (seven items). The scale included items regarding transmission, consequences, risk factors, vaccination procedure, and protection. The response options for all items were “true,” “false,” and “I don’t know.” To measure participants’ attitudes toward the HPV vaccination, this study used the revised Carolina HPV Immunization Attitudes and Beliefs Scale.Citation19 This scale measures intrapersonal attitudes and interpersonal and community factors. The scale comprises the subareas of harmfulness/effectiveness (nine items), disability (three items), and subjective norms (two items). This study used only the nine items of the harmfulness/effectiveness subarea that measures intrapersonal attitudes toward HPV vaccination. The response options for all items were “strongly disagree,” “somewhat disagree,” somewhat agree,” and “strongly agree.” Regarding subjective norms, we used the tool originally developed by AjzenCitation20 and revised by Askelson et al.Citation21 to suit HPV vaccination. The mothers were asked to respond to statements using a seven-point Likert-type scale, with higher scores representing more positive attitudes toward HPV vaccinations.
Environmental factors
In environmental factors, the influence of healthcare providers, school, and community environments were measured. The influence of healthcare providers in this study was measured using two items, meaning that they recommend vaccination and provide information related to the vaccine. The items determined whether the HPV vaccination was recommended for use for participants’ children, and whether the information emanated from healthcare providers. The two items examined school environmental factors using information and education provided at their children’s schools. The community environmental factors included accessibility, sources exposed information, and type of information. Specifically, accessibility to HPV vaccination medical center measured by the time (minutes) to medical institutions by car. The types of information were measured as positive-framed information and negative-framed information. The positive-framed message emphasized the gains or benefits of performing the behavior and the loss-framed message emphasized the losses or disadvantages of not performing the behavior.Citation22 This study was structured to answer the question “ What type of information most influenced your decision to vaccinate your daughter for HPV?” with “positive-framed messages” and “negative-framed messages.” The following examples were presented and selected so that the subject could understand the positive and negative framed messages. “By vaccinating your daughter against HPV, you make it much less likely for her to develop cervical cancer.,” “By not vaccinating your daughter against HPV, you make it much more likely for her to develop cervical cancer.”
Analytic strategy
The collected data were analyzed using a two-tailed test with a statistical significance level of .05, performed using the IBM SPSS Statistics 23 program. Descriptive statistics included the frequencies, percentages, mean values, and standard deviations for the ecological factors. Regarding inferential statistical analyses, chi‐square tests and Fisher’s exact test were used to evaluate the associations between mothers’ decision-making regarding their daughters and demographic characteristics; HPV-related characteristics; and individual and environmental factors. Variables with statistically significant differences in univariate analysis were input to logistic regression analysis. To explain the environmental influence of controlling for individual factors, hierarchical logistic regression analysis was performed to determine the odds ratios and 95% confidence intervals associated with each variable in terms of the dependent variable.
Result
Decision-making regarding HPV vaccination of the participants’ daughters
depicts the participants’ decision-making regarding HPV vaccination for their daughters. The vaccination-decision group comprised 75.7% of the respondents, while the non-vaccination-decision group accounted for 24.3%. The most common reason why mothers in the non-vaccination-decision group did not vaccinate their children was concern regarding the potential side-effects of the HPV vaccine (57.4%), followed by doubts regarding the vaccine’s effectiveness (24.1%), belief that their children were too young for the vaccine (18.5%), lack of knowledge regarding the HPV vaccine (14.8%), refusal for their children to be vaccinated (9.3%), lack of time (7.4%), and being unaware that the vaccine was free (7.4%). Further, 46.4%, of those in the non-vaccination-decision group revealed that they had no intention of obtaining the vaccination in the future. Among the participants who expressed an intention to vaccinate, 23.2% intended to vaccinate within 6 months and 30.4% after 6 months.
Table 1. Decision-making of the HPV for their daughters (N = 230)
Characteristics depending on decision-making regarding HPV vaccine administration
Analysis of the individual factors that affected mothers’ decision-making regarding HPV vaccination of their daughters showed that the mothers’ HPV-vaccination status, HPV-vaccine-related knowledge, HPV-vaccination-related attitudes, and subjective norm had statistically significant effects on their decision-making (). Regarding environmental factors, whether healthcare providers provided HPV-vaccine-related information, the presence of HPV-vaccine-related advertisement posters at medical centers, availability of access to information booklets, experience with educational materials, and type of information (positive/negative) significantly affected decision-making.
Table 2. Characteristics depending on decision-making regarding HPV vaccine administration (N = 230)
Factors affecting mothers’ decision-making
A hierarchical logistic regression analysis was conducted to identify the environmental factors affecting the mothers’ decision-making regarding HPV vaccination of their daughters. In the final model, attitudes toward HPV vaccination, information communicated by healthcare providers, and provision of positive information regarding the HPV vaccination were found to be significant, influential factors. The total explanatory value of the final model, including the individual and environmental factors, was 48%. reports these results.
Table 3. Factors affecting mothers’ decision-making (N = 230)
Discussion
This study examined the effects of individual and environmental factors on mothers’ decision-making regarding the HPV vaccination for their daughters. The daughters of 75.7% of the mothers examined in this study received their first HPV vaccination dose, similar to national immunization statistics (71.1%).Citation8 In a study conducted before the inclusion of the HPV vaccine in the South Korean national immunization project, 96.5% of the respondents reported that they would obtain the vaccination if it were covered by medical insurance.Citation7 However, although South Korea provided the vaccine free of charge to 12-year-old girls since 2016,Citation3 the expected vaccination rate has not been reached. Thus, community efforts are needed to increase vaccination rates.
In the final model of the logistic regression with the control of individual factors, the type of information was found to have the most influence on the mother’s HPV vaccination decision-making. Providing a positive message that emphasizes the benefits of vaccination is effective to improve preventative health behaviors.Citation23 These results support the research findings that the impression of information rather than the source of nformation has a strong influence on HPV vaccine decision-making.Citation24 Meaning, the message emphasizing the benefits of the vaccine, such as lowering the risk of cervical cancer, influenced the decision-making on HPV vaccination, leading to actual vaccination. Therefore, when providing HPV-vaccine-related information in medical institutions or in HPV-vaccination advertisements through the mass media, it should be presented as positive-framed messages that emphasize the benefits and effectiveness of the vaccination, rather than the negative effects that occur as a result of not vaccinating.
Additionally, the communication of information by healthcare providers was found to be an important influential factor. The information communicated by healthcare providers on vaccines has previously been found to be an influential factor in HPV vaccination and other immunizations.Citation25 In this study, although information communicated by healthcare providers was an important consideration, recommendations from these professionals to obtain HPV vaccination did not influence the mothers’ decisions to vaccinate their children. A study that systematically reviewed parents’ HPV-vaccination-related communication with healthcare providers found that parents tended to make the final decision regarding vaccination after seeking additional information, even if their healthcare providers had recommended vaccination.Citation26 These results demonstrate that simply recommending vaccination is insufficient for mothers to decide to administer the HPV vaccination to their daughters. Therefore, healthcare providers must communicate specific information regarding the vaccine, including its purpose, effects, complications, potential adverse reactions, coping with complications or adverse reactions, and methods of vaccination, to parents to increase HPV vaccination of adolescent girls.
Concerning individual factors, the study found that if participants had negative attitudes toward HPV vaccination, they were 0.78 times less likely to vaccinate their children for HPV than those with positive attitudes. These results are consistent with the results of previous studies saying that parents’ attitudes toward HPV vaccination had a strong influence on decision-making regarding vaccination.Citation19,Citation27,Citation28 Since mothers’ positive attitudes toward HPV vaccination positively affect children’s HPV-vaccination rates, it is necessary to assist mothers in developing positive attitudes by providing advertisements and education concerning the vaccine’s effects. In particular, as confirmed in this study, it is necessary to use a message emphasizing the benefits of vaccines when a reliable expert delivers sufficient information so that the mothers can make an informed decision.
This study had several limitations. First, the study was cross-sectional, which made it difficult to analyze cause and effect. Moreover, the study was conducted in specific areas of South Korea. However, in our interpretation of the data, we attempted to consider the size of the areas to reflect the various characteristics. Furthermore, to reflect regional characteristics, proportional sampling considering the sizes of the metropolises and provinces in the study area was applied. In addition, the study was conducted only in South Korea, where the HPV vaccine is administered as part of a national vaccination program and has high accessibility within the health system. Future consideration should be given to environmental factors including policies and accessibility to medical institutions appropriate to each country’s circumstances. Further, although this study considered information-related factors in the community that affect vaccination decision-making, it was limited to confirm the specific contents of the information. In the future, specific experimental studies such as framing and transmitting what information and how the subject receives such information is suggested.
Conclusions
This study examined the environmental factors affecting mothers’ decision-making regarding HPV vaccination of their middle-school-aged daughters. This involved comprehensive examination of multilevel individual and environmental factors affecting decision-making. Based on this study, when providing information or education regarding the HPV vaccine, using positive-framed messages that emphasize the benefits of vaccination can be an effective method for improving the vaccination rate. Furthermore, rather than simply recommending vaccinations, healthcare providers should communicate specific information to assist mothers in their decision-making. It is necessary to provide a sufficient amount of vaccine-related information for mothers to develop a positive attitude toward the HPV vaccine and thereby improve the vaccination rates for adolescent girls.
Disclosure of potential conflicts of interest
No existing or potential conflict of interest relevant to this article was reported.
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