Journal of Adolescent Health 37 (2005) S17–S23

Review article

Improving adolescent health: Focus on HPV vaccine acceptance

Gregory D. Zimet, Ph.D.*
Department of Pediatrics, Section of Adolescent Medicine, Indiana University School of Medicine, Indianapolis, Indiana
Manuscript received July 20, 2005; manuscript accepted September 20, 2005

Abstract The success of future human papillomavirus (HPV) vaccination programs will depend on individ-
uals’ willingness to accept vaccination, parents’ willingness to have their preadolescent and early
adolescent children vaccinated, and health care providers’ willingness to recommend HPV vacci-
nation. The purpose of this article is to provide a qualitative review of the relevant literature,
including research on knowledge and attitudes about HPV infection and its clinical sequelae, the
acceptability of HPV vaccination to individuals and parents, and health care providers’ attitudes
about recommending HPV vaccination. Additionally, strategies are suggested by which providers of
adolescent health care can discuss and recommend HPV vaccines with parents and their children.
The research published to date suggests that there is a good deal of misunderstanding about HPV
infection, cervical cancer screening, and the sequelae of HPV infection. However, the majority of
research studies to date indicate that young women, parents, and health care providers are interested
in vaccines that prevent HPV and other sexually transmitted infections (STIs). Of particular note are
the consistent findings that providers are less comfortable vaccinating younger versus older ado-
lescents and that endorsement of vaccination by a professional organization is of great importance.
Furthermore, research suggests that most parents are interested in having their preadolescent and
adolescent children vaccinated against HPV. Parents value the information and recommendations
provided by their children’s health care providers. To the extent that providers are concerned about
potential negative reactions of parents to a recommendation of HPV vaccination, these findings
should provide reassurance. At the same time, health care providers will need to be prepared to
provide patients and parents with information about HPV and HPV immunization and to respond
productively to the rare parent who expresses opposition to HPV vaccine or any other vaccine. ©
2005 Society for Adolescent Medicine. All rights reserved.
Keywords: Vaccination; HPV; Sexually transmitted infection; Parents; Adolescent; Health personnel

Vaccines that protect against infection with the most however, may depend on age at vaccination, duration of
common disease-causing human papillomavirus (HPV) immunity, whether males as well as females are immunized,
types are predicted to prevent thousands of cases of cervical and the potential reduction in recommended frequency of
cancer worldwide, as well as substantially reduce emotional Pap smears after vaccination [2– 4]. Data from 2002 indi-
stress associated with abnormal Papanicolaou (Pap) test cate that 5.7% of females and 7.9% of males report having
results and diagnosis with a sexually transmitted infection had sexual intercourse by age 14 [5], with many adolescents
(STI) [1]. In addition, economic modeling studies suggest engaging in other forms of sexual activity before initiating
that HPV vaccination can result in significant savings in sexual intercourse. Ideally, therefore, vaccination would be
health care dollars [2– 4]. The extent of economic benefit, directed toward preadolescents and early adolescents in
order to provide the greatest public health benefit offered by
prophylactic HPV vaccines [6]. In addition, there have been
*Address correspondence to: Dr. Gregory D. Zimet, Department of questions as to whether health care providers, parents, and
Pediatrics, Section of Adolescent Medicine, Indiana University School of
Medicine, 575 N. West Drive, Room 070, Indianapolis, IN 46202. adolescents will be comfortable with administering or rec-
E-mail address: gzimet@iupui.edu ommending a vaccine designed to prevent infection with an

1054-139X/05/$ – see front matter © 2005 Society for Adolescent Medicine. All rights reserved.
doi:10.1016/j.jadohealth.2005.09.010
S18 G.D. Zimet / Journal of Adolescent Health 37 (2005) S17–S23

100 gest that more effort needs to be made to educate young

79 78 women and the parents of adolescents about HPV and HPV
80
Percent Reporting

vaccination before infection takes place.

60 52 Although women have been poorly educated about HPV,
42 39 research indicates that there is a great desire for information
40
about HPV infection [11,17]. Holcomb et al found that
20 women are interested in learning about HPV, how the virus
6 1 3
is transmitted, and how they can prevent becoming infected
0
Pelvic Exam STD Test Have No Idea Test for Cervical [11]. Furthermore, 86% of the participants in this study
Cancer/HPV
thought that information about HPV should be given to
Have had sexual intercourse Have not had sexual intercourse
individuals before they initiate sexual activity. Two addi-
Fig. 1. Young women’s understanding of the term Pap smear. Subjects tional findings are particularly relevant for physicians and
were asked to check all of the choices that mean the same thing as Pap emphasize the value of physician-provided education.
smear. Adapted from [15]. Women whose primary source of information about HPV
was a doctor had better knowledge about HPV compared
with those who identified alternative sources. Also, after
STI that is poorly understood by many women [6,7]. This pamphlets and brochures, respondents identified health care
article will review the research relevant to adolescents’, providers as the best source of information about HPV.
parents’, and health care providers’ understanding and atti- Providers were identified as important sources of education
tudes about HPV and HPV vaccination, and recommend more frequently than were health education classes, the
strategies designed to foster vaccine acceptance among ad- Internet, friends, or family. Anhang et al reported similar
olescents and their parents. results, noting that the women in their study wanted more
information about HPV transmission, prevention, treatment,
and the risks associated with HPV infection [17]. Moreover,
Knowledge and attitudes about HPV
consistent with research described above, there was a great
It is well established that adult as well as adolescent deal of confusion about some aspects of HPV infection,
women have limited understanding of HPV [8 –13]. In two including the distinction between high-risk and low-risk
United Kingdom studies, only 30% of women participants types. Overall, women were interested in gaining an under-
had ever heard of HPV [10,12] and in a Canadian study only standing of their personal risk for HPV infection and its
13% of adolescents had heard of HPV [9]. Similarly, among clinical sequelae, and were eager to learn more about HPV.
a sample of university students in the United States, 37%
had ever heard of HPV [13]. Although research with pa- HPV vaccination: personal acceptability
tients attending health clinics in the United States found
more encouraging results (67% indicated that they had Clearly, adolescent and adult women are concerned
heard of HPV), it is still concerning that one-third of the about HPV and want to be better informed about infection,
participants had not heard of the infection [11]. Prior expe- transmission, screening, and prevention. However, this de-
rience with an abnormal Pap smear result is associated with sire for education about HPV does not imply that an HPV
greater knowledge about HPV [10,12], suggesting that vaccine will be widely accepted by women. Given that HPV
HPV-related educational efforts may often occur after is an STI, potential barriers to vaccine acceptance may
women have experienced an adverse consequence of HPV include the stigma associated with STIs and the possibility
infection. Conversely, a separate study found poor knowl- that acceptance of the vaccine may be seen as an admission
edge about Pap smears and no association between prior of risky sexual behavior [7]. Although HPV vaccines may
experience with abnormal Pap smear results and knowledge be presented to adolescents and their parents as a vaccine
[14]. Even among persons who have heard about HPV, that prevents cervical cancer, thereby avoiding or minimiz-
misconceptions about the virus are widespread. For in- ing the STI issue, any vaccine that protects against the HPV
stance, few women know about the links between genital types responsible for both genital warts and cervical cancer
HPV infection, abnormal Pap smear results, and cervical would undoubtedly be categorized as an STI vaccine. In
cancer [8 –12]. Furthermore, a recent study reported that addition, consumers of health care have a right to receive
68% of the adolescent and young adult women incorrectly complete, accurate information about HPV infection and
thought that Pap smears and pelvic examinations were the vaccination.
same procedures [15] (Figure 1), a result consistent with Interestingly, concerns about the STI issue have so far
findings from an earlier study [16]. Adolescent and adult proven to be largely unfounded. The empirical research to
women also generally do not know who should get a Pap date has found high levels of interest in HPV vaccination
smear and have a poor understanding of the meaning of Pap among adolescents and young women [18 –21]. Adult and
smear results [8,9,14]. Overall, these sets of findings sug- adolescent women recruited from health care clinics were
 G.D. Zimet / Journal of Adolescent Health 37 (2005) S17–S23 S19

particularly interested in vaccine efficacy and physician consistent with personal acceptability literature. The major-
recommendation [18]. Although the prevention of cervical ity of parents surveyed across studies are very interested in
cancer was seen by participants as a compelling feature of protecting their children against HPV and other STIs [23–
HPV vaccination, the addition of genital warts prevention 29]. In a study of mothers in Cuernavaca, Mexico, the vast
did not reduce interest in the vaccine. Some young women majority of participants favored HPV vaccination for their
found that vaccines that protect against warts increased daughters [23]. The women in this study were told that the
acceptability of HPV vaccines [19]. In a third study of vaccine would prevent HPV infection, a virus that is sexu-
young women recruited from community and clinical sites, ally transmitted, and that HPV is the cause of cervical
approximately 85% of participants indicated an intention to cancer. Two qualitative studies used in-depth interviews to
receive an HPV vaccine for cervical cancer prevention once assess attitudes of parents in the United States toward HPV
it became available [20]. These women had broadly positive vaccination [24,27]. Parents were told that HPV was sexu-
attitudes about many aspects of HPV vaccination. Finally, a ally transmissible, and in both studies the majority of par-
study of male and female university students found that ents expressed support for the HPV vaccination of their
74% said that they would accept an HPV vaccine [21]. adolescent children. In the study by Mays et al, parents who
Acceptance rates differed neither by gender nor on the basis rejected the vaccine at their child’s current age indicated
of whether the vaccine was described primarily as an STI that they would favor vaccination when their child was
vaccine or a reproductive health vaccine. older [24]. Furthermore, rejection of vaccination at times
These research studies indicate that young women and appeared to result from a lack of understanding the impor-
men view HPV vaccination in a positive light. They also tance of conferring immunity before the initiation of sexual
suggest that the STI issue does not reduce personal accept- activity. Themes that emerged from the study by Olshen et
ability of HPV vaccination. Although one study showed that al included the importance of pediatrician recommendations
young men were interested in HPV vaccination, this issue is about vaccination, poor understanding of HPV, and differ-
deserving of more study. If HPV vaccines are efficacious in ent viewpoints on the ideal age of administration [27]. Some
men, vaccinating men may be an important public health parents expressed concern that HPV vaccination would en-
strategy because men are an important vector in the trans- courage unsafe sexual behavior, but most parents supported
mission of the virus and can develop both genital warts and vaccination.
anogenital cancers as a result of infection. The fact that A third study evaluated HPV vaccine acceptability
physician recommendation was central to acceptability fur- among parents of 10- to 15-year-old children [25]. Parents
ther emphasizes the important role played by health care completed questionnaires before and after reading a one-
providers in affecting patients’ attitudes about vaccination page information sheet about HPV, addressing prevalence
[18]. of infection, mode of transmission, and severity of sequelae.
Before reading the information sheet, 55% were in favor of
vaccinating their children, 23% were opposed, and 22%
HPV vaccination: parental acceptability
were undecided. After reading about HPV and HPV vacci-
The research summarized in the previous section sug- nation, acceptability of the vaccine rose to 75%. The infor-
gests that most women are interested in HPV vaccines; mation sheet was particularly influential with the undecided
however, given the fact that HPV vaccines are prophylactic, parents; 65% of these parents moved to a position in favor
and will provide the greatest public health benefit prior to of vaccination after reading the information sheet. In addi-
infection with the virus, the major targets of HPV vaccina- tion, consistent with other research reports, parents identi-
tion campaigns should be pre- and early adolescents. Re- fied doctors as the strongest influence in terms of decisions
search on hepatitis B vaccination indicates that adolescents about vaccinating their children. In another study, 840
look to their parents for guidance around vaccination issues mailed surveys evaluating acceptability of HPV vaccination
[22]. Moreover, parental consent most likely will be re- were returned by parents of 8- to 12-year-old children, with
quired for vaccination. The acceptability of adolescent HPV half of the parents randomized to receive a detailed infor-
vaccination to parents, therefore, is a critical issue. Ques- mation sheet on HPV infection [29]. Parents were moder-
tions have been raised about whether most parents would be ately interested in HPV vaccination for preadolescent chil-
willing to have their children vaccinated [7]. Parents may be dren. However, in contrast to the study described above,
concerned that their adolescent child would interpret paren- attitudes toward vaccination were not influenced by receipt
tal approval of HPV vaccination as a tacit condoning of of the information sheet. The authors did report that health
early sexual behavior. In addition, preadolescents and ado- beliefs, such as perceived susceptibility of the child to STI,
lescents are more likely to ask questions about health care were predictive of HPV vaccine acceptability.
issues than are younger children, and parents may be con- Two recent articles have reported on vaccine acceptabil-
cerned about how to describe an HPV vaccine to children. ity to parents of 12- to 17-year-old children [26,28]. In one
Despite these potentially troubling issues, the research to study, specific infections were not identified, but descrip-
date on parental attitudes about HPV/STI vaccination is tions of vaccine scenarios were varied on the basis of mode
S20 G.D. Zimet / Journal of Adolescent Health 37 (2005) S17–S23

50 lack of clear prevention strategies, and the potential conse-

45 quences of HPV infection.
40
Importance Score

35
Health care providers
30
25 Health care providers are important sources of informa-
20 tion and parents value physician recommendations about
15 health-related matters, including vaccines. The success of
10 HPV vaccination programs, therefore, will depend on phy-
5 sicians’ willingness and ability to recommend HPV vac-
0
Vaccine Efficacy Severity of Availability of Sexual cines to their patients. This will undoubtedly involve devel-
Infection Behavioral Transmissability oping skills to effectively communicate the advantages of
Prevention
vaccination to adolescents and their parents.
Fig. 2. Parents’ most important issues regarding vaccination against sex- Three research studies have been published on health
ually transmitted infections for their adolescent children. Adapted from care providers’ attitudes about STI vaccination. In one
[26]. study, 224 nurses (predominantly pediatric nurse practitio-
ners) rated 13 vaccine scenarios with respect to their will-
ingness to recommend the vaccines to parents of adoles-
of transmission of infection (STI, non-STI); severity of cents [30]. Each scenario was uniquely defined according to
infection (curable, chronic, fatal); vaccine efficacy (50%, patient age (11, 14, or 17 years old); infection prevented by
70%, 90%); and availability of behavioral methods for pre- the vaccine (mononucleosis, genital herpes, human immu-
vention (available, not available) [26]. STI and non-STI nodeficiency virus); gender of the patient; and whether the
vaccines were not rated differently and both were seen as vaccine had been endorsed by the American Academy of
highly acceptable, although a small percentage of parents Pediatrics (AAP). The mean rating across all vaccine sce-
(6%) viewed STI vaccines negatively. Parents based their narios was 72 on a 0-to-100 scale, indicating a positive
ratings of vaccine scenarios primarily on severity of infec- disposition towards recommending vaccination. Ratings
tion and vaccine efficacy, with the availability of behavioral were highest for scenarios in which the adolescent patient
prevention of infection (e.g., parents preferred vaccines that was older and the AAP endorsed the vaccine. The type of
prevented infections for which no behavioral prevention STI and the gender of the patient did not substantially
was available) having a more moderate effect on parental influence ratings.
ratings (Figure 2). These findings suggest that parents In a second study using a similar methodology, 207
would view an efficacious HPV vaccine as beneficial for Fellows of the American College of Obstetricians and Gy-
their adolescents. Furthermore, parental acceptability was necologists (ACOG) rated 13 HPV-specific vaccine scenar-
the single best predictor of their adolescents’ attitudes about ios with respect to their willingness to recommend each
STI vaccines, again indicating the importance to adoles- vaccine to patients [31]. Each scenario was uniquely defined
cents of their parents’ beliefs about vaccination [28]. Con- according to patient’s age (13, 17, or 22 years old); vaccine
cern about STI vaccination leading to unsafe sex was asso- efficacy (50% or 80%); ACOG recommendation (yes or
ciated with lower acceptability, but overall acceptability no); and disease targeted (genital warts, cervical cancer, or
was still quite high. both). The mean rating across all vaccines was 79 on a
Taken as a whole, this series of studies suggests that the 0-to100 scale, indicating a fairly positive disposition to-
sexual transmissibility of HPV may not be a significant wards recommending HPV vaccination. Physicians rated
obstacle to parental acceptance of HPV vaccination for their most highly those vaccines with ACOG approval and higher
children. Although parents may have some concerns that efficacy. In contrast, they were relatively reluctant to rec-
HPV/STI vaccination may lead to increases in risky sexual ommend vaccination for younger patients (i.e., 13-year-
behavior, the majority of parents recognize that the benefits olds) or to recommend a vaccine that only prevented warts.
of an HPV vaccine significantly outweigh the risks. Parents A third study examined family physicians’ attitudes
are eager to protect their children from serious illnesses about adolescent HPV vaccine recommendation as a func-
regardless of the source of the illness and are generally tion of provider characteristics, patient characteristics, and
responsive to their physicians’ recommendations regarding vaccine characteristics (i.e., cervical cancer only; cervical
vaccination. Although one study found that a brief informa- cancer and genital warts) [32]. Participants were signifi-
tion-based intervention influenced parents’ attitudes about cantly more willing to consider vaccination of older ado-
HPV vaccination [25], another study found no such effect lescents (aged 14 or 17 compared with 11) and girls. En-
[29]. More research is needed, but it may be possible to dorsement by professional organizations, such as the
encourage HPV vaccine acceptability among parents by American Academy of Family Physicians (AAFP), was
providing information about the prevalence of infection, the seen as very important. More than 90% of respondents
 G.D. Zimet / Journal of Adolescent Health 37 (2005) S17–S23 S21

viewed vaccine safety and efficacy as important factors patients will come into appointments having heard about
regarding recommendations. medical conditions and treatments from the media and are
Two common findings across these three studies were more likely to research medical information on the Internet
the importance of approval by professional organizations [48]. A recent study found that patients who research vac-
and a relative reluctance to vaccinate younger adolescents. cination issues on the Internet are likely to encounter so-
This latter issue is one that deserves attention as HPV phisticated anti-vaccination Web sites [49]. In addition,
vaccines move toward availability, given that the ideal age press coverage of vaccination also can, at times, have an
for vaccination would be 13 years or younger, in order to anti-immunization slant [50]. However, when media report-
protect the most vulnerable young adolescents and to confer ing on medical issues is balanced and accurate, it can be an
immunity before initiation of sexual activity. Also, despite excellent source of corrective information for patients [51].
the clear importance of endorsements by professional orga- Providers should be prepared to direct patients to accurate
nizations, these recommendations may be necessary, but not news and Web-based information about immunization in
sufficient for widespread utilization of HPV vaccines by general and HPV infection and immunization in particular.
health care providers. For instance, Rupp et al [33] point to
a study which found that only 21% of pediatricians in one Provider recommendations
city were immunizing infants against hepatitis B virus
(HBV) despite the recommendation of the AAP for univer- The body of research described in this article should
sal infant HBV immunization [34]. In addition, research reassure physicians and other clinicians who have concerns
over the years has documented the reluctance of health care about offering or recommending HPV vaccination to their
providers to discuss sexuality with adolescent patients [35– preadolescent and adolescent patients. Women want more
38]. These issues will certainly need to be addressed in information on HPV for themselves and their daughters and
planning HPV vaccine campaigns. value information provided by health care providers, sug-
gesting that physicians will have an important role in edu-
cating adolescent patients and their parents about HPV and
Other HPV issues
HPV vaccination. The research also indicates that most
Genital HPV infection is the most common STI, with young women and parents feel positively about HPV vac-
high incidence and prevalence rates [39 – 42]. HPV infec- cination for themselves and for their children. For the large
tions that cause warts are, from a medical standpoint, rela- majority of parents, the sexual transmissibility of HPV may
tively benign. Furthermore, infections with high-risk, onco- be of some concern, but does not represent a significant
genic types are usually either spontaneously cleared or barrier to vaccine acceptability, as their overriding concern
regress to an undetectable level [43– 45]. HPV, therefore, is appears to be to protect their children from harm. Parents
a common sexually transmitted infection, but a less com- also look to their physicians for recommendations regarding
mon sexually transmitted disease. To encourage vaccina- vaccination, and this is also likely to be true for any new STI
tion, it is important to emphasize the risks associated with vaccines.
persistent infection with high-risk HPV types. Care should Health care providers should anticipate that parents will
be taken not to increase confusion, guilt, or psychological have varying degrees of comfort with vaccination, including
stress [1]. In addition, HPV vaccination will not obviate the ambivalence and outright opposition [52,53]. Opposition
need for Pap testing because HPV vaccines offer protection may come from persons who are broadly anti-vaccine, as
against only the most common types of high-risk HPV. It well as those who have specific concerns about an STI
will be essential to ensure that recipients of an HPV vaccine vaccine. Several authors discuss approaches that clinicians
continue to get regular Pap testing [46]. This issue again can use to work with parents who are against vaccination or
serves to illustrate the importance of educating parents and undecided about the issue [54 –57]. A common approach
adolescents about the nature of HPV infection and its rela- recommended in several articles is for the physician to
tionship to women’s health. initiate with parents or adolescents a discussion about what
Another issue has to do with anticipating and preparing questions or concerns they might have about vaccination.
for the eventuality that a great deal of information—and Clearly, it is very important that health care providers re-
misinformation—about HPV vaccination will be dissemi- spect parents’ and adolescents’ opinions about vaccination
nated by media outlets, including the Internet. Much of the and treat their opinions seriously, even if the opinions are
recent news media coverage of HPV has been incomplete based on misinformation. Parents and adolescents who feel
and, at times, misleading [47]. In a recent commentary, for that their perspectives are taken into consideration may be
instance, Rosenthal [6] noted that a newspaper article pub- more open to corrective information provided by the phy-
lished earlier this year suggested that parents were hesitant sician (which should include Web sites that provide accu-
about the idea of HPV vaccination, despite several research rate immunization information). This process of elicitation,
studies showing great parental interest in HPV and other listening, and respectful response enables the parent/adoles-
STI vaccines. Health care providers should be aware that cent to feel empowered by their health care provider to
S22 G.D. Zimet / Journal of Adolescent Health 37 (2005) S17–S23

make informed decisions [54]. An article published in Pe- that will help to protect their children during adolescence
diatrics emphasizes the importance of respectful discussion and, importantly, will help to ensure that their children have
and includes excellent recommendations for how to respond long and healthy adult years.
to parents who oppose immunization [57].
In circumstances when HPV vaccination involves ado-
lescent and young adult women, education about the vac-
References
cine should be included as part of comprehensive education
about HPV, including the roles of Pap smears, DNA testing [1] Harper DM. Why am I scared of HPV? CA Cancer J Clin 2004;54:
for HPV, and other behavioral issues (e.g., tobacco use) in 245–7.
maintaining women’s health. Spigener and Mayeaux em- [2] Goldie SJ, Kohli M, Grima D, et al. Projected clinical benefits and
phasize the importance of developing multiple strategies for cost-effectiveness of a human papillomavirus 16/18 vaccine. J Natl
Cancer Inst 2004;96:604 –15.
delivering HPV-related information in busy office settings,
[3] Taira AV, Neukermans CP, Sanders GD. Evaluating human papillo-
including the involvement of nurse educators to elaborate mavirus vaccination programs. Emerg Infect Dis 2004;10:1915–23.
on information provided by physicians as well as the pro- [4] Kulasingam SL, Myers ER. Potential health and economic impact of
vision of clear and accurate written materials [58]. Consis- adding a human papillomavirus vaccine to screening programs.
tent with some of the patient communication methods JAMA 2003;290:781–9.
[5] Abma JC, Martinez GM, Mosher WD, Dawson BS. Teenagers in the
described previously, Anhang et al discuss a “shared
United States: sexual activity, contraceptive use, and childbearing,
decision-making” approach in which the health care pro- 2002. Vital Health Stat 23 2004;1– 87.
vider offers information and elicits reactions from the pa- [6] Rosenthal SL. Protecting their adolescents from harm: parental views
tient so that, ultimately, an informed collaborative decision on STI vaccination. J Adolesc Health 2005;37:177– 8.
can be made about HPV-related health care [59]. In a [7] Zimet GD, Mays RM, Fortenberry JD. Vaccines against sexually
transmitted infections: promise and problems of the magic bullets for
valuable study by Gilbert et al, frequently asked questions
prevention and control. Sex Transm Dis 2000;27:49 –52.
about HPV were identified, and brief, accurate answers to [8] Mays RM, Zimet GD, Winston Y, et al. Human papillomavirus,
each question were developed [60]. These answers to com- genital warts, pap smears, and cervical cancer: knowledge and beliefs
mon questions could readily be integrated into the shared of adolescent and adult women. Health Care Women Int 2000;21:
decision-making approach described by Anhang et al or 361–74.
[9] Dell DL, Chen H, Ahmad F, Stewart DE. Knowledge about human
incorporated into written material.
papillomavirus among adolescents. Obstet Gynecol 2000;96:653– 6.
The recent and future emergence of multiple vaccines [10] Pitts M, Clarke T. Human papillomavirus infections and risks of
(e.g., meningitis, pertussis, HPV) for preadolescents and cervical cancer: what do women know? Health Educ Res 2002;17:
adolescents provides us with a unique opportunity to pro- 706 –14.
vide a valuable package of preventive interventions for [11] Holcomb B, Bailey JM, Crawford K, Ruffin MT. Adults’ knowledge
and behaviors related to human papillomavirus infection. J Am Board
adolescents, which will help to keep them healthy well into
Fam Pract 2004;17:26 –31.
their adult years. It is important, therefore, that HPV vac- [12] Waller J, McCaffery K, Forrest S, et al. Awareness of human papil-
cination be considered within the context of a comprehen- lomavirus among women attending a well woman clinic. Sex Transm
sive health promotion strategy for youth. These new vac- Infect 2003;79:320 –2.
cines could be central to the establishment of a standardized [13] Yacobi E, Tennant C, Ferrante J, et al. University students’ knowl-
edge and awareness of HPV. Prev Med 1999;28:535– 41.
well-child preadolescent health care visit and, ultimately,
[14] Breitkopf CR, Pearson HC, Breitkopf DM. Poor knowledge regarding
successful delivery of HPV vaccine will depend on wide- the pap test among low-income women undergoing routine screening.
spread implementation of such a visit. Humiston and Perspect Sex Reprod Health 2005;37:78 – 84.
Rosenthal discuss some of the challenges associated with [15] Blake DR, Weber BM, Fletcher KE. Adolescent and young adult
vaccinating adolescents and propose some potential ways to women’s misunderstanding of the term Pap Smear. Arch Pediatr
Adolesc Med 2004;158:966 –70.
enhance vaccination rates, including system-based strate-
[16] Kahn JA, Chiou V, Allen JD, et al. Beliefs about papanicolaou smears
gies (e.g., use of non-traditional settings for vaccine deliv- and compliance with papanicolaou smear follow-up in adolescents.
ery), provider-based interventions (e.g., the use of standing Arch Pediatr Adolesc Med 1999;153:1046 –54.
orders), and community-directed strategies (e.g., patient re- [17] Anhang R, Wright TC Jr, Smock L, Goldie SJ. Women’s desired
minder systems) [61]. information about human papillomavirus. Cancer 2004;100:315–20.
[18] Zimet GD, Mays RM, Winston Y, et al. Acceptability of HPV
Preventive HPV vaccines have the potential to substan-
immunization. J Womens Health 2000;9:47–50.
tially reduce HPV-associated morbidity and mortality. En- [19] Hoover DR, Carfioli B, Moench EA. Attitudes of adolescent/young
suring widespread vaccine acceptance will require reaching adult women toward human papillomavirus vaccination and clinical
out to parents and adolescents with accurate and pertinent trials. Health Care Women Int 2000;21:375–91.
information on both the risks of HPV-disease sequelae and [20] Kahn JA, Rosenthal SL, Hamann T, Bernstein DI. Attitudes about
human papillomavirus vaccine in young women. Int J STD AIDS
the benefits of a vaccine that provides coverage for some of
2003;14:300 – 6.
the most common HPV types. In addition, with the arrival [21] Boehner CW, Howe SR, Bernstein DI, Rosenthal SL. Viral sexually
of several adolescent-focused vaccines, physicians have the transmitted disease vaccine acceptability among college students. Sex
opportunity to offer parents a set of preventive measures Transm Dis 2003;30:774 – 8.
 G.D. Zimet / Journal of Adolescent Health 37 (2005) S17–S23 S23

[22] Rosenthal SL, Kottenhahn RK, Biro FM, Succop PA. Hepatitis B [41] Tarkowski TA, Koumans EH, Sawyer M, et al. Epidemiology of
vaccine acceptance among adolescents and their parents. J Adolesc human papillomavirus infection and abnormal cytologic test results in
Health 1995;17:248 –54. an urban adolescent population. J Infect Dis 2004;189:46 –50.
[23] Lazcano-Ponce E, Rivera L, Arillo-Santillan E, et al. Acceptability of [42] Brown DR, Shew ML, Qadadri B, et al. A longitudinal study of
a human papillomavirus (HPV) trial vaccine among mothers of ado- genital human papillomavirus infection in a cohort of closely fol-
lescents in Cuernavaca, Mexico. Arch Med Res 2001;32:243–7. lowed adolescent women. J Infect Dis 2005;191:182–92.
[24] Mays RM, Sturm LA, Zimet GD. Parental perspectives on vaccinat- [43] Moscicki AB, Shiboski S, Broering J, et al. The natural history of
ing children against sexually transmitted infections. Soc Sci Med human papillomavirus infection as measured by repeated DNA test-
2004;58:1405–13. ing in adolescent and young women. J Pediatr 1998;132:277– 84.
[25] Davis K, Dickman ED, Ferris D, Dias JK. Human papillomavirus [44] Franco EL, Villa LL, Sobrinho JP, et al. Epidemiology of acquisition
vaccine acceptability among parents of 10- to 15-year-old adoles- and clearance of cervical human papillomavirus infection in women
cents. J Low Genit Tract Dis 2004;8:188 –94. from a high-risk area for cervical cancer. J Infect Dis 1999;180:1415–
23.
[26] Zimet GD, Mays RM, Sturm LA, et al. Parental attitudes about
[45] Sellors JW, Karwalajtys TL, Kaczorowski J, et al. Incidence, clear-
sexually transmitted infection vaccination for their adolescent chil-
ance and predictors of human papillomavirus infection in women.
dren. Arch Pediatr Adolesc Med 2005;159:132–7.
Can Med Assoc J 2003;168:421–5.
[27] Olshen E, Woods ER, Austin SB, et al. Parental acceptance of the
[46] Franco EL, Harper DM. Vaccination against human papillomavirus
human papillomavirus vaccine. J Adolesc Health 2005;37:248 –51.
infection: a new paradigm in cervical cancer control. Vaccine 2005;
[28] Zimet GD, Perkins SM, Sturm LA, et al. Predictors of STI vaccine
23:2388 –94.
acceptability among parents and their adolescent children. J Adolesc [47] Anhang R, Stryker JE, Wright TC Jr, Goldie SJ. News media cov-
Health 2005;37:179 – 86. erage of human papillomavirus. Cancer 2004;100:308 –14.
[29] Dempsey AF, Zimet GD, Davis RL, Koutsky L. Parental acceptance [48] Borzekowski DLG, Rickert VI. Adolescent cybersurfing for health
of HPV vaccine: a randomized, controlled trial of written information information: a new resource that crosses barriers. Arch Pediatr Ado-
about HPV. Pediatrics 2005; In press. lesc Med 2001;155:813–7.
[30] Mays RM, Zimet GD. Recommending STI vaccination to parents of [49] Davies P, Chapman S, Leask J. Antivaccination activists on the world
adolescents: the attitudes of nurse practitioners. Sex Transm Dis wide web. Arch Dis Child 2002;87:22–5.
2004;31:428 –32. [50] Leask J, Chapman S. ‘An attempt to swindle nature’: press anti-
[31] Raley JC, Followwill KA, Zimet GD, Ault KA. Gynecologists’ atti- immunisation reportage 1993–1997. Aust N Z J Public Health 1998;
tudes regarding human papilloma virus vaccination: a survey of 22:17–26.
Fellows of the American College of Obstetricians and Gynecologists. [51] Lashuay N, Tjoa T, de Nuncio MLZ, et al. Exposure to immunization
Infect Dis Obstet Gynecol 2004;12:127–33. media messages among African American parents. Prev Med 2000;
[32] Riedesel JM, Rosenthal SL, Zimet GD, et al. Attitudes about human 31:522– 8.
papillomavirus vaccine among family physicians. J Pediatr Adolesc [52] Keane MT, Walter MV, Patel BI, et al. Confidence in vaccination: a
Gynecol 2005; In press. parent model. Vaccine 2005;23:2486 –93.
[33] Rupp R, Stanberry LR, Rosenthal SL. New biomedical approaches [53] Gust D, Brown C, Sheedy K, et al. Immunization attitudes and beliefs
for sexually transmitted infection prevention: vaccines and microbi- among parents: beyond a dichotomous perspective. Am J Health
cides. Adolesc Med Clin 2004;15:393– 407. Behav 2005;29:81–92.
[34] Siegel RM, Baker RC, Kotagal UR, Balistreri WF. Hepatitis B vac- [54] Ball LK, Evans G, Bostrom A. Risky business: challenges in vaccine
cine use in Cincinnati: a community’s response to the AAP recom- risk communication. Pediatrics 1998;101:453– 8.
mendation of universal hepatitis B immunization. J Natl Med Assoc [55] Evans G, Bostrom A. The evolution of vaccine risk communication in
1994;86:444 – 8. the United States: 1982–2002. In: National Institute of Allergy and
[35] Maheux B, Haley N, Rivard M, Gervais A. STD risk assessment and Infectious Diseases, ed. Jordan Report 20th anniversary: Accelerated
Development of Vaccines 2002. Washington, DC: U.S. Department
risk-reduction counseling by recently trained family physicians. Acad
of Health and Human Services, National Institute of Allergy and
Med 1995;70:726 – 8.
Infectious Diseases, 2002:58 –71.
[36] Millstein SG, Igra V, Gans J. Delivery of STD/HIV preventive
[56] Sturm LA, Mays RM, Zimet GD. Parental beliefs and decision-
services to adolescents by primary care physicians. J Adolesc Health
making about child and adolescent immunization. From polio to
1996;19:249 –57.
sexually transmitted infections. J Dev Behav Pediatr 2005; In press.
[37] Schuster MA, Bell RM, Petersen LP, Kanouse DE. Communication
[57] Diekema DS, American Academy of Pediatrics Committee on Bio-
between adolescents and physicians about sexual behavior and risk ethics. Responding to parental refusals of immunization of children.
prevention. Arch Pediatr Adolesc Med 1996;150:906 –13. Pediatrics 2005;115:1428 –31.
[38] Torkko KC, Gershman K, Crane LA, et al. Testing for chlamydia and [58] Spigener SD, Mayeaux EJ Jr. Patient education and issues of HPV
sexual history taking in adolescent females: results from a statewide infection. Hosp Pract 1998;33:133–5.
survey of Colorado primary care providers. Pediatrics 2000;106:e32. [59] Anhang R, Goodman A, Goldie SJ. HPV communication: review of
[39] Moscicki AB, Ellenberg JH, Vermund SH, et al. Prevalence of and existing research and recommendations for patient education. CA
risks for cervical human papillomavirus infection and squamous in- Cancer J Clin 2004;54:248 –59.
traepithelial lesions in adolescent girls. Arch Pediatr Adolesc Med [60] Gilbert LK, Alexander L, Grosshans JF, Jolley L. Answering fre-
2000;154:127–34. quently asked questions about HPV. Sex Transm Dis 2003;30:193– 4.
[40] Ho GYF, Bierman R, Beardsley L, et al. Natural history of cervico- [61] Humiston SG, Rosenthal SL. Challenges to vaccinating adolescents:
vaginal papillomavirus infection in young women. N Engl J Med vaccine implementation issues. Pediatr Infect Dis J 2005;24:S134 –
1998;338:423– 8. 40.