Abstract
Men aged 27 to 45 are eligible for human papillomavirus (HPV) vaccination as of 2019, yet relatively little is known about whether they have received or intend to receive it. We conducted a cross-sectional, online survey among fathers aged 27 to 45 between March and April 2022, to assess associations between HPV vaccination awareness, behaviors, intentions, and psychosocial constructs from the Health Belief Model. We examined the characteristics of those who had (a) heard of the HPV vaccine, (b) already received ≥ 1 dose, and (c) intentions for future vaccination among those who had never been vaccinated. Among 400 men who completed the survey, 32% were not aware of the HPV vaccine. Among those who were aware, 41% had received ≥ 1 dose. Sixty-three percent of unvaccinated men reported that they intended to get vaccinated in the future. Multivariable logistic regression analyses revealed that age and race/ethnicity were associated with having been vaccinated previously. Among the unvaccinated, multivariable logistic regression analyses revealed that those with a higher perceived risk of HPV-associated cancer had 3.73 greater odds of reporting they would seek vaccination compared to those with lower perceived risk (95% confidence interval [CI] = [1.28, 12.3]). We did not find perceived benefits, barriers, or decision self-efficacy to be related to future vaccine intentions. Since recommendations for this group include shared clinical decision-making, public health efforts should focus on raising awareness of vaccine eligibility, emphasizing risk factors for HPV-associated cancers so that individuals have an accurate perception of risk, and encouraging conversation between men and their providers.
Introduction
Human papillomavirus (HPV) is the most common sexually transmitted infection in the world, with more than 80% of adults acquiring the virus at some point in their lifetimes (Chesson et al., 2014). Although infection typically resolves without issue, it can cause cancer and anogenital warts in both men and women. Each year in the United States, approximately 13 million people are diagnosed with an HPV infection, and 37,000 individuals are diagnosed with HPV-associated cancers, which include cervical, penile, anal, and oropharyngeal cancers (Centers for Disease Control and Prevention [CDC], 2022; Kreisel et al., 2021). Between the years 2015 and 2019, approximately 41% of all HPV-associated cancers in the United States occurred in men, and the incidence of HPV-associated cancer in men climbed by an average of 2.36% points per year from 2001 to 2017 (CDC, 2022; Liao et al., 2022). Oropharyngeal cancer is particularly prevalent in men and has outpaced the incidence of cervical cancer in the United States since 2012 (National Cancer Institute, 2023).
Safe and effective vaccines that protect against nearly all HPV-associated diseases have been available since 2006 (Kamolratanakul & Pitisuttithum, 2021; Meites et al., 2019; Rosenblum et al., 2021; Shimabukuro et al., 2019). Since their authorization, there have been numerous changes in recommendations and eligibility for HPV vaccination by gender and age. At the time of authorization (2006), the Centers for Disease Control and Prevention (CDC)’s Advisory Committee on Immunization Practices (ACIP) recommended routine vaccination for girls aged 11 to 12 and catch-up vaccination for women up to 26 years old. It was not until 2011 that the ACIP began recommending routine vaccination for men, although the cut-off for catch-up vaccination at that time was 21 years of age, except for certain subgroups (e.g., men who have sex with men). In 2019, 13 years after the first HPV vaccine authorization, recommendations were synchronized across genders. The FDA also extended HPV vaccine eligibility to all adults aged 27 to 45 years in 2019, with the ACIP recommending that healthcare providers engage in shared clinical decision-making with patients in this age range. This involves a joint decision that is individually tailored based on clinician recommendations and patients’ values and preferences (Davidson et al., 2022). While it is true that exposure to HPV for most individuals is likely to predate 27 years of age, it has also been shown that at the current rate of vaccination in the United States, the incidence of oropharyngeal cancer in men is estimated to continue rising for another 15 to 20 years, with a peak of 23,850 new cases per year (Damgacioglu et al., 2022). Increasing vaccination rates in men over the age of 27, many of whom likely missed the opportunities available to younger men and boys now, can help ameliorate this burden.
There is a voluminous literature on HPV vaccine knowledge, attitudes, and behaviors among adolescents (Mansfield et al., 2021) and young adult women (Heyman et al., 2011; Unger et al., 2015). However, since expanded vaccine eligibility, HPV vaccine awareness and adoption among those aged 27 to 45 years has received relatively little attention (Davidson et al., 2022). We identified only a few HPV vaccination studies that included men since 2019 (Adekanmbi et al., 2023; Alaraj et al., 2023; Arevalo et al., 2023; Galvin et al., 2023; Thompson et al., 2021). A qualitative study published in 2023 investigated knowledge, attitudes, and beliefs about HPV vaccination among men aged 27 to 45 (Alaraj et al., 2023). They reported that their participants had low awareness of the HPV vaccine and that they perceived the vaccine to be “new” and primarily for women. In hand with the misperception of the HPV vaccine as new, participants in this study were circumspect about the notion of getting vaccinated due to safety concerns. One study focused on vaccine uptake and used data from the 2018 Health Information National Trends Study, which included both men and women aged 27 to 45 years (n=725; Thompson et al., 2020). They reported that most individuals were aware of HPV and the HPV vaccine. Women were more likely to be aware than men (73% and 67%, respectively), as were those who had a higher level of education and those who previously sought information about cancer. Other studies have generally reported no differences between males and females in multivariable analyses in terms of HPV vaccination status or intention (Adekanmbi et al., 2023; Arevalo et al., 2023; Thompson et al., 2021). In general, systematic reviews of studies investigating HPV vaccination among younger men (age 26 years or younger), including those focusing specifically on racially/ethnically minoritized men, as well as others focused specifically among men who have sex with men, have determined that lack of knowledge, lack of provider recommendation, and beliefs about vaccine safety or benefits are associated with acceptance (mboree & Darkoh, 2021; Laserson et al., 2020; Newman et al., 2013).
The goal of this study was to assess HPV vaccine awareness, behaviors, and psychosocial constructs that have been reported to impact HPV vaccine behaviors among a diverse sample of men aged 27 to 45 years. We were particularly interested in a racially/ethnically diverse sample, as prior research has recorded differences in HPV vaccine behaviors across groups (Amboree & Darkoh, 2021). We had three primary research questions (RQs):
The Health Belief Model (HBM), which has been used extensively in studying HPV vaccine behaviors, provides the theoretical framework for this study (Becker, 1974; Brewer & Fazekas, 2007; Rosenstock et al., 1988). Central tenets of this model include perceived susceptibility (subjective perception of the risk of illness), perceived benefits (effectiveness of the behavior in reducing the threat of illness), perceived barriers (obstacles to performing the behavior), cues to action (stimulus to trigger the behavior), and self-efficacy (confidence in the ability to enact the behavior). The model hypothesizes that those most likely to engage in the behavior perceive themselves to be at risk of illness, believe that there are benefits to performing the behavior, perceive few obstacles to engaging in the behavior, experience cues to action, and have confidence in their ability to accomplish the behavior. In our study, we hypothesized that those who intended to be vaccinated had a greater perceived risk of developing HPV-related cancer, high perceived benefits of vaccination (safety and efficacy, protecting others), low perceived barriers (including logistical barriers, discomfort, lack of perceived need), and high levels of confidence in making an informed decision. We did not assess cues to action (provider recommendation) in the current study since current recommendations are for healthcare providers to talk with their patients, not make routine recommendations (see Figure 1 for our conceptual framework). Findings from the study will add to our understanding of the knowledge, attitudes, and behaviors regarding HPV vaccination in a demographic that has received less attention and can help guide public health actions.
Health Belief Model and HPV Vaccination
Method
An online, cross-sectional online survey (~15 min) was conducted between March 23 and April 5, 2022. This national survey focused on adult parents’ vaccine behaviors and intentions, as well as behaviors and intentions for their children. Therefore, the larger survey was conducted among adults (all genders, aged 27-45 years, N=800) with at least one child aged 0 to 17 years. For this study, only those who reported being assigned male at birth were included. The sample was recruited via a national Qualtrics panel, using racial/ethnic quotas (i.e., approximately 25% Black, 25% Latino, 25% Asian, and 25% White). Qualtrics is a U.S. survey company conducting health, social, and marketing research. They provide a cloud-based subscription software platform for creating and distributing online surveys. They maintain a verified panel of individuals designed to be representative of the U.S. population. Panelists have agreed to participate in research and are contacted by email with a hyperlink to participate in surveys in exchange for a modest incentive. All participants provided informed consent, and study procedures were approved by the Institutional Review Board at Tufts University (protocol #00001954).
Measures
Outcome Variables
We first assessed HPV vaccine awareness (RQ1) by asking respondents, “Have you ever heard of the HPV vaccine?” (yes, no, or don’t know). Among those who reported having heard of the vaccine, we asked, “Have you ever had the HPV vaccine?” (yes, no, or don’t know) (RQ2). If the participant responded in the affirmative, we inquired about the number of vaccine doses received (1, 2, or 3). Among those who had heard of the HPV vaccine but reported not receiving any doses (RQ3), we asked, “People aged 9–45 are eligible for the HPV vaccine. How likely are you to get the HPV vaccine in the future?” with responses on a five-point Likert-type scale from very likely to very unlikely.
Independent Variables
In line with the HBM, we included items to assess the following constructs:
Perceived Risks
We included one item that asked, “Compared to the average person your age, would you say that you are: more likely to get HPV-related cancer, less likely to get HPV-related cancer, or at the same risk to get HPV related cancer.”
Perceived Benefits
We included items to assess benefits related to oneself and others. Questions included several items from the validated Vaccine Confidence Index (Betsch et al., 2018). Specifically, we included 3 items that assessed confidence in vaccines: “I am completely confident that vaccines are safe,” “Vaccinations are effective,” and “Regarding vaccines, I am confident that public authorities decide in the best interest of the community.” For benefits related to “collective gains,” we included 2 items: “I get vaccinated because I can also protect people with a weaker immune system,” and “Vaccination is a collective action to prevent the spread of disease.” For all items, response options were on a seven-point Likert-type scale from strongly agree to disagree strongly. Higher scores on these scales indicate greater perceived benefits. Cronbach’s alphas for vaccine confidence and collective responsibility had values of 0.88 and 0.79, respectively, indicating good internal consistency in this sample.
Perceived Barriers
We conceptualized barriers as a lack of perceived need to be vaccinated, as well as logistical challenges getting the vaccine. We included five items from the Vaccine Confidence Index to assess barriers, including “Vaccination is unnecessary because vaccine-preventable diseases are not common anymore,” “My immune system is so strong, it also protects me against disease,” “Vaccine-preventable diseases are not so severe that I should get vaccinated,” “For me, it is inconvenient to receive vaccinations,” and “Visiting the doctor’s makes me feel uncomfortable; this keeps me from getting vaccinated.” For all items, response options were on a seven-point Likert-type scale from strongly agree to strongly disagree and combined for an overall score such that higher scores indicate greater perceived barriers. In this sample, the Cronbach’s alpha was 0.89, indicating good reliability.
Decision Self-Efficacy
We utilized the 11-item Decision Self-Efficacy Scale to evaluate vaccine decisions (O’Connor, 1995). Items assessed: confidence in the ability to “Get the information you need to make a decision about [getting vaccinated],” “Get facts about the benefits of [vaccines],” and “Get the facts about the risks of [vaccines].” It also assesses whether individuals feel that they can: “Understand available information about [vaccines] enough to be able to make an informed decision,” “Ask your healthcare provider questions about [vaccines] without feeling dumb,” “Express your concerns about [vaccines] to your healthcare provider,” and “Ask for advice about getting [vaccines].” The final questions assessed the extent to which respondents were able to: “Figure out the [vaccination] choices that best suit you personally,” “Handle unwanted pressure from others when making your choices about [vaccines],” “Tell your healthcare provider what you think is right for you,” and “Delay your decision if you feel you need more time to make decisions about [vaccines].” Responses are on a three-point Likert-type score such that higher scores indicate greater self-efficacy. In this sample, the internal consistency was excellent, with a Cronbach’s alpha of .90.
Sociodemographic Characteristics
We also assessed age (grouped as 27-32, 33-39, and 40-45 years of age), race/ethnicity (grouped based on sample size, Hispanic, Non-Hispanic [NH] White, NH Asian, NH Black, NH another race [i.e., multiracial, Native American and Alaska Native, Native Hawaiian, and Pacific Islander]), annual household income (≥$75,000, $35,000 to 74,999, and <$35,000), health insurance (private or self-pay, public, or no insurance/unreported), gender identity at the time of survey, and assigned sex at birth.
Statistical Analysis
We started by examining descriptive statistics, including frequencies and percentages for categorical variables and mean and standard deviations (SD) for continuous variables. For RQ1, we summarized the proportion of men who reported having heard of the vaccine (see Figure 2). For RQ2, we compared the characteristics of participants who had received and had not received the vaccine among those who stated they were aware of it. For RQ3, we examined differences in socio-demographic characteristics, as well as perceived risk, benefits, barriers, and self-efficacy by future vaccine intentions (collapsing “very likely” and “somewhat likely” to “likely” and “somewhat unlikely” and “very unlikely” to “unlikely). Pearson’s chi-square tests or Fisher’s exact tests were used for categorical variables, and t tests for continuous variables were used to obtain p-values for the bivariate analyses. Two multivariable logistic regression models were constructed to explore: (a) associations between participant characteristics and HPV vaccination (RQ2), and (b) associations between participant characteristics and future HPV vaccine intentions (RQ3). The first model (RQ2) included only age and race/ethnicity (non-modifiable variables); we did not include the participant’s current income or current health insurance type as men in the sample could have received the vaccine from 2011 onward, making them anywhere from 15 to 33 years old at the time of vaccine authorization. Income and insurance are likely to have changed over this period. The second model (RQ3) included all current participant characteristics. Covariates were selected based on the bivariate analysis, specifically, variables with a p value <.10. The models were evaluated by the variance inflation factor for multicollinearity, Hosmer-Lemeshow goodness of fit test, and c-statistics. Odds ratios (ORs) and 95% confidence intervals (CIs) were computed from the logistic regression models. A p value <.05 was considered statistically significant. All analyses were performed in the R version 4.2.2.
Flowchart of Data Analysis
Results
RQ1: Awareness of the HPV Vaccine (n = 400)
Table 1 presents characteristics of the entire sample (n=400), stratified by awareness of the HPV vaccine. The mean age was 36.2 years. One hundred twenty-two individuals (30.5%) identified as Hispanic, 77 (19.3%) as NH White, 76 (19%) as NH Black, 92 (23%) as NH Asian, and 33 (8.3%) as NH Other (i.e., multiracial [n=15; 3.8%], Native American/Alaska Native [n=14; 3.5%], Pacific Islander [n=2; 0.5%]). Just over than two-thirds of the sample (n=274, 68.5%) had heard of the HPV vaccine. Among them, NH White had a higher proportion, and NH Black had a lower proportion compared with the corresponding proportions among those who had not heard of the HPV vaccine, χ2 (4, n = 400) = 16.95, p=.002. Those with less than US$35,000 annual income had a lower proportion among those who had heard of the HPV vaccine than those who had not, χ2 (2, n=400) = 14.02, p < .001.
Characteristics and Awareness of the HPV Vaccine (n = 400)
Note. NH = non-Hispanic.
Include “Not sure/Don’t know.” b A p-value was obtained from Chi-square or Fisher’s exact test. Values in bold indicate statistical significance. cAnother race includes multiracial, Native Americans, Native Alaska, Native Hawaiians, and Pacific Islanders. d Five subjects were excluded due to missing responses.
RQ#2: HPV Vaccination Among Those Aware of the Vaccine (n = 274)
Table 2 presents characteristics of men who had heard of the vaccine, stratified by vaccination status. Among the 274 participants who were aware of the HPV vaccine, 41% (n=112) reported having had at least one HPV vaccine dose. In bivariate analyses, there were significant differences in terms of age and race/ethnicity between those who had been vaccinated vs. those who had not.
Characteristics and HPV Vaccine Receipt Among Those Who Reported Awareness of the HPV Vaccine (n = 274)
Note. NH = non-Hispanic.
Include “Not sure/Don’t know.” b A p-value was obtained from chi-square or Fisher’s exact test. Values in bold indicate statistical significance. cAnother race includes multiracial, Native Americans, Native Alaska, Native Hawaiians, and Pacific Islanders. d Two subjects were excluded due to missing responses.
Table 3 presents the multivariable analysis of HPV vaccine receipt among those who were aware of the HPV vaccine. Men in the oldest age group (40–45 years) had about half the odds of having been vaccinated compared with those in the lowest age group (27–32 years; OR 0.49, 95% CI [0.26, 0.92]). In the context of race and ethnicity, those identifying as NH another race were significantly less likely to have been vaccinated compared with NH White (OR 0.23, 95% CI [0.07, 0.63]). NH Asian also appeared less likely, but it did not reach the statistically significant level (OR 0.49, 95% CI [0.23, 1.00]).
Multivariable Logistic Regression Model a (OR, 95% Confidence Interval)
Note. Receipt of one or more HPV vaccine doses versus no prior vaccination. OR = odds ratio; HPV = human papillomavirus; NH = non-Hispanic.
The model was evaluated with variance inflation factor (VIF<5), Hosmer-Lemeshow goodness of fit test (p>.05), and c-statistics (Area=.64, 95% CI= [0.58, 0.71]). b A p-value was obtained from a multivariable regression model. Values in bold indicate statistical significance.
Among those who were previously vaccinated (n=112), only 59.8% reported receiving two or more doses of vaccine (n=67); 31.3% reported having had only one dose (n=35), and 8.9% reported not knowing how many doses they received (n=10; data not shown in Tables). The reported ages for vaccination were: 23.2% reported vaccination at age 27 or older, 28.6% between ages of 18 to 26 years, 18.8% between ages of 15 to 17 years, and 29.4% reported obtaining the vaccine at age 14 or younger (data not shown).
RQ3: Among Those Not Previously Vaccinated, How Many Intend to Obtain an HPV Vaccine in the Future? (n = 162)
Table 4 presents future intentions to be vaccinated among men who were aware of the HPV vaccine but had never been vaccinated (n=162). Two-thirds (63%) reported that they were very/somewhat likely to get the vaccine in the future (n=102). In bivariate analyses, there were significant differences between groups in terms of age, χ2 (2, n=162) = 13.46, p< .001. Among men who answered they were unlikely to seek HPV vaccination in the future, over half (n= 32; 53.3%) were between the ages of 40 to 45 years. Men who reported they were likely to get the vaccine also had a significantly higher mean score on both domains of perceived benefits compared with those who were unlikely to seek vaccination (vaccine confidence: 12.9 vs. 15.2, p = .002; collective gains: 9.6 vs. 10.9, p = .002). There were no significant differences in perceived barriers or decision self-efficacy, and a marginal difference in perceived risk, although this difference was not statistically significant (p = .068).
Bivariate Associations Between Sociodemographic Characteristics and Intention to Get the HPV Vaccine in the Future
Note. HPV = human papillomavirus; NH = non-Hispanic.
“Unlikely” includes “Very unlikely,” “Somewhat unlikely,” and “Not sure/Don’t’ know.”b“Likely” includes “Very likely” and “Somewhat likely.”c A p value was obtained from Chi-square or Fisher’s exact test for categorical variables and t-test for continuous variables. Values in bold indicate statistical significance. d Another race includes multiracial, Native Americans, Native Alaska, Native Hawaiians, and Pacific Islanders. e One subject was excluded due to missing response. f Assessed by the question, “Compared to the average person your age, would you say that you are ¾ to get HPV-related cancer.”g Total score of three questions (potential score range 3–21). h Total score of 2 questions (potential score range 2–14). i Total score of 5 questions (potential score range 5–35). j Standardized total score of 11 questions (potential score range 0–100).
In multivariable analyses (Table 5), men who reported that they perceived themselves to be at higher risk of HPV-associated cancers had nearly four times greater odds of intending to be vaccinated in the future compared with those who believed themselves to be at lower risk (OR 3.73, 95% CI [1.28, 12.3]), regardless of age. There was a small difference in collective responsibility between groups, although this was not statistically significant (OR 1.16, 95% CI [0.98, 1.38]).
Odds Ratios and 95% Confidence Intervals: Multivariable Logistic Regression Analyses a for Intention to Obtain the HPV Vaccine in the Future
Note. OR = odds ratio; CI = confidence interval; HPV = human papillomavirus.
The model was evaluated with variance inflation factor (VIF<5), Hosmer-Lemeshow goodness of fit test (p>.05), and c-statistics (Area = 0.76, 95% CI = [0.68, 0.83]). b A p-value was obtained from a multivariable regression model. Values in bold indicate statistical significance.
Discussion
We assessed HPV vaccine awareness, receipt, and future vaccination intentions among fathers aged 27 to 45 years two years after the ACIP expanded vaccine eligibility to include this age group. Nearly a third of men had not heard of the HPV vaccine. Among those aware of the vaccine, 41% reported that they had previously received at least one dose. Men in the oldest age range (40-45 years) were half as likely to have been vaccinated compared with those in the lowest age range (27-32 years), and those reporting race/ethnicity as NH another race were significantly less likely to have been vaccinated as compared with men who identified as NH White. Among men not previously vaccinated but aware of the HPV vaccine, two-thirds (63%) reported that they were likely to get vaccinated in the future, and those who perceived themselves to be at greater risk than others had nearly four times greater odds of saying they would be vaccinated compared with those who perceived themselves to be at lower risk.
In our sample, 68% of men had heard of the HPV vaccine which is slightly higher than findings from the 2018 HINTS study in which 54% of men were aware of the HPV vaccine (Thompson et al., 2020). As parents of one or more children at 17 years or younger, our findings suggest that parents (who may be making HPV vaccine decisions for their children) have a higher likelihood of having heard of the vaccine. To a smaller degree, this may also be due to the additional 4 years that the vaccine has been available for men in this age range (data collection 2018 vs. 2022), but it is not surprising that parents are more aware given that HPV is universally recommended for everyone aged 9 to 26 years.
Past HPV Vaccination
Our findings that 41% of men in the sample had at least one dose of the vaccine and that younger men were more likely to have been previously vaccinated compared with older men are not surprising. Men in the 27- to 32-year age range would have been eligible to receive the vaccine in 2011, whereas those more than age 32 would not have been. The relationship between age and the likelihood of HPV vaccination has been demonstrated in other studies of men aged 18 to 26 (Adjei Boakye et al., 2018; Patel et al., 2018). In addition, catch-up vaccination for men up to age 26 was recommended only for high-risk groups (men who have sex with men, transgender, and immunocompromised individuals) until 2019. Still, findings suggest that most men have not been vaccinated and among those who have, only 60% had received at least two doses (data not shown). This suggests, like other studies (Alaraj et al., 2023; Pingali et al., 2023), that series completion is suboptimal, similar to women and girls (Bruni et al., 2021; Liu et al., 2016). Prior research on HPV vaccination among boys and younger men has revealed that there are many missed vaccination opportunities, perhaps resulting from changing ACIP guidelines (Cummings et al., 2015; Fontenot et al., 2014).
Across all age groups, NH White men were more likely than men in all other racial/ethnic groups to have received at least one dose of the vaccine. Prior studies have also reported that compared with NH White women, Hispanic and Black women tend to have less knowledge of HPV and the HPV vaccine, which leads to racial and ethnic disparities in vaccine uptake (Adjei Boakye et al., 2017; Amboree & Darkoh, 2021), although this trend is not clear in men (Adjei Boakye et al., 2018; CDC, 2021). Data presented in 2021 suggest that low awareness of the HPV vaccine among racial and ethnic minority groups is in part due to the absence of provider recommendations for the vaccine. Nonetheless, the acceptability of the vaccine among these groups is relatively high compared with non-Hispanic Whites (Amboree & Darkoh, 2021). For example, Black and Hispanic women more often sought HPV vaccine initiation for their children despite lower overall awareness of the HPV vaccine.
Future Intentions for HPV Vaccination
Our finding that men who felt themselves to be at higher-than-average risk of getting HPV-associated cancer had nearly four times greater odds of reporting that they intended to be vaccinated in the future is consistent with the posited relationships in the HBM. The relationship between the perceived risk of HPV-associated diseases and vaccination has been well documented among women and girls (Jain et al., 2009), as well as among younger men and men who have sex with men (Fontenot et al., 2014; Hunter & Weinstein, 2016; Meites et al., 2022). It is important to consider the context in which this study was performed. Data collection took place in March and April of 2022 during the COVID-19 pandemic. The pandemic dramatically affected primary care office visits (Hays & Skootsky, 2022; Saxena et al., 2021), as well as the public’s trust in vaccines (Carrieri et al., 2023). Given this backdrop, it is likely that, in March and April 2022, the participants were experiencing the psychological and logistic effects of the COVID-19 pandemic, and this may have influenced whether men got the HPV vaccine and their interest in getting vaccinated in the future.
Limitations
Before interpreting the practical implications of this study, we acknowledge that it is not without limitations. First, this was a cross-sectional sample, so causality could not be determined. Second, our sample was restricted to parents of children under the age of 18. Parents may have different attitudes, beliefs, and behaviors than men without children, so again, caution should be exercised when generalizing results. The racial/ethnic diversity of the sample is a strength, and we collected data from men across the nation; however, the study is not nationally representative. Another limitation is that we did not gather information regarding the sexual orientation of men in our sample. As the ACIP encouraged catch-up vaccination for men who have sex with men (CDC, 2011), men in this group may have different attitudes and behaviors with regard to HPV vaccination (Fontenot et al., 2016; Mann-Barnes et al., 2023; Reiter et al., 2010). We also did not examine factors related to intention to be vaccinated among the 32% of men who were not aware of the HPV vaccine before taking the survey as we did not feel that this would yield valid results. Given the lack of awareness of the HPV vaccine, it is likely that few, if any, of these men ever received it or would accurately recall their HPV vaccination status; this would mean that our findings underestimate the true proportion of those vaccinated. We also acknowledge that intention is not the same as behavior, although it is believed to be one of the most proximal predictors. Although two-thirds of the men who were aware of the HPV vaccine but not previously vaccinated said that they were amenable to getting vaccinated in the future, we cannot assume that they actually will or that their healthcare providers would recommend it. Finally, it would be valuable to investigate the likelihood of unvaccinated men in this age group initiating discussion regarding HPV vaccination with their healthcare provider. While it is helpful to know whether an individual would get vaccinated in the future, understanding the likelihood of initiating this discussion is valuable because the ACIP guidelines call for shared clinical decision-making, rather than a universal recommendation for men aged 27 to 45. It has been reported that there are many missed opportunities for HPV vaccination, and providers do not always initiate the decision-making process or are uncertain about how to undertake shared clinical decision-making (Kempe et al., 2021). A participant may report they are likely to get vaccinated in the future, but if the conversation does not arise, they may not get vaccinated.
Implications and Conclusion
Our findings suggest several implications for practice. First, many men are not aware of the HPV vaccine and, therefore, are not likely to raise it with their healthcare providers. Prior studies have determined that lack of knowledge and awareness are major barriers to vaccine uptake (Alaraj et al., 2023; Grandahl & Nevéus, 2021; Laserson et al., 2020; Ratanasiripong, 2015; Shin et al., 2022). As such, men’s lack of awareness means that they do not have access to the potential benefits of vaccination. Second, our findings suggest that perceptions about risk influence vaccine intentions, which is also consistent with prior research. Therefore, it is essential that men be given adequate information so that they can accurately assess their risks of developing HPV-related cancer. While shared decision-making is recommended for men in this age group, at least one study suggests that the burden of initiating shared decision-making with regard to HPV vaccination may lie with the patient (Alaraj et al., 2023). We recognize that time constraints and other challenges can make discussion of HPV and the HPV vaccine difficult at clinical visits (Gilkey & McRee, 2016) and that this may not take priority over other health issues. Per recommendations, healthcare providers are not required to raise HPV vaccination in this age group (Meites et al., 2019). Indeed, a major challenge is the lack of clinical guidelines that would enable providers to identify and counsel patients who may benefit from the vaccine. Most men above the age of 26 at the time of this survey were likely to have been excluded from consideration for the HPV vaccine, yet the incidence of HPV-associated cancers in men is now 41% in the United States, and this is predicted to climb (CDC, 2022; Damgacioglu et al., 2022). Most men over the age of 26 will indeed have been previously exposed to HPV; vaccination still conveys immunity toward types of HPV these men may have not yet been exposed to. Furthermore, data that suggest receipt of the HPV vaccine even after infection with the same type boosts immunity (Scherer et al., 2016). We believe this is a significant portion of the population that deserves consideration. While we did not assess provider recommendation in the current study, future research should examine providers’ confidence in engaging in SCDM with their patients about HPV vaccination. In addition to improving men’s awareness of their eligibility for vaccination and risk factors for HPV, it may be helpful to develop specific guidelines for providers to guide their recommendations. Taken together, these initiatives could help to ensure that men who could most benefit from the vaccine are engaged in SCDM with their healthcare providers and can arrive at a decision that is best for the individual.
Footnotes
Acknowledgements
Allen and Fontenot have full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. All authors made substantial contributions to the interpretation of data and have drafted the work or substantively revised it. All authors have approved the submitted version and agree both to be personally accountable for the author’s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.
Data Availability Statement
The dataset generated and analyzed during the current study is not publicly available but is available from the corresponding author on reasonable request. No AI technologies were used in the writing process of this manuscript.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Outside of the current work, Gregory Zimet has received consulting fees from Merck for work on HPV vaccination and has served on external advisory committees for Moderna (COVID-19 vaccination) and Pfizer (meningococcal vaccination), and through Indiana University, has also received investigator-initiated grant funding from Merck related to HPV vaccination. Dr. Fontenot has also received investigator-initiated grant funding from Merck regarding adolescent vaccination. Drs. Fontenot and Zimet confirm that their funding source(s) have had no involvement in the conduct of this work. No other authors have conflicts of interest to report, nor competing financial interests. None of the other authors have conflicts of interest to declare.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Tufts University Office of the Vice Provost for Research (PI Allen) and the Frances A. Matsuda Chair (Co-I Fontenot). EL and MM were partially supported by the U54MD007601 and the U54GM138062 from the National Institute of Health. The funding agency had no role in the study.
Ethical Approval
All study procedures were approved by the Institutional Review Board at Tufts University, Medford, Massachusetts.
Informed Consent
All study participants provided informed consent.
