Parental Attitudes About Sexually Transmitted Infection Vaccination for Their Adolescent Children

ARTICLE Parental Attitudes About Sexually Transmitted Infection Vaccination for Their Adolescent Children

Gregory D. Zimet, PhD; Rose M. Mays, RN, PhD; Lynne A. Sturm, PhD; April A. Ravert, MS; Susan M. Perkins, PhD; Beth E. Juliar, MA, MS

Objectives: To evaluate parental attitudes about adoles- Results: The mean vaccine scenario rating was 81.3. Sexu- cent vaccination as a function of vaccine characteristics, in- ally transmitted infection vaccines (mean, 81.3) were not cluding whether the vaccine prevented a sexually transmit- rated differently than non-STI vaccines (mean, 80.0). Con- tedinfection(STI),andtoexplorepossiblesociodemographic joint analysis indicated that severity of infection and vac- predictors of acceptability of STI vaccines. cine efficacy had the strongest influence on ratings, followed by availability of behavioral prevention. Mode of Design: Participants were 278 parents who accompa- transmission had a negligible effect on ratings. Child age nied their children (69.1% female, aged 12-17 years) to (P=.08) and sex (P=.77), parent age (P=.32) and educa- appointments at medical clinics. By using computer- tion (P=.34), insurance status (P=.08), and data collection based questionnaires, parents rated 9 hypothetical vac- site (P=.48) were not significantly associated with STI vaccine scenarios, each of which was defined along 4 di- cine acceptability. mensions: mode of transmission (STI or non-STI), severity Conclusions: Parents were accepting of the idea of vac- of infection (curable, chronic, or fatal), vaccine efficacy cinating their adolescent children against STIs. The most (50%, 70%, or 90%), and availability of behavioral meth- salient issues were severity of infection and vaccine ef- ods for prevention (available or not available). Willing- ficacy, not sexual transmissibility. Parents also favored ness by parents to vaccinate their adolescents under each vaccines for infections that had no method of behav- vaccine scenario was assessed on a scale that ranged from ioral prevention available. 0 to 100. Conjoint analysis was used to determine the relative contribution of each dimension to the ratings. Arch Pediatr Adolesc Med. 2005;159:132-137

EVERAL VACCINES FOR THE best predictor of adolescent acceptance was prevention of sexually trans- the adolescent’s belief that vaccination was mitted infections (STIs) are in regarded as important by the parent.8 This various stages of develop- finding suggests that the success of these ment. Included among these immunization programs will depend to a Sare preventive vaccines for Neisseria gon- large extent on parental acceptance of STI orrhoeae, Chlamydia trachomatis, herpes immunization for adolescents and pre- simplex virus type 2 (the principal cause adolescents. Furthermore, it has been sug- of genital herpes), human papillomavi- gested that pediatricians may be reluc- rus (HPV), and human immunodefi- tant to recommend STI vaccination,9 an ciency virus.1-4 Based on cost-effective- attitude that may be due, in part, to an- ness analyses, the Institute of Medicine ticipation of negative parental reactions. suggested that many STI vaccines are likely to result in substantial savings in health For editorial comment Author Affiliations: care costs.5 Ideally, an effective STI im- see page 190 Department of Pediatrics munization program would target young (Drs Zimet and Sturm and adolescents and preadolescents, prefer- Although several studies have exam- Ms Ravert) and Section of ably before they become sexually ac- ined determinants of acceptability of Biostatistics (Dr Perkins and tive.5-7 Sexually transmitted infection im- hypothetical STI vaccines, including Ms Juliar), Indiana University munization strategies targeted toward individuals’ health beliefs10-16 and atti- School of Medicine; and 6,17,18 Department of Family Health, children and early adolescents will place tudes about vaccine characteristics, Indiana University School of much of the decision-making burden on relatively little has been published Nursing (Dr Mays), parents. For instance, a study of hepatitis related to parental attitudes.19-21 One Indianapolis. B vaccination of adolescents found that the study examined attitudes of mothers in

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Sexually Transmitted Infection Severity of Infection Efficacy, % Behavioral Prevention Available Score, Mean (SD)* No Chronic 50 Yes 74.9 (27.6) Yes Curable 50 No 75.7 (26.6) No Curable 70 Yes 76.4 (27.7) Yes Curable 90 Yes 80.9 (25.9) Yes Fatal 50 Yes 81.2 (26.0) Yes Chronic 70 No 82.0 (24.3) Yes Chronic 90 Yes 83.8 (22.8) Yes Fatal 70 Yes 84.4 (23.3) No Fatal 90 No 88.6 (20.2)

*Vaccine scenarios were rated on a scale of 0 to 100, in increments of 10, reflecting the probability of parental acceptance of vaccination for their child.

Mexico about the idea of HPV/cervical cancer vaccina- participants were recruited from clinic waiting rooms by re- tion for their adolescent daughters. The results indi- search assistants and oriented to the research project. Of the cated that more than 83% of the mothers would allow eligible potential participants approached (those able to un- their daughters to have the vaccine.19 However, many of derstand English who had a child aged 12-17 years), 62.8% the participants may not have understood that HPV is agreed to participate. Of the 37.2% who declined participa- tion, 67.4% declined because of time constraints. Once the ques- an STI. A second qualitative study involved in-depth tionnaire was started, all participants adequately completed the interviews performed with 34 parents from the United instrument. 20 States. Content analysis indicated that most parents Data were collected via anonymous, audio, computer- approved of the STI vaccines described (for gonorrhea, assisted, self-administered interviews. Notebook computers with genital herpes, HPV, and human immunodeficiency touch-sensitive screens were used, allowing respondents to an- virus). Parents opposed to vaccination with one or swer questions by touching the screen with a plastic stylus. The more of the vaccines generally perceived their children study was approved by the university’s Institutional Review to be at less risk for infection. Another recently pub- Board, and written informed consent was obtained from all par- lished study initially found somewhat lower endorse- ticipants. Construction of the content of the audio, computer- ment by parents of an HPV vaccine (55%), but demon- assisted, self-administered interviews was based on prior STI vaccine research6,13,17,22 and preliminary semistructured inter- strated an increase to 75% endorsement of vaccination 20 21 views performed with parents. Before fielding the audio, com- after a brief educational intervention. puter-assisted, self-administered interviews, 20 pilot question- The primary objective of the present study was to evalu- naires were administered in paper-and-pencil format with ate how different characteristics associated with vacci- debriefing interviews to ensure that questions were under- nation (eg, sexual transmissibility of the infection, se- stood and that relevant issues were addressed. verity of the infection, efficacy of the vaccine, and availability of behavioral methods of prevention) might MEASURES influence parents’ willingness to have their children vaccinated. An additional exploratory objective was to ex- Background Information amine whether the age and sex of the child would influence parental acceptability of STI vaccination. It is possible Background variables assessed included parent and child age that parents may be more willing to vaccinate younger and sex, clinic site (urban adolescent health clinic or private children (because the potential onset of sexual activity practice), insurance status, and parental education. is more distant and, therefore, less threatening) and girls (because girls and women typically experience greater Vaccine Acceptability adverse consequences due to an STI). Our primary research aim was to determine whether acceptability of STI To assess vaccine acceptability, participants responded to 9 items. The items were presented in random order by the computer to vaccines would be influenced by the following charac- eliminate the possible influence of ordering effects. Each item teristics: (1) the sexual transmissibility of the infection described a hypothetical vaccine scenario uniquely defined along being prevented, (2) the severity of the infection, (3) the the following 4 dimensions: mode of transmission (STI or non- efficacy of the vaccine, and (4) whether behavioral meth- STI), severity of infection (curable with antibiotics, chronic and ods are available for preventing infection. incurable, or usually fatal), vaccine efficacy (50%, 70%, or 90%), and availability of behavioral methods of prevention (yes or no). For example, one scenario read as follows: “This vaccine keeps METHODS people from getting a disease that can be sexually transmitted. The disease can be cured with antibiotics. The vaccine works SAMPLE AND STUDY DESIGN for 9 out of 10 people who get it. Using condoms will keep a person from getting the disease.” The Table provides descrip- Data were collected from parents or guardians who accompa- tions of the 9 vaccine scenarios. Parents were asked, “If this nied their children (aged 12-17 years) to medical appoint- vaccine was available today and you had the time, would you ments at urban primary care adolescent health clinics and com- let your child get vaccinated?” An 11-point response format was munity-based pediatric private practice settings. Parent provided, ranging from 0 (“I would never let my child get this

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©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 vaccine”) to 100 (“I would definitely let my child get this vac- RESULTS cine”) in intervals of 10. These 9 items allowed us to evaluate the relative effects of STI transmission, the severity of infection, vaccine efficacy, and availability of behavioral preven- The 278 parents or guardians who participated in this tion on vaccine acceptability. study were 92.8% female and ranged in age from 24 to Sexually transmitted infection vaccine acceptability in gen- eral was evaluated by creating a scale score based on the mean 66 years (mean, 40.9 years; SD, 7.2 years). Their chil- value across 6 of the 9 items addressing vaccines preventing STIs dren were 69.1% female and ranged in age from 12 to 17 (coefficient ␣=.92). The acceptability of non-STI vaccines was years (mean, 14.4 years; SD, 1.5 years). Of the children, assessed by creating a scale score based on the mean value across 66.5% were recruited from urban adolescent medicine the 3 remaining items (coefficient ␣=.77). The unequal num- clinics and 33.5% from private practice settings. Of the ber of STI vs non-STI vaccines was an unavoidable result of the parents, 56.1% described themselves as white, whereas fractional factorial design generated for the conjoint analysis 39.6% described themselves as African American. Less method (see the “Data Analysis” subsection of this section for than 2% reported Hispanic ethnicity. In terms of paren- more information) and did not seem to bias the analysis. tal education level, the participants were fairly evenly di- vided, with 26.3% reporting less than high school edu- DATA ANALYSIS cation, 25.2% reporting a high school degree, 30.6% indicating having received some college education, and A paired t test was used to compare the mean score for the 6 STI vaccine scenarios with the mean score for the 3 non-STI 18.0% reporting a 4-year college degree. Of the parents, vaccine scenarios. The associations of continuous back- 65.7% reported that they either received Medicaid or were ground variables (parent and child ages) to the 6-item STI vac- self-pay for medical care, whereas the remaining 34.3% cine acceptability measure were evaluated with Pearson prod- reported having private insurance. uct moment correlations. A 1-way analysis of variance was used Across the 9 vaccine scenarios, overall willingness of to evaluate the association of each categorical variable (child parents to accept vaccination for their adolescent chil- sex, data collection location, insurance status, and parental edu- dren ranged from 0 to 100 (mean, 81.3; SD, 21.1). The cation) to STI vaccine acceptability. least acceptable vaccine scenario (“This vaccine keeps A full-profile ratings-based conjoint analysis was used to evalu- people from getting a disease that is not sexually trans- ate the effects of vaccine scenario dimensions on parental will- mitted. The disease cannot be cured, but people don’t die ingness to allow childhood vaccination. This regression-based analytic technique is frequently used in marketing research to from it. The vaccine works for 5 of 10 people who get it. evaluate how the characteristics of a product influence the prod- Washing hands several times a day will keep a person uct’s acceptability.23 During the past several years, conjoint ana- from getting the disease.”) received a mean score of 74.9 lytic techniques have increasingly been applied to the study of (SD, 27.6), whereas the most acceptable vaccine sce- health care preferences,24-27 including preferences related to hy- nario (“This vaccine keeps people from getting a dis- pothetical human immunodeficiency virus vaccines.6,28 As pre- ease that is not sexually transmitted. People die from this viously noted, in this study there were 4 dimensions evaluated disease in most cases. The vaccine works for 9 of 10 people (sexual transmissibility of infection, severity of infection, vac- who get it. Washing hands several times a day will not cine efficacy, and availability of behavioral prevention), each with keep a person from getting the disease.”) received a mean either 2 or 3 attribute levels (eg, sexual transmissibility had 2 score of 88.6 (SD, 20.2). The Table lists the mean scores levels, whereas vaccine efficacy had 3 levels). Presenting every possible combination of characteristics (ie, a full factorial de- and standard deviations for all 9 vaccine scenarios. A sign) would have involved asking participants to rate 36 sepa- paired t test indicated that the mean score for the 6 STI rate vaccine scenarios, a process that would be repetitious and vaccine scenarios (score, 81.3) was higher, although not time-consuming. Therefore, we chose to use a fractional facto- significantly so, compared with the mean score for the 3 rial design with a representative subset of 9 scenarios, which was non-STI vaccine scenarios (score, 80.0) (t=1.9, P=.06). constructed using a procedure (Conjoint) from a commercially Parent and child ages were not significantly correlated available software program (SPSS).29 The use of a fractional fac- with STI vaccine acceptability (r=0.06 [P=.32] and r=0.11 torial design makes the rating task more feasible, but limits the [P=.08], respectively). Sexually transmitted infection vac- analysis to the main effects of each dimension. cine acceptability also was not significantly associated with Conjoint analysis of the 9 vaccine items resulted in the de- child sex (F=0.09, P=.77, ␩2Ͻ0.001), data collection lo- velopment of a descriptive model, which provided information ␩2 on each subject’s relative preferences with respect to attributes cation (F=0.49, P=.48, =0.002), insurance status ␩2 within each dimension (eg, preference for an STI vaccine vs a (F=3.2, P=.08, =0.011), or parent education (F=1.13, 2 non-STI vaccine within the sexual transmissibility dimension). P=.34, ␩ =0.012). In conjoint analysis, these relative preferences are called part- Eighty-one parents (29.1%) gave each of the 9 con- worth utilities. The more that respondents preferentially distin- joint vaccine scenarios the same score. Of these 81 re- guish among attributes, the wider the range in part-worth utili- spondents, 2 gave ratings of 0 across all vaccines, indi- ties. For example, if an STI vaccine was strongly preferred relative cating that they found none of the vaccines acceptable. to a non-STI vaccine, the STI attribute would have a high posi- Five parents gave ratings of 50 to all vaccines. Seventy- tive part-worth utility value and the non-STI attribute would have four parents (26.6% of the total sample) gave ratings of an equally strong, but negative, part-worth utility value. For each 100 to every vaccine, indicating that they found all of the dimension, the sum of the part-worth utilities is 0. The extent to which each dimension contributed to the vaccine ratings was vaccines to be acceptable for their children. By using analy- measured by importance scores, which reflect the relative ranges sis of variance and logistic regression, we examined of the part-worth utilities across the 4 dimensions. In this ap- whether these high acceptors of vaccination (n=74) dif- proach to conjoint analysis, the sum of importance scores across fered from the remaining participants (n=204) in terms dimensions always equals 100. of the sociodemographic measures previously de-

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©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 scribed. Parent age was not significantly different for high ␩2 compared with low acceptors (F=0.59, P=.44, =0.002). Sexually Yes The high acceptor group had children who were signifi- Transmitted cantly, but marginally, older (mean age, 14.7 years) than No Curable the low acceptor group (mean age, 14.2 years) (F=4.55, Severity 2 Chronic P=.03, ␩ =0.016). Child sex was not associated with ac- of Infection ceptor group (odds ratio [OR], 1.08; 95% confidence in- Fatal terval [CI], 0.60-1.93). However, parents who were re- 50 cruited from the urban clinics were more likely to be high Efficacy, % 70 acceptors than those who were recruited from the pri- 90

vate practice settings (OR, 2.20; 95% CI, 1.18-4.09). Simi- Scenario Characteristics Vaccine Behavioral Yes larly, parents reporting self-pay for medical care or Med- Prevention icaid insurance were more likely to be high acceptors than No those with private insurance (OR, 2.31; 95% CI, 1.24- –10 –8 –6 –4 –2 0 2 4 6 8 10 4.30). Finally, parents who had not graduated from high Part-Worth Utility Scores school (OR, 4.30; 95% CI, 1.62-11.43) and parents with a high school diploma (OR, 3.36; 95% CI, 1.25-9.06) were Figure. The part-worth utility values across dimensions. more likely to be high acceptors than those who had graduated from college. ential in vaccine ratings, with importance scores rang- Given that 81 participants demonstrated no variabil- ing from 12.0 to 55.6 (mean, 29.2; SD, 10.4). ity in preferences across the vaccine scenarios, by neces- sity they were eliminated from the conjoint analysis, which is designed to identify determinants of preferences. The COMMENT overall conjoint model, therefore, was based on the remaining 197 respondents. This study evaluates factors related to the willingness of The conjoint analysis resulted in the following find- parents to have their adolescent children vaccinated. We ings. There was little difference in acceptability to par- focused this particular study on the following character- ents of an STI compared with a non-STI vaccine. How- istics of the vaccination situation: sexual transmissibil- ever, parents expressed a clear and strong preference for ity of the infection, severity of the infection, vaccine ef- a vaccine that prevented a potentially fatal infection com- ficacy, and availability of behavioral prevention methods. pared with vaccines that prevented a chronic or curable We were also interested in examining possible demo- infection. In addition, there was a relatively strong pref- graphic predictors of STI vaccine acceptability. A pri- erence for a 90% efficacious vaccine vs 70% and 50% ef- mary finding of this study was the willingness of most ficacious vaccines. Finally, parents expressed a mild rela- parents to consider STI vaccination for their adolescent tive preference for a vaccine that prevented an infection children, regardless of parent age, child age, child sex, for which there was no behavioral prevention available data collection location, insurance status, or parent edu- compared with one for which a behavioral prevention cation. More than one quarter of the sample indicated strategy existed. The Figure shows the part-worth util- 100% willingness to vaccinate their children with any of ity values across the dimensions. As previously noted, the 9 vaccines described. These high acceptors were more conjoint analysis importance scores are derived from the likely to be recruited from urban clinics, were less likely range of part-worth utilities and reflect the extent to which to have private insurance, and were more likely to have each dimension contributed to parental ratings of vac- a high school education or less. Our results are gener- cine scenarios. Vaccine efficacy was most influential in ally consistent with a recent study that involved a ran- vaccine ratings (importance score, 44.5), followed by se- dom digit–dialing survey of 315 parents of children verity of infection (importance score, 31.4) and avail- younger than 18 years (Nicole Liddon, PhD, written com- ability of behavioral prevention (importance score, 17.7). munication, 1998). In this study, 69% of parents indi- Sexual transmissibility of the infection had negligible in- cated that they would have their child vaccinated against fluence on parental ratings (importance score, 6.4). The human herpesvirus 2. overall conjoint analysis model demonstrated an excel- The lack of a significant correlation of STI vaccine ac- lent fit with the data, reflected in a Pearson product mo- ceptability with child age in the present study indicates ment r of 0.99. that these parents did not differentiate the need for STI Although sexual transmissibility was not an impor- vaccination based on the age of their children. This find- tant issue for the parents overall, it was an important fac- ing, in turn, suggests that parents may not base decisions tor in ratings for a subset of the participants. By using a about vaccination on the relative temporal proximity of part-worth utility cutoff of 7.0 or −7.0 (indicating mod- their children to the onset of sexual activity. However, given erately strong preferences in the context of this study), that the adolescents in this study were 12 to 17 years of 31 parents (11.2% of the total sample) indicated a rela- age, it will be important in future research to extend the tively strong preference for an STI vaccine (part-worth age range downward to fully explore this issue. utilities, Ͼ7.0), whereas 16 parents (5.8% of the sample) It has been suggested that pediatricians and other ado- indicated relatively strong opposition to an STI vaccine lescent health care providers (eg, family practice physi- (part-worth utilities, Ͻ−7.0). For these 47 participants, cians and nurses) may be reluctant to recommend STI sexual transmissibility as a dimension was quite influ- vaccines to parents of adolescents, perhaps in part be-

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©2005 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/27/2021 cause of concerns about how parents might react to the reports in the literature that indicate that these same fac- recommendation.9 The high acceptability ratings re- tors are associated with underimmunization of young chil- ported by most parents in this study suggest that most dren.31,32 This discrepancy may be a reflection of some parents would not react negatively to the suggestion that of the limitations associated with having parents re- their children be immunized against STIs. As might be spond to hypothetical vaccines. However, the use of hy- expected, vaccine efficacy and severity of infection sub- pothetical scenarios is an unavoidable part of any re- stantially influenced parents’ ratings of vaccine sce- search focused on intention to try products not yet narios. This result is consistent with prior STI and hu- available. Furthermore, marketing and health behavior man immunodeficiency virus vaccination research studies research indicates that intention to perform a behavior with adolescents, college students, and other adults, which is a reasonable, if imperfect, predictor of performing the have found that efficacy of immunization and severity behavior.33,34 Finally, this study focused on vaccine sce- of infection are important determinants of acceptabil- nario characteristics and on sociodemographic factors. ity.6,17,18,20,30 We also found that parents were more likely In future studies of STI vaccine acceptability, other is- to endorse vaccines that prevented infections for which sues will need to be examined, including but not lim- no behavioral method of prevention was available. A pre- ited to parental health beliefs, religious beliefs relevant liminary qualitative study also found that some parents to vaccination and STIs, behavioral risk factors, and rel- talked about how their attitudes about STI vaccination evant parental history and experiences (eg, history of STI were influenced to some extent by the degree to which a in the parent). person could prevent infection through behavior (eg, ab- In summary, severity of infection, vaccine efficacy, and, stinence or condom use).20 As new STI vaccines become to a lesser extent, a lack of available behavioral preven- available, it may be important to emphasize to parents tion were associated with greater willingness of parents that behavior prevention methods do not always work, to accept vaccination for their adolescent children. Sexual that vaccination would not obviate the need for behav- transmissibility of the targeted infection was not an im- ioral prevention of STIs, and that, therefore, vaccina- portant issue for most parents, but was a concern for a tion against STIs would be a way of providing added pro- small subset. In addition, child age was not significantly tection against infection. correlated with STI vaccine acceptability. These results Our results did not support the notion that parents suggest that there is not substantial opposition by par- would be more reluctant to have their children vacci- ents to the idea of vaccinating their adolescent children nated with an STI vaccine compared with a non-STI vac- against STIs. If these findings are replicated in other cine. This result is relatively consistent with prelimi- samples of parents, it will be important to inform pedia- nary research, which indicated that most parents are tricians and other physicians and nurses that most par- focused on protecting their children’s health and not so ents will be likely to accept recommendations regarding concerned about the source of infection.20 Clearly, the STI vaccination. severity of disease and the efficacy of the vaccine were much more salient dimensions to these parents than was sexual transmissibility. There was, however, a small sub- Accepted for Publication: September 7, 2004. set of parents (5.8%) who expressed a relatively strong Correspondence: Gregory D. Zimet, PhD, Department antipathy toward an STI vaccine. In future studies, it will of Pediatrics, Indiana University School of Medicine, 575 be important to focus more specifically on this group of N West Dr, Room 070, Indianapolis, IN 46202 (gzimet parents to better understand the source of their reluc- @iupui.edu). tance to consider STI vaccination for their children. Funding/Support: This study was supported by grant U19 This study has several limitations, suggesting that the AI31494 from the National Institute of Allergy and In- results should be interpreted with some caution. First, fectious Diseases, Bethesda, Md. the sample of parents was a nonrandom clinic-based con- Acknowledgment: We thank Freddie Harris, BA, for his venience sample, indicating that the results cannot be gen- assistance with data entry and management. eralized to all parents. 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