Maternal Perceptions of Vaccinating Boys against Human Papillomavirus (HPV) in Seoul, South Korea: A Descriptive Exploratory Qualitative Study

"...can serve as a starting point to determine contextually appropriate approaches to educate parents about the importance of HPV vaccination for their sons."

Although human papillomavirus (HPV) vaccination reduces the risk of HPV-associated cancers in both genders, it is frequently recognised only as a means of preventing cervical cancer, with little attention given to male HPV vaccination in many parts of the world, especially in Asian countries. Studies report that the HPV vaccination rate among Korean male adolescents ranges from 0.7-1.3%, compared to 35.0-43.8% for female adolescents. This study explores perceptions of male HPV vaccination and underlying factors for vaccine hesitancy among mothers of unvaccinated boys in Seoul, Korea.

The researchers conducted one-on-one telephone interviews with 10 mothers of unvaccinated middle-school-aged boys living in one of the 25 districts in Seoul. None of the mothers had been previously diagnosed with HPV-related diseases, and 6 mothers had never received an HPV vaccine. The average age of the mothers' sons was 14.1 years. The interviews explored mothers' views on vaccinating boys against HPV and the reasons for not vaccinating their sons.

The researchers found that mothers were hesitant to vaccinate their sons against HPV due to high out-of-pocket costs, fear of side effects concerning the young age of their sons, and low awareness of HPV and HPV vaccine, all of which stemmed from the exclusion of male HPV vaccination from the national immunisation programme (NIP). Mothers explained that part of their lack of knowledge was attributed to how the vaccine was labeled. In Korea, the English abbreviation of "HPV" and the Korean word for human papillomavirus are unfamiliar to lay people and, thus, rarely used. The HPV vaccine is commonly referred to as "the cervical cancer vaccine", which conveys the false message that the vaccine is irrelevant to their sons. Many of them did not even know that males could get the HPV vaccine, let alone that males are potential carriers of STIs.

Sociocultural factors, including vaccination norms and values associated with sexually transmitted infections (STIs), were also likely to negatively impact mothers' vaccination decision-making. With the ongoing tendency among community members not to vaccinate their sons, mothers were not willing to deviate from the norm of non-vaccination and experiment on their own sons. Furthermore, the cultural influence of circumventing the sensitive topic of sexual health and inexperience talking about sex for the mothers led to mothers' unwillingness to explain HPV and HPV vaccination. Other factors include limited sex education at school and lack of recommendations from healthcare providers. In Asian cultures, parents tend to be heavily influenced by, or even defer decision-making regarding HPV vaccination to, physicians. Perceived disapproval from the mothers' most trusted source of health information was a reason for them to be undecided or postpone the vaccine for their sons.

Despite the barriers, mothers were willing to accept HPV vaccination when it was framed as cancer prevention for not only the sons but also their future spouses. This finding reinforces the notion that individuals are more likely to undergo a behavioural change when they have higher perceived susceptibility or when an issue becomes more salient to them. For example, messages about penile cancer prevention may draw attention from parents of boys and result in increased vaccine acceptability. According to the researchers, "Focus on perceived relevance is vital when promoting HPV vaccination in males, and cancer protection benefits should be presented for males along with their future partners using pertinent gain-framed messages."

Among the other recommendations provided in response to the findings: Community-based interventions that create a casual environment for vaccination promotion and the correction of misinformation may change parents' perceptions of the HPV vaccine for boys. For example, public service announcements and webinars in health clinics to raise awareness about male HPV vaccination, as well as images of positive parenting to protect their son against HPV in the media, have been reported as effective methods. Also, mothers in this study, most of whom were university graduates, believed that the topic of HPV vaccination should be part of the sex education their sons receive at school. "This effort may facilitate mother-son sexual health communication at home with a more positive outlook on HPV vaccination for sons."

In conclusion, themes gleaned from the data highlight that the reasons for mothers' hesitancy towards HPV vaccine uptake for their sons are multifaceted, primarily stemming from the exclusion of male HPV vaccination from the NIP. To alleviate negative sentiments around the HPV vaccine for boys, healthcare providers in community-based clinics should emphasise and convey the importance of gender-neutral HPV vaccination. Finally, tailored cancer prevention messages should be delivered to parents of boys that highlight the significant benefits of the vaccine beyond the prevention of cervical cancer.