Barriers towards HPV Vaccinations for Boys and Young Men: A Narrative Review

"HPV and HPV vaccination needs to be seen not as a women's problem but a responsibility for everyone. Therefore, it is urgent to vaccinate boys and men."

Human papillomavirus (HPV) infection causes cancer in men as well as women, yet HPV vaccine coverage is suboptimal among men in many countries. To understand barriers to pan-gender HPV vaccination, this narrative review examines publications about attitudes and beliefs regarding HPV vaccination for boys and young men.

A total of 103 studies conducted in North America, South America, Asia, Europe, and Oceania on the topic of HPV vaccination and boys/men, written in English and published from 2010-2021, were included in the final analysis. Findings include:

• There is broad variation in boys' opinions about HPV vaccination and in whether they intend to be vaccinated or not. Knowledge and awareness of cancer correlates with the intention to vaccinate. Schoolboys believe the school health service is an adequate arena for information about HPV and HPV vaccination. Boys also consider access to HPV vaccination to be a matter of equal rights.
• Studies indicate that young men have even lower knowledge about HPV vaccination than women, and they perceive their own susceptibility to be affected by the virus to be low. As usual, knowledge - especially knowledge regarding men's risk to be affected by HPV - increases vaccine acceptance. Furthermore, there is a correlation between young men's perceived self-efficacy in health practices and HPV vaccination intentions.
• Many parents who had accepted the vaccine for their daughters were not aware of the recommendation or the benefits for boys. Several studies have found that parents who had discussed sexual health with their sons were more likely to vaccinate. On the other hand, many parents were afraid the HPV vaccine would promote promiscuity. Further reasons not to vaccinate sons were the belief that the vaccine is harmful and/or gives limited benefit, fear of unknown side effects, and vaccine hesitancy in general. Perceived support from others in the decision is a facilitator for vaccine completion, especially recommendations from healthcare providers (HCPs).
• Although HCPs are generally in favour of including boys in national vaccination programmes, they routinely recommend vaccination to girls more often than to boys. HCPs face challenges such as parental vaccine hesitancy and lack of time to provide adequate information; some experience discomfort when discussing the link between HPV and sexual behaviour, especially when explaining oral and anal HPV transmission. Finally, even this group are concerned that the vaccine may decrease condom use.
• Men who have sex with men (MSM) tend to know more about the virus than other men, and they have in general a more favourable attitude towards HPV vaccination. However, only a minority have discussed the vaccine with HCPs, and MSM report feelings of stigma. Nonetheless, MSM have trust in healthcare and request more information, and the information given is an important facilitator for vaccination in this group.
• Cultural norms and religious and ethnic customs play a role as determinants of vaccine acceptance. For example, traditional patriarchal gender roles have an impact, and there may be a cultural taboo against discussing sexuality and sexual health, as well as perception of low risk due to religiously sanctioned sexual abstinence. Minority groups request targeted information about HPV and HPV vaccination adjusted to their cultural and ethnic group.
• Other barriers to HPV vaccination among boys/men include: low knowledge, ideas about sexual promiscuity, fear of side effects, and cost and logistics.

As has been highlighted from several perspectives in this review, the more one knows about HPV and the HPV vaccine, the greater the likelihood is that one will become vaccinated or have one's sons vaccinated. In terms of strategies for boosting knowledge, research has looked at the potential of mass media, for example, but a Canadian study showed that newspaper articles failed to mention the vaccine's approval for males and tended to report HPV's relation to cervical cancer to the exclusion of other HPV-associated cancers.

The researchers acknowledge that the nature of HPV transmission means that parents must discuss sexual health behaviour with their sons. They suggest that a school-based HPV vaccination could have positive consequences by encouraging open discussions in the family. School-based vaccination also provides an opportunity for HCPs to inform children about the virus and discuss sexual health in general, before the children have become sexually active. One way to strengthen HCPs' self-efficacy to address questions and concerns is by providing education and training about HPV and HPV vaccine.

In conclusion: "There is a need for interventions developed together with the stakeholders, i.e., HCPs, parents and the children themselves, both boys and girls (regardless of sexual identity). The school nurse and family physician should be encouraged to provide scientifically correct information about the virus, its transmission and its long-term risks. They should not shy away from non-judgmental discussions about sexual habits and the need to protect not just the individual but also their future sexual partners. They should be provided with information material that acknowledges diversity and addresses the differing situation of diverse ethnic minorities, cultural groups and sexual orientations."