A Qualitative Analysis of Young Sexual Minority Men's Perspectives on Human Papillomavirus Vaccination

This study was conducted to inform interventions for promoting human papillomavirus (HPV) vaccination among young men who have sex with men (MSM), who are disproportionately affected by cancers caused by HPV, such as anal cancer. A vaccine determined to be safe and effective for preventing HPV infection has been available for males in the United States (US) since 2011, yet uptake among MSM is low.

The study was guided by the Information, Motivation, and Behavioral Skills (IMB) model, which proposes that individuals engage in health behaviour when they are adequately informed, are motivated to act, and have the appropriate behavioural skills and self-efficacy to do so. The motivation component consists of personal motivation (e.g., attitudes toward HPV vaccination, perceived vulnerability to HPV infection, and perceived severity of HPV infection) and social motivation (e.g., subjective norms for HPV vaccination and social support for HPV vaccination).

Twenty-nine men who were 18-26 years of age, living in Chicago, Illinois, US, and who identified as gay, bisexual, or queer participated in a semistructured interview that was guided by the IMB model and that assessed relevant contextual factors (e.g., provider recommendation). Twenty of the participants had not been vaccinated against HPV. Interviews were coded for recurring themes, which are shared through quotations included in Table 2 in the paper. In brief:

• Information: Most participants were aware of HPV and the HPV vaccine; however, misconceptions and knowledge gaps were common, with many believing that HPV vaccination was only for women.
• Motivation: Factors included: perceived advantages (e.g., reducing risk of HPV-related disease for self and partner) and disadvantages (e.g., stigma - being labeled as promiscuous) of HPV vaccination; perceived threat of HPV-related disease; and subjective norms for HPV vaccination (the large majority thought that most people in their lives would be supportive of them receiving the HPV vaccine, but very few participants knew another gay man who had been vaccinated). Among vaccinated participants, the primary social factor that motivated them to get vaccinated was a recommendation from a healthcare provider. Some participants attributed their decision to a discussion with a family member, but most participants indicated that their parents had little to no involvement in their decision to get vaccinated.
• Behavioural skills: Relevant behavioural skills included disclosure of sexual orientation (willingness to disclose their sexuality was intimately connected to the type of clinic at which they were being seen - e.g., lesbian, gay, bisexual, transgender, or queer (LGBTQ) friendly vs. general) and comfort discussing HPV vaccination (the majority of participants said they would be comfortable asking a provider for the HPV vaccine; some men questioned why their sexual orientation was even relevant, as the HPV vaccine is universally recommended). When asked about external factors that would facilitate or hinder their ability to get vaccinated (self-efficacy), 3 main themes emerged: cost, access, and convenience. Participants were especially keen on getting vaccinated at a walk-in clinic or pharmacy or, if they were students, on campus.

As part of the initial interview process, participants were asked to read a brief fact sheet to help ensure they had a basic understanding of HPV vaccination before answering the remaining questions. The researchers observe that, after reviewing the handout, "participants often expressed dismay and frustration about the inability to get tested for HPV. This finding suggests that young sexual minority men may be especially receptive to HPV vaccination when informed about the current lack of HPV testing for men."

Beyond clarifying misinformation and addressing knowledge gaps, the researchers suggest facilitating HPV vaccine uptake among this population by:

• Directing uninsured men to clinics that provide the HPV vaccine for free/reduced cost and sharing information about patient assistance programmes;
• Incorporating online tools such as the HealthMap Vaccine Finder, which identifies all pharmacies offering HPV vaccination for a given ZIP code;
• Combining HPV vaccination with other preventive health visits such as HIV testing;
• Fostering behavioural skills related to sexual orientation disclosure and increasing self-efficacy to discuss the HPV vaccine with a healthcare provider or parent;
• Developing complementary multilevel interventions such as public health messaging campaigns and communication efforts to encourage providers working with sexual and gender minority individuals to offer the HPV vaccine to all eligible patients; and
• Exploring clinic-based efforts, such as those that incorporate reminder/recall messages that alert patients when they are overdue for the vaccine and electronic immunisation information systems that allow providers to easily track and update the vaccination status of their patients.

In conclusion, findings from this study could provide a foundation for the development of future interventions promoting HPV vaccination among young sexual minority men. "Adopting a theoretically informed approach that draws on the lived experience of MSM will help to ensure that interventions are tailored appropriately for this population."