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Key factors influencing Italian mothers’ intention to vaccinate their sons against HPV: influence of trust in health authorities, perceived regret and past behavior
Received: 3 October 2019 / Revised: 27 November 2019 / Accepted: 28 November 2019 / Published: 3 December 2019
The Tacomaprobono Team
Human papillomavirus (HPV), the most common sexually transmitted infection in the world, is associated with various types of cancer, especially cervical cancer. In Italy in 2017, the Italian Ministry of Health introduced a free HPV vaccination program for 12-year-old boys. In this study we tested an integrated theory of planned behavior (TPB) model to explain Italian mothers’ intentions to vaccinate their sons against HPV. TPB variables and past attitudes, trust in health authorities and perceived regret were measured by questionnaire in a sample of 333 Italian mothers of boys aged 6-11 years, not yet vaccinated against HPV. Results showed that subjective norm was the strongest predictor of mothers’ intentions followed by anticipated regret, trust in health officials, behavioral control, and perceived behavior. Mediation analysis found that past behavior influenced intention through behavior. The discussion considers the relevance of these factors in promoting maternal adherence.
Human papillomavirus (HPV) is the most common sexually transmitted infection (STI) in the world and is associated with various types of cancer in women, especially cervical cancer. The most consistent predictors of HPV infection are sexual activity, age at first intercourse and number of sexual partners . HPV can cause significant health complications in men, including genital and rectal, penile, and oropharyngeal cancers. However, male vaccination is still less widespread in 11 European countries .
In determining adherence to HPV vaccination, an important role is played by parents’ decisions to vaccinate young daughters and sons. Interestingly, a systematic review of 19 international studies (excluding Italy)  summarized the role of a list of factors, such as parental knowledge of prevention, safety and/or side effects. Parental concerns, parental trust in health provider and/or government and/or school, positive parenting attitudes and parent-child relationship. In the specific case of vaccinating daughters, parents’ decisions were based on various aspects, such as knowledge about HPV, attitudes of health care providers, attitudes of parents, potential unintended consequences of HPV vaccination  . In the case of less widespread son vaccination, eg Perez et al.  found that the lack of free programs for boys in Canada and lack of information explained why many parents were disengaged or uninformed . In addition, another study showed that fathers who were concerned about their son’s exposure to HPV and perceived it to be a dangerous infection were more likely to accept the HPV vaccine for their son.
In Italy, the HPV vaccination program was introduced for women in 2008 and for men in 2017 , when the Italian Ministry of Health decided to offer free vaccination to the target population of 12-year-olds. Now, the HPV vaccine is free in their twelfth year of life. This is not mandatory but is strongly recommended by pediatricians. Compared to other European countries, Italy’s percentage for HPV vaccination in women is very good (72.73% vaccinated with at least one dose and 66.42% completed the entire cycle). Nevertheless, it is still below the optimal level set by the Italian Vaccine Prevention Plan 2017-2019 (95%). Also in the Italian context, parental attitudes, intentions and acceptance of HPV vaccination are determinants of women’s adherence to HPV vaccines [ 8 , 9 , 10 ].
Understanding The Demand Curve (and How It Works)
In the case of 12-year-old male adolescents, the Italian average coverage is low (19.04% vaccinated with at least one dose and 14.58% completed the entire course). This average is still well above the expected range (60% for 2017, 95% in 2019). However, no previous study has previously investigated the role of parental psychosocial factors on HPV vaccination of Italian 12-year-old males. Starting from the lack of literature in the Italian context, the present study attempted to clarify the psychosocial factors involved in the intention of Italian mothers to initiate HPV vaccination for their male children. The focus on maternal intentions is justified based on previous research showing that in many countries, mothers are the first to make health decisions about their children , including vaccination choices . To achieve this goal, in the present study, we applied the Theory of Planned Behavior (TPB) as a theoretical framework.
The TPB model states that attitude, subjective norm, and perceived behavioral control (PBC) influence behavioral intention, which in turn predicts the related behavior. Attitudes toward a behavior refer to an individual’s general evaluation of the behavior. Subjective norm is defined as an individual’s perception of social expectations regarding behavior. PBC is an individual’s perception of the ease or difficulty of a particular behavior or the subjective belief that they can perform it . The TPB has been used effectively to explain a variety of health behaviors [14, 15, 16], including parental preventive behaviors such as vaccinating their children [1, 13, 17], for example, influenza vaccination. A recent study of the TPB  showed several potential influences on parents’ decisions to choose to vaccinate their sons. This study showed that both physical, contextual, socio-demographic aspects and psychological determinants (perception of risk, past behaviour, knowledge and experience) were important factors influencing parents’ decisions about vaccinating their sons.
In the case of HPV, research has shown that the TPB model was equally useful for understanding people’s intentions to receive the HPV vaccine and parents’ intentions to vaccinate their children. For example, Juraskova et al.  showed that the TPB model predicted 54% of the variance in Australian female university students’ intention to receive vaccination. In addition, applying the TPB model, some scholars have shown the important role of positive attitude and subjective norm in explaining the intention of young American men to receive the HPV vaccine [1, 20]. Following the above results, Catalano et al.  designed an intervention for American college students who are eligible for vaccination. This study found that attitude toward behavior and subjective norm were significant predictors of behavioral intention, accounting for 58% of the variance. Importantly, previous studies have also shown that the TPB factors help to understand parents’ decisions about vaccinating their children. For example, Hoffmann  found that Dutch parents, who had positive attitudes towards HPV vaccination, high subjective norms and PBC, also had a high intention to vaccinate their children.
In the present study, to examine the intention of Italian mothers to initiate HPV vaccination in their male children, we specifically focused on TPB variables and the additional role of past attitudes on adherence to other recommended vaccines. , anticipated regret over failure. Immunization and trust in health officials. We analyzed the role of past behavior because we expected that past experiences might influence parents’ decisions about other vaccines. Past behavior, in fact, significantly improves the prediction of later behavior and adding past behavior to the TPB variables improves the predictive power of the model [ 22 ]. In fact, previous studies have found that mothers whose children had received all their vaccinations in the past were more likely to be willing to vaccinate their child against HPV [23, 24, 25].
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We also analyzed the role of perceived regret in predicting Italian mothers’ intention to vaccinate their sons. Anticipated (inaction) regret refers to an anticipated negative feeling when an individual thinks about the possibility of not performing the behavior . For example, Christy et al.  found that perceived regret predicted HPV vaccination intentions among adolescents and this result suggests that
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