Multilevel factors impact HPV vaccine series initiation and completion among adolescents in the U.S. Synthesis of these factors is needed to inform intervention development and to direct future research. Current frameworks synthesizing factors focus on females only and do not include both series initiation and completion outcomes. We conducted a systematic review of reviews to identify modifiable individual-, provider-, and clinic-level factors associated with HPV vaccination outcomes among U.S. adolescents and developed a multilevel framework illustrating relations between factors to inform intervention development. We searched Medline, PsychInfo, Pubmed, CINAHL, and ERIC databases and included reviews published 2006 to July 2, 2018 describing individual-, provider-, or clinic-level factors quantitatively associated with HPV vaccination among U.S. adolescents. Two coders independently screened reviews, extracted data, and determined quality ratings. Sixteen reviews containing 481 unique primary studies met criteria. Factors synthesized into the multilevel framework included parent psychosocial factors (knowledge, beliefs, outcome expectations, intentions) and behaviors, provider recommendation, and patient-targeted and provider-targeted clinic systems. The scope of our framework and review advances research in two key ways. First, the framework illustrates salient modifiable factors at multiple levels on which to intervene to increase HPV vaccination. Second, the review identified critical gaps in the literature at each level. Future research should link the body of literature on parental intentions to vaccination outcomes, identify provider psychosocial factors associated with recommendation behaviors and subsequent vaccine uptake in their patient population, and

SUMMARY BackgroundThe burden of functional GI disorders and their associations with psychological distress in women veterans is unclear.

IntroductionThe incidence of human papillomavirus (HPV) infection and cervical cancer can be reduced by increasing vaccination for HPV. Yet vaccination uptake and completion of the 3-dose series remain low among Puerto Rican females. This study explored psychosocial factors associated with HPV vaccination uptake decisions among Puerto Rican mothers and daughters.MethodsWe conducted 7 focus groups with young women aged 16 to 24 (n = 21) and their mothers (n = 9) to assess knowledge, attitudes, and beliefs related to cervical cancer, HPV, and HPV vaccination. We analyzed the focus group transcripts and identified themes by using a constant comparison method of qualitative data analysis and interpretation, guided by a grounded theory approach.ResultsThe analysis identified several emergent themes related to vaccine uptake: 1) low knowledge about cervical cancer, HPV, and the HPV vaccine; 2) inconsistent beliefs about susceptibility to HPV infection and cervical cancer; 3) vaccine effectiveness; 4) vaccine safety and side effects; 5) concerns that the vaccine promotes sexual disinhibition; and 6) availability of insurance coverage and overall cost of the vaccine.ConclusionOur study found that adolescent girls and young women in Puerto Rico have low levels of knowledge about HPV and cervical cancer, low perceived susceptibility to HPV, and concerns about the safety and efficacy of the vaccine, and these factors may influence uptake and completion of HPV vaccination. Interventions are needed for both mothers and daughters that address these psychosocial factors and increase access to vaccination.

A multi-site study was conducted to assess HPV vaccine initiation and correlates of initiation among Latina adolescents. The study was a collaboration of the CDC/NCI-funded Cancer Prevention and Control Research Network. Data were collected in 2009 from caregivers of Latina adolescents recruited from Los Angeles Country (n = 274), Washington State (Yakima Valley region; n = 90), and Texas (Houston, n = 38; Lower Rio Grande Valley, n = 42). A set of 24 survey items assessed use of the HPV vaccine and awareness, attitudes and barriers to vaccination. Moderate levels of vaccine awareness among caregivers and low uptake of the vaccine (26-37%) among girls were observed. Attitudinal barriers such as concerns about negative effects of the vaccine on daughter's sexual behavior, fertility, and future health were infrequently endorsed. Efforts to understand regional similarities and differences may help inform interventions.

Results indicated that there are no significant differences in CRCS uptake between groups.