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Intention of Mothers in Israel to Vaccinate their Sons against the Human Papilloma Virus
YJPDN-01530; No of Pages 5 Journal of Pediatric Nursing xxx (2017) xxx–xxx
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Journal of Pediatric Nursing
Intention of Mothers in Israel to Vaccinate their Sons against the Human Papilloma Virus Merav Ben Natan ⁎, Kareem Midlej, Olga Mitelman, Katya Vafiliev Pat Matthews Academic School of Nursing, Hillel Yaffe Medical Center, Hadera, Israel
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Article history: Received 10 August 2016 Revised 3 January 2017 Accepted 5 January 2017 Available online xxxx Keywords: Human papilloma virus Mothers Male children Vaccine uptake Health belief model Arabs
a b s t r a c t Purpose: This study investigated the intention of mothers in Israel to vaccinate their sons against HPV, using the Health Belief Model (HBM) as a framework, while comparing between Arab and Jewish mothers. Design and Methods: The study has a quantitative cross-sectional design. A convenience sample of 200 Jewish and Arab mothers of boys aged 5–18 completed a questionnaire based on the HBM. Results: The research findings indicate that only 14% of the mothers, constituting mostly Arab mothers, vaccinated their sons against HPV. Moreover, mothers showed a moderate level of intention to vaccinate their sons. This level was similar among Arab and Jewish mothers. However, the health beliefs of Jewish and Arab mothers differed. The HBM was found to explain 68% of mothers' intention to vaccinate their sons against HPV, and the perceived benefits of the vaccine were the factor most affecting this intention. Conclusions: Although mothers' health beliefs concerning vaccinating their sons against HPV may vary between sectors, the HBM can be used to explain what motivates mothers to vaccinate their sons. Practice Implications: The research findings can assist in designing a national project among mothers of boys aimed at raising HPV vaccination rates, in both the Jewish and the Arab sector. © 2017 Published by Elsevier Inc.
Introduction The HPV Vaccine The Human Papilloma Virus (HPV) is the most common sexually transmitted infection (Taylor et al., 2014). HPV is a contagious virus transmitted through skin and sexual contact (Dempsey, Butchart, Singer, Clark, & Davis, 2011). Among men, HPV is linked to approximately 80% of all cases of anal and penile cancer (Ortashi, Raheel, & Khamis, 2013). HPV causes some 33,000 cancers a year in the US, of which 12,000 are among men (Perkins et al., 2013). In Israel, approximately 60 men with HPV are diagnosed with anal cancer every year and around 100 are diagnosed with penile cancer (Ministry of Health, 2015). In June 2006, the World Health Organization (WHO) approved the use of the quadrivalent prophylactic HPV vaccine. The vaccine is administered in three doses over a period of six months (In: Dempsey et al., 2011). In Israel, the instruction to vaccinate boys was publicized in early 2015, recommending that the vaccine be given to eighth grade boys aged 13–14 years old beginning in September 2015 (Ministry of Health, 2015). Unfortunately, there are still no data on the HPV ⁎ Corresponding author at: Pat Matthews Academic School of Nursing, Hillel Yaffe Medical Centre, P.O.B. 169, Hadera 38100, Israel. E-mail address: [email protected] (M. Ben Natan).
vaccination rate of boys in Israel and on the difference between Arabs and Jews. Nonetheless, data derived from the Ministry of Health website indicates that the uptake of routine vaccinations among boys aged 0–2 during 2009–2011 was 98.5% in the Arab sector versus 93.5% in the Jewish sector (Ministry of Health, 2015). A study that examined the prevalence of vaccination uptake among various population groups in Israel found a vaccination rate of 95% among the Arab population, versus 89% among the Jewish population (Degani & Degani, 2008). In Israel, the HPV vaccine is administered to eighth grade students by school nurses at school at no cost. Vaccinations are only administered to students whose parents give their permission. Usually, mothers are those who give this permission. Factors Affecting Mothers' Intention to Vaccinate Many factors affect the intention of mothers to vaccinate their sons, first and foremost their belief in the benefits of the vaccine for preventing HPV infection. Vaccination of men, in addition to women, raises the overall vaccination rate (Seven, Güvenç, Şahin, & Akyüz, 2015). There are also several barriers to vaccination uptake. One of the apparent barriers to vaccination is its side effects, which consist mainly of pain, inflammation, and redness of the vaccination site (MadridMarina, Torres-Poveda, López-Toledo, & García-Carrancá, 2009). In certain cases more serious side effects were reported, such as fainting and anaphylaxis, however these are no different than the side effects of the
http://dx.doi.org/10.1016/j.pedn.2017.01.001 0882-5963/© 2017 Published by Elsevier Inc.
Please cite this article as: Ben Natan, M., et al., Intention of Mothers in Israel to Vaccinate their Sons against the Human Papilloma Virus, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.01.001
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M. Ben Natan et al. / Journal of Pediatric Nursing xxx (2017) xxx–xxx
pneumococcal vaccine (Madrid-Marina et al., 2009). Moreover, the need for three vaccine doses to complete each vaccination series is a source of inconvenience and might affect parental decisions concerning the male HPV vaccine (Zimet & Rosenthal, 2010). Social perceptions of the vaccine might also constitute a barrier to mothers' intention to vaccinate their sons. Because HPV is a sexually transmitted illness, this might be reflected in the stigmatic perceptions of parents, who might perceive the vaccine as increasing their children's tendency to sexual promiscuity (Muhwezi, Banura, Turiho, & Mirembe, 2014). Nonetheless, in a study conducted by Taylor et al. (2014), parents felt more comfortable vaccinating their young sons than their young daughters, as the concept of male sexual activity caused less discomfort than that of female sexual activity. The variable of perceived susceptibility to the disease also impacts mothers' decision whether to vaccinate their sons against HPV. Mothers of sexually active teens in the US reported a higher vaccination intention (Brewer & Fazekas, 2007). Moreover, the more parents perceive the disease as severe the more they are inclined to vaccinate their children. Mothers who had more information about causes of cervical cancer and about the possibility of preventing cervical cancer through vaccination demonstrated a greater intention to vaccinate their daughters (Ben Natan, Aharon, Palickshvili, & Gurman, 2011). Medical recommendations also have a significant impact on mothers' intention to vaccinate their sons (Perkins et al., 2013). Rosenthal et al. (2008) showed that mothers who consulted with a doctor had a more positive attitude towards administering the vaccine before their sons had become sexually active. Information provided by healthcare service providers also affects vaccine uptake (Dahlström et al., 2010). Furthermore, sons whose mothers had high health motivation, demonstrated increased HPV vaccination rates (Muhwezi et al., 2014). The cultural and ethnic features of mothers affect their decision whether to vaccinate their sons against HPV. Seven et al. (2015) found that mothers' willingness to vaccinate their sons may vary according to their ethnicity and according to cultural beliefs concerning men's sexual activity. In certain cultures, such as Turkey, premarital sex is more customary for men than for women and society expects women to have only one intimate partner. Taylor et al. (2014) found that black and Hispanic parents had a greater intention of vaccinating their children than white parents. White parents believed that the male HPV vaccine is not important, compared to other parents in the sample, such as black parents. Additionally, Reiter et al. (2013) found that the difference in vaccination between non-whites and whites may stem from the different socioeconomic status of these groups. Ortashi et al. (2013) examined knowledge and views on HPV vaccine uptake among Arab men at the United Arab Emirates University. Participants displayed a low level of knowledge. Moreover, factors such as safety, protection of one's spouse, and medical recommendations were significant factors in the decision whether to be vaccinated. Furthermore, the leading factor found to inhibit the vaccination of students was fear of side effects. Yet another study on the attitudes of mothers and daughters with regard to their motivation for consenting to the HPV vaccine found limited knowledge among Arab mothers in Denmark. While they knew that HPV can cause cervical cancer, they did not know that the virus might cause genital warts (Zeraiq, Nielsen, & Sodemann, 2015).
Perceived Susceptibility Perceived susceptibility to the disease, meaning one's subjective perception of his or her risk of contracting the disease. In the current study this means susceptibility to anal cancer, genital warts, penile cancer, and oropharyngeal cancer. Perceived Severity Perceived severity of the illness, meaning the severity of the health problem as evaluated by the individual. In the current study, this means the severity of possible damage and the implications if the mother should decide against permitting her sons to receive the HPV vaccine. Perceived Benefits The individual's perceptions of his or her susceptibility to the disease and belief that it is indeed a grave disease constitute motivation for action, i.e., the benefits of receiving the HPV vaccine. Perceived Barriers The perceived barriers to taking action refer to those negative aspects that accompany health actions or that serve as barriers to taking action, and/or that arouse conflicting motivations for avoiding action. In the current study, this means those barriers and obstacles that prevent mothers from vaccinating their sons against HPV. Health Motivation Health motivation refers to the individual's level of interest in health issues, the desire to realize or to preserve a positive state of health and to avoid a state of illness. The higher health motivation of mothers will result in greater intention to vaccinate their sons. Cues to Action Cues to action refer to factors that influence the individual and encourage him or her to take a health action. In the current study, this means those factors that affect and encourage mothers to vaccinate their sons against HPV. Several studies examined the prediction ability of the HBM. Dempsey et al. (2011) found that mothers had the greatest intention of vaccinating their sons against HPV when perceiving the vaccine as having significant health benefits and few barriers. Similar results were found in a study conducted among adolescents, young adults, and parents of adolescents in the United States, which found that perceived benefits were the main predictor of HPV vaccine uptake (Brewer & Fazekas, 2007). In contrast, Reiter et al. (2013) found that the most important factor affecting parents' intention to vaccinate their daughters was the parent's beliefs concerning the HPV vaccine. Moreover, in a study conducted among Afro-American women aged 18–26, the most prominent factor affecting HPV vaccine uptake were cues to action (Bynum, Brandt, Sharpe, Williams, & Kerr, 2011). Hence, the issue is still ambiguous; in addition, it is not clear which factors most affect the intention of Arab and Jewish mothers in Israel to vaccinate their sons against HPV. In light of the lack of clarity in the literature regarding the ability of the HBM to predict mothers' intention to vaccinate their sons against HPV, the study will investigate this issue. Methods Study Design and Participants
Theoretical Framework The Health Belief Model (HBM) was developed by Becker (1974) and is designed to explain decision making and behaviors associated with health and illness based on the individual's subjective perceptions in states of uncertainty. The premise underlying the HBM is that one must be in a state of psychological willingness in order to effect a change in his or her health behavior, i.e., to take preventive action against illness. The major constructs of the model are as follows:
This study has a quantitative cross-sectional design. A convenience sample of 200 Israeli mothers – 100 Jewish and 100 Arab – took part in the study. The inclusion criteria were: Mothers of sons, of whom at least one was between the ages of 5–18. The exclusion criteria were lack of good literacy skills in Hebrew or Arabic. A total sample size of 220 was determined. This size was calculated at 80% power with 95% confidence interval for a 2-tailed difference of means test. Calculations were based on seeking a difference of 0.5 on the Likert scale.
Please cite this article as: Ben Natan, M., et al., Intention of Mothers in Israel to Vaccinate their Sons against the Human Papilloma Virus, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.01.001
M. Ben Natan et al. / Journal of Pediatric Nursing xxx (2017) xxx–xxx
Instrument The study instrument was a questionnaire designed by Ben Natan and Maor (2014). The questionnaire consisted of 35 items and included two parts: sociodemographic data and constructs of the HBM (intention to be vaccinated, susceptibility to the disease, severity of the disease, benefits of the vaccine, barriers, health motivation, and cues to action). Responses were given on a Likert scale ranging from 1 to 6, with 1 representing “strongly disagree” and 6 “strongly agree”. In addition, three knowledge questions were asked, with correct answers scored as 1. The sum of all knowledge scores ranged from 0 to 3. The questionnaire was translated into Arabic and was externally validated by retranslation into Hebrew and examination of the congruence. An internal validity test was also performed by three expert nurses in the field of vaccination. The questions were reformulated based on their comments. The reliability of the questionnaire demonstrated an alpha Cronbach of 0.8–0.95. Research Procedure and Ethical Considerations The questionnaire was approved by the ethics committee of Tel Aviv University. The researchers distributed the questionnaire in Arab villages in northern and central Israel among mothers who live in their vicinity, from January–March 2016. The researchers explained the purpose of the study to the participants and that the participants are not obliged to participate. In addition, they stated that the research data would remain anonymous and would be used only for research purposes. The participants completed the questionnaire at home over 20 min on average. Data analysis Statistical analysis was performed with the Statistical Package for Social Sciences (SPSS, v. 21; SPSS PC, SPSS Inc., Chicago IL, USA). The descriptive statistics included means, standard deviations (SD), frequencies, and percentages. Reliability was examined by alpha Cronbach. Correlations between variables were examined by Pearson's correlation; t-tests and multiple linear regression analysis were performed to determine HBM prediction of the explored phenomenon. Statistical significance was set at p b 0.01. Results The response rate was 91%, i.e., 200 mothers – 100 Jewish (n = 100, 50%) and 100 Arab (n = 100, 50%). The mean age of the mothers was 38.46 (SD = 7.78), with a range of 23–60. Most of the mothers in the sample were married (n = 183, 91.5%). Each had 2 children on average, with a range of 1–6 (M = 2.37, SD = 1.22). Of the Jewish respondents, the highest educational level attained by 77% (n = 77) was an academic education, 13% (n = 13) - a tertiary education, 11% (n = 11) - a secondary education, and none of the respondents had only an elementary education. In contrast, of the Arab respondents, 45% (n = 45) had an academic education, 28% (n = 28) a secondary education, 23% (n = 23) a tertiary education, and 3% (n = 3) an elementary education. Most of the mothers in the sample were employed (n = 155, 77.5%). Approximately 39% (n = 78) reported a below-average income, 42.5% (n = 85) an average income, and about 18% (n = 37) an above-average income, based on the average income in Israel. Approximately 14% (n = 28) of all respondents vaccinated their sons against HPV, of whom approximately two thirds were Arabs (n = 18, 64%) and one third Jews (n = 10, 36%). Examination of respondents' compliance with vaccination of their sons shows that the number of Jews and Arabs who received the first vaccine dose was identical, at 50% (n = 7). A difference was evident between Arab and Jewish respondents, however, where 87.5% (n = 7) of Arabs gave permission for their sons to receive the second dose and 66.7% (n = 4) the third dose, while
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only 12.5% (n = 1) of the Jews (p b 0.01) gave permission for their sons to receive the second dose and 33.3% (n = 2) the third dose. The research findings show that the intention of mothers to vaccinate their sons was moderate, with no difference between Arab and Jewish mothers (see Table 1). A significant difference was found between Arab and Jewish mothers in the perceived susceptibility of their sons to the disease. Arab mothers perceived their sons' susceptibility to HPV as lower than did Jewish mothers, with 33% of the latter of the opinion that their son is susceptible to HPV, versus 6% of Arab mothers. Moreover, a significant difference was found between Arab and Jewish mothers in the perceived severity of the disease, such that Jewish mothers perceived the disease as more severe than did Arab mothers. The findings indicate that 37% (n = 37) of the Jewish mothers strongly agreed that the illness caused by HPV is dangerous, versus 16% (n = 16) of the Arab mothers. Additionally, some 42% (n = 42) of the Jewish mothers agreed with the statement that the illness caused by HPV is detrimental to one's quality of life, in contrast to 15% (n = 39) of Arab mothers. The research findings indicate that no significant difference was found between the perceptions of Arab and Jewish mothers concerning the benefits of the vaccine. The variable of perceived benefits of the vaccine was moderate among both population groups. In contrast, a significant difference was found between the perceived barriers of Arab and Jewish mothers, such that the variable of mean perceived barriers was significantly higher among Arab than among Jewish mothers. Sixty four percent (n = 64) of Jewish mothers did not agree with the statement whereby they would not vaccinate their sons due to their concern of early initiation of sexual activity, versus 39% (n = 39) of Arab mothers. A significant difference was found between the health motivation of Arab and Jewish mothers, with the health motivation of Jewish mothers higher than that of Arab mothers. The research findings indicate that half the Jewish mothers (n = 50) arrange for their sons to engage in physical activity, versus 22% (n = 22) of the Arab mothers. The findings also show that 37% (n = 37) of the Jewish mothers arrange for their sons to undergo periodical medical checkups, versus 25% (n = 25) of the Arab mothers. A significant difference was found between Arab and Jewish mothers in cues to action, where Arab mothers had a higher mean perception of cues to action than Jewish mothers. The findings indicate that the most influential element were nurses, followed by television ads. The results show that 49% (n = 49) of the Jewish mothers strongly agreed that a community nurse provided them with information about the HPV vaccine, versus 6% (n = 6) of the Arabs. A significant difference was also found between the knowledge of Arab and Jewish mothers, where Jewish mothers had a higher level of knowledge than Arab mothers. Moreover, 77.8% of the Arab mothers
Table 1 Differences between Jewish (n = 100) and Arab mothers (n = 100). tb,c
Sector Jews a
Variable Perceived susceptibility Perceived severity Perceived benefits Perceived barriers Health motivation Cues to action Knowledge Intention a b c
M 3.22 4.71 3.47 1.93 4.61 1.88 1.70 3.32
Arabs SD 1.57 1.38 1.45 1.00 1.43 0.87 0.46 1.71
M 3.93 3.71 3.71 2.81 4.07 2.25 1.60 3.59
SD 1.43 1.54 1.52 1.67 1.34 1.20 0.58 1.76
3.339⁎ −4.846 1.104 4.515⁎
−2.750⁎⁎ 2.509⁎⁎ −1.342⁎ 1.097
Range for all variables is 1–6, with exception for knowledge, which is 1–3. ⁎p b 0.05, ⁎⁎p b 0.01. df = 198.
Please cite this article as: Ben Natan, M., et al., Intention of Mothers in Israel to Vaccinate their Sons against the Human Papilloma Virus, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.01.001
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M. Ben Natan et al. / Journal of Pediatric Nursing xxx (2017) xxx–xxx
thought that the HPV vaccine should only be given to boys who are sexually active, while only 22.2% of the Jewish mothers provided an incorrect response to this statement. The research findings indicate a significant positive correlation between perceived susceptibility to the disease (r = 0.143, p b 0.05), severity of the disease (r = 0.457, p b 0.01), benefits of the vaccine (r = 0.792, p b 0.01), health motivation (r = 0.413, p b 0.01), cues to action (r = 0.481, p b 0.01), and knowledge (r = 0.193, p b 0.01), and mothers' intention to vaccinate their sons. A significant negative correlation was found between barriers and mothers' intention to vaccinate their sons (r = 0.422-, p b 0.01). The research findings indicate that the HBM predicted mothers' intention of vaccinating their sons against HPV, with an explained variance rate of 68% (R2 = 0.68), where the most influential variable is perceived benefits, while the regression found no significance for the variables of susceptibility and knowledge (see Table 2).
Discussion The research findings indicate that only 14% of the mothers vaccinated their sons against HPV. These findings are consistent with global vaccination rates (Perkins et al., 2013; Reiter et al., 2013) and point to problems with the vaccination of boys against HPV. In addition, mothers' intention to vaccinate their sons against HPV was found to be moderate, indicating that mothers are not certain whether vaccination is necessary. Nonetheless, the greater the mothers' perceived susceptibility of their sons to HPV and the higher the perceived severity of the disease, the higher their intention to vaccinate their sons against HPV. Similarly, Brewer and Fazekas (2007) and Muhwezi et al. (2014) also found that high perceived susceptibility to the disease was be associated with higher uptake of the vaccine. Thus, Ben Natan et al. (2011) found that the more mothers perceived HPV as a threat to their daughters, the greater their inclination to vaccinate them. The current study shows that the more positive mothers' perceptions of the vaccine's benefits, the higher their intention to vaccinate their sons against HPV. Similar to Dempsey et al. (2011), the strongest predictor of parents' intention to vaccinate was the benefits of the vaccine. Furthermore, the research findings show that the lower mothers' perceived barriers, the higher their intention to vaccinate their sons against HPV. Dempsey et al. (2011) stated that parents' intention to vaccinate their sons diminishes with the increase in barriers to vaccine uptake. One of the barriers to vaccine uptake in the current study was the number of doses necessary to complete the vaccination process. Mothers reported that the need for three vaccine doses to complete the series is inconvenient. Another barrier was that Arab mothers were concerned that their sons would become sexually active at an early age as a result of the vaccination. Our study showed that the more cues to action mothers perceive, and the more recommendations by medical staff, the higher mothers' intention to vaccinate their sons against HPV. The findings indicate that the element that most influenced mothers was nurses. In contrast,
Table 2 Predictors of mothers' intention to vaccinate their sons (N = 200). Variable
B
β
ta
Perceived susceptibility Perceived severity Perceived benefits Perceived barriers Health motivation Cues to action Knowledge
−0.075 −0.162 0.792 −0.177 0.208 0.222 0.057
−0.067 −0.144 0.678 −0.147 0.168 0.136 0.024
−1.502 −2.540⁎ 11.991⁎⁎ −2.890⁎⁎ 3.514⁎⁎ 2.807⁎⁎
a
⁎p b 0.05, ⁎⁎p b 0.01.
0.539
Perkins et al. (2013) found that most parents said that physicians are the most important element causing them to vaccinate their sons. The disparity might result from the fact that all vaccinations in Israel are administered by nurses. Additionally, the greater mothers' health motivation, the higher their intention to vaccinate their sons against HPV. This finding contradicts Shahrabani, Benzion, and Din (2009), who did not find health motivation to be a predictor of vaccination. This discrepancy might be a result of the different research population, as Shahrabani et al. (2009) examined the perceptions of medical staff with regard to the flu vaccine. The study found that the more mothers knew about the vaccine and about the disease, the higher their intention to vaccinate their sons. Seven et al. (2015) stated that lack of knowledge and awareness of the HPV vaccine constitutes the greatest barrier to uptake of the vaccine. This unlike Dempsey et al. (2011), who found no significant difference in HPV vaccine uptake between a trial group that received an explanation about the vaccine and a control group that received no explanation. The research findings reveal that Arab mothers perceived their sons' susceptibility to HPV as lower, perceived barriers as higher, had lower health motivation and a lower level of knowledge, than did Jewish mothers. However, the research findings indicate that more Arab mothers vaccinated their sons than did Jewish mothers. The difference may be associated with the fact that nurses' explanatory activity with regard to the importance of vaccinating sons is more extensive and significant in the Arab sector, and implementation of the entire vaccination policy began in Arab villages. The current finding that supports this assumption is the finding that Arab mothers had a higher mean perception of cues to action than Jewish mothers. Healthcare provider recommendations have been identified as a positive predictor of HPV vaccine uptake (Kessels et al., 2012). A US study showed this relationship to be consistent across all racial/ethnic groups (Ylitalo, Lee, & Mehta, 2013). The limitations of our study derive from the form of sampling utilized, which was based on a convenience method, possibly hampering generalization of the findings to the general population. In addition, the study refers to mothers' self-report of intention to vaccinate, and not on actual vaccination rates.
Conclusions and Implications Mothers showed a low level of compliance with vaccination of their sons against HPV, with higher compliance evident among mothers from the Arab sector. Nonetheless, the level of intention to vaccinate their sons was moderate, with no difference between Arab and Jewish mothers. The research findings show that the HBM predicts mothers' intention to vaccinate their sons against HPV, with the most influential factor being the perceived benefits of vaccination. Hence, in order to promote mothers' intention to vaccinate their sons and actual vaccination, it is necessary to raise mothers' awareness of the benefits of vaccination through national projects managed by nurses as well as through television ads that stress the benefits of vaccination. Moreover, it is important to emphasize the role of nurses in instructing parents about vaccination as early as the seventh grade in preparation for vaccination in the eighth grade. It is important to hold instruction days at school for mothers and their sons in the seventh grade and to distribute informational pamphlets explaining the benefits of the vaccine and its significance. In addition, nurses should hold lectures at women's athletic clubs, health clubs, and community clinics frequented by women with high health motivation, and should explain the benefits of vaccination. In order to enable wider generalization of the findings, further research should be conducted using randomized sampling. In addition, it is important to conduct a prospective study on actual administration of the vaccine, in order to examine the proportion of Arab and Jewish boys vaccinated in practice and what should be done to increase the vaccination rate.
Please cite this article as: Ben Natan, M., et al., Intention of Mothers in Israel to Vaccinate their Sons against the Human Papilloma Virus, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.01.001
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Please cite this article as: Ben Natan, M., et al., Intention of Mothers in Israel to Vaccinate their Sons against the Human Papilloma Virus, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.01.001
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Journal of Pediatric Nursing
Intention of Mothers in Israel to Vaccinate their Sons against the Human Papilloma Virus Merav Ben Natan ⁎, Kareem Midlej, Olga Mitelman, Katya Vafiliev Pat Matthews Academic School of Nursing, Hillel Yaffe Medical Center, Hadera, Israel
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Article history: Received 10 August 2016 Revised 3 January 2017 Accepted 5 January 2017 Available online xxxx Keywords: Human papilloma virus Mothers Male children Vaccine uptake Health belief model Arabs
a b s t r a c t Purpose: This study investigated the intention of mothers in Israel to vaccinate their sons against HPV, using the Health Belief Model (HBM) as a framework, while comparing between Arab and Jewish mothers. Design and Methods: The study has a quantitative cross-sectional design. A convenience sample of 200 Jewish and Arab mothers of boys aged 5–18 completed a questionnaire based on the HBM. Results: The research findings indicate that only 14% of the mothers, constituting mostly Arab mothers, vaccinated their sons against HPV. Moreover, mothers showed a moderate level of intention to vaccinate their sons. This level was similar among Arab and Jewish mothers. However, the health beliefs of Jewish and Arab mothers differed. The HBM was found to explain 68% of mothers' intention to vaccinate their sons against HPV, and the perceived benefits of the vaccine were the factor most affecting this intention. Conclusions: Although mothers' health beliefs concerning vaccinating their sons against HPV may vary between sectors, the HBM can be used to explain what motivates mothers to vaccinate their sons. Practice Implications: The research findings can assist in designing a national project among mothers of boys aimed at raising HPV vaccination rates, in both the Jewish and the Arab sector. © 2017 Published by Elsevier Inc.
Introduction The HPV Vaccine The Human Papilloma Virus (HPV) is the most common sexually transmitted infection (Taylor et al., 2014). HPV is a contagious virus transmitted through skin and sexual contact (Dempsey, Butchart, Singer, Clark, & Davis, 2011). Among men, HPV is linked to approximately 80% of all cases of anal and penile cancer (Ortashi, Raheel, & Khamis, 2013). HPV causes some 33,000 cancers a year in the US, of which 12,000 are among men (Perkins et al., 2013). In Israel, approximately 60 men with HPV are diagnosed with anal cancer every year and around 100 are diagnosed with penile cancer (Ministry of Health, 2015). In June 2006, the World Health Organization (WHO) approved the use of the quadrivalent prophylactic HPV vaccine. The vaccine is administered in three doses over a period of six months (In: Dempsey et al., 2011). In Israel, the instruction to vaccinate boys was publicized in early 2015, recommending that the vaccine be given to eighth grade boys aged 13–14 years old beginning in September 2015 (Ministry of Health, 2015). Unfortunately, there are still no data on the HPV ⁎ Corresponding author at: Pat Matthews Academic School of Nursing, Hillel Yaffe Medical Centre, P.O.B. 169, Hadera 38100, Israel. E-mail address: [email protected] (M. Ben Natan).
vaccination rate of boys in Israel and on the difference between Arabs and Jews. Nonetheless, data derived from the Ministry of Health website indicates that the uptake of routine vaccinations among boys aged 0–2 during 2009–2011 was 98.5% in the Arab sector versus 93.5% in the Jewish sector (Ministry of Health, 2015). A study that examined the prevalence of vaccination uptake among various population groups in Israel found a vaccination rate of 95% among the Arab population, versus 89% among the Jewish population (Degani & Degani, 2008). In Israel, the HPV vaccine is administered to eighth grade students by school nurses at school at no cost. Vaccinations are only administered to students whose parents give their permission. Usually, mothers are those who give this permission. Factors Affecting Mothers' Intention to Vaccinate Many factors affect the intention of mothers to vaccinate their sons, first and foremost their belief in the benefits of the vaccine for preventing HPV infection. Vaccination of men, in addition to women, raises the overall vaccination rate (Seven, Güvenç, Şahin, & Akyüz, 2015). There are also several barriers to vaccination uptake. One of the apparent barriers to vaccination is its side effects, which consist mainly of pain, inflammation, and redness of the vaccination site (MadridMarina, Torres-Poveda, López-Toledo, & García-Carrancá, 2009). In certain cases more serious side effects were reported, such as fainting and anaphylaxis, however these are no different than the side effects of the
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Please cite this article as: Ben Natan, M., et al., Intention of Mothers in Israel to Vaccinate their Sons against the Human Papilloma Virus, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.01.001
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pneumococcal vaccine (Madrid-Marina et al., 2009). Moreover, the need for three vaccine doses to complete each vaccination series is a source of inconvenience and might affect parental decisions concerning the male HPV vaccine (Zimet & Rosenthal, 2010). Social perceptions of the vaccine might also constitute a barrier to mothers' intention to vaccinate their sons. Because HPV is a sexually transmitted illness, this might be reflected in the stigmatic perceptions of parents, who might perceive the vaccine as increasing their children's tendency to sexual promiscuity (Muhwezi, Banura, Turiho, & Mirembe, 2014). Nonetheless, in a study conducted by Taylor et al. (2014), parents felt more comfortable vaccinating their young sons than their young daughters, as the concept of male sexual activity caused less discomfort than that of female sexual activity. The variable of perceived susceptibility to the disease also impacts mothers' decision whether to vaccinate their sons against HPV. Mothers of sexually active teens in the US reported a higher vaccination intention (Brewer & Fazekas, 2007). Moreover, the more parents perceive the disease as severe the more they are inclined to vaccinate their children. Mothers who had more information about causes of cervical cancer and about the possibility of preventing cervical cancer through vaccination demonstrated a greater intention to vaccinate their daughters (Ben Natan, Aharon, Palickshvili, & Gurman, 2011). Medical recommendations also have a significant impact on mothers' intention to vaccinate their sons (Perkins et al., 2013). Rosenthal et al. (2008) showed that mothers who consulted with a doctor had a more positive attitude towards administering the vaccine before their sons had become sexually active. Information provided by healthcare service providers also affects vaccine uptake (Dahlström et al., 2010). Furthermore, sons whose mothers had high health motivation, demonstrated increased HPV vaccination rates (Muhwezi et al., 2014). The cultural and ethnic features of mothers affect their decision whether to vaccinate their sons against HPV. Seven et al. (2015) found that mothers' willingness to vaccinate their sons may vary according to their ethnicity and according to cultural beliefs concerning men's sexual activity. In certain cultures, such as Turkey, premarital sex is more customary for men than for women and society expects women to have only one intimate partner. Taylor et al. (2014) found that black and Hispanic parents had a greater intention of vaccinating their children than white parents. White parents believed that the male HPV vaccine is not important, compared to other parents in the sample, such as black parents. Additionally, Reiter et al. (2013) found that the difference in vaccination between non-whites and whites may stem from the different socioeconomic status of these groups. Ortashi et al. (2013) examined knowledge and views on HPV vaccine uptake among Arab men at the United Arab Emirates University. Participants displayed a low level of knowledge. Moreover, factors such as safety, protection of one's spouse, and medical recommendations were significant factors in the decision whether to be vaccinated. Furthermore, the leading factor found to inhibit the vaccination of students was fear of side effects. Yet another study on the attitudes of mothers and daughters with regard to their motivation for consenting to the HPV vaccine found limited knowledge among Arab mothers in Denmark. While they knew that HPV can cause cervical cancer, they did not know that the virus might cause genital warts (Zeraiq, Nielsen, & Sodemann, 2015).
Perceived Susceptibility Perceived susceptibility to the disease, meaning one's subjective perception of his or her risk of contracting the disease. In the current study this means susceptibility to anal cancer, genital warts, penile cancer, and oropharyngeal cancer. Perceived Severity Perceived severity of the illness, meaning the severity of the health problem as evaluated by the individual. In the current study, this means the severity of possible damage and the implications if the mother should decide against permitting her sons to receive the HPV vaccine. Perceived Benefits The individual's perceptions of his or her susceptibility to the disease and belief that it is indeed a grave disease constitute motivation for action, i.e., the benefits of receiving the HPV vaccine. Perceived Barriers The perceived barriers to taking action refer to those negative aspects that accompany health actions or that serve as barriers to taking action, and/or that arouse conflicting motivations for avoiding action. In the current study, this means those barriers and obstacles that prevent mothers from vaccinating their sons against HPV. Health Motivation Health motivation refers to the individual's level of interest in health issues, the desire to realize or to preserve a positive state of health and to avoid a state of illness. The higher health motivation of mothers will result in greater intention to vaccinate their sons. Cues to Action Cues to action refer to factors that influence the individual and encourage him or her to take a health action. In the current study, this means those factors that affect and encourage mothers to vaccinate their sons against HPV. Several studies examined the prediction ability of the HBM. Dempsey et al. (2011) found that mothers had the greatest intention of vaccinating their sons against HPV when perceiving the vaccine as having significant health benefits and few barriers. Similar results were found in a study conducted among adolescents, young adults, and parents of adolescents in the United States, which found that perceived benefits were the main predictor of HPV vaccine uptake (Brewer & Fazekas, 2007). In contrast, Reiter et al. (2013) found that the most important factor affecting parents' intention to vaccinate their daughters was the parent's beliefs concerning the HPV vaccine. Moreover, in a study conducted among Afro-American women aged 18–26, the most prominent factor affecting HPV vaccine uptake were cues to action (Bynum, Brandt, Sharpe, Williams, & Kerr, 2011). Hence, the issue is still ambiguous; in addition, it is not clear which factors most affect the intention of Arab and Jewish mothers in Israel to vaccinate their sons against HPV. In light of the lack of clarity in the literature regarding the ability of the HBM to predict mothers' intention to vaccinate their sons against HPV, the study will investigate this issue. Methods Study Design and Participants
Theoretical Framework The Health Belief Model (HBM) was developed by Becker (1974) and is designed to explain decision making and behaviors associated with health and illness based on the individual's subjective perceptions in states of uncertainty. The premise underlying the HBM is that one must be in a state of psychological willingness in order to effect a change in his or her health behavior, i.e., to take preventive action against illness. The major constructs of the model are as follows:
This study has a quantitative cross-sectional design. A convenience sample of 200 Israeli mothers – 100 Jewish and 100 Arab – took part in the study. The inclusion criteria were: Mothers of sons, of whom at least one was between the ages of 5–18. The exclusion criteria were lack of good literacy skills in Hebrew or Arabic. A total sample size of 220 was determined. This size was calculated at 80% power with 95% confidence interval for a 2-tailed difference of means test. Calculations were based on seeking a difference of 0.5 on the Likert scale.
Please cite this article as: Ben Natan, M., et al., Intention of Mothers in Israel to Vaccinate their Sons against the Human Papilloma Virus, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.01.001
M. Ben Natan et al. / Journal of Pediatric Nursing xxx (2017) xxx–xxx
Instrument The study instrument was a questionnaire designed by Ben Natan and Maor (2014). The questionnaire consisted of 35 items and included two parts: sociodemographic data and constructs of the HBM (intention to be vaccinated, susceptibility to the disease, severity of the disease, benefits of the vaccine, barriers, health motivation, and cues to action). Responses were given on a Likert scale ranging from 1 to 6, with 1 representing “strongly disagree” and 6 “strongly agree”. In addition, three knowledge questions were asked, with correct answers scored as 1. The sum of all knowledge scores ranged from 0 to 3. The questionnaire was translated into Arabic and was externally validated by retranslation into Hebrew and examination of the congruence. An internal validity test was also performed by three expert nurses in the field of vaccination. The questions were reformulated based on their comments. The reliability of the questionnaire demonstrated an alpha Cronbach of 0.8–0.95. Research Procedure and Ethical Considerations The questionnaire was approved by the ethics committee of Tel Aviv University. The researchers distributed the questionnaire in Arab villages in northern and central Israel among mothers who live in their vicinity, from January–March 2016. The researchers explained the purpose of the study to the participants and that the participants are not obliged to participate. In addition, they stated that the research data would remain anonymous and would be used only for research purposes. The participants completed the questionnaire at home over 20 min on average. Data analysis Statistical analysis was performed with the Statistical Package for Social Sciences (SPSS, v. 21; SPSS PC, SPSS Inc., Chicago IL, USA). The descriptive statistics included means, standard deviations (SD), frequencies, and percentages. Reliability was examined by alpha Cronbach. Correlations between variables were examined by Pearson's correlation; t-tests and multiple linear regression analysis were performed to determine HBM prediction of the explored phenomenon. Statistical significance was set at p b 0.01. Results The response rate was 91%, i.e., 200 mothers – 100 Jewish (n = 100, 50%) and 100 Arab (n = 100, 50%). The mean age of the mothers was 38.46 (SD = 7.78), with a range of 23–60. Most of the mothers in the sample were married (n = 183, 91.5%). Each had 2 children on average, with a range of 1–6 (M = 2.37, SD = 1.22). Of the Jewish respondents, the highest educational level attained by 77% (n = 77) was an academic education, 13% (n = 13) - a tertiary education, 11% (n = 11) - a secondary education, and none of the respondents had only an elementary education. In contrast, of the Arab respondents, 45% (n = 45) had an academic education, 28% (n = 28) a secondary education, 23% (n = 23) a tertiary education, and 3% (n = 3) an elementary education. Most of the mothers in the sample were employed (n = 155, 77.5%). Approximately 39% (n = 78) reported a below-average income, 42.5% (n = 85) an average income, and about 18% (n = 37) an above-average income, based on the average income in Israel. Approximately 14% (n = 28) of all respondents vaccinated their sons against HPV, of whom approximately two thirds were Arabs (n = 18, 64%) and one third Jews (n = 10, 36%). Examination of respondents' compliance with vaccination of their sons shows that the number of Jews and Arabs who received the first vaccine dose was identical, at 50% (n = 7). A difference was evident between Arab and Jewish respondents, however, where 87.5% (n = 7) of Arabs gave permission for their sons to receive the second dose and 66.7% (n = 4) the third dose, while
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only 12.5% (n = 1) of the Jews (p b 0.01) gave permission for their sons to receive the second dose and 33.3% (n = 2) the third dose. The research findings show that the intention of mothers to vaccinate their sons was moderate, with no difference between Arab and Jewish mothers (see Table 1). A significant difference was found between Arab and Jewish mothers in the perceived susceptibility of their sons to the disease. Arab mothers perceived their sons' susceptibility to HPV as lower than did Jewish mothers, with 33% of the latter of the opinion that their son is susceptible to HPV, versus 6% of Arab mothers. Moreover, a significant difference was found between Arab and Jewish mothers in the perceived severity of the disease, such that Jewish mothers perceived the disease as more severe than did Arab mothers. The findings indicate that 37% (n = 37) of the Jewish mothers strongly agreed that the illness caused by HPV is dangerous, versus 16% (n = 16) of the Arab mothers. Additionally, some 42% (n = 42) of the Jewish mothers agreed with the statement that the illness caused by HPV is detrimental to one's quality of life, in contrast to 15% (n = 39) of Arab mothers. The research findings indicate that no significant difference was found between the perceptions of Arab and Jewish mothers concerning the benefits of the vaccine. The variable of perceived benefits of the vaccine was moderate among both population groups. In contrast, a significant difference was found between the perceived barriers of Arab and Jewish mothers, such that the variable of mean perceived barriers was significantly higher among Arab than among Jewish mothers. Sixty four percent (n = 64) of Jewish mothers did not agree with the statement whereby they would not vaccinate their sons due to their concern of early initiation of sexual activity, versus 39% (n = 39) of Arab mothers. A significant difference was found between the health motivation of Arab and Jewish mothers, with the health motivation of Jewish mothers higher than that of Arab mothers. The research findings indicate that half the Jewish mothers (n = 50) arrange for their sons to engage in physical activity, versus 22% (n = 22) of the Arab mothers. The findings also show that 37% (n = 37) of the Jewish mothers arrange for their sons to undergo periodical medical checkups, versus 25% (n = 25) of the Arab mothers. A significant difference was found between Arab and Jewish mothers in cues to action, where Arab mothers had a higher mean perception of cues to action than Jewish mothers. The findings indicate that the most influential element were nurses, followed by television ads. The results show that 49% (n = 49) of the Jewish mothers strongly agreed that a community nurse provided them with information about the HPV vaccine, versus 6% (n = 6) of the Arabs. A significant difference was also found between the knowledge of Arab and Jewish mothers, where Jewish mothers had a higher level of knowledge than Arab mothers. Moreover, 77.8% of the Arab mothers
Table 1 Differences between Jewish (n = 100) and Arab mothers (n = 100). tb,c
Sector Jews a
Variable Perceived susceptibility Perceived severity Perceived benefits Perceived barriers Health motivation Cues to action Knowledge Intention a b c
M 3.22 4.71 3.47 1.93 4.61 1.88 1.70 3.32
Arabs SD 1.57 1.38 1.45 1.00 1.43 0.87 0.46 1.71
M 3.93 3.71 3.71 2.81 4.07 2.25 1.60 3.59
SD 1.43 1.54 1.52 1.67 1.34 1.20 0.58 1.76
3.339⁎ −4.846 1.104 4.515⁎
−2.750⁎⁎ 2.509⁎⁎ −1.342⁎ 1.097
Range for all variables is 1–6, with exception for knowledge, which is 1–3. ⁎p b 0.05, ⁎⁎p b 0.01. df = 198.
Please cite this article as: Ben Natan, M., et al., Intention of Mothers in Israel to Vaccinate their Sons against the Human Papilloma Virus, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.01.001
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thought that the HPV vaccine should only be given to boys who are sexually active, while only 22.2% of the Jewish mothers provided an incorrect response to this statement. The research findings indicate a significant positive correlation between perceived susceptibility to the disease (r = 0.143, p b 0.05), severity of the disease (r = 0.457, p b 0.01), benefits of the vaccine (r = 0.792, p b 0.01), health motivation (r = 0.413, p b 0.01), cues to action (r = 0.481, p b 0.01), and knowledge (r = 0.193, p b 0.01), and mothers' intention to vaccinate their sons. A significant negative correlation was found between barriers and mothers' intention to vaccinate their sons (r = 0.422-, p b 0.01). The research findings indicate that the HBM predicted mothers' intention of vaccinating their sons against HPV, with an explained variance rate of 68% (R2 = 0.68), where the most influential variable is perceived benefits, while the regression found no significance for the variables of susceptibility and knowledge (see Table 2).
Discussion The research findings indicate that only 14% of the mothers vaccinated their sons against HPV. These findings are consistent with global vaccination rates (Perkins et al., 2013; Reiter et al., 2013) and point to problems with the vaccination of boys against HPV. In addition, mothers' intention to vaccinate their sons against HPV was found to be moderate, indicating that mothers are not certain whether vaccination is necessary. Nonetheless, the greater the mothers' perceived susceptibility of their sons to HPV and the higher the perceived severity of the disease, the higher their intention to vaccinate their sons against HPV. Similarly, Brewer and Fazekas (2007) and Muhwezi et al. (2014) also found that high perceived susceptibility to the disease was be associated with higher uptake of the vaccine. Thus, Ben Natan et al. (2011) found that the more mothers perceived HPV as a threat to their daughters, the greater their inclination to vaccinate them. The current study shows that the more positive mothers' perceptions of the vaccine's benefits, the higher their intention to vaccinate their sons against HPV. Similar to Dempsey et al. (2011), the strongest predictor of parents' intention to vaccinate was the benefits of the vaccine. Furthermore, the research findings show that the lower mothers' perceived barriers, the higher their intention to vaccinate their sons against HPV. Dempsey et al. (2011) stated that parents' intention to vaccinate their sons diminishes with the increase in barriers to vaccine uptake. One of the barriers to vaccine uptake in the current study was the number of doses necessary to complete the vaccination process. Mothers reported that the need for three vaccine doses to complete the series is inconvenient. Another barrier was that Arab mothers were concerned that their sons would become sexually active at an early age as a result of the vaccination. Our study showed that the more cues to action mothers perceive, and the more recommendations by medical staff, the higher mothers' intention to vaccinate their sons against HPV. The findings indicate that the element that most influenced mothers was nurses. In contrast,
Table 2 Predictors of mothers' intention to vaccinate their sons (N = 200). Variable
B
β
ta
Perceived susceptibility Perceived severity Perceived benefits Perceived barriers Health motivation Cues to action Knowledge
−0.075 −0.162 0.792 −0.177 0.208 0.222 0.057
−0.067 −0.144 0.678 −0.147 0.168 0.136 0.024
−1.502 −2.540⁎ 11.991⁎⁎ −2.890⁎⁎ 3.514⁎⁎ 2.807⁎⁎
a
⁎p b 0.05, ⁎⁎p b 0.01.
0.539
Perkins et al. (2013) found that most parents said that physicians are the most important element causing them to vaccinate their sons. The disparity might result from the fact that all vaccinations in Israel are administered by nurses. Additionally, the greater mothers' health motivation, the higher their intention to vaccinate their sons against HPV. This finding contradicts Shahrabani, Benzion, and Din (2009), who did not find health motivation to be a predictor of vaccination. This discrepancy might be a result of the different research population, as Shahrabani et al. (2009) examined the perceptions of medical staff with regard to the flu vaccine. The study found that the more mothers knew about the vaccine and about the disease, the higher their intention to vaccinate their sons. Seven et al. (2015) stated that lack of knowledge and awareness of the HPV vaccine constitutes the greatest barrier to uptake of the vaccine. This unlike Dempsey et al. (2011), who found no significant difference in HPV vaccine uptake between a trial group that received an explanation about the vaccine and a control group that received no explanation. The research findings reveal that Arab mothers perceived their sons' susceptibility to HPV as lower, perceived barriers as higher, had lower health motivation and a lower level of knowledge, than did Jewish mothers. However, the research findings indicate that more Arab mothers vaccinated their sons than did Jewish mothers. The difference may be associated with the fact that nurses' explanatory activity with regard to the importance of vaccinating sons is more extensive and significant in the Arab sector, and implementation of the entire vaccination policy began in Arab villages. The current finding that supports this assumption is the finding that Arab mothers had a higher mean perception of cues to action than Jewish mothers. Healthcare provider recommendations have been identified as a positive predictor of HPV vaccine uptake (Kessels et al., 2012). A US study showed this relationship to be consistent across all racial/ethnic groups (Ylitalo, Lee, & Mehta, 2013). The limitations of our study derive from the form of sampling utilized, which was based on a convenience method, possibly hampering generalization of the findings to the general population. In addition, the study refers to mothers' self-report of intention to vaccinate, and not on actual vaccination rates.
Conclusions and Implications Mothers showed a low level of compliance with vaccination of their sons against HPV, with higher compliance evident among mothers from the Arab sector. Nonetheless, the level of intention to vaccinate their sons was moderate, with no difference between Arab and Jewish mothers. The research findings show that the HBM predicts mothers' intention to vaccinate their sons against HPV, with the most influential factor being the perceived benefits of vaccination. Hence, in order to promote mothers' intention to vaccinate their sons and actual vaccination, it is necessary to raise mothers' awareness of the benefits of vaccination through national projects managed by nurses as well as through television ads that stress the benefits of vaccination. Moreover, it is important to emphasize the role of nurses in instructing parents about vaccination as early as the seventh grade in preparation for vaccination in the eighth grade. It is important to hold instruction days at school for mothers and their sons in the seventh grade and to distribute informational pamphlets explaining the benefits of the vaccine and its significance. In addition, nurses should hold lectures at women's athletic clubs, health clubs, and community clinics frequented by women with high health motivation, and should explain the benefits of vaccination. In order to enable wider generalization of the findings, further research should be conducted using randomized sampling. In addition, it is important to conduct a prospective study on actual administration of the vaccine, in order to examine the proportion of Arab and Jewish boys vaccinated in practice and what should be done to increase the vaccination rate.
Please cite this article as: Ben Natan, M., et al., Intention of Mothers in Israel to Vaccinate their Sons against the Human Papilloma Virus, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.01.001
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Please cite this article as: Ben Natan, M., et al., Intention of Mothers in Israel to Vaccinate their Sons against the Human Papilloma Virus, Journal of Pediatric Nursing (2017), http://dx.doi.org/10.1016/j.pedn.2017.01.001