Factors Influencing Parental Decisions about HPV Vaccination

This systematic review explores the factors that influence parental decisions about Human Papilloma Virus (HPV) vaccination. The review identifies four major themes: susceptibility and age of children, educational attainment, apprehension regarding vaccine effectiveness and safety, and religious affiliation, ethnicity, and socioeconomic status. The findings highlight the importance of healthcare professionals' recommendations, parental knowledge and beliefs, and the need for effective communication to increase vaccination rates.

Running head: SYSTEMATIC REVIEW
A systematic review to explore the factors that influence parental decisions about Human Papilloma Virus
(HPV) vaccination.
Name of the Student
Name of the University
Author Note

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Abstract
Background- HPV vaccination is an inactive vaccine that provides protection against different types of HPV
and also prevents the onset of cervical cancer and genital warts. However, the need for parental permission is a
considerable system-level obstacle to mounting rates of HPV vaccination among minors.
Design and review method- A systematic review was conducted for peer reviewed articles. Four articles were
selected from the university library database by using specific key words like, “human papillomavirus”,
“papillomavirus infections”, “HPV vaccines”, “children”, “papillomavirus vaccines”, “parents”, “acceptance”,
“parental”, “attitude”, “awareness”, “factors”, “behaviours”, “decision”, “uptake”, “perception”,
“effectiveness”, and “decision making”.
Results and conclusions- Four major themes identified from the four articles were susceptibility and age of
children, educational attainment, and apprehension regarding vaccine effectiveness and safety, and religious
affiliation, ethnicity, and socioeconomic status.
Keywords: parents, children, vaccination, HPV, education, religion, ethnicity, safety
Synonyms: blood relation, kids, immunization, schooling, faith, background, security

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Introduction
HPV vaccines have the potential of preventing the onset of different types of infection that are caused
due to human papillomavirus. The major advantage of these vaccines can be associated with the fact that they
help in providing protection against HPV type 16 and 18 that are responsible for the onset of cervical cancer.
Furthermore, HPV is a common infection that is sexually transmitted and results in the development of genital
wards. Owing to the fact that several men and women act as carriers of this virus, HPV plays a crucial role in
the onset of other kinds of cancer that affects the penis, vulva, throat and anus. CDC recommends
administration of 2 doses of the vaccine for children aged 11-12 years, for protecting them against cancers.
The review will focus on exploring the factors that influence parental decision regarding HPV
vaccination of their children owing to the fact that around 14 million US residents, including teenagers acquire
HPV every year. The theoretical implication of this research is that it will add evidence to the already existing
arguments regarding the features that play an important role in altering parent acceptability of HPV vaccines
(Holman et al., 2014). The practical significance can be associated with the fact that the research will help in
eliminating the barriers to HPV vaccination (if any), and will also target future interventions,
PICO- The elements of the PICO question are as follows:
 P/Population- Parents of children aged 7-12 years
 I/Intervention- Exploring the factors that govern their decision making
 C/Comparison- Not assessing the influencing factors
 O/Outcome- Greater acceptability among parents
Aims and Objective(s)
Research aim- To determine the factors that influence the decision of parents regarding HPV
vaccination of their children.

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Research objectives-
 To explore the factors that prevent parents from vaccinating their child against HPV.
 To determine the factors that encourage parents from vaccinating their child against HPV.
 To explore future directions for exploiting HPV vaccination acceptance.
Research question
What are the factors that influence parental decisions about Human Papilloma Virus (HPV)
vaccination?
Justification of the research question
Recommendation proposed by healthcare professionals such as, pediatricians and gynecologists play an
important role in influencing the adolescent and parental decision making, with regards to acceptability of HPV
vaccine administration. Furthermore, adolescents are at an increased likelihood to be tested by a pediatrician, in
comparison to other healthcare providers, which creates a considerable impact on patients’ immunization
decision. HPV knowledge, age, beliefs regarding the sexual history and experience of patients, practice
location, and comfort in discussing sexual behaviour creates a noteworthy impact on immunization decisions. In
addition, parental factors such as, denial that their child is at danger, vaccination requests, unwillingness
regarding STD immunization, concerns regarding safety of vaccine and the conviction that kid receives several
vaccines also influence vaccination decisions. Hence, there is a need to identify these factors that should be
addressed in order to increase vaccination acceptability among parents.
Methods
With the aim of extracting pertinent articles from different databases, MEDLINE, CINAHL, and
EMBASE were searched by two independent researchers from January 2019 to February 2019. The search
terms that were used for retrieval of articles were namely, “human papillomavirus”, “papillomavirus
infections”, “HPV vaccines”, “children”, “papillomavirus vaccines”, “parents”, “acceptance”, “parental”,

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“attitude”, “awareness”, “factors”, “behaviours”, “decision”, “uptake”, “perception”, “effectiveness”, and
“decision making”. These terms were combined with the help of boolean operators AND, NOT and OR that
helped in either broadening or narrowing the search results. Truncations were also used at the end of the root
words for obtaining articles with titles that included a separate ending, other than the root word such as,
“child*” helped in retrieving articles that contained information on HPV vaccination of child, children,
childhood.
With the aim of obtaining scholarly evidences that were pertinent to the formulated research question,
wildcards were also used that helped in extracting literature that contained similar words with different
spellings. Snowballing technique was also used where the bibliography of the extracted articles were manually
searched for identifying any more relevant pieces of literature.
Inclusion and exclusion criteria
Articles that were peer reviewed, and reported on HPV vaccination and its acceptability by parents were
included in the systematic review. The search strategy included all types of qualitative and quantitative studies,
including already published systematic review. Mixed method studies were also included. The strategy
excluded manuscripts, clinical guidelines, and cost-effectiveness studies. Those that had been published on or
after 2008, in English language were retrieved.
Findings/ Results/Synthesis
An analysis of the four articles that were based on qualitative, quantitative, mixed-method and
systematic review design helped in the identification of four themes, based on specific data patterns reported in
the literature.
Susceptibility and age of children-Krawczyk et al. (2015) suggested that 32 parents held the opinion
that their daughters were not at a risk of acquiring HPV, which was concomitant with the view that the age of
their daughters was too less for being sexually active and being infected with HPV. As much as 25 parents
provided responses that elaborated on the fact that they had instilled moral values in their daughters that would

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make the latter abstain from any kind of sexual interaction, thus negating the possibility of being affected with
HPV infection. Reports from Rendle and Leskinen (2017) suggested that the parents did not pay much attention
to HPV concerns and held the notion that vaccinating their child against HPV would make them more sexually
active, and interfered with the parent-child relationship. The findings also illustrated the fact that adolescent
sexuality such as, the emotional and sexual readiness of children to engage in sexual activity acted as a major
indicator of HPV vaccination. Kessels et al. (2012) also suggested that greater vaccination rates were associated
with girls who were aged between 13-15 years, with a reduction in its acceptability, with an increase in age.
Parental concerns that were related with refusal of vaccines comprised of fear regarding sexual activities among
children with early initiation. Additionally, parents were worried about the effect of vaccine on children sexual
practices. Those parents who believed that HPV vaccine is not associated with risky sexual behaviours,
displayed an increased likelihood to vaccinate their sons (Ogilvie et al., 2008).
Educational attainment- According to Ogilvie et al. (2008) less educated parentages were more likely
to depend on the views of healthcare professionals and felt more comfortable in banking on the judgment of
government recommendations and health policy references, compared to educated parents. Increased
vaccination acceptability was correlated with parents who had received college education, in the systematic
review conducted by Kessels et al. (2012). However, other studies reported in the review suggested that higher
HPV vaccination uptake were related with lesser parental education attainment. Rendle and Leskinen (2017)
suggested that most parents had high educational attainment who reported hesitancy in vaccinating their
children and were also cautious regarding the vaccine novelty.
Apprehension regarding vaccine effectiveness and safety- Most parents who accepted HPV vaccination
for their daughters cited the potential benefits of the vaccine such as, general health protection, HPV and cancer
prevention, positive attitude, and the notion that the advantages of the vaccine will outweigh the risks, as the
principle reasons for their uptake (Krawczyk et al., 2015). Awareness of HPV and its transmission, knowledge
of the likelihood of a person being affected with cervical cancer, and positive attitudes towards HPV vaccine,
and its restricted influence on the sexual behaviour of children made most parents display acceptance of the

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vaccination (Ogilvie et al., 2008). According to Rendle and Leskinen (2017) most parents often waited for
greater evidences that would help them determine the effectiveness and safety of HPV vaccinations, prior to
administering them on their kids. Delaying HPV vaccination also allowed the parents to adequately address
their apprehensions by gathering data from children who had been vaccinated earlier. Having prior information
about vaccine benefits from healthcare providers was positively correlated with greater acceptance of HPV
vaccines. HPV vaccine refusal was also associated with dissatisfaction amid parents regarding available
information on vaccine safety.
Religious affiliation, ethnicity, and socioeconomic status- Ogilvie et al. (2008) opined that presence of
a female sibling, religious beliefs and affiliations failed to create a significant impact in daily life decisions of
parents, with regards to vaccinating their children. Krawczyk et al. (2015) suggested that most parents reported
their household income less than $60,000, of which 88% of them accepted the administration of HPV vaccines
to their daughters. Majority of them had English as their first language. Reduced likelihood among Hispanics
for uptake of vaccination programs were reported by Kessels et al. (2012). Additionally, smaller distance
between vaccination center and home was meaningfully associated greater acceptance.
Discussion of the usefulness & significance of the findings to practice
Hence, the major findings from the thematic analysis suggests that the results are in accordance to the
already existing literature that focus on several predictors of vaccination uptake including: the race and/or
ethnicity, socioeconomic status, religious affiliation, educational attainment of parents, knowledge about HPV,
apprehensions regarding its efficacy and safety, and susceptibility of children to sexual behaviours. Time and
again it has been proved that recommendations provided by healthcare professionals are imperative in
influencing the decision of parents in vaccinating their children. Hence, the findings helped in elaborating on
the fact that adequate information among parents regarding the safety of HPV vaccines, appear to endorse
efficacious immunization delivery. Additionally, parents with lower educational attainment are likely to rely
more on the instructions provided by the healthcare providers, in contrast to their educated counterparts. The
findings of the review are also consistent with the fact that parents do not expect their children to engage in

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sexual behaviour at a young age, which in turn influences their decision to not get the latter vaccinated. Lack of
awareness and false beliefs, regarding the effects of immunisation on sexual behaviour of adolescents and
uncomfortableness while engaging in discussions concerning sexual issues of children, are other governing
factors.
Conclusion
To conclude, parental attitudes are imperative to gaining a sound understanding of the outcomes of HPV
vaccination. Poor understanding among parents regarding the potential benefits and contraindications of the
vaccine often makes them display a reluctance to get their child immunised. Age, ethnicity, education, and
religion also appear to be significantly correlated with reception of HPV vaccination. This calls for the need for
fostering parent–child communication on protective sexual health among adolescents. My role as an RN would
encompass increasing awareness among parents on the health advantages that their children are likely to gain
from HPV vaccination, with the aim of increasing the rates of vaccination uptake.

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References
Kessels, S. J., Marshall, H. S., Watson, M., Braunack-Mayer, A. J., Reuzel, R., &Tooher, R. L. (2012). Factors
associated with HPV vaccine uptake in teenage girls: a systematic review. Vaccine, 30(24), 3546-3556.
https://doi.org/10.1016/j.vaccine.2012.03.063
Krawczyk, A., Perez, S., King, L., Vivion, M., Dubé, E., &Rosberger, Z. (2015). Parents’ decision-making
about the human papillomavirus vaccine for their daughters: II. Qualitative results. Human vaccines
&immunotherapeutics, 11(2), 330-336. https://doi.org/10.4161/21645515.2014.980708
Ogilvie, G. S., Remple, V. P., Marra, F., McNeil, S. A., Naus, M., Pielak, K., ...& Money, D. M. (2008).
Intention of parents to have male children vaccinated with the human papillomavirus vaccine. Sexually
transmitted infections, 84(4), 318-323. http://dx.doi.org/10.1136/sti.2007.029389
Rendle, K. A., &Leskinen, E. A. (2017). Timing is everything: exploring parental decisions to delay HPV
vaccination. Qualitative health research, 27(9), 1380-1390.
https://doi.org/10.1177%2F1049732316664499

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Appendix A
Table 1: Data extraction
PAPER 1:
Rendle, K. A., &Leskinen, E. A. (2017). Timing is everything: exploring parental decisions to
delay HPV vaccination. Qualitative health research, 27(9), 1380-1390.
https://doi.org/10.1177%2F1049732316664499
Level of Evidence Level II-2
Country where Data was
collected
The USA
Introduction-Background HPV is commonly transmitted across the US and is related to
several types of cancer. However, there are cultural anxieties and
debate over parenting decisions and its acceptance
Research question What factors influence parental decision to delay HPV vaccination?
Methods: Research approach,
Research design, Paradigm,
population, sample Size,
Sampling technique, Data
collection, Data analysis
method.
Mixed-method design; pragmatism; 50 parents from Northern
California; purposive sampling through screening questionnaires;
semistructured interviews conducted, followed by iterative coding
to recognise themes
Research Ethics considerations

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Written consent taken from participants; approval obtained from
Institutional Review Board
Results: Main finding
Parents are apprehensive of the vaccine novelty, its benefits and
risks grounded on the emotional and sexual development of the
children, and the absence of adequate evidence for determining
safety of the vaccines.
Discussion
Parental indecisions to immunise are not purely related to scientific
uncertainty but are reflective of assessments of sexual readiness of
children.
Strength, Limitations&rigour Factors governing parental decision identified
Lack of generalizability
High rigour
Implication of the findings to
nursing practice
The findings will help in increasing HPV vaccine uptake
Your global appreciation

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The study is beneficial in exploring the factors that govern HPV
acceptance
Table 2: Data extraction
PAPER 2:
Kessels, S. J., Marshall, H. S., Watson, M., Braunack-Mayer, A. J., Reuzel, R., &Tooher, R. L.
(2012). Factors associated with HPV vaccine uptake in teenage girls: a systematic
review. Vaccine, 30(24), 3546-3556. https://doi.org/10.1016/j.vaccine.2012.03.063
Level of Evidence Level I
Country where Data was
collected
Australia
Introduction-Background
HPV is responsible for 99% of all cervical cancer cases and is
sexually transmitted.
Research question What are the factors related with uptake of HPV vaccine among
teenage girls?
Methods: Research approach,
Research design, Paradigm,
population, sample Size,
Sampling technique, Data
collection, Data analysis
method.
Systematic review; constructivist; 25 studies obtained by PRISMA;
critical appraisal; thematic analysis
Research Ethics considerations Not applicable
Results: Main finding Most studies formed a correlation between increased vaccine
uptake rates with health insurance, old age, childhood vaccine

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reception, and adequate information from healthcare providers.
Discussion Efforts must be taken to resolve the disparities that exist regarding
acceptance of HPV vaccines
Strength, Limitations &rigour First systematic review
Lack of generalizability of results
Low rates of vaccination uptake
Implication of the findings to
nursing practice
Identification of factors would help in increasing HPV vaccination
program success rate
Your global appreciation
The study is beneficial in exploring the factors that govern HPV
acceptance
Table 3: Data extraction
PAPER 3:
Ogilvie, G. S., Remple, V. P., Marra, F., McNeil, S. A., Naus, M., Pielak, K., ...& Money, D. M.
(2008). Intention of parents to have male children vaccinated with the human papillomavirus
vaccine. Sexually transmitted infections, 84(4), 318-323. http://dx.doi.org/10.1136/sti.2007.029389

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Level of Evidence Level II-1
Country where Data was
collected
Canada
Introduction-Background HPV is a prevalent sexually transmitted disease among males and
females
Research question What are the parental intentions for vaccinating their sons with
HPV vaccine?
Methods: Research approach,
Research design, Paradigm,
population, sample Size,
Sampling technique, Data
collection, Data analysis
method.
Quantitative study; positivism; 1381 respondents having male
children; survey tool based on ‘Theory of Planned Behaviour’
(TPB); logistic regression analysis
Research Ethics considerations Ethical approval and informed consent obtained prior to the study
Results: Main finding 67.8% parents wanted to vaccinate their kids and were influenced
by subjective norms. Higher education was linked with less
intention of vaccinating children.
Discussion Most parents wanted to vaccinate their children
Strength, Limitations &rigour Public funded vaccination programs were effective in initiating
positive attitude among parents
Random digit dialling method and large sample size
High rigour
Implication of the findings to More school-based immunisation programs must be implemented

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nursing practice
Your global appreciation The study is beneficial in exploring the factors that govern HPV
acceptance
Table 4: Data extraction
PAPER 4:
Krawczyk, A., Perez, S., King, L., Vivion, M., Dubé, E., &Rosberger, Z. (2015). Parents’
decision-making about the human papillomavirus vaccine for their daughters: II. Qualitative
results. Human vaccines &immunotherapeutics, 11(2), 330-336.
https://doi.org/10.4161/21645515.2014.980708
Level of Evidence Level I
Country where Data was
collected
Canada
Introduction-Background HPV infects an estimated 3 out of 4 individuals in the world.
Research question What factors govern parent’s decision making about HPV
vaccination for their daughters?
Methods: Research approach,
Research design, Paradigm,
population, sample Size,
Sampling technique, Data
collection, Data analysis
method.
Qualitative; constructivist; 806 parents; questionnaire data
collection; thematic analysis
Research Ethics considerations Informed consent taken
Results: Main finding 88% parents were in support of vaccination and cited perceived

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benefits, physician recommendation, and trust in school vaccine
program as major influencers. Fear of adverse effects and low
susceptibility made them refuse vaccination for their child.
Discussion Parent perspectives were clearly understood.
Strength, Limitations &rigour Helped in gaining awareness on parent perspectives
Modest overall response rate
Small percentage refused vaccination
Use of open-ended questions
High rigour
Implication of the findings to
nursing practice
Knowledge on the identified factors will help in encouraging
parents to vaccinate their child
Your global appreciation The study is beneficial in exploring the factors that govern HPV
acceptance

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Appendix B
(Research Worksheet 2017; Instruction: Use the appropriate template to your article)
Critical appraisal of 4 articles:
QUALITATIVE RESEARCH: The Reader’s Companion Worksheet
Article Title:Parents’ decision-making about the human papillomavirus vaccine for their daughters: II.
Qualitative results
Author(s):Krawczyk, A., Perez, S., King, L., Vivion, M., Dubé, E., &Rosberger, Z.
TITLE
Topic of interest Yes No Maybe
Method of interest Yes No Maybe
Population of interest Yes No Maybe
ABSTRACT
Results useful Yes No Maybe
INTRODUCTION
Why was the study done (i.e., problem, concern, issue)?
The study focuses on the raging health care trend of HPV vaccination to prevent the risk of HPV infection,

17SYSTEMATIC REVIEW
which is also a risk factor for cervical cancer. The study focuses on a very crucial aspect, exploring and
understanding the perception and ideation among the parents regarding whether or not to let their daughters
take the HPV vaccination.
What is the purpose of the study or what questions is the investigator trying to answer
The purpose of the research study is to explore the reasoning underlying parents’ decisions to either accept or
refuse HPV vaccination for their daughters within this provincial HPV vaccination program
What are the central concepts (e.g., pain, grief, nursing work)?
The central concept associated with the research study is associated with understanding the school of thoughts
among the parents and whether the benefits of HPV vaccination provided free of cost outweigh the cons
associated with it. As the consumer decision making can be influenced by nursing education and health
promotion, hence, it can be considered that the concept of the research is related to nursing work.
Are most of the references recent (less than 5 years old)? Yes No
If not, is this a classic/groundbreaking reference or one that has reemerged in importance (e.g., research
relating to tuberculosis)?
The research articles that has been used past the limit of last 5 years, the references had been classic or
groundbreaking in the information that they have provided in the content
Are experts cited? Yes No Not sure
All of the experts have been cited successfully in the research, and follows the general standard academic
referencing guidelines effectively
METHODS

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Design
What is the research design (e.g., case study, grounded theory, phenomenology, narrative research)?
The research design in this case is a case study based qualitative analysis.
Is the research design appropriate for answering the
research question?
Yes No Not sure
In this case, the purpose of the research is to examine the exact thought process or perception of the
individuals regarding the HPV, and whether or not it is beneficial to take the vaccination. Hence, it is very
important to assess and explore the exact contributing factors leading to the decision making process. Hence,
a qualitative research design which aims to capture the exact point of view and perception is apt for the
research study with respect to the questions and purpose.
Sample
What are the characteristics of the participants who were included and excluded from the study (e.g., health
status, age, education, gender, ethnicity, occupation, socioeconomic status)?
The sampling had been random incorporating parents of 9/10 year old girls that completed a mail-in
questionnaire. Considering demographics adjusted for the article includes language, ethnicity, religion, family
outcome, marital status, educational attainment, Ever had or know anyone close who has had an STI, and
Ever had or know anyone close who has had cancer.
Included:
Not mentioned
Excluded:

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Not mentioned
Does the selection of the participants fit with the
concept being studied?
Yes No Not sure
Where were the participants recruited (e.g., self-help group, clinical unit)?
The participants were recruited separately and was not associated with recruitment into any self-help group or
clinical unit.
What were the procedures for choosing participants (e.g., purposively selected, snowball technique)?
The sampling had been randomized, as a result there had not been any purposive or snowball technique of
sampling used in the study.
Research Ethics Concerns
Was informed consent obtained? Yes No
Were the participants reasonably able to take part? Yes No
Was the study potentially/actually harmful to
participants/others?
Yes No
List any ethical issues with the study that are of concern to you as a reader and potential user of the research
(e.g., truthfulness, confidentiality, coercion).
No pertinent ethical issue observed.
Setting

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What was the setting in which data were collected?
Busy unit Home setting Private room Other
The data had been collected through questionnaire which was provided to each of participants singularly.
Data Collection
What strategy or strategies were used for the data collection?
Focus group Structured interview Unstructured interview Observation Other
Did the research explain his or her role in the data
collection process?
Yes No Not stated
How were the data recorded (e.g., field notes, tape-recorded, videotaped)?
The data collection had been done via questionnaires and was recorded as that only.
Were strategies used to ensure rigour/trustworthiness? Yes No Not stated
If yes, what were they (e.g, review by others, exemplars provided, audit trail)?
Data Analysis
Did the researcher critically examine his or her own Yes No Not sure

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role, assumptions, and preconceptions?
Were the data analyzed inductively? Yes No Not stated
What methods of data analysis were used (e.g., how the categories/themes were derived, constant
comparison)?
The data analysis was done separately for each group and based on the data that had been identified and
analyzed, two frames had been developed, the first had been for the parents who agreed for the vaccine and
the second one for the parents that declined the vaccine
Was data saturation/informational
redundancy reached?
Yes N
o
Not stated Not applicable
The authors created conceptual categories along with concepts that belonged to similar dimensionswhich then
had been regrouped. Followed by that, the regrouped conceptual categories had been updated and revised
until data saturation was attained.
RESULTS AND DISCUSSION
What are the main findings of the study (i.e., major categories/themes that emerged)?
The major themes were divided into two categories, factors that contributed to the positive or negative
decision making to the HPV vaccination. 88% of the total participants agreed to vaccinate their daughter.
What information is presented in tables, figures or graphs? Are these easy to understand or confusing?

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The focus group based recruitment of the sample population and their baseline characteristics had been
presented in tables, figures or graphs.
Do you agree with the investigator’s interpretation of the
results?
Yes No
If not, why not?
Are the results consistent with those of past research? Yes No
If not, why not?
Does the interpretation make sense theoretically? Yes No Not applicable
If not, why not?
Does the interpretation offer any ideas that you can
use?
Yes No Not applicable
If not, why not?
OVERALL IMPRESSIONS
Overall, is the article important or significant for the practice of
health care?
Ye
s
No
Do the findings resonate (seem correct and familiar) with you and
your practice)
Ye
s
No
If yes, why?

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The article had discovered that the perception of the participants relates largely with the decision making
process of whether or not vaccinating their daughters. As nurses, we often have to overcome any factors that
lead to negative attitude towards vaccination. Hence, the factors such as fear of side effects should be
overcome with counselling.
Major limitations of the study (two or three):
Relatively modest response rate, open-ended question giving way for recall bias, no evidence on dosage
calculation.
Major strengths of the study (two or three):
The correlation of qualitative data findings with the existing evidence is a notable strength and the sampling
is quiet large which is a notable strength
Are the results transferable? Yes No Not sure
Mixed research method:
MIXED METHODS RESEARCH
The Reader’s Companion Worksheet
Please note: if the mixed methods research is presented in two articles, use Worksheets 1 and 2. This worksheet
is for use when the mixed methods research is presented in one article.
Article Title:Timing Is Everything: Exploring Parental Decisions to Delay HPV Vaccination
Author(s):Rendle, K. A., &Leskinen, E. A.

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TITLE
Topic of interest Ye
s
No Maybe
Method of interest Ye
s
No Maybe
Population of interest Ye
s
No Maybe
ABSTRACT
Results useful Ye
s
No Maybe
INTRODUCTION
Why was the study done (i.e., problem, concern, issue)?
The research study focuses entirely on the delayed uptake of HPV vaccination among the society which risks
the parents from embracing the protective measures wholeheartedly. The study attempted to explore the
decision making in parents regarding HPV and the perception of the risk of their daughters acquiring the HPV
infection, or even the associated types of cancers.
What is the purpose of the study or what questions is the investigator trying to answer (e.g., literature
review)?
This research study takes the assistance of critical theories of risk, and attempts to explore how present and

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future risk assessment delays the HPV vaccination rates, and evaluate how temporality, risk, and sexuality
overlap process of making health care related decisions.
What are the central ideas, concepts, or variables (e.g., pain, immobility, grief, nursing work)?
The central concept of research study is the decision making in the parents and whether they understand the
present or future risk of their children acquiring HPV infection, and the greater risk of cervical, anal, or head
and neck cancers post infection.
Are most of the references recent (less than 5 years old)? Yes No
If not, is this a classic/groundbreaking reference or one that has reemerged in importance (e.g., research
relating to tuberculosis)?
Most of the old references had been classic or groundbreaking references which helped in understanding the
research study effectively.
Are experts cited? Ye
s
No Not sure
METHODS
Design
What reason is given for using mixed methods?
There is no clear representation or justification provided for choosing the mixed method design for the study,
although the authors have stated that they used semi-structured interviews and structured questionnaires both

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as just survey methods are not sufficient in exploring complex decision-making processes or capture context
of delaying decisions, which can be easily availed by using qualitative design.
Which mixed methods approach was selected (e.g., sequential exploratory, concurrent triangulation)?
The authors used constant comparative method of mixed research design.
Is the weighting of qualitative and quantitative part made clear (i.e., which part was given priority, or were
they equal)?
Both of the parts were almost equal, although as the emphasis of the study had been on understanding the
complex decision making procedure, the emphasis was slightly higher on qualitative part of the study.
Was an overarching theory used (transformative approach)? Ye
s
No Not sure
Is the research design appropriate for answering the research question? Ye
s
No Not sure
Did the qualitative researcher critically examine his or her own role,
assumptions, and preconceptions?
Ye
s
No Not sure
At what point in the study did the integration of methods occur (e.g., data collection, data analysis)?
Both in data collection and data analysis.
Sample
Are the sampling strategies for both the qualitative and quantitative phases of
the study described?
Ye
s
No Not sure
What are the characteristics of the participants who were included and excluded from the study (e.g., health
status, age, education, gender, ethnicity, occupation, socioeconomic status)?

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Total 50 participants were included in the study, out of which 46% at least vaccinated their children once
before, 18% reported they planned to vaccinate their children, 10% stated that they did not plan to vaccinate
and 26% reported to be uncertain. Nothing mentioned regarding exclusion of the participants.
Included:
Qualitative
Total 50 participants were included in the study, out of which 46% at least vaccinated their children once
before, 18% reported they planned to vaccinate their children, 10% stated that they did not plan to vaccinate
and 26% reported to be uncertain. The majority of the parents identified as either non-Hispanic White (68%)
or Asian/Asian American (20%), and female (92%).
Quantitative
Nothing is mentioned.
Excluded:
Qualitative
Not mentioned
Quantitative
Not mentioned

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Does the selection of the participants fit with the concept being studied?
Qualitative Ye
s
No Not sure
Quantitative Ye
s
No Not sure
Where were the participants recruited (e.g., self-help group, clinical unit)?
The participant recruitment had been done through local school-based and community-based parenting
networks, which can be considered as self- help groups.
What was the rationale for the sample size (e.g., data saturation, power calculation)?
Qualitative
Not rationale given
Quantitative
Not rationale given
What were the procedures for choosing participants (e.g., purposively selected, snowball technique, random
sample, convenience)?
Qualitative
The participants had been purposively selected.
Quantitative
Not mentioned
In the qualitative part, were strategies used to ensure rigour (e.g., reliability Ye No Not

29SYSTEMATIC REVIEW
and validity, trustworthiness)? s stated
If yes, what were they (e.g., review by others, audit trail, member check, triangulation)?
All study activities were reviewed and approved by the University of Michigan Institutional Review Board.
Do you think the methods used to select quantitative participants for the study biased the results?
Selection bias Yes No
If yes, how?
In the quantitative portion, were there many refusals, withdrawals, dropouts, or deaths?
Participation bias Yes No
Research Ethics Concerns
Was informed consent obtained? Yes No
Were the participants reasonably able to take part? Yes No
Was the study potentially/actually harmful to participants/others? Yes No
List any ethical issues with the study that are of concern to you as a reader and potential user of the research
(e.g., truthfulness, confidentiality, coercion).
No such issues involving lack of truthfulness, confidentiality breach, or coercion.
Setting
What was the setting in which data were collected?
Busy unit Home Private room Other

30SYSTEMATIC REVIEW
setting
Quantitative Research Experiment (if applicable)
What was the special treatment/intervention?
Not mentioned.
Did the participants in the study know whether they received the intervention or a
placebo?
Yes No
What methods, if any, were used to “blind” the applicants, staff, and data collectors from knowledge about
the study that might influence the results?
Not any details provided.
Was there any contamination or mixing of treatments across the study groups?
No such information provided.
Were there any other factors related to the intervention/treatment that might have influenced the outcome?
Not mentioned
Performance bias Yes No

31SYSTEMATIC REVIEW
If yes, what were they?
Data Collection
What qualitative strategy or strategies were used for the data collection?
Focus group Structured
interview
Unstructured
interview
Observatio
n
Other
Semi-structured interview
Did the qualitative research explain his or her role in the data collection
process?
Ye
s
No Not
stated
How were the data recorded (e.g., field notes, tape-recorded, videotaped)?
The interviews were digitally recorded and transcribed verbatim.
In the qualitative analysis, was data saturation reached? Yes No Not
stated
Not
applicabl
e
What quantitative strategy or strategies were used for data collection?
Questionnair
e
Interview Chart review Procedure Observatio
n
Other

32SYSTEMATIC REVIEW
Were methods used to ensure that quantitative data were reliably collected
(e.g., differences between raters, differences between times of measurement)?
Ye
s
No Not
reported
If yes, what were they?
Were methods used to ensure the validity of the quantitative data collected
(e.g., expert review, comparison with other measures)?
Yes
Ye
s
No Not
reported
If yes, what were they?
Do you think that the measurement methods biased the results?
Measurement bias Yes No
If yes, how?
Data Analysis
What methods of data analysis were used? For the qualitative analyses, how were the categories/themes were

33SYSTEMATIC REVIEW
derived (e.g., constant comparison)? For quantitative analyses, what statistical tests were used (e.g., t-tests,
regression analysis)?
Qualitative
For the qualitative analysis, both constant comparison and independent iterative open coding scheme was
used to derive the emergent themes.
Quantitative
Nothing illustrated enough
RESULTS AND DISCUSSION
Sequential studies: How did the first phase of the mixed methods inform the second?
The themes were correlated with questionnaire data.
Concurrent studies: Did the weight given o each phase of the mixed methods
fit the approach taken?
Ye
s
No Not sure
What are the main findings of the study (i.e., major categories/themes that emerged; statistical findings)?
Qualitative:
The major themes discovered includes General Concerns About Vaccine Novelty, Waiting for More Evidence
of Safety and Effectiveness, and Assessing Sexual Activity and Readiness
Quantitative:
With the continued growth of evidence regarding the safety and effectiveness of HPV vaccination,
completion rates would increase.

34SYSTEMATIC REVIEW
Was the quantitative response rate satisfactory? Ye
s
No Not sure
What information is presented in tables, figures, or graphs? Are these easy to understand or confusing?
None
Were the findings statistically significant? Ye
s
No Not sure
If yes, what were they?
Were there clinically meaningful results/trends? Yes No
If not, why not?
Are the results consistent with those of past research? Yes No Not
applicabl
e
Not sure
If yes, what were they?
Previous studies have shown mixed results of the impact of message framing on HPV vaccination uptake, and
this study identifies the major emergent themes in the decision making.
DISCUSSION
Do you agree with the investigator’s interpretation of the results? Yes No
If not, why not?
Are the results consistent with those of past research? Ye No Not

35SYSTEMATIC REVIEW
s applicabl
e
If not, why not?
Does the interpretation make sense theoretically? Ye
s
No Not
applicabl
e
If not, why not?
Does the interpretation offer any ideas that you can use? Ye
s
No Not
applicabl
e
If not, why not?
OVERALL IMPRESSIONS
Overall, is the article important or significant for the practice of health care?
Yes
No
Yes No
Do the findings resonate (seem correct and familiar) with you and your practice)
Yes
No
Yes No
If yes, why?

36SYSTEMATIC REVIEW
Major limitations of the study (two or three):
The lack of generalizable point of views among the participants, lack of observational data of communication
between parents and providers, and lastly, old data collection which might not be relevant now.
Major strengths of the study (two or three):
The study incorporates both qualitative and quantitative data and contributes to relevant discussions on the
topic,
Are the results transferable or generalizable? Ye
s
No Not sure
Quantitative research method:
QUANTITATIVE RESEARCH: The Reader’s Companion Worksheet
Article Title:Intention of parents to have male children vaccinated with the human papillomavirus vaccine
Author(s):Ogilvie, G. S., Remple, V. P., Marra, F., McNeil, S. A., Naus, M., Pielak, K., ... & Money, D.
TITLE
Topic of interest Yes No Maybe
Method of interest Yes No Maybe

37SYSTEMATIC REVIEW
Population of interest Yes No Maybe
ABSTRACT
Results useful Yes No Maybe
INTRODUCTION
Why was the study done (i.e., problem, concern, issue)?
The study focuses on the decision making climate of the parents regarding whether or not their sons should be
taking HPV vaccination
What is the purpose of the study or what questions is the investigator trying to answer (e.g., literature
review)?
The purpose of the study had been to determine whether parental intentions impact decision making to
vaccinate their sons with an HPV vaccine and to determine the factors that predict this intention.
What are the central concepts (e.g., pain level, confidence, exercise activity)?
The central concept in this case had been preventative control of the HPV infection in the male counterpart of
the society and why there is resistance in decision making regardinhg taking the vaccination.
The experimental (independent) variable is defined as:
Not defined
The outcome (dependent) variable is defined as:

38SYSTEMATIC REVIEW
Not defined.
Other variables that the researcher has not thought about that might influence the results are:
Not identified.
Note that sometimes there are many factors included in descriptive surveys and not a primary or secondary
outcome. If this is the case in the article that you are reading, provide an overall description.
Are most of the references recent (less that 5 years old) Yes No
If not, is this a classic/groundbreaking reference or one that has reemerged in importance (e.g., research
relating to tuberculosis)?
Most were classic or groundbreaking reference.
Are experts cited? Ye
s
No Not sure
METHODS
Design
What is the research design (e.g., survey, case-control, cohort study)?
Survey study
Sample
What are the characteristics of the participants who were included and excluded from the study (e.g., health
status, age, education, gender, ethnicity, occupation, geographical residence, socioeconomic status)?

39SYSTEMATIC REVIEW
Included:
Men and women who were parents of children between the ages of 8–18 years, were at least 19 years of age
and could respond to questions in English or French were invited to participate.
Excluded:
Parents having children younger than 8 or older than 18 and could not respond to English or French were
excluded.
Are the participants similar to those in your setting? Ye
s
No Somewha
t
What were the procedures for choosing participants (e.g., convenience, quota, random selection, volunteers)?
Random selection.
Do you think the methods used to select participants for the study biased the results?
Selection bias Yes No
If yes, how?
Were there many refusals, withdrawals, dropouts, or deaths?
Participation bias Yes No
Research Ethics Concerns
Was informed consent obtained? Yes No
Were the participants reasonably able to take part? Yes No

40SYSTEMATIC REVIEW
Was the study potentially/actually harmful to participants/others? Yes No
List any ethical issues with the study that are of concern to you as a reader and potential user of the research
(e.g., truthfulness, confidentiality, coercion).
Not such issues
Setting
What was the environment in which the data were collected?
Home setting Private
room
Laborator
y
Other
Experiment (if applicable)
What was the special treatment or intervention?
Standardised information to participants on HPV, the HPV vaccine, role of HPV in cervical cancer and
genital warts, the nature of HPV transmission and the efficacy of the HPV vaccine as it related to cervical
cancer prevention
Did the participants in the study know whether they received the intervention or a
placebo?
Yes No
What methods, if any, were used to “blind” the participants, staff, and data collectors from knowledge about

41SYSTEMATIC REVIEW
the study that might influence the results?
No information provided
Was there any
contamination or
mixing of treatments
across the study
groups?
Ye
s
No
Were there any
factors related to the
intervention/treatmen
t that might have
influenced the
outcomes?
Performance bias Ye
s
No
Data Collection
What was the data collection method/tool used?
Questionnaire Intervie
w
Chart
review
Procedur
e
Observatio
n
Othe
r

42SYSTEMATIC REVIEW
For survey
Were methods used
that data were
reliably collected
(e.g., differences
between raters,
differences between
times of
measurement)??
Yes No Not
reporte
d
If yes, what were they?
Were methods used to ensure the validity of the collected data (e.g., expert
review, comparison with other measures)?
Ye
s
No Not
reported
If yes, what were they?
Do you think that the measurement methods biased the results?
Measurement bias Yes No
If yes, how?
Data Analysis
What statistical methods were used to analyze the data?
Bivariate and multivariate analysis.
RESULTS

43SYSTEMATIC REVIEW
Was the response rate satisfactory? Ye
s
No Not sure
What are the main findings of the study?
The majority of the Canadian parents reported to intend to vaccinate their sons with HPV vaccine in the
context of a publicly funded school-based immunisation programme. The most important predictors of the
intention includes overall attitudes toward vaccine, recommendations from health professionals and impact of
the vaccine on sexual practices.
What information is presented in tables, figures or graphs? Are these easy to understand or confusing?
The baseline characteristics along with the bivariate and multivariate analysis represented in tables and
depicted with clarity.
Were any of the findings statistically significant? Ye
s
No Not sure
If yes, what were they?
Were there clinically meaningful results/trends? Yes No Not
sure
Not
applicable
If yes, what were they?
The results indicate that the overall attitude for HPV vaccine, recommendations from health professionals and
impact of the vaccine on sexual practices, can improve or positively influence the decision making of the
parents regrading vaccination.
DISCUSSION

44SYSTEMATIC REVIEW
Do you agree with the investigator’s opinions? Ye
s
No Somewha
t
If not, why not?
Does the interpretation make sense theoretically? Ye
s
No Not sure
If not, why not?
Does the interpretation make sense clinically? Ye
s
No Not sure
If not, why not?
OVERALL IMPRESSIONS
Overall, is the article important or significant for the practice of health care? Yes No
Do the findings resonate (seem correct and familiar) with you and your practice) Yes No
If yes, why?
The findings appear to resonate with my clinical practice due to the interrelated predictors of better HPV
vaccination rates, which can be addressed by proper patient education and advocacy by nurses like myself.
Major limitations of the study (two or three):
Random digit dialing which could have resulted in in over recruitment of more educated individuals and
under recruitment of rural and remote regions, response rate being less than 60%, and poor inconsistency y of
the scale item for perceived behavioural control.

45SYSTEMATIC REVIEW
Major strengths of the study (two or three):
Novel information provided relevant to clinical practice, emphasizing on parents of male children, and
finding the intention to vaccinate son varies by region and this variation is consistent with the variation in
rates for vaccinating daughters with the HPV vaccine.
Are the results applicable or relevant to other settings, populations, or disciplines?
Yes.

46SYSTEMATIC REVIEW
SYSTEMATIC REVIEWS
The Reader’s Companion Worksheet
Article Title:Factors associated with HPV vaccine uptake in teenage girls: A systematic
review
Author(s):Kessels, S. J., Marshall, H. S., Watson, M., Braunack-Mayer, A. J., Reuzel, R.,
&Tooher, R. L.
TITLE
Topic of interest Yes No Maybe
Method of interest Yes No Maybe
Population of interest Yes No Maybe
ABSTRACT
Results useful Yes No Maybe
INTRODUCTION
Why was the study done (i.e., problem, concern, issue)?
The study identified the availability of HPV vaccinations on a global basis, to women and
adolescent girls and realized the importance of identifying the factors that create an impact on

47SYSTEMATIC REVIEW
uptake of the vaccine among girls, with the aim of maximizing its coverage.
What is the purpose of the study or what questions is the investigator trying to answer (e.g.,
literature review)?
To assess factors allied with the accomplishment of HPV vaccination for pre-adolescent girls.
What are the central concepts (e.g., pain, grief, nursing work)?
The central concepts are related to the features that make adolescent girls either accept or
refuse immunization with HPV vaccines, where the researchers measured success of
immunization programs, in terms of vaccine initiation or completion of vaccine course. The
researchers recognised the fact that already existing reviews have chiefly comprised of
scholarly studies that were conducted with an ‘intention to vaccinate’ principle.
Were these concepts defined according to clear inclusion
and exclusion criteria for the selection of published research
studies?
Yes No Unsure
Was the search strategy explained clearly? Yes No Unsure
Dates of studies that were published: From year
2008
To year
2011
Databases that were used (check all that apply): PubMe
d
Medlin
e
EMBA
SE
CINA
HL
PsycIN
FO
Sociologica
l Abstracts
BIOS
IS
SportDis
cus
OtherMed
line in
PsycIN

48SYSTEMATIC REVIEW
process FO
Do you think that the search was comprehensive? Yes Partly Clearly
Not
Why? The researchers obtained 66 studies that were considered potentially eligible for the
results, of which 33 relevant articles that represented g 25 unique researches were retrieved
and included in the review.
METHODS
Was the methodological quality of the study rated with a
structured scoring system?
Yes No Not
sure
If yes, what tool?
How was the quality of each study included in the review
rated?
High Medium Low
Were low-quality reviews excluded? Yes No
If not, were the limitations of low-quality studies taken into account? Yes No
Designs: Quantitative Reviews
What types of studies were included in the review and how many of each type?
RCTs Pretest-post-test
control group
Cohort Observational studies with no
control group
Other

49SYSTEMATIC REVIEW
Designs: Qualitative Reviews
What types of studies were included in the review and how many of each type?
Phenomenol
ogy
Grounded theory Ethnogra
phy
Cas
e
stud
y
Participatory action
research
Other
RESULTS
What were the overall results?
The majority of scholarly pieces of evidences that were included in the review comprised of
surveys and retrospective evaluations of data. Of the 25 included studies, only 5 investigation
could report significant data on completion of HPV vaccination program. Most of the included
studies had been conducted in the United States (20 studies). Greater rates of vaccination
uptake was allied with provisions among the teenage girls of having necessary health
insurance, increased age, acceptance of childhood vaccines, an advanced knowledge on
vaccination and its benefits, greater healthcare utilization, presence of healthcare providers as a
reliable source of information and positive attitude of vaccines. African American girls present
in the US setting displayed a reduced likelihood of either initiating or completing the three
dose series of HPV vaccination.

50SYSTEMATIC REVIEW
Are these results consistent (for the most part) across all the studies
included?
Yes No
(i.e.,
mixed
results)
If the results were mixed, what factors led to differences in results across each study (e.g.,
different populations or samples; different settings such as hospital, clinic, or home; health
care systems in different countries)?
Quantitative Reviews
Do you agree with the investigator’s interpretation of the results? Yes No
If not, why not?
The included studies were based on the US population. Hence, there might be variations in the
factors that determine HPV vaccine acceptance among parents and adolescents, belonging to
different regions of the world. The study population was also heterogeneous that prevented the
researchers from statistically pooling the results.
Are the results consistent with those of past research? Yes No

51SYSTEMATIC REVIEW
If not, why not?
Does the interpretation make sense theoretically? Yes No Not
applica
ble
If not, why not?
Does the interpretation offer any ideas that you can use? Yes No Not
applica
ble
If not, why not?
OVERALL IMPRESSIONS
Overall, is the article important or significant for the practice of health
care?
Yes No
Do the findings resonate (seem correct and familiar) with you and your
practice)
Yes No
If yes, why?
The findings are familiar with the fact that people belonging to diverse race, ethnicity, health

52SYSTEMATIC REVIEW
insurance status, and educational attainment have dissimilar knowledge about vaccinations that
influences the decision to accept HPV vaccines. In current practice it has been found that
parents are often apprehensive of the potential benefits and side effects of HPV vaccines that
makes them delay immunization of their children.
Major limitations of the study (two or three):
 Lack of generalizability of the results
 Heterogeneous population
 Low uptake of vaccination
 Lack of consistency between the adjustment variables
Major strengths of the study (two or three):
 First systematic review to identify the factors that govern HPV vaccine uptake.
 The findings were in accordance with previously conducted studies and determined
similar predictors of vaccination uptake.
Are the results transferable? Yes No Not
sure

53SYSTEMATIC REVIEW
Abstract 1: (Rendle & Leskinen, 2017)
The delayed uptake of the human papillomavirus (HPV) vaccine offers an opportunity to
explore how temporality and risk are at work in everyday life. Drawing from a mixed-methods
study with parents (N = 50) in Northern California, this study explored parents’ decision to delay
HPV vaccination for their children among parents who had not yet vaccinated (n = 27). At the
core of these decisions were temporal assessments of risk whereby parents weighed their child’s
(perceived) present risk of HPV exposure against the uncertain perceived risks of the vaccine
itself. Our findings are promising as they indicate that given time, and the continued growth of
evidence regarding the safety and effectiveness of HPV vaccination, completion rates should
increase. However, our results also suggest that vaccination delays are not merely a matter of
scientific doubt but also based on parents’ (potentially inaccurate) perceptions of their child’s
sexual readiness, and thus potentially more difficult to overcome.
Abstract 2: (Kessels et al., 2012)
Background- Since 2006 Human papillomavirus (HPV) vaccination has become
available to adolescent girls and women in an increasing number of countries, to protect against
the virus causing cervical cancer. The vaccine series is offered in three doses over 6 months, and
this study aimed to identify factors associated with initiation and/or completion of the 3 dose
series in (pre-) adolescent girls. Previous studies have considered intention to vaccinate rather
than actual vaccination uptake.
Methods- A systematic search of Medline, Medline in process, Embase and CINAHL,
from 2006 to March 2011 for articles related to HPV-vaccine uptake among adolescent girls and
factors potentially associated with uptake yielded 25 studies.

54SYSTEMATIC REVIEW
Results- The majority of studies were surveys or retrospective reviews of data, only 5
studies reported data on program completion. Most were conducted in the United States (20/25).
Higher vaccine uptake was associated with having health insurance, of older age, receipt of
childhood vaccines, a higher vaccine related knowledge, more healthcare utilization, having a
healthcare provider as a source of information and positive vaccine attitudes. In US settings,
African American girls were less likely to have either initiated or completed the three dose
vaccination series.
Conclusions- HPV vaccination programs should focus on narrowing disparities in
vaccine receipt in ethnic and racial groups and on providing correct information by a reliable
source, e.g. healthcare providers. School-based vaccination programs have a high vaccine
uptake. More studies are required to determine actual vaccine course completion and factors
related to high uptake and completion, and information from a broader range of developed and
developing settings is needed.