'I Also Want to Be Vaccinated!' - Adolescent Boys' Awareness and Thoughts, Perceived Benefits, Information Sources, and Intention to Be Vaccinated against Human Papillomavirus (HPV)

Globally, most national human papillomavirus (HPV) vaccination programmes only include girls. However, the high-risk HPV types (mainly HPV 16 and 18) can cause lesions that may progress to cancer in both women and men. Thus, sex-neutral (gender neutral) vaccinations are in line with the United Nations Convention on the Rights of the Child (UNCRC) and the national public health goal of equal health for the entire population. To that end, this study investigates Swedish boys' awareness and thoughts about HPV and HPV vaccination, perceived benefits of vaccinating men, information sources, and intention to be vaccinated against HPV.

The qualitative study used semi-structured interviews, conducted between February and April 2017, as part of the project 'Prevention of HPV in a school-based setting'. The 31 participating boys (upper secondary school students) attended both theoretical and vocational programmes in different socioeconomic and geographic areas. Researchers were guided by the Health Belief Model (HBM), which includes the following constructs: perceived susceptibility, perceived severity, perceived benefit, and perceived barriers.

The central finding of the study is that the participating boys were in favour of vaccination against HPV and would accept the vaccine if it was offered free of charge in the national vaccination programme. They not only perceived benefits for themselves but would accept the vaccine for altruistic reasons, i.e., for the good of others, to promote public health, and to prevent cancer. The boys believed that it was important and just to give boys and girls equal protection against HPV; it was considered unfair to only vaccinate girls if boys also could be affected. The researchers suggest that ongoing discussion in media (and among politicians) about the goal of equal health for the population might have acted as a cues to action and influenced these responses.

However, some boys were unsure about the HPV vaccine; they wanted to read about the vaccine and increase their research-based knowledge about benefits and barriers before making the decision. Some boys stated that the decision was their own to make: Parents did not have a mandate to decide about their lives any longer, and they would neither discuss the vaccine with them nor ask for their advice on the subject. On the other hand, the opinions of family and friends were important for some boys and would influence their decision. These boys considered it beneficial if parents were involved in the decision and read the information about the vaccine provided as part of the larger educational intervention.

The boys did not have health concerns in relation to unprotected sex, they had perceived low risk for an sexually transmitted infection (STI), and they preferred not to use condoms. They stated they were unsure if HPV was an STI, since the virus was not mentioned during sexual health education in school. In fact, the boys had low awareness of the virus and the vaccine. The boys who had received the extra HPV information (in connection with the larger educational intervention) stated that this was the only time they had heard about the virus and the vaccine. They had appreciated the information.

Moreover, the school nurse and school health services were considered adequate arenas for information about HPV and HPV vaccination. Teachers, primary care centres, and midwives working at youth clinics were also mentioned as trustworthy sources of information. It was considered more uncertain to search information online, although national e-health webpages such as youth clinic online (UMO.se) and the national care guide (Vårdguiden 1177.se) were regarded as suitable sources for information about these topics. The informants had different views as to whether information about HPV should be given individually, in group, and/or both, and whether it should be given face-to-face and/or in writing. However, it was considered important to receive the information early, starting at primary school, and then repeatedly at different ages.

According to the HBM, knowledge is a modifying factor for the individual health beliefs and the actual health behaviour. The low perceived risk and low knowledge about severity implies the need to start education about HPV early and reinforce it with repetition. Even though sexual education is mandatory in school in Sweden, this does not include information about HPV on a regular basis. Thus, the researchers conclude, information about HPV needs to be provided in schools. This approach, they say, is in accordance with the WHO recommendation about sexuality education in Europe and in the best interest of the individual child, as stated in UNCRC.