title: Barriers and facilitators to HPV vaccination of young women in high-income countries: a qualitative systematic review and evidence synthesis.
abstract: BACKGROUND
  Vaccination against Human Papillomavirus (HPV) is recommended for adolescent young women prior to sexual debut to reduce cervical cancer related mortality and morbidity. Understanding factors affecting decision-making of HPV vaccination of young women is important so that effective interventions can be developed which address barriers to uptake in population groups less likely to receive the HPV vaccine.
  
  
  METHODS
  We undertook a qualitative systematic review and evidence synthesis to examine decision-making relating to the HPV vaccination of young women in high-income countries. A comprehensive search of databases from inception to March 2012 was undertaken to identify eligible studies reporting the perspectives of key stakeholders including policy makers, professionals involved in programme, parents, and young women. Factors affecting uptake of the vaccine were examined at different levels of the socio-ecological model (policy, community, organisational, interpersonal and intrapersonal).
  
  
  RESULTS
  Forty-one studies were included. Whether young women receive the HPV vaccine is strongly governed by the decisions of policy makers, healthcare professionals, and parents. These decisions are shaped by: financial considerations; social norms and values relating to sexual activity, and; trust in vaccination programmes and healthcare providers. Financial constraints may be overcome through universal healthcare systems offering the HPV vaccine free at the point of delivery. In the healthcare setting, judgements by healthcare professionals about whether to recommend the vaccine may restrict a young woman's access to the vaccine irrespective of her own beliefs and preferences. Parents may decide not to allow their daughters to be vaccinated, based on cultural or religious perceptions about sexual activity.
  
  
  CONCLUSIONS
  Barriers to the uptake of the HPV vaccine have implications for young women's future sexual, physical and reproductive health. Interventions to address barriers to uptake of the vaccine should target appropriate, and multiple, levels of the socio-ecological model. Issues of trust require clear, accessible, and sometimes culturally appropriate, information about the HPV vaccination programme. Although young women are central to the HPV vaccination programme, their views are underrepresented in the qualitative literature. Future research should consider young women's perceptions of, and involvement in, consent and decision-making.
authors.affiliation: School of Social and Community Medicine, University of Bristol, Bristol BS8 2PS, UK. Harriet.Fisher@bristol.ac.uk.
authors.forename: Harriet Batista
authors.initials: HB
authors.lastname: Ferrer
authors.forename: Caroline
authors.initials: C
authors.lastname: Trotter
authors.forename: Matthew
authors.initials: M
authors.lastname: Hickman
authors.forename: Suzanne
authors.initials: S
authors.lastname: Audrey
mesh_terms: D000293:Adolescent; D001294:Attitude to Health; D003657:Decision Making; D003695:Delivery of Health Care; D019049:Developed Countries; D005260:Female; D006801:Humans; D007182:Income; D027383:Papillomaviridae; D030361:Papillomavirus Infections / Q000517:prevention & control* / Q000821:virology; D053918:Papillomavirus Vaccines / Q000008:administration & dosage; D010290:Parents; D010342:Patient Acceptance of Health Care; D012725:Sexual Behavior; D002583:Uterine Cervical Neoplasms / Q000517:prevention & control* / Q000821:virology; D014611:Vaccination
chemical_list: D053918:Papillomavirus Vaccines