title: Exploring reasons for non-vaccination against human papillomavirus in Italy.
abstract: BACKGROUND
  In Italy, free-of-charge HPV vaccination is offered to 11-year-old girls since 2007. The National Immunization Plan established the target coverage at a minimum of 70%; it should increase to 95% within 3-year time frame. In 2012, four year after the introduction of HPV vaccination, coverage was stable at 69%. We conducted a national cross-sectional study to explore barriers to vaccination in Italy.
  
  
  METHODS
  Vaccination services selected, through the immunization registries, a sample of unvaccinated girls born in 1997 or 1998 and posted to their families a 23-items questionnaire inquiring barriers to vaccination, HPV knowledge, source of information on HPV, perception of risk of contracting HPV, advice from consulted health professionals on HPV vaccination.
  
  
  RESULTS
  We analysed 1,738 questionnaires. Main barriers were fear of adverse events (reported by 80% of families), lack of trust in a new vaccine (76%), discordant information received by health professionals (65%) and scarce information on HPV vaccination (54%). Overall, 54% of families replied correctly to more than half of 10 questions exploring knowledge on HPV vaccination. Families with a high knowledge score were more likely to live in Northern and Central Italy, be Italian, have a high educational level, include a mother who attended cervical screening regularly and consult more information sources. Although paediatricians/general practitioners and gynaecologists were considered the most trusted source of information by 79% and 61% of respondents, they were consulted only by 49% and 31%. Among parents who discussed vaccination with a physician, 28% received discordant advices and 31% received the recommendation of accepting vaccination.
  
  
  CONCLUSIONS
  Fear of adverse events, discordance of information and advices from physicians, and scarce information were the more commonly reported barriers to HPV vaccination. Health professionals played a key role as information providers, thus they must be better trained to provide clear notions. Training needs to include the development of communication skills; transparent discussion about the pros and cons of vaccination may reduce fear of adverse events and increase trust in vaccination. The creation of a public health network around vaccination would allow sharing information and attitudes on vaccinations, so that homogeneous messages could reach the target population.
authors.affiliation: Communicable Disease Epidemiology Unit; National Centre for Epidemiology, Surveillance and Health Promotion; Istituto Superiore di Sanità, Viale Regina Elena 299; 00161, Rome, Italy. cristina.giambi@iss.it.
authors.forename: Cristina
authors.initials: C
authors.lastname: Giambi
authors.forename: Fortunato
authors.initials: F
authors.lastname: D'Ancona
authors.forename: Martina
authors.initials: M
authors.lastname: Del Manso
authors.forename: Barbara
authors.initials: B
authors.lastname: De Mei
authors.forename: Ilaria
authors.initials: I
authors.lastname: Giovannelli
authors.forename: Chiara
authors.initials: C
authors.lastname: Cattaneo
authors.forename: Valentina
authors.initials: V
authors.lastname: Possenti
authors.forename: Silvia
authors.initials: S
authors.lastname: Declich
mesh_terms: D000293:Adolescent; D003430:Cross-Sectional Studies; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D007558:Italy; D027383:Papillomaviridae / Q000276:immunology; D030361:Papillomavirus Infections / Q000517:prevention & control*; D053918:Papillomavirus Vaccines; D010290:Parents; D010358:Patient Participation; D011795:Surveys and Questionnaires; D014611:Vaccination; D055815:Young Adult
chemical_list: D053918:Papillomavirus Vaccines