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Determinants of Human Papillomavirus Vaccination Intention Among Female Sex Workers in Amsterdam, the Netherlands

Marra, Elske MSc*; van Dam, Laura MSc*; Kroone, Niki MD*; Craanen, Marianne RN*; Zimet, Gregory D. PhD; Heijman, Titia PhD*; Hogewoning, Arjan A. MD, PhD*‡; Sonder, Gerard J.B. MD, PhD; de Vries, Henry J.C. MD, PhD*¶∥; Alberts, Catharina J. PhD*; Paulussen, Theo G.W.M. MD, PhD; Schim van der Loeff, Maarten F. MD, PhD

doi: 10.1097/OLQ.0000000000000676
Original Studies

Introduction Female sex workers (FSWs) are at risk for human papillomavirus (HPV)–induced diseases but are currently not targeted by the HPV vaccination program in the Netherlands. We explored determinants of their intention to get vaccinated against HPV in case vaccination would be offered to them.

Methods In 2016, FSWs 18 years and older having a sexually transmitted infection consultation with the Prostitution & Health Center (P&G292) in Amsterdam, either at the clinic or at their working location, were invited to complete a questionnaire assessing sociopsychological determinants of HPV vaccination intention (scale ranging from −3 to +3). Determinants of HPV vaccination intention were assessed with univariable and multivariable linear regression. In addition, we explored the effect of out-of-pocket payment on intention.

Results Between May and September 2016, 294 FSWs participated. The median age was 29 years (interquartile range, 25–37 years). Human papillomavirus vaccination intention was high (mean, 2.0; 95% confidence interval [CI], 1.8–2.2). In multivariable analysis, attitude (β = 0.6; 95% CI, 0.5–0.7), descriptive norm (β = 0.2; 95% CI, 0.1–0.3), self-efficacy (β = 0.2; 95% CI, 0.1–0.3), beliefs (β = 0.1; 95% CI, 0.0–0.2), and subjective norm (β = 0.1; 95% CI, 0.0–0.2) seemed to be the strongest predictors of HPV vaccination intention (R 2 = 0.54). Human papillomavirus vaccination intention decreased significantly to a mean of 0.2 when vaccination would require out-of-pocket payment of €350.

Conclusions The HPV vaccination intention among FSWs seems relatively high and is most strongly constituted in attitudinal, normative, and self-efficacy beliefs. Out-of-pocket payment will probably have a negative impact on their HPV vaccination acceptability.

We assessed human papillomavirus vaccination intention among female sex workers in Amsterdam. Intention was high and was explained by attitudinal, normative, and self-efficacy beliefs. Required payment had a negative impact. Supplemental digital content is available in the text.

From the *Department of Infectious Diseases, Public Health Service Amsterdam, Amsterdam, the Netherlands; †Section of Adolescent Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN; §Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; ¶Centre for Infectious Disease Control, National Institute for Public Health and the Environment (RIVM), Bilthoven, the Netherlands; ∥Department of Dermatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; and ‡Expertise Center Child Health, Netherlands Organization for Applied Scientific Research (TNO), Leiden, the Netherlands

Acknowledgments: The authors gratefully acknowledge all study participants for their cooperation. Furthermore, they would like to thank the staff of the P&G292 in Amsterdam for their valuable contribution to data collection, in particular, Annelies van Dijk, Jane Ayal, Marjo Broere, and Sjaak van der Kolk, for contributing to the implementation of this study, and Michelle Kroone for assisting in data management.

Conflict of Interest and Sources of Funding: The institution of M.F. Schim van der Loeff received study funding from Sanofi Pasteur MSD; he was a coinvestigator in a Merck-funded investigator-initiated study; he was an investigator on a Sanofi Pasteur MSD–sponsored trial; he served on a vaccine advisory board of GSK; his institution received in-kind contribution for a human papillomavirus study from Stichting Pathologie Onderzoek en Ontwikkeling; his institution receives research funding from Janssen Infectious Diseases and Vaccines. H.J.C. de Vries was an investigator in a Sanofi Pasteur MSD–sponsored human papillomavirus vaccine trial. Gregory Zimet has served as an investigator on investigator-initiated research funded by Merck and Roche; he received travel funds from Merck to present research at a scientific meeting, and served as a consultant for an adolescent immunization meeting organized by Sanofi Pasteur. For the remaining authors, no conflicts of interest were declared. This work was supported by funding from the Public Health Service Amsterdam.

Correspondence: Maarten Schim van der Loeff, PhD, Public Health Service Amsterdam, Nieuwe Achtergracht 100, 1018 WT, Amsterdam, the Netherlands. E-mail:

Received for publication April 11, 2017, and accepted June 3, 2017.

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