human papillomavirus ( hpv ) is the most common sexually 
 transmitted infection ( sti ) and a known risk factor for cervical 
 cancer [ 1 , 2 ] . hpv is highly prevalent in younger populations , 
 with prevalence rates of approximately 50% in sexually 
 active adolescent girls and young women . early age of 
 first sexual intercourse is associated with greater susceptibility 
 to hpv infection , possibly due to cervical immaturity . current estimates suggest that approximately 15% of sexually 
 active adults in the united states have clinical or subclinical 
 infections . despite the fact that most sexually active individuals 
 will become exposed throughout their lives , knowledge 
 about hpv and the diseases that hpv causes is generally 
 very limited . the average age of first sexual intercourse innorth america 
 is approximately 16 years for both men and women . 
 to provide the greatest public health benefit , hpv vaccines must be administered prior to initiating sexual activity and 
 hence would be most effective if offered during early adolescence . 
 because gynecologists often serve as the sole health 
 care provider for many women , they are in an excellent position 
 to disseminate information about the risks and consequences 
 of hpv infection as well as provide information 
 about hpv vaccines that will soon become commercially 
 available . population awareness of the risks associated with acquiring hpv and the consequences associated with infection is low . numerous studies have demonstrated that most patients are 
 unaware of hpv and its association with genital warts and 
 cervical cancer [ 2 , 6 , 
 814 ] . furthermore , awareness has not 
 improved in the past decade : approximately 33% of women 
 and half of men surveyed have never heard of hpv [ 9 , 11 ] . women want to know how hpv is transmitted , 
 including whether intercourse is required to transmit disease , 
 and how they and their sexual partners can prevent becoming 
 infected . additional information of interest includes 
 whether condoms protect against the virus , how hpv is detected , 
 the likelihood of spontaneous resolution of infection , 
 and the risk of cervical cancer . vaccines designed to reduce the incidence of hpv infection 
 are in late stages of clinical development and studies to date 
 have demonstrated that these vaccines are safe and highly efficacious . widespread acceptance of hpv vaccines are likely 
 to lend enormous health benefits by decreasing morbidity 
 and mortality associated with cervical cancer and by reducing 
 the psychosocial burden of both genital warts and abnormal 
 papanicolaou ( pap ) test results . savings in health care 
 expenditures , including treatments for genital warts , preinvasive 
 cervical lesions , and cervical cancer would also be considerable 
 . underestimates of both the 
 level of risk and the severity of hpv - associated disease may become barriers to vaccine acceptance 
 . hence , physician , parent , and patient education about hpv and hpv 
 vaccines will be crucial to effectively implement hpv vaccination 
 programs . attitudes regarding hpv vaccine acceptance can be assessed 
 based on acceptability of previous vaccines and through 
 questionnaires completed by patients , parents , and health 
 care providers . for example , kahn et al presented questionnaires 
 to 52 young women regarding hpv vaccination , and 
 found that most viewed vaccination positively . furthermore , 
 most reported a high intention of receiving the 
 vaccine , both for themselves and their hypothetical daughters . knowledge about hpv and the vaccine , personal beliefs 
 about vaccination , beliefs that others would approve of vaccination , 
 higher number of sexual partners , and perceived support 
 of provider , partner , and parents were all significantly 
 associated with intention to receive the vaccine . in a 
 separate study of 256 college students , 74% endorsed hpv 
 vaccination . of those surveyed , acceptance significantly 
 correlated with higher number of sexual partners , parental 
 support , endorsement of universal hpv vaccination , low 
 cost , and vaccine safety . hoover et al evaluated knowledge 
 of hpv and attitudes toward hpv vaccination and clinical 
 trial participation among 60 female adolescents and young 
 adults . almost all of the participants expressed interest 
 in receiving a vaccine that would prevent cervical cancer and 
 genital warts . another study examined the attitudes about 
 hypothetical hpv vaccines in adolescent ( n = 20 ) and adult women ( n = 20 ) attending two urban sti clinics . here , 
 the idea of an hpv vaccine was favorably received and several 
 factors affected potential acceptance , including vaccine 
 efficacy , physician endorsement , and cost . although , 
 in general , overall confidence in vaccines remains 
 high , many americans distrust public health policy and 
 refuse vaccination on these grounds . concern over potential 
 side - effects from vaccines is a common barrier to vaccination 
 . parents may also object to vaccination for religious 
 or philosophical reasons . to overcome these barriers , clinicians should informparents 
 of the prevalence of hpv among adolescents and discuss 
 the potential consequences of forgoing vaccination and becoming 
 infected . although many childhood vaccines are for 
 diseases that are now rare , hpv is highly prevalent and educational 
 efforts should stress that most sexually active adolescents 
 will acquire hpv . the sexual nature of hpv infections may introduce 
 unique barriers to parental consent not previously encountered 
 with other vaccines . parents may feel that consenting 
 to a vaccine for an sti may inadvertently encourage their 
 adolescent children to engage in sexual intercourse . similarly , 
 parentsmay feel that vaccination at an early age will encourage 
 earlier sexual debut . acceptance of the vaccine represents an acknowledgment of risk of infection , and 
 some parents may have difficulty accepting the fact that their 
 children are approaching an age at which sexual activity is 
 often initiated . contrary to these beliefs , several studies have suggested 
 that the sexually transmitted nature of hpv may not pose a 
 major obstacle tohpv vaccine acceptance . in one study , 70% 
 of parents approved of vaccination for stis [ 18 , 28 ] . desire 
 to protect their children , concern about specific disease characteristics , 
 and personal experience with an sti were directly 
 correlated with vaccine acceptance . rejection was associated 
 with the perception that their child was at low risk for infection 
 or with the parent having a low concern about severity 
 of the disease . in a similar study , zimet et al questioned 
 278 parents about their attitudes toward adolescent vaccination , 
 incorporating nine hypothetical sti scenarios defined 
 along four different dimensions : mode of transmission 
 ( sti vs non - sti ) , severity ( curable / chronic / fatal ) , vaccine efficacy 
 ( 50% , 70% , 90% ) , and behavioral method for prevention 
 ( available / not available ) . interestingly , whether a 
 disease was sexually transmitted did not affect the parents ' 
 decision . instead , severity of the hypothetical disease and 
 vaccine efficacy predicted vaccine acceptance . when parents who were undecided about hpv vaccination were provided with a basic information sheet about 
 hpv and hpv vaccines , they became significantly more likely to support hpv vaccination . physician endorsement and school requirements have also been identified 
 as important catalysts for parental vaccine acceptance . conversely , information acquired from friends , relatives , or 
 advertisements had a marginal impact . one study concluded that 
 a recommendation from the american college of obstetricians 
 and gynecologists would be the most important factor 
 influencing whether gynecologists would recommend vaccination 
 . if the endorsements included a specific age for 
 vaccination , this would undoubtedly increase acceptance of 
 early - adolescent hpv vaccination . educational initiatives targeting health care professionals 
 have demonstrated effectiveness in fostering vaccine acceptance . a study to measure the effectiveness of a statewide 
 peer educational program on changes in clinician immunization 
 practice patterns and behaviors was conducted between 
 june 1999 and october 2000 ( figure 1 ) . interventions 
 included hospital grand rounds lectures and officebased 
 small group in - service sessions . forty - two percent of 
 the 532 providers who attended the 16 grand rounds lectures 
 completed both the pre- and posttests ; the response 
 rate was the same for the 368 physicians who attended the 
 15 office - based sessions . knowledge ( p < .05 ) and practice 
 attitudes ( p < .01 ) pertaining to vaccine - preventable disease 
 and immunization improved after attending a lecture 
 or in - service session . grand rounds were more effective than 
 in - service sessions at convincing physicians to change their vaccine - preventable disease office 
 practices ( p < .01 ) , but everyone 
 who participated in one or more interventions had 
 better knowledge recall , improved attitudes toward vaccinepreventable 
 disease , and practice patterns that were more 
 likely to improve patient vaccine awareness compared with 
 those who did not participate ( p < .05 ) . educational efforts aimed at health care professionals 
 should include physician assistants and nurse practitioners , 
 as well as physicians . educating patients about hpv and 
 the hpv vaccine will be time consuming , and the assistance 
 these groups can provide will prove to be invaluable . clinicians should provide information in an individualized 
 fashion , tailoring educational sessions according to the 
 patient 's background , age , and literacy level . an effort 
 should be made to provide needed information to parents 
 and adolescents without creating needless anxiety over the 
 situation . nonetheless , it is crucial that the high risk of 
 infection , the frequent negative consequences associated with 
 infection , and the importance of vaccinating in early adolescence , 
 before the individual has become sexually active , be 
 made clear to the parent . attitudes regarding hpv vaccine acceptance can be assessed 
 based on acceptability of previous vaccines and through 
 questionnaires completed by patients , parents , and health 
 care providers . for example , kahn et al presented questionnaires 
 to 52 young women regarding hpv vaccination , and 
 found that most viewed vaccination positively . furthermore , 
 most reported a high intention of receiving the 
 vaccine , both for themselves and their hypothetical daughters . knowledge about hpv and the vaccine , personal beliefs 
 about vaccination , beliefs that others would approve of vaccination , 
 higher number of sexual partners , and perceived support 
 of provider , partner , and parents were all significantly 
 associated with intention to receive the vaccine . in a 
 separate study of 256 college students , 74% endorsed hpv 
 vaccination . of those surveyed , acceptance significantly 
 correlated with higher number of sexual partners , parental 
 support , endorsement of universal hpv vaccination , low 
 cost , and vaccine safety . hoover et al evaluated knowledge 
 of hpv and attitudes toward hpv vaccination and clinical 
 trial participation among 60 female adolescents and young 
 adults . almost all of the participants expressed interest 
 in receiving a vaccine that would prevent cervical cancer and 
 genital warts . another study examined the attitudes about 
 hypothetical hpv vaccines in adolescent ( n = 20 ) and adult women ( n = 20 ) attending two urban sti clinics . here , 
 the idea of an hpv vaccine was favorably received and several 
 factors affected potential acceptance , including vaccine 
 efficacy , physician endorsement , and cost . although , 
 in general , overall confidence in vaccines remains 
 high , many americans distrust public health policy and 
 refuse vaccination on these grounds . concern over potential 
 side - effects from vaccines is a common barrier to vaccination 
 . parents may also object to vaccination for religious 
 or philosophical reasons . to overcome these barriers , clinicians should informparents 
 of the prevalence of hpv among adolescents and discuss 
 the potential consequences of forgoing vaccination and becoming 
 infected . although many childhood vaccines are for 
 diseases that are now rare , hpv is highly prevalent and educational 
 efforts should stress that most sexually active adolescents 
 will acquire hpv . the sexual nature of hpv infections may introduce 
 unique barriers to parental consent not previously encountered 
 with other vaccines . parents may feel that consenting 
 to a vaccine for an sti may inadvertently encourage their 
 adolescent children to engage in sexual intercourse . similarly , 
 parentsmay feel that vaccination at an early age will encourage 
 earlier sexual debut . acceptance of the vaccine represents an acknowledgment of risk of infection , and 
 some parents may have difficulty accepting the fact that their 
 children are approaching an age at which sexual activity is 
 often initiated . contrary to these beliefs , several studies have suggested 
 that the sexually transmitted nature of hpv may not pose a 
 major obstacle tohpv vaccine acceptance . in one study , 70% 
 of parents approved of vaccination for stis [ 18 , 28 ] . desire 
 to protect their children , concern about specific disease characteristics , 
 and personal experience with an sti were directly 
 correlated with vaccine acceptance . rejection was associated 
 with the perception that their child was at low risk for infection 
 or with the parent having a low concern about severity 
 of the disease . in a similar study , zimet et al questioned 
 278 parents about their attitudes toward adolescent vaccination , 
 incorporating nine hypothetical sti scenarios defined 
 along four different dimensions : mode of transmission 
 ( sti vs non - sti ) , severity ( curable / chronic / fatal ) , vaccine efficacy 
 ( 50% , 70% , 90% ) , and behavioral method for prevention 
 ( available / not available ) . interestingly , whether a 
 disease was sexually transmitted did not affect the parents ' 
 decision . instead , severity of the hypothetical disease and 
 vaccine efficacy predicted vaccine acceptance . when parents who were undecided about hpv vaccination were provided with a basic information sheet about 
 hpv and hpv vaccines , they became significantly more likely to support hpv vaccination . physician endorsement and school requirements have also been identified 
 as important catalysts for parental vaccine acceptance . conversely , information acquired from friends , relatives , or 
 advertisements had a marginal impact . one study concluded that 
 a recommendation from the american college of obstetricians 
 and gynecologists would be the most important factor 
 influencing whether gynecologists would recommend vaccination 
 . if the endorsements included a specific age for 
 vaccination , this would undoubtedly increase acceptance of 
 early - adolescent hpv vaccination . educational initiatives targeting health care professionals 
 have demonstrated effectiveness in fostering vaccine acceptance . a study to measure the effectiveness of a statewide 
 peer educational program on changes in clinician immunization 
 practice patterns and behaviors was conducted between 
 june 1999 and october 2000 ( figure 1 ) . interventions 
 included hospital grand rounds lectures and officebased 
 small group in - service sessions . forty - two percent of 
 the 532 providers who attended the 16 grand rounds lectures 
 completed both the pre- and posttests ; the response 
 rate was the same for the 368 physicians who attended the 
 15 office - based sessions . knowledge ( p < .05 ) and practice 
 attitudes ( p < .01 ) pertaining to vaccine - preventable disease 
 and immunization improved after attending a lecture 
 or in - service session . grand rounds were more effective than 
 in - service sessions at convincing physicians to change their vaccine - preventable disease office 
 practices ( p < .01 ) , but everyone 
 who participated in one or more interventions had 
 better knowledge recall , improved attitudes toward vaccinepreventable 
 disease , and practice patterns that were more 
 likely to improve patient vaccine awareness compared with 
 those who did not participate ( p < .05 ) . educational efforts aimed at health care professionals 
 should include physician assistants and nurse practitioners , 
 as well as physicians . educating patients about hpv and 
 the hpv vaccine will be time consuming , and the assistance 
 these groups can provide will prove to be invaluable . clinicians should provide information in an individualized 
 fashion , tailoring educational sessions according to the 
 patient 's background , age , and literacy level . an effort 
 should be made to provide needed information to parents 
 and adolescents without creating needless anxiety over the 
 situation . nonetheless , it is crucial that the high risk of 
 infection , the frequent negative consequences associated with 
 infection , and the importance of vaccinating in early adolescence , 
 before the individual has become sexually active , be 
 made clear to the parent . prophylactic hpv vaccines may soon become available for 
 public distribution ; however , general knowledge about hpv 
 and hpv - associated disease is limited and may affect vaccine 
 acceptability . research suggests that vaccine acceptance will 
 be maximized by effectively communicating the risks associated 
 with hpv infection and the benefits of vaccination . educational 
 initiatives targeted towards patients , parents , and 
 health care providers will play key roles in fostering positive 
 attitudes towards vaccination . gynecologists 
 who attended in - service or grand rounds educational lectures 
 were more likely to vaccinate or provide vaccine information 
 to their patients than those who did not .
vaccines that protect against infection with the types of human papillomavirus ( hpv ) commonly associated with cervical cancer 
 ( hpv 16 and 18 ) and genital warts ( hpv 6 and 11 ) are expected to become available in the near future . 
 because hpv vaccines are 
 prophylactic , they must be administered prior to exposure to the virus , ideally during preadolescence or adolescence . 
 the young 
 age of the target vaccination population means that physicians , parents , and patients will all be involved in the decision - making 
 process . 
 research has shown that parents and patients are more likely to accept a vaccine if it is efficacious , safe , reasonably priced , 
 and recommended by a physician . 
 widespread education of physicians , patients , and parents about the risks and consequences of 
 hpv infection and the benefits of vaccination will be instrumental for fostering vaccine acceptance .