This argues for increasing the number of HCPs who specialize in adolescent medicine, which remains limited in many countries [72]. Knowledge about STIs varies greatly among HCPs worldwide. Studies of midwives, nurses, and physicians in Greece [73], Tanzania [74], Thailand [66], Italy [75], Canada [76], and the United States [24], [29] and [48] – conducted both pre- and post-licensure of HPV vaccine – have shown that HCPs may be relatively well-informed about certain aspects of HPV infection, yet have suboptimal knowledge about many other aspects of HPV infection, transmission, and its association with cervical cancer. This knowledge

may impact their likelihood of recommending the HPV vaccine. In one study, for example, HCPs with greater HPV knowledge had a 25% greater odds of recommending HPV vaccination to their 11–12 year-old patients compared to those with less knowledge Ruxolitinib manufacturer [24]. Evidence suggests that HCPs may feel uncomfortable discussing adolescent sexual health, including STIs and STI prevention [77], and this could impact their decision to discuss and/or recommend STI vaccines [45]. In one study of Asian physicians and parents, 21% of physicians

believed HPV vaccination was a potentially sensitive subject, and 16% reported difficulty with knowing how and when to raise the subject [7]. Perhaps consequently, only two-thirds of those who had initiated a conversation about HPV vaccination find protocol felt comfortable doing so. Interestingly, only one of the 1617 mothers included in that study reported feeling embarrassed when a HCP initiated a conversation about HPV vaccination. HCP communication also reflects their knowledge about the specific vaccine. Studies of physicians from Australia, Taiwan, Korea, Malaysia, Thailand, and the United Kingdom have shown that those who reported greater knowledge about the HPV vaccine were more likely to initiate a conversation about it and

encourage HPV vaccination compared to those with less knowledge [7], [22] and [61]. In these studies and others from Brazil [78], Thailand [66], and Sweden [67], some physicians, to nurses, and midwives lacked key knowledge regarding the HPV vaccine, including vaccine efficacy and safety. Data suggest that HCP concerns about efficacy and safety impact intention of recommending HPV vaccination [79]. Studies also indicate that some HCPs are not aware of specific STI vaccination recommendations. For example, studies in Italy, Australia, and the United States have shown that some HCPs base HPV vaccination on prior HPV testing [31] and [80] or Papanicolaou screening [22] and [80]—practices that are inconsistent with vaccination guidelines. Similarly, in a survey of U.S. family physicians, only 69% knew that a pregnancy test was not required before HPV vaccination [29]. This lack of knowledge could lead to inappropriate communication with adolescents and parents about pre-vaccination “requirements”.