RESEARCH ARTICLE Open Access
Association between parent attitudes and receipt of human papillomavirus vaccine in adolescents Jeffrey J. VanWormer1*, Casper G. Bendixsen1, Elizabeth R. Vickers1, Shannon Stokley2, Michael M. McNeil2, Julianne Gee2, Edward A. Belongia1 and Huong Q. McLean1
Background: Human papillomavirus (HPV) vaccine coverage rates remain low. This is believed to reflect parental hesitancy, but few studies have examined how changes in parents’ attitudes impact HPV vaccine uptake. This study examined the association between changes in parents’ vaccine attitudes and HPV vaccine receipt in their adolescent children.
Methods: A baseline and 1-year follow-up survey of HPV vaccine attitudes was administered to parents of 11–17 year olds who had not completed the HPV vaccine series. Changes in attitudinal scores (barriers, harms, ineffectiveness, and uncertainties) from the Carolina HPV Immunization Attitudes and Beliefs Scale were assessed. Two outcomes were measured (in parents’ adolescent children) over an 18-month period and analyzed using multivariable regression; receipt of next scheduled HPV vaccine dose and 3-dose series completion.
Results: There were 221 parents who completed the baseline survey (11% response rate) and 164 with available follow-up data; 60% of their adolescent children received a next HPV vaccine dose and 38% completed the vaccine series at follow-up. Decrease in parents’ uncertainties was a significant predictor of vaccine receipt, with each 1-point reduction in uncertainties score associated with 4.9 higher odds of receipt of the next vaccine dose. Higher baseline harms score was the only significant predictor of lower series completion.
Conclusions: Reductions in parents’ uncertainties appeared to result in greater likelihood of their children receiving the HPV vaccine. Only baseline concerns about vaccine harms were associated with lower series completion rate. Education for parents should emphasize the HPV vaccine’s safety profile.
Keywords: Human, Papillomavirus vaccines, Parents
Background The human papillomavirus (HPV) vaccine was introduced in 2006, but coverage has remained lower than for other recommended adolescent vaccines for tetanus, diphtheria, pertussis (Tdap), and meningococcal disease . HPV vaccine series completion, which included three doses in 2015, was recently estimated at 35% in the U.S. Factors contributing to low population-level HPV vaccine cover- age are not well understood. Parents are generally aware of the HPV vaccine , but specific knowledge about
HPV vaccination (e.g., schedule, benefits) is weakly corre- lated with actual coverage . While multiple causes likely exist, low coverage is hypothesized to be a function of hesitancies, ambivalence, or resistance by many parents who are deciding about their child’s healthcare. In considering their adolescent’s young age and (presumed) timeline until sexual exposure, parents typically underesti- mate their child’s susceptibility to acquiring sexually transmitted infections or cervical cancer [4, 5]. Parents also tend to overestimate the risks of HPV vaccine adverse events [4, 6, 7], some of which are real (e.g., syncope) , while causal links to others have been repudiated (e.g., thromboembolism , risky sexual behaviors ) despite widely available false claims.
* Correspondence: [email protected] 1Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Institute, 1000 North Oak Ave, Marshfield, WI 54449, USA Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
VanWormer et al. BMC Public Health (2017) 17:766 DOI 10.1186/s12889-017-4787-5
The degree to which parents’ HPV vaccine attitudes influence their decisions to have their adolescent chil- dren get the HPV vaccine series has been examined in prior studies [11–13]. Most prior investigations, how- ever, were cross-sectional and assessed self-reported vac- cination or vaccine intent. There are few longitudinal studies that have examined how HPV vaccine attitudes influence HPV vaccine series completion, particularly those that take advantage of more objective vaccination data sources such as medical records. The purpose of this study was to examine the association between changes in parents’ HPV vaccine attitudes and HPV vac- cine uptake in their adolescents, using electronic health records (EHR) data from a north-central Wisconsin inte- grated healthcare system. The hypothesis was that posi- tive changes in parental attitudes would be associated with greater adolescent HPV vaccine uptake.
Methods Design and participants This was a cohort analysis of survey data, conducted in parallel with a medical care quality improvement project designed to increase HPV vaccine coverage in adolescent patients from seven Wisconsin communities who receive care from Marshfield Clinic Health System (MCHS; head- quarters Marshfield, WI) . Briefly, intervention activ- ities included medical department-level education and support, individualized provider feedback on adolescent vaccination coverage in their patient panel, and initiation of HPV vaccine reminder/recall notices mailed to parents of 12 year old adolescent children. Interventions were focused on medical providers in the outpatient primary care environment, and did not target parents or the gen- eral public directly. Parental HPV attitudes were surveyed at baseline and one year later in the intervention commu- nities. Study eligible individuals completed both the base- line and follow-up attitudinal survey and were parents of adolescents who, at baseline: were medically homed to one of the nine MCHS regional centers (in the seven target communities) selected for the intervention, were aged 11–16 years, had failed to start or complete the HPV vaccine series (i.e., <3 vaccine doses), and were able to respond to the English language survey. Criteria used to assign each adolescent’s medical home included their named primary care provider at a given medical center; ≥1 preventive care visit there in the past year, or ≥2 qualifying visits (Evaluation and Management visit types) for diagno- sis and treatment within the past three years.
Survey procedures Survey-eligible parents were selected using stratified ran- dom sampling by community. Baseline surveys were dis- tributed over three months in Spring 2015, with the follow- up survey administered one year later. Contact information
for eligible adolescents was extracted from MCHS adminis- trative records and an invitation was mailed to the “Parents of” each enumerated adolescent. The mailing contained a cover letter describing the study and an invitation to participate, as well as the survey instrument and a postage- paid return mailer. A reminder letter was sent to non- respondents about one month after the initial mailing, and a phone outreach was also made to remaining non- respondents. A passive consent procedure was utilized whereby participants were informed that completed surveys would be linked to their EHR data. A $2 cash incentive was enclosed in all mailed follow-up survey invitations. Study procedures were approved by the Marshfield Clinic Institutional Review Board.
Measures The primary predictor was change between baseline and 1- year follow-up in the sub-factor scores from the Carolina HPV Immunization Attitudes and Beliefs Scale (CHIAS) . Attitudinal changes were accounted for by subtracting each participant’s follow-up CHIAS (sub-factor) score from their baseline CHIAS score. The CHIAS is a 16-item instru- ment that includes four sub-factor scores for perceived bar- riers, harms, effectiveness, and uncertainties related to the HPV vaccine. Each item has Likert-scale response options scored from 1 to 4 points, with a mean score generated for each of the four sub-factors. To improve interpretation, a slight modification was made to the effectiveness sub-factor in that responses were reverse ordered and it was renamed ‘ineffectiveness’ so that, for all sub-factor scores, higher values corresponded to less favorable attitudes/endorsement of the HPV vaccine. As done previously , CHIAS items with missing responses were imputed with sample mean values. Also, for those with multiple HPV vaccine eligible adolescent children, parents were asked to only consider their youngest adolescent child when formulating their baseline survey responses, and to again consider that same adolescent child for their follow-up survey responses. Two HPV vaccine outcomes were examined in separate
analyses, and these variables again pertained to each parent’s youngest HPV vaccine eligible adolescent child. These HPVvaccine outcomes were assessed over 18 months of follow-up after each participant completed their baseline survey. The first outcome was receipt of the next (scheduled) HPV vaccine dose, which captured those who received their first (i.e. initiation), second, or third (i.e., series completion) dose (depending on how many HPV vaccine doses were received before baseline). The second outcome was receipt of all three doses of HPV vaccine (i.e., 3-dose series completion, the standard of care during this study timeframe). Data on vaccinations were collected from a regional population-based immunization registry , which is sourced by EHR and other data (e.g., public health agencies, schools).
VanWormer et al. BMC Public Health (2017) 17:766 Page 2 of 7
Several covariates were also analyzed that were sus- pected of possibly modifying or confounding the associ- ation between changes in parents’ HPV attitudes and adolescent HPV vaccine receipt. From the baseline sur- vey, this included each parent’s age, gender, education level (high school or less, some college, Associate degree, Bachelor’s degree, Graduate degree), health insurance coverage (private, public-assisted, none), and baseline CHIAS scores. From the follow-up survey, this included report of a physician’s recommendation to get the HPV vaccine in the prior year. In addition, EHR data on each parent’s youngest adolescent child’s prior HPV, Tdap, and meningococcal vaccination history, number of am- bulatory care visits over three years (prior to baseline), gender, and age were also examined as covariates.
Analysis Sociodemographic characteristics were reported descrip- tively. Logistic regression was used to examine the asso- ciation between changes in parents’ HPV vaccine attitudes and receipt of the HPV vaccine in their adoles- cent child. Basic models were first created to examine the crude associations between each CHIAS sub-factor change score (follow-up score minus baseline score) and HPV vaccine receipt. Next, given the well docu- mented influence of physician advice on HPV vaccin- ation [17–19], a test for effect modification was entered into the basic model by creating two-way interaction terms between each CHIAS sub-factor change score and physician’s recommendation to get the HPV vaccine in the prior year. Any interaction terms with a significant (p < 0.05) association with HPV vaccine receipt were retained in subsequent models. Finally, a reduced multi- variable model was fit by adding each covariate separ- ately and applying forward selection to exclude any covariates that were not significant independent predic- tors of HPV vaccine receipt. The two HPV vaccine re- ceipt outcomes were tested separately using this same analytical approach. All analytical procedures were con- ducted using SAS Version 9.4 (Cary, NC).
Results At baseline, 1998 surveys were mailed to eligible parents, with 221 (11%) respondents. Among those, 187 returned responses at the 1-year follow-up, with 175 confirmed as the same parent who responded at baseline (cohort reten- tion 79%). Eleven respondents were excluded from ana- lyses due to missing covariate data, yielding a final analytical sample of 164 parents. Parent respondents were primarily Non-Hispanic White females (Table 1). Because surveys were mailed to the parents of study-eligible ado- lescent patients (and any parent/guardian could respond), the enumerated sample was not identifiable. Thus parent information (e.g., age, sex) only became available upon
survey completion, which precluded comparisons between invited parents who did vs. did not respond to the survey. Comparisons were possible on some adolescent character- istics though. Relative to non-responders, study-eligible adolescents of parents who responded to the survey were significantly younger and more likely to have received
Table 1 Baseline characteristics of parents of North-Central Wisconsin adolescents without a completed human papillomavirus vaccine series, separated by characteristics of parents and their adolescent child
n = 164
Survey non- respondents n = 1777
Mean age (years) 43.7 ± 6.1 NA
Female 136 (83%)
Male 28 (17%)
White, Non-Hispanic 157 (96%)
Not White or Hispanic 5 (3%)
Unknown 2 (1%)
High school or less 13 (8%)
Some college 23 (14%)
Associates degree 40 (24%)
Bachelors degree 48 (29%)
Graduate degree 40 (24%)
Health insurance NA
Private 137 (83%)
Public-assisted 26 (16%)
Unknown 1 (1%)
11–13 years 118 (72%) 1137 (64%)
≥ 14 years 46 (28%) 640 (36%)
Female 79 (48%) 732 (41%)
Male 85 (52%) 1045 (59%)
Mean number of ambulatory care visits over past 3 years
4.2 ± 2.6 3.9 ± 2.9 0.182
Received 1–2 prior HPV vaccine doses 0.921
Yes 53 (32%) 581 (33%)
No 111 (68%) 1196 (67%)
Received Tdap and meningococcal vaccines 0.001
Yes 142 (87%) 1385 (78%)
No 22 (13%) 392 (22%) aValues are reported as frequency (% of column total) or mean ± SD
VanWormer et al. BMC Public Health (2017) 17:766 Page 3 of 7
Tdap and meningococcal vaccines. There was no differ- ence in the proportion of adolescents who received a prior HPV vaccine. At baseline, 32% of parents’ adolescent children had
initiated the HPV vaccine, having received 1–2 prior HPV vaccine doses (none had completed the 3-dose series, per study eligibility criteria). Sixty percent of par- ents’ adolescent children (58% of males, 62% of females) had received at least one HPV vaccine dose and 38% (44% of males, 33% of females) had completed the 3- dose series by the end of the 18-month follow-up period. As outlined in Table 2, the highest baseline CHIAS sub- factor scores were for harms (mean ± SD = 2.2 ± 0.6 points) and uncertainties (2.2 ± 0.7 points), followed by ineffectiveness (2.1 ± 0.9 points), and barriers (1.4 ± 0.4 points). Barriers and harms scores remained stable over time. Scores for uncertainties and ineffectiveness im- proved, both decreasing by 0.2 points (~10% improve- ment; p’s < 0.001) over one year. At the 1-year follow-up survey, 77% of parents reported having received a physi- cian’s recommendation for their adolescent child to get the HPV vaccine in the prior year.
Next HPV vaccine dose The basic models revealed that changes between base- line and follow-up in CHIAS sub-factor scores for harms, uncertainties, and ineffectiveness were signifi- cantly associated with receipt of next HPV vaccine dose. Parents whose attitudes became more favorable over time had a higher likelihood of vaccine receipt. Specific- ally, each 1-point decrease in the harms, uncertainties, or ineffectiveness score was associated with 5.4 ([95%] CI: 2.0, 14.1), 3.8 (CI: 1.9, 7.5), and 2.3 (CI: 1.3, 4.2) higher odds of having received the next HPV vaccine dose, respectively. After covariate adjustment, most asso- ciations with attitudinal change scores were attenuated, leaving only the CHIAS uncertainties change score, baseline CHIAS uncertainties score, and baseline CHIAS harms score as significant predictors of receipt of next HPV vaccine dose (Table 3). Prior physician’s recom- mendation to get the HPV vaccine was not found to be
an effect modifier, but was retained in the final multivar- iable model as a significant independent predictor, along with health insurance coverage and receipt of a prior HPV vaccine dose at baseline.
HPV vaccine series completion The basic models for this analysis found changes be- tween baseline and follow-up in CHIAS sub-factor scores for harms and uncertainties were significant pre- dictors of HPV vaccine series completion. Similar to the previous analysis, parents whose attitudes improved had a greater likelihood of completing the HPV vaccine series. Each 1-point decrease in the harms or uncertain- ties score was associated with 2.8 (CI: 1.1, 6.8) and 2.3 (CI: 1.1, 4.5) higher odds of their adolescent’s series completion, respectively. And again, associations with at- titudinal change scores were attenuated after covariate adjustment, with only baseline CHIAS harms score and receipt of prior HPV vaccine being significantly associ- ated with HPV vaccine series completion during the follow-up period (Table 3).
Discussion Prior research has shown that parents’ CHIAS scores are significant predictors of their intent to get their child vaccinated against HPV, as well as their self-reported history of HPV vaccine receipt [15, 20, 21]. To our knowledge, this was the first study to examine how changes in parents’ attitudes were associated with im- provements in objectively-measured HPV vaccine re- ceipt. Despite relatively good uptake in HPV vaccine during the 18-month study timeframe, vaccine attitudes appeared to be less flexible in parents, as concerns about effectiveness and uncertainties waned modestly, while beliefs about barriers and harms did not change. In the multivariable model, only change in the CHIAS uncer- tainties score was significantly associated with receipt of the next dose of HPV vaccine. Parents who experienced a favorable shift in uncertainties had a greater likelihood of their adolescent child receiving at least one HPV vac- cine dose during the follow-up period. No changes in CHIAS scores were associated with completion of the HPV vaccine series. Though the baseline survey response rate was low and
somewhat skewed toward parents of younger adoles- cents who were more apt to have received Tdap/menin- gococcal vaccines, parental concerns about the safety of the HPV vaccine seemed to be the most influential atti- tudinal barrier. On average, the CHIAS harms score remained stable between baseline and follow-up. But even among parents whose CHIAS harms score shifted favorably, their adolescents were not more likely to get the HPV vaccine after covariate adjustment. In contrast, the baseline CHIAS harms score was strongly associated
Table 2 Baseline, 1-year follow-up, and change in Carolina HPV immunization attitudes and beliefs scale (CHIAS) sub-factor scores among parents of North-Central Wisconsin adolescents without a completed human papillomavirus vaccine series
Baselinea Follow-up Change (follow-up minus baseline points)
CHIAS scores (1–4 points)
Barriers 1.4 ± 0.4 1.4 ± 0.4 0.0 ± 0.4
Harms 2.2 ± 0.6 2.1 ± 0.6 0.0 ± 0.5
Uncertainties 2.2 ± 0.7 2.0 ± 0.7 −0.2 ± 0.6
Ineffectiveness 2.1 ± 0.9 1.8 ± 0.9 −0.2 ± 0.7 aValues are reported as mean ± SD
VanWormer et al. BMC Public Health (2017) 17:766 Page 4 of 7
with receipt of the next HPV vaccine dose and was the only significant attitudinal predictor of HPV vaccine series completion. Thus it seemed parents with high harms scores were not apt to change their minds, and even if they did, it had no impact on HPV vaccine re- ceipt. This finding was consistent with some prior stud- ies. Notably, the CHIAS harms score was also among the strongest predictors of HPV vaccine initiation after one year among parents of adolescent girls in North Carolina . Also, fear of side effects was among the main reasons cited for avoiding HPV vaccination (or in- tent to vaccinate) in cross-sectional studies with Dutch  and Romanian parents . This suggests that pub- lic awareness and patient education interventions should emphasize the HPV vaccine’s post-licensure safety profile . How to best translate such messaging to a clinical environment, however, is yet unclear. Compared to brief/straightforward recommendations, more in-depth conversational approaches by medical providers may yield limited influence on parents’ decision-making re- garding HPV vaccination [24, 25].
Several covariates were also significantly associated with HPV vaccine receipt. As expected, a prior HPV vaccine dose was the strongest predictor of both receipt of next dose and series completion. A reported physician’s recom- mendation to get the HPV vaccine in the prior year was also associated with receiving the next HPV vaccine dose, but adolescents’ age and gender were not associated with receipt of next dose or series completion. Interestingly, parents with publicly-assisted health insurance had six times greater odds of their adolescent child initiating or getting their next HPV vaccine dose during the follow-up period relative to parents with private health insurance. Reasons for this are obviously speculative, but it may be related to some Medicaid pay-for-performance initiatives targeting childhood immunizations , recognizing that such incentives have had limited impact in other settings [27, 28]. Why public-assisted health insurance did not translate into greater likelihood of HPV vaccine series completion though was unclear, but could be related to fewer total preventive care visits in adolescents from lower income households .
Table 3 Basic and multivariable logistic regression models of the association between human papillomavirus (HPV) vaccine receipt and Carolina HPV immunization attitudes and beliefs scale (CHIAS) sub-factor scores, along with covariates, among North-Central Wisconsin parents (N = 164)
Next HPV vaccine dose receipt (Yes vs. No) HPV vaccine series completion (Yes vs. No)
Basic a OR (95% CI) Multivariable OR (95% CI) Basic OR (95% CI) Multivariable OR (95% CI)
CHIAS change scores (follow-up minus baseline points)
Barriers 1.6 (0.6, 4.1) p = 0.320
— b 1.9 (0.7, 5.1) p = 0.215
Harms 5.4 (2.0, 14.1) p < 0.001
— 2.8 (1.1, 6.8) p = 0.025
Uncertainties 3.8 (1.9, 7.5) p < 0.001
4.9 (2.0, 12.2) p < 0.001
2.3 (1.1, 4.5) p = 0.022
Ineffectiveness 2.3 (1.3, 4.2) p = 0.004
— 1.3 (0.8, 2.1) p = 0.334
CHIAS baseline scores (points at baseline)
Harms — 11.7 (4.0, 34.2) p < 0.001
— 5.2 (2.2, 12.1) p = 0.001
Uncertainties — 2.5 (1.0, 6.2) p = 0.044
Public-assisted vs. private — 6.0 (1.5, 23.6) p = 0.011
Provider recommended HPV vaccine
Yes vs. no — 4.1 (1.3, 12.9) p = 0.015
1–2 prior HPV vaccine doses
Yes vs. no — 7.1 (2.0, 25.6) p = 0.003
— 14.0 (5.8, 34.1) p < 0.001
aValues are reported as odds ratio (95% confidence interval, p-value), relative to the reference category for categorical variables or a 1-unit decrease for CHIAS scores, for the HPV vaccine outcomes b— Variable not considered in basic models or excluded from multivariable model cComparison between none vs. private health insurance was not estimable due to so few participants without health insurance coverage
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This study was strengthened by the systematic sampling of parents of adolescents who receive primary care within an integrated regional healthcare system, a level at which clinical care quality improvement initiatives are apt to occur. Also, adolescents’ clinical data on HPV vaccine coverage was linked to their parents’ CHIAS scores. In terms of limitations, the baseline survey response rate was of particular concern because it was very low, which might reflect sensitivities about the general topic of HPV or the lack of a baseline response incentive. Low baseline re- sponse does not negate the associations observed within the cohort and is not by itself indicative of nonresponse bias [30, 31], but it can increase the potential for selection biases if respondents were very different from non- respondents. Unfortunately, a comparison between par- ents who did vs. did not respond to the survey was impos- sible since only those who responded could be identified from the enumerated sample. The adolescent children of parent respondents vs. non-respondents, however, were significantly younger and more likely to have received Tdap/meningococcal vaccine, but not HPV vaccine. The assumption in this analysis was that changes in parents’ HPV vaccine attitudes affected their decision to have their adolescent child get the HPV vaccine. But the temporality of the attitudinal exposures (or time when measured) and HPV vaccination period overlapped some, thus reverse causation could be influential to a degree in that some parents’ HPV attitudes measured at the 1-year follow-up may have only shifted after (and as a function of) their adolescent child received the HPV vaccine. Other study limitations included the limited generalizability of our sample, which was relatively small and selected from a racially homogenous source population.
Conclusion HPV vaccine coverage remains low in the U.S. , but im- proving parents’ HPV vaccine attitudes is considered a key factor in increasing these low rates . How flexible some parents’ HPV vaccine attitudes are, or how respon- sive to targeted intervention they may be, remains uncer- tain. Though the baseline response rate was low in this sample of Wisconsin parents, attitudes about the HPV vaccine’s effectiveness and certainty in having their adoles- cent child get it improved modestly. Reduced uncertain- ties scores over one year was a significant predictor of adolescent children getting their next scheduled HPV vac- cine dose, while baseline harms score (which, on average, did not improve over time) was the main attitudinal factor associated with HPV vaccine series completion. Given the positive influence of medical providers’ advice on parents’ HPV vaccine decisions in prior studies [17–19], as well as our current study, the healthcare system appears to be an optimal setting to test future methods to improve HPV vaccine attitudes and coverage.
Abbreviations CHIAS: Carolina HPV Immunization Attitudes and Beliefs Scale; CI: Confidence Interval; EHR: Electronic Health Records; HPV: Human Papillomavirus; MCHS: Marshfield Clinic Health System; OR: Odds ratio; Tdap: tetanus, diphtheria, and pertussis
Acknowledgements The authors gratefully acknowledge the assistance of all study staff.
Funding This study was supported by the U.S. Centers for Disease Control and Prevention (CDC) under contract 200–2012-53587/0006.
Availability of data and materials The survey and medical records data that support the study conclusions are unavailable for public access because informed consent to share said data (beyond the research team) was not obtained from study participants.
Authors’ contributions JV, EB, and HM developed the research methodology and analytical framework. EV led the data collection and study management activities. JV conducted the statistical analyses. CB, SS, MM, and JG critically reviewed and edited manuscript drafts. All authors read and approved the final manuscript.
Ethics approval and consent to participate A passive consent procedure was utilized whereby participants were informed in a cover letter information sheet that their completed surveys would be linked to their medical records data and used for research. This was done to reduce respondent burden for this minimal risk survey study. All study procedures, including consent processes, were approved in advance by the Marshfield Clinic Institutional Review Board.
Consent for publication Not applicable.
Competing interests The authors declare that they have no competing interests.
Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Author details 1Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Institute, 1000 North Oak Ave, Marshfield, WI 54449, USA. 2Centers for Disease Control and Prevention, Atlanta, USA.
Received: 9 March 2017 Accepted: 21 September 2017
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VanWormer et al. BMC Public Health (2017) 17:766 Page 7 of 7
- Design and participants
- Survey procedures
- Next HPV vaccine dose
- HPV vaccine series completion
- Availability of data and materials
- Authors’ contributions
- Ethics approval and consent to participate
- Consent for publication
- Competing interests
- Publisher’s Note
- Author details
A National Study of HPV Vaccination of Adolescent Girls: Rates, Predictors, and Reasons for Non-Vaccination
Laura M. Kester • Gregory D. Zimet •
J. Dennis Fortenberry • Jessica A. Kahn •
Marcia L. Shew
Published online: 23 June 2012
� Springer Science+Business Media, LLC 2012
Abstract Despite recommendations in the U.S. for routine
HPV vaccination of adolescent girls since 2006, rates of
vaccination continue to be low. This study reports vacci-
nation uptake, factors associated with vaccine uptake and
reasons for non-vaccination within a national sample of
adolescent females during 2010. Using a computer admin-
istered survey of a national sample of 501 mothers of
daughters 14–17 years old we assessed maternal reports of
HPV vaccination as well as socio-demographical factors,
maternal HPV exposures and reasons chosen for non-
vaccination. Reported HPV vaccination rates were slightly
over 50 % (51.1 %), with 38.3 % reporting completion of
all 3 doses. Socioeconomic and demographic factors were
not associated with vaccination initiation; however, Blacks
and Hispanics were less likely to complete vaccination. The
most common reasons for non-vaccination were concerns
about vaccine safety, danger to daughter, and provider non-
recommendation. Relatively poor HPV vaccine initiation
and only modest 3-dose completion continues to be a major
public health concern that requires continued efforts to
address identified predictors and reasons for non-vaccination.
Keywords HPV � Vaccination rates � Adolescent health behaviors � Sexually transmitted infections
Human papillomavirus (HPV) vaccination can lead to
substantial reductions in the incidence of HPV infection
and HPV-related diseases, including anogenital cancers
and genital warts . The introduction and licensing of the
quadrivalent HPV vaccine in 2006 and the subsequent
licensing of the bivalent vaccine in 2008 created opportu-
nities to counter the existing HPV disease burden [1, 2].
Given the high rates of HPV infection that occur shortly
after the initiation of sex and the vaccine’s ability to pre-
vent infection only prior to exposure, HPV vaccination has
been particularly targeted to young adolescents [3, 4].
Routine vaccination with either the bivalent or quadrivalent
vaccine has been recommended by the Centers for Disease
Control and Prevention’s (CDC’s) Advisory Committee for
Immunization Practices (ACIP) for adolescent females
ages 11–12, with catch-up vaccination for young women
13–26 years of age. However, 4 years post vaccination
licensure, at least half of the target population of adolescent
females had not initiated HPV vaccination [5, 6].
Various studies have assessed predictors of HPV vacci-
nation initiation and completion. The CDC reported most
recently that poverty was not a factor in HPV vaccination
initiation. On the other hand, poverty status and minority
group membership were found to be associated with lower
HPV vaccine completion rates [5, 6]. Other studies have
shown conflicting results for the significance of socio-
demographic factors in HPV vaccination initiation (e.g.,
parental education level, income level, insurance status)
[7–11]. Other factors that have been evaluated as predictors
of vaccine acceptance include maternal attitudes, such as:
knowledge of HPV, perception of daughter’s risk for HPV
acquisition, belief in vaccination benefits, degree of concern
about vaccine side effects, child’s age, social influences,
L. M. Kester (&) � G. D. Zimet � J. D. Fortenberry � M. L. Shew
Department of Pediatrics, Indiana University,
410 W. 10th Street, Suite 1001, Indianapolis, IN 46202, USA
e-mail: [email protected]
J. A. Kahn
Department of Pediatrics, Cincinnati Children’s Hospital
Medical Center, Cincinnati, OH, USA
Matern Child Health J (2013) 17:879–885
concern regarding post-vaccination sexual disinhibition,
physician’s recommendation, and parent’s personal expo-
sure to HPV infection [7, 9–14].
In light of the morbidity and mortality associated with
HPV disease as well as the disproportionately high HPV
disease burden in minority and uninsured women within
the United States, it is pivotal that we continue to evaluate
factors related to HPV vaccine initiation and completion.
Understanding the current trends of vaccination and
continuing to re-evaluate predictors of vaccination and
non-vaccination allows for the development of more
effective strategies designed to increase rates of HPV
vaccination and reduce future health disparities.
In 2010 we conducted a survey with a national U.S. sample
of mother-daughter pairs to assess the following aims: (1)
number of HPV vaccination doses received (0, 1, 2, or 3)
by each daughter in middle to late high school, age of
14–17 years, (2) to evaluate potential predictors of vacci-
nation initiation and completion, and (3) to survey mothers
whose daughters had not initiated vaccination to identify
reasons for non-initiation of HPV vaccination.
For this cross-sectional study, 501 mother-daughter pairs
were recruited from across the U.S. from a pre-formed
research panel developed by Knowledge Networks (KN)
[Menlo, CA]. This nationally representative panel was
acquired using random digit dialing methodology as well as
address-based sampling to include those households without
landline phones. To ensure adequate representation of
African American and Hispanic American households, an
oversampling of recruitment was performed in certain
Census-defined areas. For each survey administered, a ran-
dom sample was chosen from the existing panel. Surveys
were distributed via link-containing emails with reminder
emails and phone calls for non-responders to recruit well-
balanced, non-biased samples. All surveys through KN were
administered on-line. Those families without a home com-
puter or internet service were provided with a laptop com-
puter as well as free monthly internet access as compensation
for participating in the KN. For those families with existing
internet access, compensation points, redeemable for cash,
were given for each survey in which they participated.
Inclusion criteria for this study required the presence in
the home of a mother and daughter (between the ages of
14–17). Only one daughter per home, randomly selected,
was allowed to participate in the study; other siblings and
those mothers whose daughters did not consent to partici-
pate in the study were excluded from participation.
On initial recruitment of the study sample, 857 mothers
from the existing KN panel confirmed a 14–17 year old
daughter living in their household. Panel recipients were
given a brief description of the study, its purpose, and the
voluntary nature of participation in the study. Potential
participants were asked if they would be willing to par-
ticipate in a study seeking to understand why some ado-
lescents receive HPV vaccination and others do not. Initial
consent was obtained from 637 of these mothers (74.3 %).
If mothers agreed to participate, their daughters were then
asked if they were willing to consent to participate in the
study. Six hundred and twenty daughters consented
(97.3 %) representing 47 of the 50 states. Once consent had
been obtained from both mothers and daughters, the
daughters were allowed access to the online survey, which
was completed by all 620 adolescents (100 %). Once the
daughters had completed and submitted their surveys, the
mothers were then allowed access to complete the surveys
through their separate email account access. Five hundred
and one of the mothers (80.8 %) completed and submitted
the survey and were included in this study (Fig. 1). The
Fig. 1 Sample recruitment process
880 Matern Child Health J (2013) 17:879–885
surveys were distributed in this order to minimize the
mother’s influence on the daughters’ survey responses.
Institutional Review Board (IRB) approval was obtained
from the Indiana University prior to the beginning of the
Each participant was assigned a separate email account to
which all communication was sent. Survey questionnaires
were completed in either English or Spanish. A total of
nine standard questions were utilized in this study, to assess
daughter and maternal socio-demographic factors (daugh-
ter’s age, daughter’s insurance status, daughter’s insurance
plan, maternal age, maternal racial identification, maternal
marital status, maternal education, maternal working status,
and maternal geographic location). Additional questions
were asked to assess maternal HPV-related exposures,
seeking whether the mother had any history of an abnormal
Pap test, history of a colposcopy, knowledge of a friend or
family member being diagnosed with cervical cancer, or a
personal history of cervical cancer.
The number of HPV vaccination doses received (0, 1, 2,
or 3) was obtained via maternal report. The mothers of
daughters who had initiated vaccination, were asked whe-
ther or not their healthcare provider discussed with them
that their daughter could receive HPV vaccination. They
were also asked to report the strength with which their
health care provider had recommended that their daughter
receive the vaccine (strongly recommended the vaccine,
recommended the vaccine, provided no recommendation,
recommended against the vaccine, or strongly recom-
mended against the vaccine).
Mothers of daughters who had not initiated vaccination
were asked to select one or more reasons for why their
daughters had not received the HPV vaccination; the
choices given to select from included: (1) We have not seen
a health care provider in a long time, (2) My healthcare
provider has not recommended the vaccine, (3) I think the
HPV vaccine could be dangerous to my daughter, (4) I
don’t have insurance or money to pay for the vaccine, (5) I
don’t believe the vaccine works, (6) I believe the vaccine
will have side effects, (7) I believe the vaccine will make it
easier for my daughter to have sex.
Oversampling of African-Americans and Hispanics, which
was inclusive of Spanish-speaking, Latino panel members
was performed. Data was analyzed using census-based
post-stratification probability sampling weights provided
by KN to ensure nationally representative data estimates to
adjust for sample (including oversampled populations),
non-sample error, study design and survey non-response.
Bivariate analyses were conducted using SPSS Statistics
17.0 to examine factors associated with HPV vaccination
status. Chi-square analyses were performed for categorical
variables and analysis of variance tests were performed to
assess differences across vaccination status for household
income and age. Associations with a p value \0.05 were considered significant.
A total of 501 mother-daughter dyads were enrolled in the
study from 47 states in the U.S. Given the high congruence
of daughters’ and mothers’ reported rates of vaccination
(Kappa = 0.96), only maternal surveys were analyzed in
this study and mothers’ reports of vaccination status were
used as the outcome for vaccination status. Maternal mean
age was 45 years. The mothers identified as White (59 %),
Hispanic (22 %), Black (14 %), and Other (5 %). Almost
all surveys were completed in English, except for 14
(2.8 %), which were completed in Spanish. Most mothers
had some college education, were working, and were
married (Table 1). In regards to maternal experience with
HPV related diseases, greater than one-third of the mothers
reported a history of an abnormal Pap smear, 26 % had
undergone a colposcopy, and 16 % either had cervical
cancer or had a friend or family member with cervical
Half of the daughters had not received HPV vaccination
(49.9 %), 28 had received 1 dose (5.6 %), 28 had received
2 doses (5.6 %), and 192 had received all 3 doses of vac-
cine (38.3 %). Three mothers were unsure of how many
doses their daughters had received. Of those daughters that
had received 1 dose of HPV vaccination, 67.9 % were
greater than 5 months out from initial vaccination and for
those who had received 2 doses, 57.1 % were greater than
6 months out from their second dose administration.
Neither socio-economic/demographic factors (including
daughter’s insurance status, mother’s education level,
marital status, geographic location, or working status) nor
maternal HPV-related exposures were significantly corre-
lated with vaccine initiation. Although daughter’s race/
ethnicity was not found to be associated with initiation of
vaccination, Black and Hispanic girls were both signifi-
cantly less likely to complete the 3-dose series than non-
Hispanic White girls (p \ 0.001) (Table 2). For daughters who had initiated vaccination and had
received one or more vaccine doses (n = 248), 90 % of
their mothers (n = 223) reported that their healthcare
provider had discussed HPV vaccine with them, while only
10 % (n = 25) indicated that the health care provider had
not discussed the vaccine. Looking more closely at strength
Matern Child Health J (2013) 17:879–885 881
of provider recommendation, 88.9 % of those whose doctor
had ‘‘strongly recommended’’ the vaccine completed the
vaccination series compared with 71.3 % completion in
those whose doctors had only ‘‘recommended’’ the vaccine
(p = 0.013).
Mothers whose daughters had not initiated vaccination
were asked to select one or more reasons for non-vaccina-
tion. The top three reasons chosen were: concerns about
vaccine side effects, fear that the vaccine could be dangerous
to their daughter, and provider non-recommendation
(Table 3). There was only moderate overlap of mothers who
indicated concern about vaccine side-effect with those who
indicated concern that the vaccination could be dangerous
(Kappa = 0.34). Of the 90 non-vaccinating parents report-
ing concern about side-effects, only 52 also reported concern
about the vaccine being dangerous (57.8 %). Race and
ethnicity was not associated with any of the reasons for non-
Results of this study are largely consistent with those of the
CDC’s most recent adolescent vaccination surveillance
report, despite the difference between our methodology and
the National Immunization Survey . The strength of our
study compared to that of the CDC is that they utilized
random-digit-dialing for sample recruitment, while our
study utilized both random digit dialing as well as
addressed-based sampling to ascertain those individuals
without home phones. While our study used internet sur-
veying as compared to the CDC who used mailed surveys,
our methodology required that individuals be able and
willing to use the internet (which was placed in homes by
KN). In our study, we found that 51.1 % of our target
population initiated vaccination compared to 48.7 %
reported by the CDC. Additionally, we found that 38.3 %
completed the vaccine series compared to 32 % reported
by the CDC . It is concerning that half of this age group
continues either delaying or not initiating vaccination.
Our data showed no evidence that socioeconomic/
demographic factors (maternal age, education, partner
status, working status, geographic location, race/ethnicity,
or daughter’s insurance status) were associated predictors
for the rates of HPV vaccination initiation. This set of
findings differs from other studies where insurance status,
income and parental education where found to be associ-
ated with vaccination initiation [11, 15].
Race/ethnicity was the only socioeconomic/demo-
graphic factor associated with 3-dose completion showing
consistent results with the CDC that Black and Hispanic
adolescents were significantly less likely to complete vac-
cination . This finding has been consistent throughout
several other studies that found that adolescents who
racially identified as Black were less likely than those who
identified as White to complete the vaccine series [16–20].
Some studies have found that even when Blacks had higher
rates of initiation compared to Whites, they maintained
lower rates of 3-dose completion . A recent study by
Chou et al.  found that practice location was a signif-
icant association with vaccination completion and that the
Table 1 Sample demographics reported by mothers
Socio-economic/demographic factors Frequency (N) Percent (%)
14 125 25
15 125 25
16 122 24
17 129 26
18–39 106 21.2
40–44 133 26.5
45–49 140 27.9
50? 122 24.4
Maternal racial background
White, non-Hispanic 297 59
Black, non-Hispanic 69 14
Other or 2? races, non-Hispanic 26 5
Hispanic 109 22
Maternal marital status
Married/partnered 422 84
Single 79 16
High school or less 93 18.6
Some college 198 39.5
Bachelor’s or higher 210 41.9
Maternal working status
Working 355 70.9
Non-working 146 29.1
Maternal geographic region
Northeast 71 14
Midwest 156 31
South 136 27
West 138 28
Daughter’s insurance status
Insured 473 94.4
Uninsured 27 5.4
Daughter’s insurance plan
Private 286 61
Medicaid 51 10.9
Self-pay 12 2.6
Other 56 11.9
Unknown 63 13.4
Refused 1 0.2
882 Matern Child Health J (2013) 17:879–885
combination of being a young woman, 11–17 years old, in
an urban practice was a significant predictor of failure to
complete vaccination. The etiology of this racial discrep-
ancy for vaccination is not clear, but may be related to
variability in access to care, cultural influences, or patient-
provider communication. Given the disproportionately
higher HPV disease burden and mortality rates amongst
Black and other minority populations it will be important to
better understand and address these lower rates of vacci-
nation completion [11, 17, 21–23].
Maternal HPV exposure was not found to be a statisti-
cally significant predictor of vaccination, a finding similar
to a study by Caskey et al.  that found no association
between history of an abnormal pap smear and vaccination.
This lack of association could signify that experience with
HPV related conditions does not ensure increased knowl-
edge and understanding of HPV infection, and therefore
may not motivate vaccination against HPV. Additionally,
there is also no assurance that individuals with friends or
family members with cervical cancer are aware of the
causal connection between HPV infection and cervical
cancer. We note that our findings differ from a previous
study that found daughters who received HPV vaccination
were fifty percent more likely to have mothers who had
received Pap tests, which they interpreted as being due to
mothers’ attitudes toward preventive measures. However,
when this same study looked at mothers’ STI exposure
history, which included HPV, they found that there was
only a slight association with daughters’ HPV vaccination
status and that the nature of this association was incon-
sistent across racial/ethnic groups .
Provider recommendation shows a strong correlation to
vaccination decisions. Previous studies have identified the
importance of provider recommendation in HPV vaccina-
tion [26, 27]. However, studies looking at strength of
physician recommendation have shown some physicians
continue to alter the strength of their recommendation
based on the age of the female patient . One study
found that for girls 11–12 years of age, only 56 % of
physicians and 50 % of family physicians strongly rec-
ommended vaccination . Another study found 60 % of
individuals who had not intended to vaccinate reported that
they had not received a provider recommendation . In
our study, strength of provider recommendation was sig-
nificantly correlated with higher rates of vaccination
completion. Individuals whose providers ‘‘strongly rec-
ommended’’ vaccination as compared to those whose
providers ‘‘recommended’’ vaccination had higher rates of
completion. This could in part indicate that those providers,
who ‘‘strongly recommended’’ vaccination, were more
proactive about ensuring series completion. Additionally, it
may also represent a transfer of vaccine importance from
provider to patient, providing further motivation for parents
to ensure vaccination completion. Although other studies
have shown HPV vaccine recommendations to be influ-
enced by patient age, we found no relationship of provider
recommendation with age of the adolescent girls (data not
shown), which may be a function of the narrow age range
of our study sample . These findings regarding strength
of provider recommendation and HPV vaccination high-
light the importance of educating physicians to provide
‘‘strong recommendations’’ for all individuals within the
vaccine age-targeted population .
Mothers, of daughters who had not initiated vaccination,
reported the most common reasons for non-vaccination
were provider non-recommendation, concern for vaccine
side effect, as well as concern that the vaccine could be
Table 2 Number of HPV vaccine doses received by racial/ethnic groups
Number of vaccination
(n = 297)
(n = 109)
(n = 69)
(n = 26)
0b 147 (49.8) 59 (54.1) 40 (61.5) 10 (38.5)
1 or 2 29 (9.8) 23 (21.1) 8 (12.3) 1 (3.8)
3 119 (40.4) 27 (24.8)* 17 (26.2)* 15 (57.7)
* Hispanics and Blacks found to have a statistically significant lower rate of HPV vaccination completion compared to Whites (p \ 0.05) a Due to small number and heterogeneity, this group was not included in analysis b No statistical difference in HPV vaccination initiation rates
Table 3 Maternal chosen reasons for vaccination non-initiation
Reason for non-vaccination Frequency
Percent of total
Concern for vaccine side effect 90 36.0
Concern for danger to daughter 90 36.0
Provider non-recommendation 86 34.4
Long lapse in doctor’s visit 29 11.6
Concern for increased ease for
daughter to have sex
Doubt of vaccine efficacy 33 6.6
Lack of insurance or finance 28 5.6
No response chosen 15 6.0
Multiple reasons could be selected by each mother
Matern Child Health J (2013) 17:879–885 883
dangerous to their daughter. Each of these reasons further
underscores the importance of the provider’s role in vac-
cine uptake, particularly with almost 50 % of the target
population having not initiated vaccination . Other
studies have found a similar significance of provider
influence being crucial to vaccine acceptance . Con-
tinued provider support throughout the vaccination process
is essential, particularly in recognizing that those who
postpone vaccination (or never receive the vaccine) lose
potential for protection once exposure to vaccine-related
HPV types has occurred.
A limitation of this study is that vaccination rates were
based solely on maternal reports and could not include
confirmation via medical records. However, congruence
between mother and daughter reports of vaccination was
found to be high, suggesting good reliability of the self-
report measure. Also, the consistency between our findings
and the results of the National Immunization Survey sug-
gests that self-reports were fairly accurate. A second lim-
itation is that our assessment of provider non-
recommendation as a reason for non-vaccination, does not
distinguish between a provider recommendations against
vaccinations compared to a complete omission of any
recommendation in either direction.
HPV vaccination provides a strong potential to improve
public health by decreasing HPV-related anogenital can-
cers and genital warts. Despite increases in vaccination
rates, half of the target population continues to remain
unvaccinated and completion rates lag in those populations
that are at highest risk for HPV disease morbidity. In light
of the recommendation for routine vaccination of young
women and the coverage of HPV vaccination by the
Vaccines for Children program, there is the potential to
greatly decrease HPV-related disease burden. However,
reduction in HPV-related diseases will require more uni-
form vaccination initiation and completion rates across
HPV naı̈ve populations and must occur prior to HPV
exposure. For individuals who have initiated vaccination,
further research is needed to better understand barriers to
vaccine completion, especially among minority adoles-
cents. Additionally, improved understanding of the reasons
chosen for non-vaccination, including vaccine safety and
provider non-recommendation may help improve efforts to
increase rates of vaccination. Recognizing that timing of
HPV vaccination is important and it is recommended prior
to sexual exposure, continued educational interventions
with physicians, patients and their parents regarding vac-
cine safety and vaccine efficacy are clearly needed.
Acknowledgments Funding support for this research was provided by NIH R56 A1079090-01A1.
Conflict of interest Kester, Laura: Has no financial disclosures. Zimet, Gregory: Investigator on grants funded through Merck’s
Investigator Initiated Studies Program. In the past year served as a
consultant to Sanofi Pasteur regarding attitudes about herpes vacci-
nation. Shew, Marcia: Investigator for Merck and Co. related HPV
vaccine trials. Kahn, Jessica: Co-PI of two clinical trials of HPV
vaccine in HIV-infected individuals; vaccine and immunogenicity
testing were provided by Merck. Fortenberry, J Dennis: Receives
compensation from American Social Health Association for contin-
uing lectures related to HPV vaccines.
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- A National Study of HPV Vaccination of Adolescent Girls: Rates, Predictors, and Reasons for Non-Vaccination
- Research Methods
- Sample Population
- Data Collection
- Data Analysis
Putting Your Paper Together
Section I – Introduction
Overview of Problem
Purpose of the Study
Research Questions, Objectives or Hypothesis
Definition of Terms
Summary Paragraph and Transition to Section II
Section II – Review of Literature & Theoretical Framework
Review of Literature
Summary Paragraph with Transition to Section III
Section III – Methodology
Protection of Subjects Rights
Consent Form & Procedures
Projected Data Analysis
Introduction – overview of procedures to be used – software package and handling of data
Identification of Levels of Significance
Identification of Levels of Significance
Wrap-up the Proposal in a paragraph or two.
Section IV – Data Analysis
Analysis of Data
Discussion of Findings
Section V – Results and Conclusions
Running head: METHODOLOGY 1
Angela-Theresa C. Green
NSG 6101 Nursing Research Methods
November 14, 2017
Research has been done on vaccinations and also imparticular the Gardasil vaccination over the years. Vaccinations are administrated all over the world for preventative measures such as for the prevention of cancer. The purpose of this study is to explorer the knowledge and attitudes of parents of middle school age. This researcher plans to determine if the attitudes and knowledge of parents impacts whether or not their children receive the Gardasil vaccination.
The research being conducted will be a quantitative experimental study (Gray, Grove, & Sutherland, 2017). A questionnaire will be distributed, by a middle school faculty teacher. The questionnaire will be disseminated after the IRB is cleared by the school board and a presentation and teaching on what the project is regarding, then the questionnaire will be distributed by faculty to the parents of the middle school children. The middle school children are between the ages of 11-15years of age. The parents will have a time frame of one week to complete the short questionnaires’ and send the completed forms back with their child to the teacher. The completed forms will be picked up by this researcher to ascertain review the results. According to the schoolboard data obtained, there is over 700 middle school children attending this one site.
A nonprobability convenience sampling design will be utilized with this study in order to select the participants which was constructed to focus on the hypothesis or question: What is the Knowledge and Attitudes towards Gardasil Vaccination among Parents for Their Children? (Gray, Grove, & Sutherland, 2017) The participants are parents of children at one middle school within the state of Florida. The sample is a non-probability sample because the individuals involved in this study would have to be parents of the children at the middle school the questionnaires’ were distributed at. All participants will have an equal opportunity to participate in said study indicated. The sample will consist of 25 or more participants. The participants can be of any race, age or gender. Exclusion criteria for participating in this research study include if the parents do not have middle school aged children at this middle school which the questionnaires were distributed.
References Gray, J. R., Grove, S. K., & Sutherland, S. (2017). Nursing Research (8th ed.). Philadelphia: Saunders.