Correlates for human papillomavirus vaccination of adolescent girls and young women in a managed care organization

Exploration of individual socioeconomic and health-related characteristics associated with human papillomavirus vaccination initiation and vaccination series completion among adult females: A comprehensive systematic evidence review with meta-analysis

INTRODUCTION

Human papillomavirus (HPV) vaccination rates among females are lower than the World Health Organization target and vaccination rates specifically among adult females are even much lower.

METHODS

We systematically evaluated individual socioeconomic and health-related characteristics associated with HPV vaccination initiation and vaccination series completion among adult females (PROSPERO: CRD42023445721). We performed a literature search on December 14, 2022, and supplemented the search on August 1, 2023. We pooled appropriate multivariable-adjusted results using an inverse variance random-effects model and expressed the results as odds ratios with associated 95 % confidence intervals. A point pooled significantly increased/decreased odds of 30-69 % was regarded to be strongly associated, and ≥ 70 % was very strongly associated.

RESULTS

We included 63 cross-sectional studies. There were strongly increased odds of vaccination initiation among White women compared with Black or Asian women, and those with higher education, health insurance, a history of sexually transmitted infection (STI), receipt of influenza vaccination in the preceding year, not married/cohabiting, not smoking, using contraception, and having visited a healthcare provider in the preceding year. We observed very strongly increased odds of vaccination initiation among those younger and having been born in the country of study. Similarly, there were strongly increased odds of completing the vaccination series for the same variables as initiating vaccination, except for higher education, prior STI, smoking and contraception use. Additional variables associated with strongly increased odds of vaccination series completion not seen in initiation were higher annual household income, being lesbian/bisexual, and having a primary care physician. We observed very strongly increased odds of vaccination series completion similar to vaccination initiation but including for White compared with Black women, higher education, and prior cervical cancer screening.

CONCLUSIONS

These individual characteristics may be the key to identifying women at increased risk of not being vaccinated against HPV and could inform targeted messaging to drive HPV vaccination.

Understanding Clinic and Community Member Experiences with Implementation of Evidence-Based Strategies for HPV Vaccination in Safety-Net Primary Care Settings

HPV vaccination rates remain below target levels among adolescents in the United States, which is particularly concerning in safety-net populations with persistent disparities in HPV-associated cancer burden. Perspectives on evidence-based strategies (EBS) for HPV vaccination among key implementation participants, internal and external to clinics, can provide a better understanding of why these disparities persist. We conducted virtual interviews and focus groups, guided by the Practice Change Model, with clinic members (providers, clinic leaders, and clinic staff) and community members (advocates, parents, policy-level, and payers) in Los Angeles and New Jersey to understand common and divergent perspectives on and experiences with HPV vaccination in safety-net primary care settings. Fifty-eight interviews and seven focus groups were conducted (n = 65 total). Clinic members (clinic leaders n = 7, providers n = 12, and clinic staff n = 6) revealed conflicting HPV vaccine messaging, lack of shared motivation to reduce missed opportunities and improve workflows, and non-operability between clinic electronic health records and state immunization registries created barriers for implementing effective strategies. Community members (advocates n = 8, policy n = 11, payers n = 8, and parents n = 13) described lack of HPV vaccine prioritization among payers, a reliance on advocates to lead national agenda setting and facilitate local implementation, and opportunities to support and engage schools in HPV vaccine messaging and adolescents in HPV vaccine decision-making. Participants indicated the COVID-19 pandemic complicated prioritization of HPV vaccination but also created opportunities for change. These findings highlight design and selection criteria for identifying and implementing EBS (changing the intervention itself, or practice-level resources versus external motivators) that bring internal and external clinic partners together for targeted approaches that account for local needs in improving HPV vaccine uptake within safety-net settings.

When culture and health collide: feminine honor endorsement and attitudes toward catch-up HPV vaccinations in college women

Sexual promiscuity stigma constitutes a significant barrier which prevents young women from receiving catch-up human papillomavirus (HPV) vaccinations. Our objective was to explore how this stigma may be particularly detrimental to women in cultures of honor, where women are expected to maintain a reputation of sexual purity.

Participants were a sample of 182 young women who had not previously received an HPV vaccination.

We measured feminine honor endorsement, HPV sexual promiscuity stigma, HPV vaccination shame, HPV vaccination intentions, and a set of covariates.

Analyses revealed that the significant association between feminine honor endorsement and HPV vaccination intentions is fully explained by HPV sexual purity stigma and HPV vaccination shame.

These findings indicate that honor-endorsing women are significantly impacted by sexual purity stigma, minimizing intentions to receive HPV vaccinations. These findings also highlight the need for the inclusion of cultural factors in the study of HPV vaccine uptake.

Correlations of HPV vaccine uptake among eight-grade students in Israel: the importance of ethnicity and level of religious observance

In Israel, human papilloma virus (HPV) vaccines are included in the national childhood immunization program for eight-grade students, but uptake remains relatively low. This article explores which demographic factors are correlated with HPV vaccination rates. HPV vaccination data for the school year 2017-2018 was assessed among members of Maccabi Healthcare Services, the second largest health service provider in Israel. By matching eighth grade students to their family members' demographic data via an electronic medical records (EMR) system, we assessed vaccination rates by taking into account sex, socioeconomic status (SES), ethnic categorization, and maternal characteristics. In a total of 45,160 eligible students, 55.3 percent of girls and 48.5 percent of boys were vaccinated for HPV. In a multivariable model, students in Arab communities had a significantly (p < .001) higher odds ratio (2.02; 95 percent CI:1.55-2.64) of being vaccinated, while ultra-orthodox (UO) Jewish students were much less likely to be vaccinated compared to all other students (OR = 0.05; 95 percent CI:0.05-0.06). Ethnicity and level of religious practice are major determinants of HPV vaccine uptake in Israel. This should be taken into account when planning intervention programs in order to improve the uptake of the vaccine.

Knowledge of Human Papillomavirus and Cervical Cancer Among Low-Income Women in New Jersey

OBJECTIVES

Although much research has been conducted on knowledge and awareness of the connection between human papillomavirus (HPV) and cervical cancer risk among university students, few studies have examined these associations among low-income populations. We examined knowledge of HPV and cervical cancer risk among racially and ethnically diverse low-income women.

METHODS

We used a cross-sectional study design to recruit and interview 476 low-income women in New Jersey from November 1, 2013, through February 28, 2016. We used multivariate logistic regression to determine whether knowledge of HPV and its association with cervical cancer risk differed by race and ethnicity.

RESULTS

Compared with non-Hispanic White women, Hispanic (odds ratio [OR] = 0.37; 95% CI, 0.18-0.77) and non-Hispanic Black (OR = 0.38; 95% CI, 0.19-0.77) women were significantly less likely to report having heard of HPV. Of women who had ever heard of HPV (n = 323), non-Hispanic Black women were significantly less likely (OR = 0.44; 95% CI, 0.21-0.89) than non-Hispanic White women to report knowing that HPV can be associated with cervical cancer.

CONCLUSIONS

Given the higher rates of HPV infection among non-Hispanic Black and Hispanic women, these results suggest a need to improve education about risks of HPV among low-income populations. These messages need to include information on the connection between HPV and cervical cancer and must be provided in culturally and linguistically appropriate ways.

Beliefs and knowledge related to human papillomavirus (HPV) vaccine among African Americans and African immigrants young adults

BACKGROUND

Despite the disparate human papillomavirus (HPV) infection rates among sexually active Black young adults, HPV vaccine uptake remains low among this population. This study aimed to explore HPV beliefs, attitudes, and knowledge among Black young adults and provide recommendations on ways to improve vaccine uptake.

METHODS

We used a mixed-method, convergent design to conduct five focus groups and administered a 40-item electronic survey that was developed with health belief model (HBM) constructs. We assessed HPV and vaccine knowledge, barriers, and attitudes toward vaccination. We analyzed quantitative data using descriptive statistics and bivariate methods. Focus group transcripts were analyzed using content analysis. Results were integrated to obtain a better understanding of the topic.

RESULTS

Forty individuals participated in the study. The mean age was 22.2 ± 4.5 years and 55% identified as African immigrants. Integrated data revealed themes mapped to relevant HBM constructs. Almost one third (32.5%) of participants were unaware of their susceptibility to HPV infection and its severity. From focus group discussions, the majority (75%) believed that vaccines are beneficial. Major cues to action include promoting HPV vaccine uptake via community wide informational sessions, provider recommendation, and social and mass media campaigns.

CONCLUSION

Barriers to vaccine uptake, limited HPV knowledge, and lack of vaccine recommendation are important factors contributing to low vaccine uptake among Black young adults. Interventions to decrease barriers to HPV vaccination, increase HPV knowledge, address misconceptions, and unfavorable beliefs are needed to promote HPV vaccine uptake.

The Impact of a Comic Book Intervention on East African-American Adolescents' HPV Vaccine-Related Knowledge, Beliefs and Intentions

HPV vaccine uptake is low among East African-American (EAA) adolescents. We developed a comic book and evaluated the impact on HPV/HPV-vaccine knowledge, beliefs and vaccine intentions. The intervention was delivered to HPV-unvaccinated EAA adolescents attending educational dinners with their mothers. Adolescents aged 14-17 were sequentially assigned alternately to a pre- or post-test. Results were compared with chi-squared tests and generalized estimating equation models adjusted for age, gender, and mother's language. Among 136 (pre-test = 64, post-test = 72) participants (90% Somali), pre/post differences were observed for proportions of correct responses to questions on HPV (44.0% vs. 82.9%, RR:1.87[95%CI 1.54-2.27]), HPV-vaccine knowledge (42.8% vs. 75.4%, RR:1.74[95%CI 1.46-2.07]), comfort discussing HPV/HPV vaccine with parents (57.8% vs. 90.3% somewhat/very comfortable, RR:1.55[95%CI 1.24-1.94]), and willingness (37.5% vs. 83.3% probably/definitely willing, RR:2.16[95%CI 1.55-3.01]) and intention (34.4% vs. 86.1% somewhat/very likely, RR:2.38[95%CI:1.69-3.37]) to get vaccinated. The intervention improved participants' HPV/HPV-vaccine knowledge, beliefs and vaccine intentions. Similar interventions could be adapted for other racial/ethnic minorities.

Factors Associated with HPV Vaccine Adherence among Latino/a Adolescents in a Rural, Texas-Mexico Border County

Objective

Completion of human papillomavirus (HPV) vaccine series among Texas Hispanic adolescents is low compared to national data. We examined the association between HPV vaccine initiation and completion among Hispanic adolescents in a rural, Texas-Mexico border county and specific individual and neighborhood-level characteristics.

Design

Cross-sectional analysis of data from a broader cancer prevention program.

Setting

Underserved colonias communities in a Texas-Mexico border county.

Participants

Hispanic mothers or caregivers (n=712) and adolescents aged 11-17 years (n=1120) linked to publicly available data about their neighborhood.

Main Outcome Measures

HPV vaccine adherence (ie, initiation and completion) as reported in either the Texas Immunization Registry or adolescents' electronic medical records, measured at the end of the cancer prevention program.

Methods

Logit and multi-level mixed-effects logistic regression of individual- and neighborhood-level data.

Results

Factors associated with HPV vaccine initiation and completion were female gender (P<.01), adolescent insurance status (P<.001), and receipt of required vaccines (P<.001). After controlling for neighborhood-level characteristics, only receipt of required vaccines remained significant.

Conclusions

Findings indicate a relationship between Hispanic adolescents' receiving the required vaccine series for school admission and HPV vaccine initiation and completion. In resource-limited settings like federally qualified health centers, further efforts should focus on implementing best practices at both the provider level (eg, education on bundled vaccine recommendation) and practice-level (eg, outreach and support by trained immunization navigators).

Incomplete Records as a Leading Cause of Missed Opportunity for Human Papillomavirus Vaccine Initiation in a Safety Net Health System

OBJECTIVE

The goal of this study was to categorize reasons behind missed opportunities for human papillomavirus (HPV) vaccine initiation in an under-resourced population and to identify associated patient and clinic characteristics.

METHODS

Manual chart review was performed for patients aged 11 to 18 years who visited a primary care clinic in a health system in Texas, USA between 06/01/18 and 08/31/18 and were due for an initial HPV vaccine dose but did not receive it. Reasons for HPV vaccine noninitiation were categorized as follows: incomplete immunization record, no documentation of discussion (no documentation that the HPV vaccine was offered or ordered), refusal, staff/provider error, and medical. Multinomial logistic regression was used to examine factors associated with each category.

RESULTS

Of 4467 adolescents seen in the study period, 575 (12.9%) were due for the first dose of HPV vaccine but did not receive it. The most common reason for noninitiation was incomplete immunization record (37%), followed by no documentation of discussion (24%), refusal (20%), staff/provider error (15%), and medical (4%). The highest odds of incomplete immunization were among older adolescents. The highest odds of no documentation of discussion were during sick visits. The highest odds of staff/provider error were among patients with commercial insurance. The lowest odds of refusal were in patients with county/indigent insurance.

CONCLUSIONS

The most common reason for missed opportunity visits for HPV vaccine initiation was lack of adequate immunization records. Our study highlights the importance of immunization record access and bidirectional reporting as important targets for future interventions.

Understanding primary care physician perspectives on recommending HPV vaccination and addressing vaccine hesitancy

HPV vaccination rates have improved in recent years, but remain suboptimal in the United States. Physician recommendation is associated with increased uptake; however, specific strategies used by physicians to recommend the vaccine and address hesitancy are underexplored. We iteratively conducted qualitative in-depth interviews with family medicine and pediatrics/adolescent medicine physicians recruited from four primary care settings (federally qualified health centers and hospital-affiliated practices) within a large academic-hospital system in New Jersey. Interviews aimed to understand factors influencing physician recommendations. Transcripts were analyzed iteratively using a team-based, thematic content analysis approach. All physicians reported strong support for HPV vaccination, intention to recommend for target age groups, and providing factsheets to parents. Many physicians used electronic medical records and/or the state immunization registry for monitoring vaccinations, but few were able to report their own clinic-level rates. The majority said they needed to overcome both hesitancy for at least 10-30% of parents and misinformation from the internet. Most cited having their own children vaccinated for HPV as a first-line strategy for addressing parental hesitancy. Other strategies included using data or professional authority to address safety concerns, linking HPV to cervical cancer, highlighting only needing two doses if vaccinated younger, and normalizing the vaccine. While our findings indicate physicians are knowledgeable about HPV vaccination and recommend it to parents, strategies to overcome parental hesitancy varied. Physician, clinic, and health-system-based strategies need to be adopted to overcome parental hesitancy for HPV vaccination.

Development and evaluation of an online continuing education course to increase healthcare provider self-efficacy to make strong HPV vaccine recommendations to East African immigrant families

OBJECTIVE

To develop and evaluate an online continuing education (CE) course designed to improve healthcare provider self-efficacy to make strong adolescent HPV vaccine recommendations to East African immigrant families.

METHODS

Focus groups with providers and East African immigrant mothers informed course development. Providers serving East African immigrant families were recruited to view the course and complete pre-/post-test and two-month follow-up surveys. Pre-/post differences were compared with paired t-tests.

RESULTS

202 providers completed the course and pre-/post-test; 158 (78%) completed two-month follow-up. Confidence to make strong HPV vaccine recommendations to East African families increased from 68% pre-test to 98% post-test. Confidence to address common parental concerns also increased: safety, 54% pre-test, 92% post-test; fertility, 55% pre-test, 90% post-test; child too young, 68% pre-test, 92% post-test; and pork gelatin in vaccine manufacturing, 38% pre-test, 90% post-test. Two-month follow-up scores remained high (97% for overall confidence, 94%-97% for addressing parental concerns). All pre-/post-test and pre-test/two-month follow-up comparisons were statistically significant (p < 0.05).

CONCLUSIONS

The online CE course focused on culturally appropriate strategies for making strong recommendations and addressing specific parental concerns was effective for increasing provider self-efficacy to recommend HPV vaccination to East African families. Similar courses could be tailored to other priority populations.

Hospital Records of Pain, Fatigue, or Circulatory Symptoms in Girls Exposed to Human Papillomavirus Vaccination: Cohort, Self-Controlled Case Series, and Population Time Trend Studies

Human papillomavirus (HPV) vaccination has been associated with subsequent diffuse symptoms in girls, reducing public confidence in the vaccine. We examined whether girls have nonspecific outcomes of HPV vaccination, using triangulation from cohort, self-controlled case series (SCCS), and population time trend analyses carried out in Denmark between 2000 and 2014. The study population consisted of 314,017 HPV-vaccinated girls and 314,017 age-matched HPV-unvaccinated girls (cohort analyses); 11,817 girls with hospital records (SCCS analyses); and 1,465,049 girls and boys (population time trend analyses). The main outcome measures were hospital records of pain, fatigue, or circulatory symptoms. The cohort study revealed no increased risk among HPV vaccine-exposed girls, with incidence rate ratios close to 1.0 for abdominal pain, nonspecific pain, headache, hypotension/syncope, tachycardia (including postural orthostatic tachycardia syndrome), and malaise/fatigue (including chronic fatigue syndrome). In the SCCS analyses, we observed no association between HPV vaccination and subsequent symptoms. In time trend analyses, we observed a steady increase in these hospital records in both girls and (HPV-unvaccinated) boys, with no relationship to the 2009 introduction of HPV vaccine to Denmark's vaccination program. This study, which had nationwide coverage, showed no evidence of a causal link between HPV vaccination and diffuse autonomic symptoms leading to hospital contact.

Determinants of Meningococcal ACWY vaccination in adolescents in the US: completion and compliance with the CDC recommendations

Since 2011, the Advisory Committee on Immunization Practices (ACIP) guidelines for routine MenACWY vaccination in the US include a primary dose before age 16 y, preferably at ages 11-12 y, with a booster dose at age 16 y. Data on rates and drivers of meningococcal vaccination completion (receipt of both doses) and compliance with recommendations (receipt of primary dose at ages 11-12 y followed by booster at 16 y) down to state-level are limited.This study evaluated rates and determinants of MenACWY vaccination completion and compliance in adolescents aged 17 y based on data from the annual National Immunization Survey-Teen between 2011 and 2016. Individual- and state-level determinants of completion and compliance were assessed using uni-level and multi-level multivariable regression models. Average national rates were 23.2% and 12.1% for completion and compliance, respectively, with large inter-state variation observed (completion: 8.7-39.7%; compliance: 3.1-26.2%). Beyond the state of residence, factors significantly associated with a higher likelihood of both completion and compliance included being male, up-to-date on other routine vaccines, having private or hospital-based vaccine providers (vs. public) and having >1 child in the household. Factors specifically associated with completion included having >1 annual health-care visit and presence of a booster-dose vaccine mandate, while a history of asthma and high-risk health conditions had a positive association with compliance. State-level determinants of completion and compliance included pediatricians-to-children ratio and the proportion of Immunization Information System use among adolescents, respectively. Outcomes of this study may help guide clinical, policy and educational interventions to further increase MenACWY completion rates and reduce disparities in vaccination.

The factors associated with maternal consent to human papillomavirus vaccination among adolescents in Israel

Purpose: To evaluate the knowledge and attitudes toward the human papillomavirus (HPV) vaccine among mothers of 8th graders in Israel, and to determine the factors associated with maternal consent to the HPV vaccine.Methods: We conducted a cross-sectional study among mothers of 8th grade students in 27 schools in Haifa and Northern districts of Israel during the 2016-17 school year. Data were collected using a structured telephone questionnaire.Results: 313 mothers answered the questionnaire (response rate = 91.8%). The mean knowledge level score was low (3.96 points [out of 10] ±2.68). Knowledge level was positively associated with Jewish nationality, being secular in religious practice and higher education. The attitude mean score was low-moderate (11.22 points [out of 18] ± 5.01). Attitude score was positively associated with Arab nationality. No significant association was found between knowledge level and attitudes. According to multivariate analysis, mothers' consent to the HPV vaccine was associated with the knowledge level score (OR = 0.82; 95%CI 0.68-0.98), the attitude score (OR = 1.76; 95%CI 1.53-2.02) and nationality (OR = 27.86, 95%CI 3.41-227.56).Conclusions: The knowledge level and attitudes toward the HPV vaccine were found to be unsatisfactory with racial disparities between Arabs and Jews. Jewish mothers compared with Arab mothers, mothers with a higher knowledge level or less positive attitudes were less likely to consent to the vaccine. These findings could contribute toward adapting programs to the different Israeli sectors in order to improve the rates of HPV vaccine receipt among adolescents.

Disparities and reverse disparities in HPV vaccination: A systematic review and meta-analysis

Studies disagree about whether racial and ethnic groups have lower or higher human papillomavirus (HPV) vaccination uptake, an important issue given large disparities in some HPV cancers. We sought to characterize and explain racial and ethnic differences in HPV vaccination. We systematically searched PubMed, CINAHL, Embase, and Web of Science to identify US studies through mid-2017 reporting associations of race and ethnicity with HPV vaccination. We identified 118 studies (n = 3,095,486) published in English that reported HPV vaccine initiation or follow-through in the US from which we could calculate effect sizes. We used random effects meta-analysis to synthesize effect sizes for comparisons of Whites or non-Hispanics to Blacks, Hispanics, Asians, or all minority groups combined. Studies showed no racial or ethnic differences in HPV vaccine initiation overall. However, when restricting to studies using provider-verified vaccination data, minorities were 6.1% [3.3%-8.8%] more likely than Whites to initiate HPV vaccination. Advantages were larger for Hispanics, males, and younger samples (age < 18). In contrast, minorities were 8.6% [5.6%, 11.7%], less likely than Whites to follow-through with the full HPV vaccine series, a disparity present across all participant and study characteristics. More recent studies found larger advantages for racial and ethnic minorities in HPV vaccine initiation and smaller disparities in follow-through. In summary, high-quality studies found racial and ethnic minorities are more likely to initiate but less likely to follow-through with HPV vaccination, a clear finding that self-report studies obscure. Higher HPV vaccine initiation among minorities suggests potential reductions in HPV cancer disparities.

Knowledge and Attitudes Toward Human Papillomavirus Vaccination Among Latina Mothers of South American and Caribbean Descent in the Eastern US

Purpose: The purpose of this study was to examine knowledge, attitudes, barriers, and facilitators for human papillomavirus (HPV) vaccination among Latina mothers of HPV vaccine-eligible children in low-income urban areas, as well as useful strategies to improve HPV vaccination. Methods: The study included 132 Latina mothers of HPV vaccine-eligible children, interviewed in 14 focus groups. Using semi-structured discussions, mothers were asked about their knowledge about HPV infection and vaccine, views toward HPV vaccination, barriers for HPV vaccine initiation as well as completion, and opinions on strategies to improve HPV vaccination. Results: Only 55% of mothers reported having ever heard of the HPV vaccine, 27% of mothers indicated initiating the HPV vaccine, and 14% indicated completing the multi-dose series. Mothers generally lacked knowledge about HPV infection and vaccination, with varying degrees by Latino descent. Health care provider (HCP) recommendation was the strongest barrier/facilitator for HPV vaccination. Useful strategies to improve HPV vaccine initiation and completion that the mothers suggested included strong recommendation from HCPs and addressing side effects and safety concerns. Other useful strategies included community and school-based approaches and the use of text messaging and smartphone technology to educate mothers and send vaccine reminders. Conclusion: The findings provide insight for the development of interventions targeting low-income Latina mothers and the need to improve HCP communication on HPV vaccination.

Why human papilloma virus vaccination coverage is low among adolescents in the US? A study of barriers for vaccination uptake

Introduction

Cervical cancer and Human papillomavirus (HPV) affects women, men, and children of all races, ethnicities, and backgrounds. The objective of this study is to examine the association between adolescent (13-17 years) HPV vaccination uptake and the key factors influencing the uptake rates of HPV vaccination.

Materials and Methods

The 2016 NIS-Teen data, an annual survey conducted by the CDC to monitor vaccination uptake in the United States is used for this study. Multivariable logistic regression model was used to estimate the relationship between various factors and HPV vaccine uptake.

Results

Male adolescents were 0.26 times less likely to get the HPV vaccines; adolescents covered by private health insurance were 0.18 times less likely to get HPV vaccines; Hispanic adolescents were 1.47 times more likely, adolescents from other races including Asians were 1.75 times more likely to get vaccinated for HPV compared to non-Hispanic white adolescents. Adolescents from the low-income families were 1.21 times more likely to get vaccinated for HPV; adolescents from North-eastern regions of the United States were 1.62 times more likely to get vaccinated; adolescents who were not recommended for vaccination by the family physicians were 0.43 times less likely to get HPV vaccination; adolescents who did not have any safety concerns and concerns about side effects were 3.24 times more likely to get the HPV vaccine; adolescents from households that did have not orthodox religious beliefs were 13.67 times more likely to get vaccinated.

Conclusions

Vaccination uptake rates are low for adolescents in the US and the results of this study identified important barriers which need to be addressed in order to improve vaccine uptake rates among the target groups which are less likely to get vaccinated. Also, knowing the sociodemographic and community level factors associated with HPV vaccination uptake status, health planners can better plan strategies to improve HPV vaccination in their local settings.

"We brought our culture here with us": A qualitative study of perceptions of HPV vaccine and vaccine uptake among East African immigrant mothers

Background

HPV vaccine studies in East African communities are few and focus mainly on Somali women and girls. We examined how HPV vaccine perceptions and uptake are shaped among Somali, Ethiopian, and Eritrean mothers.

Methods

We convened three focus groups in Somali, Amharic, and Tigrinya with mothers of 11–17 year old children. The Socio-Context Framework (social, cultural, and religious factors) and Andersen's Behavioral Model (predisposing, enabling, and need for care factors) informed question development.

Results

Negative vaccine perceptions, lack of HPV vaccine knowledge, and concerns about side effects emerged as predisposing factors. Having a provider who engages parents on HPV vaccination and takes responsibility for vaccine-related risks emerged as enabling factors. Availability of vaccine information resources (e.g., person-to-person, word of mouth education for parents) were also enabling factors. Need for care factors included having comprehensive vaccine information, strong recommendation from a doctor, and validation from a co-ethnic medical professional. Women exerted strong social influence on vaccine uptake (social), had concerns about pork gelatin in vaccines (religious), and felt discussions about sex with children were culturally unacceptable (cultural).

Conclusion

Strategies for vaccine uptake among East African immigrants need to address factors that shape HPV vaccine perceptions for adolescents, caregivers, and providers.

An Integrative Review of the Influences on Decision-Making of Young People About Human Papillomavirus Vaccine

The human papillomavirus (HPV) vaccine is a key intervention in the prevention of HPV infection and associated cancers. This review emphasizes the importance of understanding what influences decision-making about this vaccine. Guided by the work of Whittemore and Knafl, and Pluye and Hong, we identified 25 studies, from which four prominent themes emerged: fear and risk, pain, parental involvement, and involvement of others. Fear of cervical cancer was a strong motivation to receive the vaccine, and the extent of parental involvement also had an impact on decision-making. Recommendations to receive the vaccine by health-care providers were also an important influence. School nurses are fundamental to the promotion and delivery of the HPV vaccine and should stress the significant role that it plays in the prevention of cancer. Additionally, school nurses should ensure that discussions about HPV infection and vaccine include parents where appropriate and should distinctly recommend vaccination to those eligible.

Human Papillomavirus Vaccination Initiation Among Sexual Orientation Identity and Racial/Ethnic Subgroups of Black and White U.S. Women and Girls: An Intersectional Analysis

INTRODUCTION

Human papillomavirus (HPV) vaccination, which is recommended for U.S. women and girls aged 11-26 years, effectively prevents cervical cancer. Researchers have identified HPV vaccination disparities among groups of women and girls defined in relation to sexual orientation identity or race/ethnicity. However, no study has used an intersectional approach to ascertain HPV vaccine uptake among sexual orientation identity and racial/ethnic subgroups of U.S. women and girls.

METHODS

Using 2011-2015 National Survey of Family Growth data, we used multivariable logistic regression to estimate differences in the odds of HPV vaccination initiation (i.e., ≥ one dose) across sexual orientation identity and racial/ethnic subgroups of black and white U.S. women aged 15-24 years (N = 2,413), adjusting for demographic factors. We also assessed whether socioeconomic and health care factors helped explain observed disparities.

RESULTS

The overall prevalence of HPV vaccination initiation was 47.7%. Compared to white heterosexual women, black lesbians (odds ratio [OR] = 0.16; 95% confidence interval [95% CI]: 0.06-0.46) had the lowest adjusted odds of HPV vaccination initiation, followed by white lesbians (OR = 0.33; 95% CI: 0.13-0.82) and black heterosexual women (OR = 0.63; 0.47-0.85). Including socioeconomic factors in the model only slightly attenuated the HPV vaccination initiation odds ratios for black lesbians (OR = 0.19; 95% CI: 0.06-0.56), white lesbians (OR = 0.37; 95% CI: 0.15-0.90), and black heterosexual women (OR = 0.70; 95% CI: 0.52-0.93) compared to white heterosexual women. Adding health care factors only slightly additionally attenuated the odds ratio comparing black lesbians and white heterosexual women (OR = 0.21; 95% CI: 0.07-0.67).

CONCLUSIONS

Our findings identified black lesbians as a particularly underserved subgroup and suggest that sexual orientation identity and race/ethnicity may have a compounding effect on HPV vaccination initiation among black and white U.S. women and girls. Evidence-based interventions that are adapted to the specific needs and experiences of black lesbians and other multiply marginalized groups are needed to promote equity in HPV-related outcomes.

Predictors of Human Papillomavirus Vaccine Follow-Through Among Privately Insured US Patients

OBJECTIVES

To assess predictors of timely human papillomavirus (HPV) vaccine follow-through among privately insured individuals initiating the 3-dose series.

METHODS

Using MarketScan Commercial claims data, we identified 1 332 217 privately insured US individuals aged 9 to 26 years who initiated the bivalent or quadrivalent HPV vaccine series from 2006 to 2014, with follow-up data extending through 2015. The study outcome was receipt of third HPV dose within 12 months of the first, compared by year of initiation. Control variables were age, region, insurance plan type, provider type, and seasonal influenza vaccination.

RESULTS

Timely HPV vaccine follow-through fell over time. The trend was especially pronounced for females (from 67% in 2006 to 38% in 2014), but was also present for males (from 36% in 2011 to 33% in 2014). Similar patterns were present when we controlled for patient and provider characteristics or used alternative definitions of follow-through. Other positive predictors of timely follow-through included receipt of flu vaccine in the prior year and receipt of first HPV vaccine dose from an obstetrician/gynecologist.

CONCLUSIONS

HPV vaccine follow-through is low and has declined over time.

The Relationship of Health Beliefs with Information Sources and HPV Vaccine Acceptance among Young Adults in Korea

Despite the HPV vaccine&rsquo;s efficacy in preventing cervical cancer, its coverage rates among Asians are very low. To increase immunization coverage among these populations, understanding the psychological factors that affect HPV acceptability is critical. To this end, this study examined the relationships between multidimensional health beliefs and HPV vaccine acceptance, and what information sources effectively foster HPV vaccination-related health beliefs. Data were collected using a survey of 323 undergraduate students in Korea. Results showed that perceived susceptibility, perceived severity, perceived benefits, and perceived vaccine safety concerns predicted vaccine acceptance. Multiple dimensions of perceived barriers showed differing impacts on vaccine acceptance. In addition, interpersonal information sources were effective in boosting various health beliefs for HPV vaccination. The Internet also was effective in reducing social barriers, but the effects were opposite to those of social media. Theoretical and practical implications are discussed.

Patterns and correlates of cervical cancer screening initiation in a large integrated health care system

BACKGROUND

The latest 2012 US Preventive Services Task Force cervical cancer screening guidelines recommended screening initiation at age 21 years. Little is known about the cervical cancer screening initiation practices in the community and whether there are critical gaps with respect to adherence to current clinical guidelines. Despite an overall decline in cervical cancer incidence across women of all ages, the incidence rate has not declined among 24-25 year olds between 2000 (2.79 per 100,000) and 2013 (2.93 per 100,000). Thus, it is important to understand cervical cancer screening initiation in young women and how woman- and provider-level factors affect the timing of screening initiation to identify areas for improving cervical cancer prevention.

OBJECTIVE

We examined patterns and correlates of cervical cancer screening initiation among women turning age 21 years in a large community-based practice.

STUDY DESIGN

Female members of Kaiser Permanente Southern California who turned age 21 years (baseline) during 2013-2015 and had not previously received a Papanicolaou test were included. Cervical cancer screening initiation through October 2016 was captured using electronic health records. Incidence rate and cumulative incidence of screening initiation was calculated. Associations between patient and provider characteristics and screening initiation were evaluated using multivariable Cox models.

RESULTS

A total of 38,257 women were included and the Papanicolaou screening initiation rate was 44 per 100 person-years during the study period. Approximately 40% initiated screening within 1 year after turning age 21 years. In multivariable analyses, Asian/Pacific Islanders (hazard ratio, 0.91; confidence interval, 0.86-0.96 compared with non-Hispanic whites); Medicaid enrollees (hazard ratio, 0.90; confidence interval, 0.83, 0.97); those whose primary language is not English (hazard ratio, 0.71; confidence interval, 0.67, 0.75); those who have a historical inpatient visit, primary care physician in pediatrics, internal medicine, or another specialty compared with family practice; and have a male rather than female primary care physician (hazard ratio, 0.46; confidence interval, 0.36, 0.57) less often initiated screening. On the other hand, those who used other preventive services such as getting a human papilloma virus and influenza vaccination and those with a history of pregnancy, contraception use, and sexually transmitted infections more often had timely screening initiation.

CONCLUSION

Less than half of the women insured for preventative services initiated screening at age 21 years. Strategies to improve adherence to screening initiation guidelines should consider a tailored approach for at-risk subgroups and addressing initiation challenges associated with male physicians.

Healthcare providers' beliefs and attitudes regarding risk compensation following HPV vaccination

Background

Provider recommendation is a significant predictor of HPV vaccine uptake. Prior research suggests that concerns regarding risk compensation could cause some providers to hesitate recommending the HPV vaccine.

Methods

During 15–30 min semi-structured interviews in early 2015, 22 U.S. pediatric providers were asked about their beliefs regarding sexual risk compensation and cervical cancer screening following HPV vaccination. Providers were asked if these beliefs result in reservations recommending the vaccine. Interviews were audio-recorded, transcribed, and analyzed using inductive content analysis.

Results

None of the providers believed the HPV vaccine would result in risky sexual behavior. Half indicated it was better to start vaccination early, before sexual activity was a worry. Others noted that patients’ risky behavior decisions happen independently of vaccination. When providers were asked if they were concerned about decreased cervical cancer screening, half said they did not know and some stated they had never thought about it before. The main themes addressed were the significant time lapse between vaccination and screening and that women tend to get over-screened as opposed to under-screened.

Conclusion

Providers were generally in favor of HPV vaccination and do not perceive risk compensation as a barrier to HPV recommendation.

A systematic review of factors influencing human papillomavirus vaccination among immigrant parents in the United States

To critically appraise factors influencing human papillomavirus (HPV) vaccination among immigrant parents in the United States, a comprehensive search of electronic databases and reference lists was conducted. The findings from 22 articles were ordered based on a socioecological model. About 30% of children initiated and 14% completed a three-dose series. Correlates of HPV vaccine initiation rates included lack of information, concerns about vaccine safety and promiscuity, providers' recommendations, school mandates, financial issues, immigration laws, and living in disadvantaged neighborhoods. Upstream initiatives embracing cultural descriptors could facilitate HPV vaccination, reducing HPV-related disparities in cancer among immigrants in the US.

Sexual Health Care Services among Young Adult Sexual Minority Women

Young adult sexual minority women (YSMW) are at elevated risk for negative reproductive health outcomes, yet are less likely than heterosexual peers to utilize preventive health care. Medical and public health policy organizations advocate sexual orientation disclosure ("coming out") to health care providers as a strategy for increasing service utilization among YSMW. Limited research explores relationships between disclosure and receipt of sexual health services. YSMW (N=285) ages 21-24 participated in an online survey assessing their health behaviors and care utilization. We employed multivariable logistic regression models to examine the association between receipt of sexual health services and sexual orientation disclosure to provider, after adjusting for sociodemographic covariates. Thirty-five percent of YSMW were out to their provider. Less than half the sample had received Pap screening or STI testing in the previous year; approximately 15% had received at least one dose of the HPV vaccination. Disclosure was associated with increased likelihood of Pap screening (OR=2.66, p<.001) and HPV vaccination (OR=4.30, p<.001), but was not significantly associated with STI testing. Promoting coming out to providers may be a promising approach to increase sexual health care use among YSMW. Future research should explore causal relationships between these factors.

HPV vaccination and risk of chronic fatigue syndrome/myalgic encephalomyelitis: A nationwide register-based study from Norway

BACKGROUND

Vaccination has been suggested to be involved in the aetiology of chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME). HPV vaccine was introduced in the Norwegian Childhood Immunisation Programme and offered 12year old girls from 2009. We studied the association between HPV vaccination and risk of CFS/ME and also assessed medical history in relation to both risk of CFS/ME and HPV vaccine uptake.

METHODS

Individual data from national registries, including the Norwegian Population Registry, the Norwegian Patient Registry and the Norwegian Immunisation Registry were linked using the unique personal identification number. Yearly incidence rates of CFS/ME for 2009-2014 were calculated among the 824,133 boys and girls, aged 10-17 living in Norway during these 6years. A total of 176,453 girls born 1997-2002 were eligible for HPV vaccination and included in further analyses. Hazard ratios (HRs) of CFS/ME were estimated using Cox regression. Risk differences (RDs) of vaccine uptake were estimated with binomial regression.

RESULTS

A similar yearly increase in incidence rate of CFS/ME was observed among girls and boys, IRR=1.15 (95% confidence interval (CI) 1.10-1.19) and 1.15 (95% CI 1.09-1.22), respectively. HPV vaccination was not associated with CFS/ME, HR=0.86 (95% CI 0.69-1.08) for the entire follow-up period and 0.96 (95% CI 0.64-1.43) for the first two years after vaccination. The risk of CFS/ME increased with increasing number of previous hospital contacts, HR=5.23 (95% CI 3.66-7.49) for 7 or more contacts as compared to no contacts. Girls with 7 or more hospital contacts were less likely to be vaccinated than girls with no previous hospital contacts, RD=-5.5% (95% CI -6.7% to -4.2%).

CONCLUSIONS

No indication of increased risk of CFS/ME following HPV vaccination was observed among girls in the first 6 birth cohorts offered HPV vaccine through the national immunisation programme in Norway.

Cervical cancer screening in the era of HPV vaccination: A review of shifting paradigms in cytopathology

Significant changes in cervical cancer screening practice, guidelines, and prevention of cervical cancer have taken place in recent years including the raising of initial cervical cancer screening age, changes in frequency of cytology screening, and the adoption of high risk HPV and cytology co-testing for some patients; the introduction of the bivalent, quadrivalent, and 9-valent HPV vaccines; and the recent approval of high risk HPV testing as primary screening with the use of cytology as triage in positive cases. This review discusses the significance of primary HPV screening, the impact of HPV vaccination in the prevalence of cervical cancer and its precursors, the interplay between high risk HPV testing and vaccination, and the implications for clinical and cytological management. Future strategies for cervical screening in the post-vaccination era are also discussed.

A Population-Based Study of Sociodemographic and Geographic Variation in HPV Vaccination

Background: Human papillomavirus (HPV) vaccination rates in the United States remain low and lag behind other recommended adolescent vaccines. Studies evaluating the association of geographic and area-level characteristics with HPV vaccination rates provide a valuable resource for public health planning.Method: We used the Rochester Epidemiology Project data linkage system to ascertain HPV vaccination rates between 2010 and 2015 in a 7-county region of southern Minnesota. Geocoded individual patient data were spatially linked to socioeconomic data from the American Community Survey at the census block group level. Bayesian hierarchical logistic regression was used to model incident vaccination rates, adjusting for individual- and area-level sociodemographic characteristics, and geolocation. Geolocation was modeled as an approximated Gaussian field using a Stochastic Partial Differential Equations approach. All models were estimated using Integrated Nested Laplace Approximations.Results: In adjusted models, increasing age and female sex were associated with increased HPV vaccination. Lower socioeconomic status was associated with decreased rates of initiation [adjusted odds ratio (AOR); 95% confidence interval = 0.90 (0.86-0.95)], completion of the second dose [AOR = 0.88 (0.83-0.93)], and completion of the third dose [AOR = 0.85 (0.80-0.92)]. Geographic spatial analysis demonstrated increased odds of vaccination for the eastern region and in the greater Rochester metropolitan area, showing significant spatial variation not explained by individual level characteristics and ACS block group-level data.Conclusions: HPV vaccination rates varied geographically and by individual and geographically indexed sociodemographic characteristics.Impact: Identifying geographic regions with low HPV vaccination rates can help target clinical and community efforts to improve vaccination rates. Cancer Epidemiol Biomarkers Prev; 26(4); 533-40. ©2017 AACRSee all the articles in this CEBP Focus section, "Geospatial Approaches to Cancer Control and Population Sciences."

Factors associated with parental reasons for "no-intent" to vaccinate female adolescents with human papillomavirus vaccine: National Immunization Survey - Teen 2008-2012

Background

1) To identify socio-demographic factors associated with parental “no-intent” for their 13–17 year old unvaccinated daughter to receive the human papillomavirus (HPV) vaccine series within the next twelve months, 2) to describe patterns in “no-intent” by socio-demographic factors, and 3) to identify socio-demographic factors associated with parental reasons for “no-intent”.

Methods

Data from 2008–2012 National Immunization Survey - Teen (NIS - Teen) were examined in this study. Parents with “no-intent” to vaccinate their daughters were asked to identify reasons for their decision. All responses were categorized into five domains identified as barriers to receive the HPV vaccine series: 1) Safety and Effectiveness Concerns; 2) Systemic Barriers; 3) Vaccine Misinformation; 4) Lack of Knowledge about the Vaccine; and 5) Socio-cultural Barriers. Multivariable logistic regression models were performed to address the study objectives.

Results

Number of people in the household, household income, mother’s age, education, health insurance, recommendation of a health care provider, and the survey year were significantly associated with parental “no-intent”. Race/ethnicity, mother’s education, marital status, recommendation of a health care provider, household income, age of the unvaccinated daughter, and the survey year, were significantly associated with one or more domains identified as barriers to receive the HPV vaccine.

Conclusions

This study identified sub-groups of parents across different socio-demographic factors with “no-intent” for their adolescent daughters to receive the HPV vaccine. Developing strategies that target educational tools towards the identified sub-groups of parents about the purpose, safety, and efficacy of the HPV vaccine, and HPV infection, may help increase HPV vaccine acceptance, initiation and completion rates.

Differences in Human Papillomavirus Vaccination Among Adolescent Girls in Metropolitan Versus Non-metropolitan Areas: Considering the Moderating Roles of Maternal Socioeconomic Status and Health Care Access

OBJECTIVES

This study is among the first to examine metropolitan status differences in human papillomavirus (HPV) vaccine initiation and completion among United States adolescent girls and is unique in its focus on how maternal socioeconomic status and health care access moderate metropolitan status differences in HPV vaccination.

METHODS

Using cross-sectional data from 3573 girls aged 12-17 in the U.S. from the 2008-2010 Behavioral Risk Factor Surveillance System, we estimate main and interaction effects from binary logistic regression models to identify subgroups of girls for which there are metropolitan versus non-metropolitan differences in HPV vaccination.

RESULTS

Overall 34 % of girls initiated vaccination, and 19 % completed all three shots. On average, there were no metropolitan status differences in vaccination odds. However, there were important subgroup differences. Among low-income girls and girls whose mothers did not complete high school, those in non-metropolitan areas had significantly higher probability of vaccine initiation than those in metropolitan areas. Among high-income girls and girls whose mothers completed college, those in metropolitan areas had significantly higher odds of vaccine initiation than those in non-metropolitan areas. Moreover, among girls whose mothers experienced a medical cost barrier, non-metropolitan girls were less likely to initiate vaccination compared to metropolitan girls.

CONCLUSIONS

Mothers remain essential targets for public health efforts to increase HPV vaccination and combat cervical cancer. Public health experts who study barriers to HPV vaccination and physicians who come into contact with mothers should be aware of group-specific barriers to vaccination and employ more tailored efforts to increase vaccination.

HPV vaccine completion and dose adherence among commercially insured females aged 9 through 26 years in the US

BACKGROUND

Although HPV vaccination has been recommended for use in girls and young women since 2007, HPV vaccine uptake is low in the US.

METHODS

We conducted a retrospective cohort study using the 2008-2011 MarketScan data to examine HPV vaccine completion and dose adherence among commercially insured females aged 9-26 years. We performed multivariable logistic regression models to examine factors related to HPV vaccine completion and HPV vaccine dose adherence.

RESULTS

Among 378,484 females aged 9-26 years who initiated HPV vaccination, only 29.4% completed HPV vaccination. Compared with females receiving vaccines from primary care providers, those receiving vaccines from OB/GYN providers were more likely to complete the vaccine series. Age at HPV vaccine initiation, health insurance plan, seasonal pattern, and flu vaccination were also significantly associated with vaccine completion. Among 111,286 females who completed HPV vaccination, 62.4% received all doses within 30 days of the recommended schedules. Similar factors relating to HPV vaccine completion were consistently associated with HPV vaccine dose adherence. However, younger age (<22 years) and receipt of flu vaccine were negatively related to HPV vaccine dose adherence.

CONCLUSIONS

Intervention programs to improve HPV vaccine reminding system and reduce logistic barriers for both physicians and patients are warranted.

Trends and predictors of HPV vaccination among U.S. College women and men

BACKGROUND

HPV vaccination was recommended by the Advisory Committee on Immunization Practices for young adult females in 2006 and males in 2011 to prevent HPV-related cancers and genital warts. As this prevention mechanism continues to disseminate, it is necessary to monitor the uptake of this vaccine. College students represent an important population for HPV vaccination efforts and surveillance due to increased risk for HPV infection and representing a priority population for catch-up HPV vaccination. The purpose of this study was to assess the trends in HPV vaccination among U.S. college females and males from 2009 to 2013, and to examine whether predictors for HPV vaccination differ between males and females.

METHODS

The National College Health Assessment-II (Fall 2009-2013) was used to assess trends in HPV vaccination using hierarchical logistic regression across genders and demographics. Data from 2013 were used to assess demographic variables associated with HPV vaccination for males and females, respectively. The analysis was conducted in 2015.

RESULTS

Females had nearly double the rates of HPV vaccination compared to males over time. All demographic sub-groups had significant increases in vaccine rates over time, with select male sub-groups having more accelerated increases (e.g., gay). Young age (18-21 vs. 22-26years) was a significant predictor for HPV vaccination among males and females, while race/ethnicity was a predictor of vaccination among females only.

CONCLUSIONS

These findings identified specific demographic sub-groups that need continued support for HPV vaccination. Campus health centers may be rational settings to facilitate clinical opportunities for HPV vaccination among unvaccinated college students.

Knowledge about Human Papillomavirus and Time to Complete Vaccination among Vulnerable Female Youth

OBJECTIVE

To examine the association of knowledge about human papillomavirus (HPV) on the time to completion of the 3-dose quadrivalent vaccine series in an inner-city population of adolescent female subjects at high risk for infection.

STUDY DESIGN

We prospectively followed 139 female subjects aged 14-20 years enrolled in a vaccine surveillance study in New York City during a period of at least 24 months. Participants were given a 30-item true or false survey on HPV at enrollment and ranked according to the number of correct responses. Multivariate Cox regression was used to examine the association between level of knowledge about HPV and time to completion (in days) of vaccine dose 1-3, dose 1-2, and dose 2-3.

RESULTS

Overall time to completion of the 3-dose vaccine ranged from 158 days to 1114 days. Participants in the high knowledge group (top quartile) were significantly more likely to complete the 3-dose series earlier (hazard ratio 1.69, 95% CI 1.03-2.77; P = .04), in particular doses 2-3 (hazard ratio 1.71, 95% CI 1.02-2.89; P = .04), than those with low-to-moderate knowledge (bottom 3 quartiles).

CONCLUSIONS

These findings suggest that knowledge of HPV is associated with shorter time to complete the 3-dose HPV vaccine series. Educational campaigns at time of vaccination may be important to improve vaccine adherence.

Sex of Sexual Partners and Human Papillomavirus Vaccination Among U.S. Girls and Women

INTRODUCTION

Girls and women are at risk of human papillomavirus (HPV) infection and cervical cancer from male and female sexual partners throughout the life course. However, no study has assessed how sex of sexual partners, a dimension of sexual orientation, may relate to HPV vaccination among girls and women.

METHODS

In 2014, data from the 2006-2010 National Survey of Family Growth were used to conduct logistic regression analyses estimating the relationship between sex of lifetime and past-year sexual partners and HPV vaccine awareness and initiation among U.S. girls and women aged 15-25 years (N=3,253).

RESULTS

Among U.S. girls and women aged 15-25 years, the prevalence of HPV vaccine awareness and HPV vaccine initiation was 84.4% and 28.5%, respectively. Adjusting for sociodemographic factors, participants with only female past-year sexual partners had significantly lower odds of initiating HPV vaccination relative to those with only male past-year sexual partners (OR=0.16, 95% CI=0.05, 0.55). Similarly, respondents with no lifetime (OR=0.65, 95% CI=0.46, 0.92) or past-year (OR=0.69, 95% CI=0.50, 0.94) sexual partners had significantly lower adjusted odds of HPV vaccine initiation compared with those with only male sexual partners. No difference was apparent in the odds of initiating HPV vaccination between participants with male and female sexual partners and those with only male sexual partners.

CONCLUSIONS

Medical and public health professionals should ensure that girls and women with only female or no sexual partners are included in HPV vaccine education and promotion efforts.

Factors influencing completion of multi-dose vaccine schedules in adolescents: a systematic review

BACKGROUND

Completion of multiple dose vaccine schedules is crucial to ensure a protective immune response, and maximise vaccine cost-effectiveness. While barriers and facilitators to vaccine uptake have recently been reviewed, there is no comprehensive review of factors influencing subsequent adherence or completion, which is key to achieving vaccine effectiveness. This study identifies and summarises the literature on factors affecting completion of multi-dose vaccine schedules by adolescents.

METHODS

Ten online databases and four websites were searched (February 2014). Studies with analysis of factors predicting completion of multi-dose vaccines were included. Study participants within 9-19 years of age were included in the review. The defined outcome was completion of the vaccine series within 1 year among those who received the first dose.

RESULTS

Overall, 6159 abstracts were screened, and 502 full texts were reviewed. Sixty one studies were eligible for this review. All except two were set in high-income countries. Included studies evaluated human papillomavirus vaccine, hepatitis A, hepatitis B, and varicella vaccines. Reported vaccine completion rates, among those who initiated vaccination, ranged from 27% to over 90%. Minority racial or ethnic groups and inadequate health insurance coverage were risk factors for low completion, irrespective of initiation rates. Parental healthcare seeking behaviour was positively associated with completion. Vaccine delivery in schools was associated with higher completion than delivery in the community or health facilities. Gender, prior healthcare use and socio-economic status rarely remained significant risks or protective factors in multivariate analysis.

CONCLUSIONS

Almost all studies investigating factors affecting completion have been carried out in developed countries and investigate a limited range of variables. Increased understanding of barriers to completion in adolescents will be invaluable to future new vaccine introductions and the further development of an adolescent health platform. PROSPERO reg# CRD42014006765.

Differences in HPV Immunization Levels Among Young Adults in Various Regions of the United States

HPV vaccine uptake in young adult women in the Southern US has been previously found to be the lowest in the country. In addition, geographic variation with regard to HPV vaccination among young adult men has not been investigated yet. The objective of this study was to use the most recent data to determine if inequality still exists. We used Behavioral Risk Factor Surveillance System 2012 data from 8 states (no data available from Midwest) to examine the geographic variations in weighted proportion of adults who initiated (≥ 1 dose) and completed (3 doses) the HPV vaccine among 3727 young adults (2014 women and 1713 men) 18-26 years old based on self-reported HPV vaccination and socio-demographic characteristics. The weighted vaccine initiation and completion rates among men were: 6.3 and 1.7% overall, 8.5 and 2.2% in the Northeast, 6.7 and 1.6% in the West, and 4.9 and 1.4% in the South (p = 0.184 and 0.774). The rates among women were: 40.4% and 27.4, 58.7 and 45.6%, 39.0 and 24.8%, and 30.4 and 17.7% in the respective regions (p < 0.001 for both). Adjusted multivariable logistic regression showed that women living in the South and West were less likely to initiate and complete the 3-dose HPV vaccine series when compared to those in the Northeast. Despite an increase in HPV vaccine uptake among young adult women in all regions, geographic disparity still exists. Moreover, young adult men had very low HPV vaccine initiation and completion rates throughout the US.

HPV Vaccination Completion and Compliance with Recommended Dosing Intervals Among Female and Male Adolescents in an Inner-City Community Health Center

Human papillomavirus (HPV) vaccination continues to lag behind other adolescent vaccines, especially in areas with pervasive disparities in HPV-related cancers. The purpose of this study was to examine HPV vaccine completion and dosing intervals among low-income adolescents in urban areas. The study included electronic health record data on HPV vaccination for 872 adolescents who received at least one dose of the HPV vaccine. Only 28.4% completed the 3-dose series. For the whole sample, HPV vaccine completion was higher for non-English speakers and among adolescents seen at Newark-South and East Orange sites. Completion was higher among non-English speaking female and Hispanic adolescents, females seen in Newark-South and East Orange sites, and insured Black adolescents. Completion was also dramatically lower among non-English speaking Black adolescents seen at Newark-North, Irvington, and Orange sites (12.5%) compared to other Black adolescents (22.0-44.4%). The mean dosing intervals were 5.5 months (SD = 4.6) between dose 1 and 2 and 10 months (SD = 6.1) between dose 1 and 3. Longer durations between vaccine doses were found among uninsured adolescents and those seen at Newark-North, Irvington, and Orange sites. Non-English speakers had longer duration between dose 1 and 3. Further, durations between dose 1 and 3 were dramatically longer among insured adolescents seen at Newark-North, Irvington, and Orange locations for the whole sample (M = 11.70; SD = 7.12) and among Hispanic adolescents (M = 13.45; SD = 8.54). Understanding how the study predictors facilitate or impede HPV vaccination is critical to reducing disparities in cervical and other HPV-related cancer, especially among Black, Hispanic, and low-income populations.

Geographic Factors and Human Papillomavirus (HPV) Vaccination Initiation among Adolescent Girls in the United States

BACKGROUND

This study is among the first to explore geographic factors that may be associated with human papillomavirus (HPV) vaccine uptake in the United States.

METHODS

Data from the 2011 and 2012 National Immunization Survey-Teen for 20,565 female adolescents aged 13 to 17 years were analyzed to examine associations of HPV vaccine initiation (receipt of at least one dose) with ZIP code-level geographic factors. Logistic regression including individual and geographic factors was used to estimate the odds of HPV vaccine initiation.

RESULTS

Approximately 53% of girls initiated the HPV vaccine in both years. Girls in high poverty communities had higher HPV vaccine initiation compared with those in low poverty communities [61.1% vs. 52.4%; adjusted OR (AOR), 1.18; 95% confidence intervals (CI), 1.04-1.33]. Initiation was higher among girls in communities where the majority of the population was Hispanic (69.0% vs. 49.9%; AOR, 1.64; 95% CI, 1.43-1.87) or non-Hispanic mixed race (60.4% vs. 49.9%; AOR, 1.30; 95% CI, 1.17-1.44) compared with majority non-Hispanic white communities. Interactions between individual-level race/ethnicity and community racial-ethnic composition indicated significantly higher odds of initiation among Hispanic girls living in Hispanic communities compared with Hispanic girls living in predominantly non-Hispanic White (NHW) (AOR, 2.23; 95% CI, 1.87-2.65) or non-Hispanic Black (NHB) (AOR, 1.90; 95% CI, 1.20-3.04) communities, respectively.

CONCLUSION

Initiation rates of HPV vaccination among teen girls were highest in the poorest communities and among Hispanics living in communities where the racial-ethnic composition was predominantly Hispanic or mixed race.

IMPACT

Given low HPV vaccination rates in the United States, these results provide important evidence to inform public health interventions to increase HPV vaccination.

Geospatial patterns of human papillomavirus vaccine uptake in Minnesota

OBJECTIVES

To identify factors associated with human papillomavirus (HPV) vaccination and to determine the geographic distribution of vaccine uptake while accounting for spatial autocorrelation.

DESIGN

This study is cross-sectional in design using data collected via the Internet from the Survey of Minnesotans About Screening and HPV study.

SETTING AND PARTICIPANTS

The sample consists of 760 individuals aged 18-30 years nested within 99 ZIP codes surrounding the downtown area of Minneapolis, Minnesota.

RESULTS

In all, 46.2% of participants had received ≥ 1 dose of HPV vaccine (67.7% of women and 13.0% of men). Prevalence of HPV vaccination was found to exhibit strong spatial dependence ([Formula: see text] = 0.9951) across ZIP codes. Accounting for spatial dependence, age (OR=0.76, 95% CI 0.70 to 0.83) and male gender (OR=0.04, 95% CI 0.03 to 0.07) were negatively associated with vaccination, while liberal political preferences (OR=4.31, 95% CI 2.32 to 8.01), and college education (OR=2.58, 95% CI 1.14 to 5.83) were found to be positively associated with HPV vaccination.

CONCLUSIONS

Strong spatial dependence and heterogeneity of HPV vaccination prevalence were found across ZIP codes, indicating that spatial statistical models are needed to accurately identify and estimate factors associated with vaccine uptake across geographic units. This study also underscores the need for more detailed data collected at local levels (eg, ZIP code), as patterns of HPV vaccine receipt were found to differ significantly from aggregated state and national patterns. Future work is needed to further pinpoint areas with the greatest disparities in HPV vaccination and how to then access these populations to improve vaccine uptake.

A feminist information engagement framework for gynecological cancer patients

Purpose

– The purpose of this paper is to present a three-part framework of information engagement for situated gynecological cancers. These particular cancers intertwine with medicalization of sexuality and gender power dynamics, situating information behaviors and interactions in women’s socio-health perceptions. Using Kavanagh and Broom’s feminist risk framework, the framework establishes functional and temporal parameters for sense-making and information engagement.

Design/methodology/approach

– This paper employs a structured, reiterative literature review with emergent thematic analysis. Nine indices from medicine, information studies, and sociology were searched using combinations of five terms on cervical cancer (CC) and 14 terms on information engagement in the title, abstract, and subject fields. Results were examined on a reiterative basis to identify emergent themes pertaining to knowledge development and information interactions.

Findings

– Environmentally, social stigma and gender roles inhibit information seeking; normalizing CC helps integrate medical, moral, and sexual information. Internally, living with the dichotomy between “having” a body and “being” a body requires high-trust information resources that are presented gradually. Actively, choosing to make or cede medical decision-making requires personally relevant information delivered in the form of concrete facts and explanations.

Research limitations/implications

– The study covers only one country.

Originality/value

– This study’s information framework and suggestions for future research encourage consideration of gender power dynamics, medicalization of sexuality, and autonomy in women’s health information interactions.

Initiation of Human Papillomavirus Vaccination Among Predominantly Minority Female and Male Adolescents at Inner-City Community Health Centers

OBJECTIVES

We examined the prevalence and correlates of human papillomavirus (HPV) vaccine initiation among adolescents in low-income, urban areas.

METHODS

The study consisted of electronic health record data on HPV vaccination for 3180 adolescents (aged 10-20 years) at a multisite community health center in 2011.

RESULTS

Only 27% initiated the HPV vaccine. The adjusted odds ratio (AOR) of HPV vaccination was lower among older adolescents (AOR = 0.552; 95% confidence interval [CI] = 0.424, 0.718) and those seen by nonpediatric health care providers (HCPs; AOR = 0.311; 95% CI = 0.222, 0.435), and higher among non-English speakers (AOR = 1.409; 95% CI = 1.134, 1.751) and those seen at 2 site locations (AOR = 1.890; 95% CI = 1.547, 2.311). Insurance status was significant only among female and Hispanic adolescents. Language was not a predictor among Hispanic adolescents. Across all analyses, the interaction of age and HCP specialty was associated with HPV vaccination. Dramatically lower HPV vaccination rates were found among older adolescents seen by nonpediatric HCPs (3%-5%) than among other adolescents (23%-45%).

CONCLUSIONS

Improving HPV vaccination initiation in low-income urban areas is critical to reducing disparities in cervical and other HPV-related cancer, especially among Black, Hispanic, and low-income populations.

Impact of an Electronic Health Record (EHR) Reminder on Human Papillomavirus (HPV) Vaccine Initiation and Timely Completion

BACKGROUND

The initiation and timely completion of the human papillomavirus (HPV) vaccine in young women is critical. We compared the initiation and completion of the HPV vaccine among women in 2 community-based networks with electronic health records: 1 with a prompt and reminder system (prompted cohort) and 1 without (unprompted cohort).

METHODS

Female patients aged 9 to 26 years seen between March 1, 2007, and January 25, 2010, were used as the retrospective cohort. Patient demographics and vaccination dates were extracted from the electronic health records.

RESULTS

Patients eligible for the vaccine included 6019 from the prompted cohort and 9096 from the unprompted cohort. Mean age at initiation was 17.3 years in the prompted cohort and 18.1 years in the unprompted cohort. Significantly more (P < .001) patients initiated the vaccine in the prompted cohort (34.9%) compared with the unprompted cohort (21.5%). African Americans aged 9 to 18 years with ≥3 visits during the observation period were significantly more likely to initiate in the prompted cohort (P < .001). The prompted cohort was significantly more likely (P < .001) to complete the vaccine series in a timely manner compared with the unprompted cohort.

CONCLUSION

More patients aged 9 to 26 years initiated and achieved timely completion of the HPV vaccine series in clinics using an electronic health record system with prompts compared with clinics without prompts.

Direct messaging to parents/guardians to improve adolescent immunizations

PURPOSE

To study the impact on adolescent immunization rates of direct messages to parents/guardians.

METHODS

Electronic health record rules identified adolescents needing an immunization. Parents/guardians of adolescents were messaged via a single vendor using automated text, prerecorded voice, and/or postcard.

RESULTS

Parents/guardians of 3,393 patients, ages 11-18 years, with one or more primary care visits in the prior 2 years, identified as needing (average of 2.04 years) a vaccination (meningococcal conjugate, human papillomavirus, or tetanus, diphtheria, and pertussis vaccines) were messaged (mean age, 14 years; 50% male; 38% African-American; 23% white; 19% Hispanic; and 79% public health insurance). A total of 7,094 messages were sent: 3,334 automated voice (47%), 2,631 texts (37%), and 1,129 postcards (16%). After the first message, 865 adolescents (25.5%) received at least one vaccine. Within 24 weeks of messaging 1,324 vaccines (745 human papillomavirus; 403 meningococcal conjugate; and 176 tetanus, diphtheria, and pertussis vaccines) occurred in 959 visits (83.8% physician visits and 16.2% nurse visits). Average visits generated $204 gross reimbursement for $1.77 in messaging expenses per vaccine given. No differences in immunization completion rates occurred by age, gender, race/ethnicity, or insurance type. At 24 weeks, one message was more effective than two or three messages (35.6%, 19.4%, and 24.1% effectiveness, respectively; p < .0001). Texts and postcards correlated with more vaccination visits (38.8% and 40.1%, respectively) than phone calls (31.5%; p = .04). More vaccines due led to increasing message effectiveness.

CONCLUSIONS

Automated texts, voice messages, and postcards had a significant positive effect on vaccination rates in adolescents needing vaccination and required minimal financial expenditure.

Effective dual method contraceptive use and HPV vaccination among U.S. adolescent and young adult females

BACKGROUND

Problem Behavior Theory posits that risky behaviors cluster in individuals, implying that protective behaviors may follow a similar pattern. The purpose of this study was to determine whether the protective behavior of effective dual method contraception use at first and most recent sexual intercourse is associated with HPV vaccination among adolescent and young adult females.

METHODS

National Survey of Family Growth (2006-2010) data were used to examine the association between women's contraception use during first and most recent sexual intercourse and HPV vaccination. Women aged 15 to 24 years (n = 1,820) served as the study sample.

FINDINGS

At first and last sexual intercourse, effective dual method contraception use was reported by 15.3% and 16.8% women, respectively; 27.8% reported receiving at least one dose of the human papillomavirus (HPV) vaccine. Higher HPV vaccination rates were observed among dual method users at first and last sexual intercourse (36.4% and 48.2%, respectively). This trend was also observed across age groups (15-19 year olds vs. 20-24 year olds). In adjusted models, among all respondents, dual users at last sexual intercourse were significantly more likely to be vaccinated, whereas at first sexual intercourse only younger dual users were more likely to report HPV vaccination.

CONCLUSIONS

Findings suggest that the protective behavior of dual method contraceptive use at first and most recent sexual intercourse may serve as a predictor of another complementary health behavior, HPV vaccination, particularly among adolescent females. More research is needed to understand behavioral clustering to design related multi-focused women's health interventions.

Factors related to vaccine uptake by young adult women in the catch-up phase of the National HPV Vaccination Program in Australia: Results from an observational study

BACKGROUND

Australia commenced a publically-funded, National Human Papillomavirus (HPV) Vaccination Program in 2007 with a two year catch-up phase for females aged 12-26 years.

OBJECTIVE

To identify the factors associated with the uptake of the HPV vaccine (which has a recommended 3-dose schedule in Australia) by young adult women vaccinated by general practitioners and community-based programs within the catch-up phase.

METHODS

1139 women who were eligible to receive the free HPV vaccine during the catch-up period were recruited in 2008-2009 (age 20-29 years at recruitment), in New South Wales, after having a normal (negative) cervical smear result recorded on the NSW Pap Test Register. Participants completed a self-administered questionnaire providing information on vaccination status, and sociodemographic and other factors.

RESULTS

Overall, 880 (77%) women reported receiving ≥ 1 dose of the vaccine and 777 women (68%) reported receiving ≥ 2 doses. In multivariable analysis (adjusting for the period for which each woman was eligible for free HPV vaccination), uptake of ≥ 1 dose of the vaccine was significantly associated with being born in Australia (p < 0.01), being single (p = 0.02), being nulliparous (p < 0.01), living in a higher socioeconomic status area (p-trend = 0.03), living in more remote areas (p = 0.03), drinking alcohol (p < 0.01) and using hormonal contraceptives (p < 0.01). Although vaccinated women were more likely to have fewer sexual partners than unvaccinated women (p-trend = 0.02), they were also more likely to report a prior sexually transmitted infection (STI) (p = 0.03). Similar factors were associated with receiving ≥ 2 doses.

CONCLUSIONS

In this group, women living in higher socioeconomic status areas were more likely to be vaccinated against HPV in the catch-up phase of the national program. Although vaccinated women tended to have fewer sexual partners, they also reported prior STIs, which may be a marker of increased risk of prior exposure to HPV. The findings of this study reinforce the continuing need to prioritise equitable delivery of vaccination to various population subgroups.

Human papillomavirus vaccination of females in a large health claims database in the United States, 2006-2012

PURPOSE

Information on vaccine utilization from a variety of sources is useful to give a status of the vaccine program and define opportunities to improve uptake. We evaluated MarketScan Commercial Claims and Encounters database on human papillomavirus (HPV) vaccine initiation and completion of all three doses among girls/women from 2006 to 2012.

METHODS

Data were obtained from the 2006-2012 MarketScan Commercial Claims and Encounters database. The study population included female enrollees aged 11-26 years who were continuously enrolled in the same private insurance plan from 2006 to 2012 (n = 407,371). We evaluated overall and yearly vaccine initiation and completion, demographic characteristics associated with vaccine initiation, clinical visits in which vaccine was given, and missed opportunities for vaccination.

RESULTS

By the end of 2012, 36.9% of females aged 11-26 years had received at least one HPV vaccine dose. Vaccination coverage was highest among females aged 17-18 years (49.3%) and aged 15-16 years (43.1%) and lowest among females aged 11-12 years (16.8%). Between 2007 and 2012, 96.1% of the 246,192 unvaccinated females had at least one missed opportunity (a heath care visit without HPV vaccine administered).

CONCLUSIONS

Over a 6 year period, HPV vaccine initiation was lowest in the girls aged 11-12 years. Importantly, most (96.1%) unvaccinated females had at least one missed vaccination opportunity, and providers and health systems should focus efforts on using existing visits for vaccination.

Disparities in Human Papillomavirus Vaccine Literacy and Vaccine Completion Among Asian American Pacific Islander Undergraduates: Implications for Cancer Health Equity

PURPOSE

Low rates of human papillomavirus (HPV) vaccination among young Asian American and Pacific Islander (AAPI) women need to be addressed, particularly given the high incidence of cervical cancer in this population. The current study aims to investigate predictors of HPV vaccination in young AAPI and non-Latina white (NLW) women.

METHODS

A secondary data analysis was conducted of a health survey administered to college-aged women (N = 2,270) at a large public university in the Midwest. Andersen's behavioral model of health services utilization guided the study theoretically, and hierarchical logistic regression analysis was conducted to investigate research aim.

RESULTS

NLW women had a significantly higher rate of vaccine completion than AAPI women (NLW = 60.7%; AAPI = 38.6%). NLW women also scored higher on all 5 measures of HPV vaccine literacy than AAPI women. Both groups of undergraduate women reported that increasing age, knowledge about HPV, greater use of gynecological services, and knowing someone who had cancer were significant factors related to HPV vaccination completion. In the NLW group, father's income was also found to be a predictor of HPV vaccination completion.

CONCLUSIONS

Rate and predictors of HPV vaccination completion vary between NLW and AAPI women. Greater promotion of HPV literacy and gynecological service use should be made to young AAPI women to increase their HPV uptake. Further research should examine sociocultural factors that could hinder or promote HPV vaccination in young AAPI women.

Vaccinating sons against HPV: results from a U.S. national survey of parents

Purpose

The quadrivalent HPV vaccination was approved for use in males ages 9 to 26 in 2009 and recommended for routine administration in 2011. The purpose of this study was to uncover predictable commonalities amongst parents who chose to vaccinate their 11–17 year old sons against HPV.

Methods

We compiled data from a U.S. national sample of 779 parents with sons 11–17 years old using a web-based survey to gather information about behavioral and sociodemographic factors which predicted receipt of 1 or more HPV vaccine doses based on parental report. Predictors were first modeled individually for univariable associations. Significant predictors (p<0.10) were combined in a multivariable model.

Results

In the adjusted model, independent predictors included receipt of flu vaccination, health insurance coverage and sexual health topic discussions with sons. Sons who had received a flu shot in the last two years more frequently received at least one dose of the vaccine (OR 1.82; 95% CI 1.45–2.26). Sons covered by private health insurance had decreased odds of HPV vaccination (OR 0.56 95% CI 0.37–0.83). Lastly, parents who had discussed sexual health topics with their sons were more likely to vaccinate (OR 1.61; 95% CI 1.37–1.89).

Conclusions

Male vaccination rates in the U.S. have increased, but males continue to be under-immunized. Utilization of health care is an important factor in HPV vaccine uptake; therefore, health care providers should use every contact as an opportunity to vaccinate. Communication about sexual health topics may provide a forum for parents and health care providers to have conversations about HPV vaccination as those more comfortable discussing these topics may also be more comfortable discussing HPV vaccination.