Racial disparities in awareness of the human papillomavirus

An Assessment of Young Adults' Awareness and Knowledge Related to the Human Papillomavirus (HPV), Oropharyngeal Cancer, and the HPV Vaccine

BACKGROUND/OBJECTIVES

The human papillomavirus (HPV) is a prevalent sexually transmitted infection that is a known cause of morbidities such as genital warts and cancers of the cervix, anus, and oropharynx. Non-cervical HPV-related cancers have been a developing problem in North America, increasing in incidence by up to 225% in some instances over a span of two decades.

METHODS

This study investigated levels of awareness and knowledge of HPV, oropharyngeal cancer (OPC), and the HPV vaccine using a self-administered web-based survey designed specifically for this research. University students (n = 1005) aged 18-30 completed a 42-item questionnaire that included demographic information, awareness questions, and a series of "true/false/I don't know" knowledge questions.

RESULTS

The data gathered revealed that participants had relatively high levels of awareness. However, many respondents had significant gaps in their knowledge of HPV, OPC, and the HPV vaccine. Collectively, the data indicate that awareness and knowledge of HPV and the value of vaccination may place younger individuals at risk for HPV-related infections.

CONCLUSIONS

Although a relatively high level of awareness concerning HPV was observed, the gaps in knowledge suggest that further efforts are necessary to educate young adults. While all risk factors cannot be reduced, the present data may guide future efforts directed toward better education on HPV and related health concerns and associated risks.

Comparison of Treatment for Recurrent Respiratory Papillomatosis at a Public County Versus Private Academic Hospital

OBJECTIVE

To compare patient, disease and treatment characteristics of patients treated for recurrent respiratory papillomatosis (RRP) at a public county versus a private hospital.

METHODS

A retrospective cohort study was conducted of adult patients undergoing treatment for RRP at a tertiary-care academic center (TAC, n = 48) versus public safety net hospital (PSNH, n = 14), both staffed by the same Otolaryngology providers.

RESULTS

There was no difference between cohorts in age, gender, medical comorbidities, history of juvenile-onset presentation, or history of prior treatment at a different institution. PSNH patients were more likely to be Hispanic/Latino, primarily speak Spanish, have public or no insurance, and reside in a zip code with lower median income compared with TAC patients. Despite living significantly closer to the hospital, PSNH patients were more likely than TAC patients to present with respiratory symptoms (50% versus 20.8%, P = 0.04), and exhibit more than one involved laryngeal subsite at their first surgical intervention (78.6% versus 27.1%, P = 0.001). They also had high rates of referral for otolaryngologic care via the emergency department (42.9%) rather than outpatient specialty referral (35.7%) and were more likely than TAC patients to require urgent intervention (21.4% versus 2.1%, P = 0.03). There was no difference in time interval from first clinic visit to procedure date or total number of treatments.

CONCLUSIONS

PSNH patients present with more severe and symptomatic RRP disease compared with TAC patients. This finding may be related to sociodemographic disparities leading to poorer access in care.

HPV vaccine delay and refusal among unvaccinated Mexican American young adult women: a qualitative investigation of Mexican-born and US-born HPV vaccine decision narratives

Low HPV vaccination rates among Latina young adults perpetuate HPV-associated cancer disparities. Using qualitative methods, this study explored individual, interpersonal, and community factors that influence HPV vaccine delay and refusal among Mexican- and U.S.-born Mexican American young adult women. Participants (N = 30) between 18 and 26 years old were purposively sampled from two federally qualified health centers in Orange County, California. The National Institute on Minority Health and Health Disparities research framework and narrative engagement theory guided semi-structured phone interviews coded inductively and deductively. Participants primarily attributed vaccine status to individual and interpersonal reasons. Emerging themes included low HPV vaccine knowledge, insufficient provider communication, negative perceptions about HPV and the vaccine, motherhood responsibilities, mother's communication about HPV, cultural family norms, health care access, and misinformation. Compared to U.S.-born Latinas, Mexican-born participants more frequently expressed avoiding health care discussions with family. HPV vaccine recommendations for young Mexican American women should include socioculturally tailored messages that may improve HPV vaccination acceptance and uptake.

Racial and Ethnic Disparities in Adult Vaccination: A Review of the State of Evidence

Background

Adult vaccination coverage remains low in the United States, particularly among racial and ethnic minority populations.

Objective

To conduct a comprehensive literature review of research studies assessing racial and ethnic disparities in adult vaccination.

Search Methods

We conducted a search of PubMed, Cochrane Library, ClinicalTrials.gov, and reference lists of relevant articles.

Selection Criteria

Research studies were eligible for inclusion if they met the following criteria: (1) study based in the United States, (2) evaluated receipt of routine immunizations in adult populations, (3) used within-study comparison of race/ethnic groups, and (4) eligible for at least one author-defined PICO (patient, intervention, comparison, and outcome) question.

Data Collection and Analysis

Preliminary abstract review was conducted by two authors. Following complete abstraction of articles using a standardized template, abstraction notes and determinations were reviewed by all authors; disagreements regarding article inclusion/exclusion were resolved by majority rule. The Social Ecological Model framework was used to complete a narrative review of observational studies to summarize factors associated with disparities; a systematic review was used to evaluate eligible intervention studies.

Results

Ninety-five studies were included in the final analysis and summarized qualitatively within two main topic areas: (1) factors associated with documented racial-ethnic disparities in adult vaccination and (2) interventions aimed to reduce disparities or to improve vaccination coverage among racial-ethnic minority groups. Of the 12 included intervention studies, only 3 studies provided direct evidence and were of Level II, fair quality; the remaining 9 studies met the criteria for indirect evidence (Level I or II, fair or poor quality).

Conclusions

A considerable amount of observational research evaluating factors associated with racial and ethnic disparities in adult vaccination is available. However, intervention studies aimed at reducing these disparities are limited, are of poor quality, and insufficiently address known reasons for low vaccination uptake among racial and ethnic minority adults.

A Systematic Review Exploring Racial Disparities, Social Determinants of Health, and Sexually Transmitted Infections in Black Women

OBJECTIVE

To explore and describe racial disparities, the role of social determinants of health, and individual risk behaviors among Black women as related to sexual health and/or sexually transmitted infections (STIs).

DATA SOURCES

Electronic resource databases used were PubMed, CINAHL, and Google Scholar. Peer-reviewed articles published during 2010 to 2020 were considered.

STUDY SELECTION

Thirty-two studies met the criteria and included data for a total of 18,904 Black women.

DATA EXTRACTION

Data were extracted from each study using the subheadings author (year), purpose, design, sample demographics and setting, key measures, key findings, and quality assessment. In addition, PRISMA-E and PROGRESS-Plus guided data extraction to illustrate health inequity.

DATA SYNTHESIS

Black women who were more likely to report having an STI over the course of their lifetime engaged in behaviors associated with greater risk, the most common of which were unprotected sex, disproportionate partner power, and substance abuse. The primary social determinants of health associated with increased risk were lower income and lower levels of education. Black women were less likely to discuss or feel comfortable discussing their sexual health with health care providers. By contrast, engagement in safe sexual practices stemmed from internal, social, and relationship factors.

CONCLUSION

Identifying Black women who are at risk of contracting an STI is essential in driving clinical decision-making. Health care providers should be cognizant of the long-standing mistrust that Black women have of health care providers and, therefore, work to establish positive respectful and trusting relationships with open communication.

Health Disparities Associated with Females Reporting Human Papillomavirus Infection in the United States

Few studies provide detailed findings about the health disparities of women being told by a physician whether they have ever had a human papillomavirus (HPV) infection. This study sought to characterize the prevalence and characteristics associated with women age 18 to 59 years in the United States who report being told they were infected with HPV. This study used data from the National Health and Nutritional Examination Survey. Descriptive statistics were computed on study variables and multiple logistic regression analyses were conducted to explore the association of the study variables with the outcome variable. Sampling weights were applied to produce national estimates of prevalence. The sample consisted of 1,669 females, representative of 75,107,170 females in the United States population. Around 11.5% reported being told that they had an HPV infection, of which 60.9% were White, and 82.9% were born in the United States. White women are 2.0 times more likely to be told they have HPV than Asian women and 2.8 times more likely than Black women. United States-born women were 2.1 times more likely told they had an HPV infection than those foreign born. This study found that among U.S. women, less than 12% reported ever having been told they have had an HPV infection. Epidemiologic findings suggest gaps between ever being told of a previous infection and being diagnosed with a clinically relevant HPV infection. Despite epidemiologic data indicating higher HPV prevalence among those less educated and women of color, these groups were less likely to report ever being told they have an HPV infection than White women, and those with a college degree suggesting communication gaps among these subgroups about HPV infection that might exist. Strategies to address potential gaps in communication among these subgroups can potentially reduce the economic burden and health disparities related to HPV infection.

The Role of English Proficiency in HPV and HPV Vaccine Awareness: A Cross-Sectional Study Across Race/Ethnicity

Objective:

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States and associated with over 90% of cervical cancer cases. The present study aimed to examine levels of HPV and HPV vaccine awareness and associated factors, particularly English proficiency, across various racial/ethnic groups.

Methods:

Two cross-sectional datasets, 2017 and 2018 Health Information National Trends Survey (HINTs), were analyzed for the current study. Binary logistic regression analyses were conducted.

Findings:

Non-Hispanic Whites had the highest levels while non-Hispanic Asians had the lowest levels of awareness regarding HPV and the HPV vaccine. English proficiency was significantly associated with increased HPV awareness among all groups except non-Hispanic Asian, and was significantly associated with greater HPV vaccine awareness in all groups.

Discussion:

In order to promote health equity across race/ethnicity, language barriers among minorities should be addressed when implementing health education on HPV and the HPV vaccine.

Family factors associated with emerging adults' human papillomavirus vaccine behavior

Objective: The current study examined the role of family influences on the vaccine behavior of emerging adults. Participants: In Spring 2017, we conducted anonymous online surveys of undergraduate students (n = 608) at a large, public university in the mid-Atlantic. Methods: Logistic regression was used to examine associations between family factors and students' awareness of the HPV vaccine, vaccine receipt, and vaccine intentions. Family factors included sex communication, religiosity, parental monitoring, family structure, and parents' birthplace. Results: More comprehensive family sex communication is associated with less uncertainty regarding HPV vaccine receipt and greater likelihood of being already vaccinated. More frequent family religiosity and more parental monitoring are associated with greater likelihood of having decided against vaccination rather than already being vaccinated. Significant gender and racial disparities exist. Conclusion: Further research, policy, and programmatic intervention are needed to reduce disparities and to improve emerging adults' compliance with HPV vaccine recommendations.

Human Papillomavirus Awareness, Vaccine Status, and Risk Factors in Female Emergency Patients

Introduction

A vaccine targeting high-risk human papillomavirus (HPV) strains can effectively prevent HPV-associated cervical cancer risk. However, many girls and women do not receive the vaccine, more often those impacted by health disparities associated with race and/or socioeconomic status. This same disparate population has also been shown to be at higher risk for cervical cancer. Many of these women also rely on the emergency department (ED) as a safety net for their healthcare. This study sought to gather information pertaining to HPV and cervical cancer risk factors, awareness of HPV and the vaccine, as well as HPV vaccine uptake in female patients presenting to an ED.

Methods

We obtained 81 surveys completed by female ED patients. Demographics included age, race, income, insurance status, primary care provider status, and known cervical-cancer risk factors. Subsequent survey questions explored respondents’ knowledge, familiarity, and attitudes regarding HPV, cervical cancer, and the HPV vaccine, including vaccination uptake rates. We analyzed data using descriptive statistics and Fisher’s exact test.

Results

Approximately one in seven respondents (14.8%) had never previously heard of HPV and 32.1% were unaware of the existence of a HPV vaccine. Minority patients, including those who were Black and Hispanic patients, low income patients, and uninsured and publicly insured patients were less likely to be aware of HPV and the vaccine and likewise were less likely to be offered and receive the vaccine. More than 60% of all respondents (61.3%) had never previously been offered the vaccine, and only 24.7% of all respondents had completed the vaccine series.

Conclusion

Female ED patients may represent an at-risk cohort with relatively low HPV awareness and low HPV vaccine uptake. The ED could represent a novel opportunity to access and engage high-risk HPV populations.

Knowledge of HPV and acceptability of HPV vaccine among women in western China: a cross-sectional survey

BACKGROUND

Since most cervical cancer cases are caused by persistent high-risk human papillomavirus (HR-HPV) infection, knowledge of HPV among women is essential for the prevent of cervical cancer. This study was aimed to assess knowledge among women in western China about HPV and its association with cervical cancer, and to assess their acceptance of HPV vaccination.

METHODS

A sample of healthy women undergoing routine physical examinations in the Health Management Center of West China Hospital, Sichuan University between January and December 2014 completed a questionnaire.

RESULTS

A total of 1300 questionnaires were distributed, and 1109 were completed and analyzed. Only 28.85% of respondents (n = 320) had heard of HPV; among this subgroup, only half (53.44%) knew that it causes cervical cancer, only 26 (8.13%) correctly answered all questions about HPV. Multivariate analysis showed that respondents who had heard of HPV were more likely than other respondents to have a family history of any cancer, to undergo regular Pap tests and to have completed at least secondary education. Half of all respondents (51.22%) reported that they would be willing to be vaccinated against HPV.

CONCLUSION

Although most women in western China lack basic knowledge about HPV, at least half are willing to take the HPV vaccine. Public health efforts to educate the public about HPV and its connection to cervical cancer should be strengthened and expanded.

The Ethical Case for Mandating HPV Vaccination

When the HPV vaccine was released over a decade ago, there was intense opposition to mandating the vaccine, including among bioethics and legal scholars. Some of the original concerns are now obsolete, while other objections continue to present an obstacle to mandating the vaccine. This essay responds to earlier critiques of mandatory HPV vaccination and offers a series of arguments in support of a vaccine mandate. The first section briefly addresses initial concerns that are no longer relevant. The second section makes the ethical case for mandating HPV vaccination, based on three principles: 1) the best interests of children, 2) solidarity, and 3) health equity. The final section addresses concerns related to implementation of the vaccine, including the validity of linking vaccination to school entry. The essay concludes that we have a moral imperative to protect children from the leading cause of cervical cancer, and that mandating HPV vaccination is the best way to ensure that children of all backgrounds receive the vaccine before they have been exposed to the virus.

Knowledge of influenza vaccination recommendation and early vaccination uptake during the 2015-16 season among adults aged ≥18years - United States

BACKGROUND

Since 2010, the Advisory Committee on Immunization Practices (ACIP) has recommended that all persons aged ≥6months receive annual influenza vaccination.

METHODS

We analyzed data from the 2015 National Internet Flu Survey (NIFS), to assess knowledge and awareness of the influenza vaccination recommendation and early influenza vaccination coverage during the 2015-16 season among adults. Predictive marginals from a multivariable logistic regression model were used to identify factors independently associated with adults' knowledge and awareness of the vaccination recommendation and early vaccine uptake during the 2015-16 influenza season.

RESULTS

Among the 3301 respondents aged ≥18years, 19.6% indicated knowing that influenza vaccination is recommended for all persons aged ≥6months. Of respondents, 62.3% indicated awareness that there was a recommendation for influenza vaccination, but did not indicate correct knowledge of the recommended age group. Overall, 39.9% of adults aged ≥18years reported having an influenza vaccination. Age 65years and older, being female, having a college or higher education, not being in work force, having annual household income ≥$75,000, reporting having received an influenza vaccination early in the 2015-16 season, having children aged ≤17years in the household, and having high-risk conditions were independently associated with a higher correct knowledge of the influenza vaccination recommendation.

CONCLUSIONS

Approximately 1 in 5 had correct knowledge of the recommendation that all persons aged ≥6months should receive an influenza vaccination annually, with some socio-economic groups being even less aware. Clinic based education in combination with strategies known to increase uptake of recommended vaccines, such as patient reminder/recall systems and other healthcare system-based interventions are needed to improve vaccination, which could also improve awareness.

Factors Associated With Parents' Intent to Vaccinate Adolescents for Human Papillomavirus: Findings From the 2014 National Immunization Survey-Teen

Introduction

While factors associated with receipt of human papillomavirus (HPV) vaccination have been well characterized, less is known about the characteristics associated with parents’ intent to have their adolescent children vaccinated. This study aimed to examine factors associated with parental intention toward HPV vaccination.

Methods

We analyzed data on 10,354 adolescents aged 13 to 17 years from the 2014 National Immunization Survey–Teen. Weighted multivariable logistic regression was used to examine associations between sociodemographic characteristics of mothers and adolescents, as well as a health care provider recommendation with parents’ intention to have their children receive HPV vaccine.

Results

Among unvaccinated adolescents, Hispanic ethnicity (boys adjusted odds ratio [AOR], 1.87, 95% confidence interval [CI], 1.34–2.61; and girls AOR, 1.57; 95% CI, 1.05–2.35), mothers with less than a high school diploma (boys AOR, 2.41; 95% CI, 1.58–3.67; and girls AOR, 1.86; 95% CI, 1.02–3.38), and having a health care provider recommend the vaccine (boys AOR, 1.87; 95% CI, 1.52–2.31; and girls AOR, 1.38; 95% CI, 1.05–1.82) were significantly associated with parents’ intention to have their adolescent child vaccinated within the next 12 months. In addition, non-Hispanic black race was a significant predictor of parents’ intent to vaccinate for boys (AOR, 1.89; 95% CI, 1.35–2.65).

Conclusion

Maternal education and Hispanic ethnicity were the strongest predictors of parental intent to vaccinate against HPV, followed by provider recommendation. As HPV vaccination rates in the United States remain below the Healthy People 2020 goal, messages may need to be targeted based on maternal education, race/ethnicity, and provider recommendation.

Not just a woman's business! Understanding men and women's knowledge of HPV, the HPV vaccine, and HPV-associated cancers

Few studies have included men when assessing differences in knowledge about HPV, and HPV-associated cancers. We examined gender differences in knowledge about HPV, HPV vaccine, and HPV-associated cancers. Multivariable logistic regression models were used to analyze data of 3,677 survey respondents aged 18 years and older from the 2014 Health Information National Trends Survey. Covariates included age, race/ethnicity, marital status, education, income level, regular provider, general health, internet use, and family structure aged 9 to 27 years. Analyses were conducted in 2015. Sixty-four percent of respondents had heard of HPV and the HPV vaccine. Seventy-eight percent of respondents knew HPV causes cervical cancer, but only 29% knew it causes penile cancer, 26% knew it causes anal cancer, and 30% knew it causes oral cancer. In multivariable analyses, males were less likely to have heard of HPV (aOR: 0.33; 95% CI: 0.25-0.45), and less likely to have heard of the HPV vaccine (aOR: 0.24; 95% CI: 0.18-0.32) compared to females. No differences existed between males and females regarding knowledge about HPV-associated cancers. In conclusion, knowledge of HPV, the vaccine, and HPV-associated cancers in both males and females in the United States remains very low, especially among men.

Sexual Orientation Disparities in Human Papillomavirus Vaccination in a Longitudinal Cohort of U.S. Males and Females

PURPOSE

This study sought to examine how human papillomavirus (HPV) vaccination may differ across sexual orientation groups (e.g., bisexuals compared to heterosexuals)-particularly in boys and men, about whom little is known.

METHODS

Data were from a prospective cohort of 10,663 U.S. females and males enrolled in the Growing Up Today Study followed from 1996 to 2014. Participants were aged 11-24 years when the vaccine was approved for females in 2006 and 14-27 years when approved for males in 2009. In addition to reporting sexual orientation identity/attractions, participants reported sex of lifetime sexual partners. Log-binominal models were used to examine HPV vaccination across sexual orientation groups.

RESULTS

Among females, 56% received ≥1 dose. In contrast, 8% of males obtained ≥1 dose; HPV vaccination initiation was especially low among completely heterosexual males. After adjusting for potential confounders, completely heterosexual (risk ratio [RR]; 95% confidence interval [CI]: 0.45 [0.30-0.68]) and mostly heterosexual (RR; 95% CI: 0.44 [0.25-0.78]) males were half as likely to have received even a single dose compared to gay males. Compared to lesbians, no differences were observed for completely heterosexual or bisexual females, but mostly heterosexual females were 20% more likely to have received at least one dose.

CONCLUSIONS

HPV vaccination rates in the U.S. are strikingly low and special attention is needed for boys and men, especially those who do not identify as gay. Vaccinating everyone, regardless of sex/gender and/or sexual orientation, will not only lower that individual's susceptibility but also decrease transmission to partners, females and/or males, to help eradicate HPV through herd immunity.

HPV Vaccine Awareness, Barriers, Intentions, and Uptake in Latina Women

Latina women are at heightened risk of cervical cancer incidence and mortality. The human papillomavirus (HPV) is the principal cause of the majority of cervical cancer cases. A vaccine that protects against HPV was licensed in 2006. Eight years post-licensure, mixed research findings exist regarding the factors that predict vaccine uptake in Latinas. We conducted a population-based phone survey with a random sample of 296 Latinas living in a Midwestern U.S. City. Intention to vaccinate was significantly associated with health care provider recommendations, worry about side effects, knowing other parents have vaccinated, perceived severity of HPV, and worry that daughter may become sexually active following vaccination. Worry that daughter may become sexually active was the only factor related to vaccine uptake. Findings suggest that training providers to discuss the low risk of severe side effects, consequences of persistent HPV, and sexuality related concerns with Latino women may encourage vaccination.

Awareness and knowledge of Human papillomavirus (HPV) among ethnically diverse women varying in generation status

Although Human papillomavirus (HPV) is a common sexually transmitted infection, there is limited knowledge of HPV with ethnic/racial minorities experiencing the greatest disparities. This cross-sectional study used the most recent available data from the California Health Interview Survey to assess disparities in awareness and knowledge of HPV among ethnically/racially diverse women varying in generation status (N = 19,928). Generation status emerged as a significant predictor of HPV awareness across ethnic/racial groups, with 1st generation Asian-Americans and 1st and 2nd generation Latinas reporting the least awareness when compared to same-generation White counterparts. Also, generation status was a significant predictor of HPV knowledge, but only for Asian-Americans. Regardless of ethnicity/race, 1st generation women reported lowest HPV knowledge when compared to 2nd and 3rd generation women. These findings underscore the importance of looking at differences within and across ethnic/racial groups to identify sub-groups at greatest risk for poor health outcomes. In particular, we found generation status to be an important yet often overlooked factor in the identification of health disparities.

Understanding HPV vaccination among Latino adolescent girls in three U.S. regions

A multi-site study was conducted to assess HPV vaccine initiation and correlates of initiation among Latina adolescents. The study was a collaboration of the CDC/NCI-funded Cancer Prevention and Control Research Network. Data were collected in 2009 from caregivers of Latina adolescents recruited from Los Angeles Country (n = 274), Washington State (Yakima Valley region; n = 90), and Texas (Houston, n = 38; Lower Rio Grande Valley, n = 42). A set of 24 survey items assessed use of the HPV vaccine and awareness, attitudes and barriers to vaccination. Moderate levels of vaccine awareness among caregivers and low uptake of the vaccine (26-37%) among girls were observed. Attitudinal barriers such as concerns about negative effects of the vaccine on daughter's sexual behavior, fertility, and future health were infrequently endorsed. Efforts to understand regional similarities and differences may help inform interventions.

Attitudes towards human papillomavirus vaccination among African parents in a city in the north of England: a qualitative study

BACKGROUND

Human papillomavirus (HPV) is sexually transmitted and has been conclusively linked to cervical cancer and genital warts. Cervical cancer is attributed to approximately 1100 deaths annually in UK, and is the second most common female cancer globally. It has been suggested that black African women are more predisposed to HPV infection and cervical cancer. A vaccine has been developed to reduce HPV infection, and in the UK, has been offered to 12-13 year old adolescent girls through schools as part of their childhood immunization programme since 2008. Upon programme initiation, it was noted that vaccine uptake was lower in schools where girls from ethnic minority groups were proportionately higher. The study's objectives were to explore factors influencing UK based African parents' acceptance or decline of the HPV vaccine, whether fathers and mothers share similar views pertaining to vaccination and any interfamily tensions resulting from differing views.

METHODS

A qualitative study was conducted with five African couples residing in north England. Face to face semi-structured interviews were carried out. Participants were parents to at least one daughter aged between 8 and 14 years. Recruitment was done through purposive sampling using snowballing.

RESULTS

HPV and cervical cancer awareness was generally low, with awareness lower in fathers. HPV vaccination was generally unacceptable among the participants, with fear of promiscuity, infertility and concerns that it's still a new vaccine with yet unknown side effects cited as reasons for vaccine decline. There was HPV risk denial as religion and good cultural upbringing seemed to result in low risk perceptions, with HPV and cervical cancer generally perceived as a white person's disease. Religious values and cultural norms influenced vaccine decision-making, with fathers acting as the ultimate decision makers. Current information about why the vaccine is necessary was generally misunderstood.

CONCLUSION

Tailored information addressing religious and cultural concerns may improve vaccine acceptability in African parents.

Factors Associated with HPV Vaccine Awareness in a Population-Based Sample of Hispanic Women in Puerto Rico

OBJECTIVES

The objective of this study was to investigate the factors associated with HPV awareness among women aged 16 to 64 years, among underserved minority Hispanic women living in Puerto Rico.

METHODS

A population-based, cross-sectional sample of 566 women, ages 16 to 64 years, living in the San Juan metropolitan area were surveyed regarding sexual behavior, HPV knowledge, and HPV vaccine uptake. Data was analyzed using descriptive statistics and multivariate logistic regression.

RESULTS

Overall, 64.8 % of the women in the sample had heard about the HPV vaccine. Among those in the recommended catch-up vaccination age range (16-26 years, n = 86), 4.7 % had received at least one dose of the HPV vaccine. Of those aware of the availability of the HPV vaccine, most had learned about it through the media, whereas, only 39.6 % had learned about it from a physician. Multivariate logistic regression analysis showed that HPV awareness (OR 8.6; 95 % CI 5.0-14.8) and having had an abnormal Pap smear (OR 2.0; 95 % CI 1.2-3.4) were associated with HPV vaccine awareness (p < 0.05).

CONCLUSION

HPV vaccine awareness among Hispanic women in the San Juan metropolitan area of Puerto Rico continues to be low. Strong recommendations from physicians and participation in HPV vaccine educational efforts are essential if the rate of HPV vaccination is to increase in the targeted population. Compared to the USA, and to their US Hispanic counterparts, a health disparity with regard to HPV vaccine awareness and coverage is evident in Puerto Rico; targeted action to deal with this disparity is urgently needed.

Moderate Awareness and Limited Knowledge Relating to Cervical Cancer, HPV, and the HPV Vaccine Among Hispanics/Latinos in Utah

BACKGROUND

We investigate the demographic factors associated with human papillomavirus (HPV) vaccine-related awareness and knowledge in an emerging (rather than established) Hispanic/Latino population.

METHOD

We surveyed 119 Spanish-speaking, mostly low-income and immigrant, Hispanic/Latino parents and guardians of adolescents 11 to 17 years old (i.e., eligible to receive the HPV vaccine) about their HPV vaccine-related awareness and knowledge. Data collection took place between August 2013 and October 2013 in Salt Lake City, Utah.

RESULTS

Participants had moderately high awareness scores, with more than half the participants reporting having heard of cervical cancer (84.5%), HPV (76.4%), and the HPV vaccine (67.3%). HPV vaccine-related knowledge was low, with fewer than half the participants reporting they knew that most people are infected with HPV (32.7%), that HPV is asymptomatic among women (16.4%), that the HPV vaccine requires more than one dose (33.6%), and that the HPV vaccine is recommended for adolescent girls (47.3%) and boys (35.5%). Combined awareness and knowledge was significantly associated with educational attainment (p = .02) and country of origin (p = .03).

CONCLUSION

Results demonstrate moderate to high HPV vaccine-related awareness and limited HPV vaccine-related knowledge among Hispanic/Latino parents living in Utah. These findings will inform educational interventions to improve the HPV vaccine-related awareness and knowledge in this vulnerable population.

Human Papilloma Virus Awareness Among Hispanic Females with Inflammatory Bowel Disease

Women with inflammatory bowel disease (IBD) may be at increased risk of human papilloma virus (HPV) infection and HPV-related malignancies, as many are immunocompromised secondary to the use of immunosuppressant agents. Several studies have addressed the knowledge about cervical cancer risk factors in different populations, particularly HPV infection and its association with cervical malignancies; most of these studies show poor patient knowledge. The purpose of this study is to describe the knowledge of females with IBD about HPV infection and the HPV vaccine. We performed a cross-sectional study in 147 consecutive patients attending the clinics of the University of Puerto Rico Center for IBD from 2009 to 2010. An interviewer-administered questionnaire was used to collect information on demographics, lifestyles, and HPV-related knowledge of participants. Bivariate analysis using the chi-square statistics and Fisher's exact test was used to examine factors associated with HPV awareness. The mean age of participants was 36.6 years (SD = 13.91 years). Three fourth (77 %) of women had awareness of the existence of HPV, and 58 % did know about the existence of HPV vaccines. Among those who had heard about HPV, 79.6 % knew that HPV can cause cervical cancer, and 57.5 % knew that the virus is sexually transmitted. Among those who knew of the vaccine, 75.3 % learned about its existence through the media, while only 15.3 %, through their health-care provider. Only three women within recommended ages (2 %) had been vaccinated against HPV, although 50 % of participants indicated that they would definitely/probably vaccinate against HPV in the future. A significant trend was observed, where more educated women were more likely to have heard of HPV (p for trend = 0.0017). Women who were high school graduates/some college (OR = 6.63, 95 % CI = 1.71-25.66) and those with at least an associate degree (OR = 11.69, 95 % CI = 3.05-45.89) were more likely to be aware of the HPV vaccine than women without a high school degree. Our study documents poor knowledge of HPV and HPV vaccine in this population of IBD patients in Puerto Rico. Although vaccination coverage is low in this population, women are receptive to the possibility of vaccination in the future. Given that this population may be at an increased risk of HPV infection and related morbidities, education and vaccination programs should be promoted among them.

Incarcerated women's HPV awareness, beliefs, and experiences

PURPOSE

The purpose of this paper is to explore incarcerated women's awareness, beliefs, and experiences with human papillomavirus (HPV) infection and vaccination.

DESIGN/METHODOLOGY/APPROACH

Researchers conducted focus groups with 45 incarcerated women in an urban Midwestern US jail to assess how women talked about their Papanicolaou (Pap) test screening and abnormal Pap test follow-up experiences. Some focus group questions specifically assessed individual awareness, beliefs, and experiences with HPV infection and vaccination. Based on these data, the authors described participants' awareness of HPV, as well as used open coding to ultimately extract themes related to beliefs and experiences with HPV infection and vaccine.

FINDINGS

While all 45 participants reported experiencing an abnormal Pap test event within the last five years, only two-thirds of participants (n=30) reported having heard of the HPV infection. Several themes emerged from the analysis of the data: the women's beliefs about cause and severity of HPV; frustration with age requirements of the vaccine; varied experiences with vaccinations for themselves and their children; the impact of media exposure on knowledge; and desire for more HPV infection and vaccine information.

ORIGINALITY/VALUE

Incarcerated women's awareness and limited experiences with HPV infection and vaccination may be a barrier to adequate screening and cervical cancer prevention. This study has implications for the development of cervical health education for this high-risk group of women, who are four to five times as likely to have cervical cancer as non-incarcerated women.

Evaluation of fotonovela to increase human papillomavirus vaccine knowledge, attitudes, and intentions in a low-income Hispanic community

BACKGROUND

It has nearly been a decade since the introduction of the vaccine against human papillomavirus (HPV), yet vaccination rates in the United States have remained suboptimal, particularly among Hispanics. Culturally and linguistically relevant health education tools targeting Hispanics are needed to increase the current rate of HPV vaccination. This article evaluates a theory-informed, evidence-guided fotonovela (photographic short story) intervention to improve HPV vaccination knowledge, attitudes, and intention among young adults.

METHODS

Young adults (N = 41, aged 18-26 years) in a low-income primary care clinic in Southern California were administered pre- and post-intervention surveys to measure changes in perceived susceptibility to HPV, perceived benefit of vaccination in committed relationship, intention to vaccinate, intention to encourage social networks to vaccinate, and attitude towards vaccination. Post-intervention survey also examined attitudes towards fotonovela. Relationships between attitudes towards fotonovela and demographic characteristics were assessed with Fisher's exact test. Self-reported gains in knowledge were categorized and tabulated. Changes in perceptions and intentions were analyzed with the marginal homogeneity test.

RESULTS

The majority of participants were female (78.0%), Latino/Hispanic (92.7%), single (70.7%), and had at least a college education (61.0%). The mean age was 21.9 years (SD 0.4). The fotonovela was viewed as entertaining (95.1%), educational (97.6%), and easy to read (100 %). Following the intervention, Hispanic participants improved in all five variables of interest measured in the survey, including perceived susceptibility (+10.5%, p = 0.03), benefit of vaccination (+7.8%, p = 0.25), intent to vaccinate (+18.4%, p = 0.06), intent to encourage others to vaccinate (+10.5%, p = 0.14) and attitude towards vaccination (+13.1%, p = 0.05). Improvements in perceived susceptibility and attitude towards vaccination reached statistical significance (p < 0.05). The most frequent gains in knowledge were the risk of HPV infection despite condom use (N = 16) and relationship status (N = 8), three-dose vaccine administration schedule (N = 13), and burden of HPV infection among males (N = 9).

CONCLUSION

Results are promising because they demonstrate that health messages delivered through a narrative format can promote positive changes in knowledge, attitudes, and intentions. The fotonovela may be a powerful vehicle for HPV education, particularly among Hispanics.

Overcoming barriers to HPV vaccination: A randomized clinical trial of a culturally-tailored, media intervention among African American girls

Although genital HPV is the most prevalent STI in the US, rates of vaccination uptake among high-risk subgroups remain low. Investigations of vaccine compliance have mainly targeted mother-daughter dyads, which in some settings may prove difficult. This study examines an innovative culturally tailored, computer-delivered media-based strategy to promote HPV vaccine uptake. Data, inclusive of sociodemographics, sexual behaviors, knowledge, attitudes, and beliefs about HPV and vaccination were collected via ACASI from 216 African American adolescent females (ages 14-18 years) seeking services in family planning and STI public health clinics in metropolitan Atlanta. Data were obtained prior to randomization and participation in an interactive media-based intervention designed to increase HPV vaccination uptake. Medical record abstraction was conducted 7 month post-randomization to assess initial vaccine uptake and compliance. Participants in the intervention were more compliant to vaccination relative to a placebo comparison condition (26 doses vs. Seventeen doses; p=0.12). However, vaccination series initiation and completion were lower than the national average. Thorough evaluation is needed to better understand factors facilitating HPV vaccine uptake and compliance, particularly perceived susceptibility and the influence of the patient-provider encounter in a clinical setting.

Design and efficacy of a multilingual, multicultural HPV vaccine education intervention

BACKGROUND

The human papillomavirus (HPV) is the precursor and the single, most important risk factor for cervical cancer. It is also the most commonly sexually transmitted infection in the United States. An estimated 20 million persons are currently infected with the virus, with an estimated 6 million new infections occurring annually and 12,000 new cervical cancer cases and 4,000 cervical cancer deaths annually. The human papillomavirus (HPV) vaccine is thus an especially important preventive measure for racial/ethnic groups who bear an unequal burden of cervical cancer mortality.

PURPOSE

This study aimed to develop a culturally and linguistically appropriate intervention to educate and empower Latino and Korean Americans to make an informed HPV vaccination decision for their minor children.

METHODS

A parent-focused HPV vaccine education DVD was developed through focus groups and cognitive interviews with Latino and Korean Americans parents of children ages 11-17. A randomized controlled efficacy trial was subsequently conducted with 708 Latino and Korean Americans parents to assess knowledge gains, decisional conflict, decision self-efficacy and informed decision-making resulting from viewing the intervention DVD.

RESULTS

Differences between treatment and control groups for pre-post changes in knowledge, informed decision-making and decisional conflict were statistically significant among the parents exposed to the education intervention DVD.

CONCLUSION

The study demonstrated that a culturally and linguistically appropriate intervention DVD designed to educate parents about the risks and benefits of the HPV vaccine promoted informed decision-making regarding HPV vaccination among at-risk populations.

Differential uptake of recent Papanicolaou testing by HPV vaccination status among young women in the United States, 2008-2013

BACKGROUND

A positive association between recent Papanicolaou (Pap) test uptake and initiation of HPV vaccination among U.S. women has been reported. However, it is unknown whether recent Pap testing by HPV vaccination status varies by race/ethnicity. Discerning racial/ethnic variations is important given the higher prevalence of HPV types other than 16 and 18 in some racial/ethnic groups. We assessed whether uptake of recent Pap testing differed among women aged 21-30 years who had not initiated the HPV vaccination series versus those who had and whether this pattern differed by sociodemographic factors.

METHODS

2008, 2010, and 2013 National Health Interview Survey data were used to generate weighted prevalence estimates and 95% confidence intervals (CIs) (n=7095). Adjusted predicted marginal models were used to generate adjusted prevalence ratios (aPRs) to assess the relationship between recent Pap test uptake and HPV vaccination series initiation by race/ethnicity.

RESULTS

The uptake of recent Pap testing among those who had not initiated the HPV vaccination series was significantly lower (81.0%) compared to those who had initiated vaccination (90.5%) (aPR=0.93, 95% CI: 0.90-0.96). This finding was consistent across most sociodemographic factors, though not statistically significant for Blacks, Hispanics, those with lower levels of education, or those with higher levels of income.

CONCLUSION

Young women who had not initiated HPV vaccination were less likely to have had a recent Pap test compared to women who had initiated vaccination. Concerted efforts are needed to increase uptake of recommended cervical cancer screening and HPV vaccination among young women.

Human Papillomavirus Vaccination Awareness and Acceptability Among U.S.-Born and U.S. Foreign-Born Women Living in California

We examined human papillomavirus vaccine awareness and acceptance between U.S.-born and U.S. foreign-born women by utilizing California Health Interview Survey data from 1,672 women (ages 18-27) and 2,994 mothers (ages 28-65). Foreign-born women and mothers had lower vaccine awareness. Foreign-born young adult Latinas had greater vaccine acceptance than U.S.-born Latinas. Other factors associated with young adult women's vaccine acceptability were being younger, unmarried, and sexually active in the past year; having poorer self-reported health; and having heard of the vaccine. Variables associated with mothers' vaccine acceptability were being White, insured, and unmarried; having had a Pap test in past 3 years; being less educated; and being impoverished.

Correlates of human papillomavirus vaccination among female university students

Human papillomavirus (HPV) is the most frequently occurring sexually transmitted infection in the United States, but only one third of adolescent girls have received the HPV vaccine (Centers for Disease Control and Prevention [CDC], 2012; Committee on Infectious Diseases, 2012). Understanding correlates of vaccination behavior among young women has important implications for health care delivery and public service messages targeting HPV vaccination. Female college students (N = 313) completed web-based surveys during their sophomore (second) year of college, fall 2008. Surveys included questions about HPV vaccination, demographic factors (ethnicity/race, socioeconomic status [SES]), individual characteristics (romantic relationship status, grade point average, religiosity), and sexual behavior. Lifetime HPV vaccination was reported by 46.5% of participants. Being African American/Black was associated with a lower likelihood of vaccination. Having a mother with more education, adhering to religious teachings about sex-related principles, and having engaged in recent penetrative sex were associated with a higher likelihood of vaccination. Health care providers should consider young women to be an important group for HPV vaccine education and catch-up, particularly for African American/Black young women and young women from lower SES backgrounds. Providing vaccine education and access to young women before they become sexually active is critical.

Human papillomavirus vaccination uptake and completion as a preventive health measure among female adolescents

BACKGROUND

National coverage for the human papillomavirus (HPV) vaccine falls short of the targeted goals for Healthy People 2020 with disparities in completion rates noted in minority adolescent female populations. The purpose of this study was to provide a review of the literature on HPV vaccination uptake and completion rates among female minority adolescents as well as a discussion of the financial and policy dimensions of HPV vaccination with implications that impact uptake and completion rates.

METHODS

By reviewing the literature, the authors show that the two human papillomavirus (HPV) vaccines, Gardasil and Cervarix, have presented unprecedented opportunities to prevent morbidity and mortality from cervical cancer.

CONCLUSION

The authors recommend that nurses and advanced practice nurses take an active role at the point of care to educate families about HPV vaccination. Nursing interventions for practice changes are provided to improve vaccination initiation and completion rates in disadvantaged populations.

The role of human papilloma virus (HPV) infection in non-anogenital cancer and the promise of immunotherapy: a review

Over the past 30 years, human papilloma virus (HPV) has been shown to play a role in the development of various cancers. Most notably, HPV has been linked to malignant progression in neoplasms of the anogenital region. However, high-risk HPV has also been suggested to play a significant role in the development of cancers in other anatomic locations, such as the head and neck, lung, breast and bladder. In 2006, the first vaccine for HPV, Gardasil, was approved for the prevention of subtypes 6, 11, 16 and 18. A few years later, Cevarix was approved for the prevention of subtypes 16 and 18, the HPV subtypes most frequently implicated in malignant progression. Although increased awareness and vaccination could drastically decrease the incidence of HPV-positive cancers, these approaches do not benefit patients who have already contracted HPV and developed cancer as a result. For this reason, researchers need to continue developing treatment modalities, such as targeted immunotherapies, for HPV-positive lesions. Here, we review the potential evidence linking HPV infection with the development of non-anogenital cancers and the potential role of immunotherapy in the prevention and eradication of HPV infection and its oncogenic sequela.

Racial and ethnic differences in HPV knowledge, attitudes, and vaccination rates among low-income African-American, Haitian, Latina, and Caucasian young adult women

OBJECTIVE

To examine facilitators and barriers to HPV vaccine uptake in African-American, Haitian, Latina, and White women aged 18-22 and to determine vaccination completion rates among participants over 5 years.

DESIGN

Using semi-structured interviews and medical record review, we assessed HPV knowledge and attitudes towards HPV vaccination among young women. We then determined their subsequent HPV vaccination initiation and completion rates. We used constructs from the Health Belief Model and methods based in grounded theory and content analysis to identify attitudes towards HPV vaccination cues to initiate vaccination, perception of HPV, and how communication about issues of sexuality may impact vaccine uptake.

PARTICIPANTS

We enrolled 132 African-American, Haitian, Latina, and White women aged 18-22 years who visited an urban academic medical center and 2 affiliated community health centers between the years 2007 and 2012.

MAIN OUTCOME MEASURES

Intent to vaccinate and actual vaccination rates.

RESULTS

Of 132 participants, 116 (90%) stated that they were somewhat or very likely to accept HPV vaccination if offered by their physician, but only 51% initiated the vaccination over the next 5 years. Seventy-eight percent of those who initiated vaccination completed the 3 doses of the HPV vaccine series. Forty-five percent (45%, n = 50) of the adolescents who started the series completed 3 doses over a 5-year period: 42% of African-American (n = 16), 33% of Haitian (n = 13), 63% of Latina (n = 10), and 65% of White young women (n = 11) completed the 3-dose series. Despite low knowledge, they reported high levels of trust in physicians and were willing to vaccinate if recommended by their physicians.

CONCLUSION

Desire for HPV vaccination is high among older adolescents, physician recommendation, and use of every clinic visit opportunity may improve vaccine uptake in young women. More White young women completed the HPV vaccine series compared with other race and ethnic young women.

Political and news media factors shaping public awareness of the HPV vaccine

BACKGROUND

In 2006, the U.S. Food and Drug Administration licensed a vaccine for the human papillomavirus (HPV) that prevents the strains of HPV that cause 70% of cervical cancers. Within months, many states introduced legislation requiring the vaccine for girls, prompting controversy and heightened political and media attention to the issue. Previous research has shown differences in HPV vaccine awareness by individual-level characteristics such as race/ethnicity, income, and education levels. We examined how individual political orientation and exposure to media coverage can also shape awareness of the vaccine.

METHODS

Using data from a 2009 Internet survey of 1,216 nationally representative adult respondents linked to data on state-specific news coverage, we assessed how political orientation, media exposure, and state political context predicted HPV vaccine awareness.

RESULTS

Younger people, women, and those with more education were significantly more likely to be aware of the vaccine. Even after controlling for these characteristics, we found that exposure to news media was associated with higher HPV vaccine awareness. Whereas liberals and conservatives were both more aware of the vaccine compared with moderates, the data are suggestive that liberals were more sensitive to news coverage.

CONCLUSION

These findings suggest that individual-level political identities and their interaction with the informational environment may be important factors to consider in evaluating the determinants of individuals' attitudes and behaviors related to politically charged women's health issues.

HPV infection awareness and self-reported HPV vaccination coverage in female adolescent students in two German cities

Low levels of human papillomavirus (HPV) awareness and knowledge have been observed in the few studies conducted among school-going adolescents. Such data are lacking in Germany. To assess awareness of HPV and of vaccination status among girls attending grades 8-13 in Bremen and Bremerhaven, two German cities. Participants completed a questionnaire in school including questions on demographic characteristics, about HPV awareness and on vaccination status. We analysed the relationship between awareness of HPV, of vaccination status and vaccine uptake and several variables including age and migrant background using univariate and multivariate logistic regression. Six hundred and thirty-two girls aged 12-20 years completed the questionnaire. 50 % had no awareness of HPV, 12 % reported being vaccinated against HPV and 57 % did not know whether or not they were vaccinated against HPV. In multivariate analyses, ever had sex was associated with awareness of HPV, and ever been to a gynaecologist with awareness of vaccination status. Our results may be an indication that female adolescents in Germany are not adequately informed and counselled about HPV and associated issues.

Effects of socioeconomic status and health care access on low levels of human papillomavirus vaccination among Spanish-speaking Hispanics in California

Little is known about the effect of language preference, socioeconomic status, and health care access on human papillomavirus (HPV) vaccination. We examined these factors in Hispanic parents of daughters aged 11 to 17 years in California (n = 1090). Spanish-speaking parents were less likely to have their daughters vaccinated than were English speakers (odds ratio [OR] = 0.55; 95% confidence interval [CI] = 0.31, 0.98). Adding income and access to multivariate analyses made language nonsignificant (OR = 0.68; 95% CI = 0.35, 1.29). This confirms that health care use is associated with language via income and access. Low-income Hispanics, who lack access, need information about free HPV vaccination programs.

Ethnic differences in predictors of HPV vaccination: comparisons of predictors for Latina and non-Latina White women

The purpose of this study was to examine how social and behavioral factors such as age of first intercourse, mother-daughter communication, and perceived norms are associated with human papillomavirus (HPV) vaccination behaviors, and whether ethnicity moderates those associations (non-Latina White versus Latina participants). From June through December 2009, we surveyed a community sample of 309 White and Latina women, ages 15 to 30. We recruited participants from local health care clinics in Des Moines, Iowa. Vaccination status was not significantly different for Whites versus Latinas. The effects of age at first intercourse, mother-daughter communication about values related to sex, and descriptive norms of HPV vaccine uptake were all significantly moderated by ethnicity. The current findings reveal that sociocultural and behavioral factors that affect HPV vaccine uptake do not affect White and Latina women in the same fashion. In the future, public health campaigns about HPV and the HPV vaccine may be more effective if their messages are sensitive to these differences.

Cancer statistics for Hispanics/Latinos, 2012

Hispanics/Latinos are the largest and fastest growing major demographic group in the United States, accounting for 16.3% (50.5 million/310 million) of the US population in 2010. In this article, the American Cancer Society updates a previous report on cancer statistics for Hispanics using incidence data from the National Cancer Institute, the Centers for Disease Control and Prevention, and the North American Association of Central Cancer Registries and mortality data from the National Center for Health Statistics. In 2012, an estimated 112,800 new cases of cancer will be diagnosed and 33,200 cancer deaths will occur among Hispanics. In 2009, the most recent year for which actual data are available, cancer surpassed heart disease as the leading cause of death among Hispanics. Among US Hispanics during the past 10 years of available data (2000-2009), cancer incidence rates declined by 1.7% per year among men and 0.3% per year among women, while cancer death rates declined by 2.3% per year in men and 1.4% per year in women. Hispanics have lower incidence and death rates than non-Hispanic whites for all cancers combined and for the 4 most common cancers (breast, prostate, lung and bronchus, and colorectum). However, Hispanics have higher incidence and mortality rates for cancers of the stomach, liver, uterine cervix, and gallbladder, reflecting greater exposure to cancer-causing infectious agents, lower rates of screening for cervical cancer, differences in lifestyle and dietary patterns, and possibly genetic factors. Strategies for reducing cancer risk among Hispanics include increasing utilization of screening and available vaccines, as well as implementing effective interventions to reduce obesity, alcohol consumption, and tobacco use.

Awareness and acceptability of human papillomavirus vaccine: an application of the instrumental variables bivariate probit model

Background

Although lower uptake rates of the human papillomavirus (HPV) vaccine among socioeconomically disadvantaged populations have been documented, less is known about the relationships between awareness and acceptability, and other factors affecting HPV vaccine uptake.

The current study aimed to estimate the potential effectiveness of increased HPV vaccine awareness on the acceptability of HPV vaccination in a nationally representative sample of women, using a methodology that controlled for potential non-random selection.

Methods

This study used a population-based sample from the 2007 Health Information National Trends Survey, a cross-sectional study of the US population aged 18 years or older, and focused on the subsample of 742 women who have any female children under the age of 18 years in the household. An instrumental variables bivariate probit model was used to jointly estimate HPV vaccine awareness and acceptability.

Results

The proportion of HPV vaccine acceptability among the previously aware and non-aware groups was 58% and 47%, respectively. Results from the instrumental variables bivariate probit model showed that the estimated marginal effect of awareness on acceptability was 46 percentage points, an effect that was even greater than observed.

Conclusions

Among populations who are not currently aware of the HPV vaccine, the potential impact of raising awareness on acceptability of HPV vaccination is substantial. This finding provides additional support to strengthening public health programs that increase awareness and policy efforts that address barriers to HPV vaccination.