Survey Examines Why US Uptake of HPV Vaccine Remains Relatively Low
According to a recent survey, the main causes for a lack of HPV vaccine uptake are a lack of knowledge and a failure by healthcare providers to recommend it.
Anna Beavis, MD
In an effort to understand the relatively low uptake of the human papillomavirus (HPV) vaccine in the United States, a survey of parents of teenage girls has found that a lack of knowledge about the vaccine and a failure by healthcare providers to recommend it, superseded parental concern about their daughters’ not needing it because they are not sexually active.
In 2010 the third most common reason parents gave for not vaccinating their teenager was lack of sexual activity, but in 2014, that concern dropped to the bottom of the 5 most commonly cited reasons for failure to vaccinate. During the same time period, lack of knowledge about vaccine and lack of healthcare provider recommendation moved from the bottom of the list to the middle.
Concern about vaccine safety and perceived lack of necessity headed the list at both points in time, Anna Beavis, MD, a gynecologic oncology fellow at the Johns Hopkins Bloomberg School of Public Health, reported at the 2017 Society of Gynecologic Oncology Annual Meeting on Women’s Cancer.
“Our results demonstrate that safety and perceived lack of necessity, as well as lack of knowledge, make up 50% of the reason why parents don’t initiate HPV vaccination,” said Beavis. “The results also demonstrate that concern about the vaccine and its connection with sexual activity are less important to parents and that these concerns decreased over time.
“Healthcare providers should not feel dissuaded from recommending HPV vaccine simply because they feel the parents don’t want to discuss sexual activity,” she added.
Preliminary analysis of data from the 2015 survey showed that failure to vaccinate was associated with white race, younger age, and socioeconomic status above the poverty level. An HPV message targeted to those demographic characteristics is needed, said Beavis.
Given the strong association between cervical cancer and HPV infection, universal uptake of the 9-valent HPV vaccine could prevent 90% of all cervical cancer. Despite its demonstrated efficacy for preventing infection the rate of HPV vaccine uptake in the United States has lagged behind other Western nations.
In 2007, the first full year after HPV vaccine was introduced in the United States, 12% of adolescent girls were vaccinated. By 2014, the rate had increased to about 60%, still well below the 80% target established in the Healthy People 2020 initiative. In contrast, HPV vaccination rates in Australia, which has a school-based vaccination program, have exceeded 80% since 2007, Beavis noted.
Explanations for the low US uptake rate remain incomplete. Physician recommendation has a strong influence of vaccination rates, but recommendation rates vary by specialty, geography, and other factors. Access to healthcare also affects uptake.
Previous studies have shown that providers with low recommendation rates feel the need to discuss sexual activity with parents before recommending the vaccine for a child, which has contributed to the low uptake.
Studies of parental attitudes toward HPV vaccine have yielded conflicting results. Whether attitudes have changed over time has not been studied extensively, providing a rationale to examine the issue in greater detail. Beavis and colleagues hypothesized that recent data would show that parental attitudes about vaccine safety and sexual issues have decreased.
The study involved data from the CDC’s National Immunization Survey: Teen. The survey tracks national vaccination trends and elicits information about reasons for not initiating vaccination in children and teenagers. Providers are contacted to verify vaccination-related data. About 35,000 households are contacted annually, and the data are used to estimate national trends in vaccination.
Beavis and colleagues limited their analysis to households with girls aged 13 to 17. The analysis covered 85,269 individual surveys conducted during 2010-2014. Provider verification was available in 49,345 cases, which showed that HPV vaccine had not been initiated in 22,642 cases and that 26,703 girls had received at least 1 dose of HPV vaccine. Of the unvaccinated group, 12,401 parents indicated no intention to initiate HPV vaccination.
In the subgroup not intending to initiate vaccination, the median age of the child was 15. Race/ethnicity was white in 70% of cases, two-thirds had private insurance, and 89% had income that exceeded the poverty level.
The vaccine initiation rate increased gradually but steadily from 49% in 2010 to 60% in 2014 (P <.001). With regard to reasons for not initiating the vaccine, the top 2 reasons in 2010 were concerns about vaccine safety/side effects (23%) and perceived lack of need/necessity for vaccination (20%). As the third most common reason, parents said their daughters were not sexually active and did not need the vaccine (18%). Lack of knowledge (14%) and lack of provider recommendation completed the list (9%).
In 2014, however, the top 5 reasons parents gave for not pursuing HPV vaccination for their children were:
- Perceived lack of need/necessity topped the list (19%)
- Safety/side effect concerns (17%)
- Lack of knowledge about vaccines and vaccination (14%)
- Lack of provider recommendation (10%)
- The belief that the vaccine was not necessary because children were not sexually active (9%)
Comparison of 2010 and 2014 responses showed statistically significantly differences for safety/side effect concerns, perceived lack of necessity, beliefs about sexual activity, and lack of provider recommendation (P <.01 for all comparisons).
Beavis AL, Krakow M, Levinson K, Rositch AF. Reasons for persistent suboptimal rates of HPV vaccination in the US: shifting the focus from sexuality to education and awareness. In: Proceedings from the Society for Gynecologic Oncology Annual Meeting on Women’s Cancer; March 12-14, 2017; National Harbor, MD.