Early adoption of the human papillomavirus vaccine among Hispanic adolescent males in the United States
Paul L. Reiter PHD,
Division of Cancer Prevention and Control, College of Medicine, The Ohio State University, Columbus, Ohio
Comprehensive Cancer Center, The Ohio State University, Columbus, Ohio
College of Public Health, The Ohio State University, Columbus, Ohio
Corresponding author: Paul L. Reiter, PhD, Division of Cancer Prevention and Control, College of Medicine, The Ohio State University; Suite 525, 1590 North High St, Columbus, OH 43201; Fax: (614) 293-5611; Paul.Reiter@osumc.edu
Human papillomavirus (HPV) infection is common among Hispanic males, but to the authors' knowledge little is known regarding HPV vaccination in this population. The authors examined the early adoption of the HPV vaccine among a national sample of Hispanic adolescent males.
The authors analyzed provider-verified HPV vaccination data from the 2010 through 2012 National Immunization Survey-Teen (NIS-Teen) for Hispanic males aged 13 years to 17 years (n = 4238). Weighted logistic regression identified correlates of HPV vaccine initiation (receipt of ≥1 doses).
HPV vaccine initiation was 17.1% overall, increasing from 2.8% in 2010 to 31.7% in 2012 (P<.0001). Initiation was higher among sons whose parents had received a provider recommendation to vaccinate compared with those whose parents had not (53.3% vs 9.0%; odds ratio, 8.77 [95% confidence interval, 6.05-12.70]). Initiation was also higher among sons who had visited a health care provider within the previous year (odds ratio, 2.42; 95% confidence interval, 1.39-4.23). Among parents with unvaccinated sons, Spanish-speaking parents reported much higher intent to vaccinate compared with English-speaking parents (means: 3.52 vs 2.54; P<.0001). Spanish-speaking parents were more likely to indicate lack of knowledge (32.9% vs 19.9%) and not having received a provider recommendation (32.2% vs 17.7%) as the main reasons for not intending to vaccinate (both P<.05).
Hispanics are one of the fastest growing populations in the United States, currently constituting >16% of the total population and projected to be 30% by 2050.[1, 2] The Hispanic population has relatively high rates of human papillomavirus (HPV) infection and HPV-related disease (eg, cervical cancer).[3-6] Greater than 30% of Hispanic adult males have a current HPV infection, and they are twice as likely as non-Hispanic white males to be infected with multiple HPV types. Hispanic females have the highest cervical cancer incidence rate of any racial/ethnic group in the United States. HPV is highly transmissible between sexual partners, and therefore Hispanic males likely play an important role in cervical cancer incidence among Hispanic females.
US guidelines have recommended the HPV vaccine for males since October 2009.8 The Advisory Committee on Immunization Practices (ACIP) first provided a permissive recommendation that allowed the 3-dose vaccine series to be administered to males aged 9 years to 26 years. In October 2011, the ACIP began recommending routine HPV vaccination for males aged 11 years to 12 years, with catch-up vaccination for males aged 13 years to 21 years and up to age 26 years for high-risk males. Parents' acceptance of the HPV vaccine for their adolescent sons tends to be high,[10-12] but current vaccine coverage among US adolescent males is low. Recent data have indicated that ≤21% of adolescent males have received any doses of HPV vaccine and <10% have received all 3 doses.[13-15] Although a Healthy People 2020 objective has not yet been set for males, current HPV vaccine coverage among males falls far short of the goal of 80% coverage with 3 doses established for females.
To the best of our knowledge, few studies to date have focused on HPV vaccination among Hispanic males. Most Hispanic parents are willing to vaccinate their sons (range, 59%-92%),[17-19] and research suggests that HPV vaccine initiation may be slightly higher among Hispanic adolescent males compared with non-Hispanic whites.[13, 15] However, no studies we are aware of have identified correlates of HPV vaccination among Hispanic males or reasons why parents are not vaccinating their Hispanic sons. We believe such information is important given the HPV-related disparities that exist among Hispanics and because Hispanic individuals may face unique challenges to receiving the HPV vaccine (eg, acculturation). We analyzed data among a national sample of Hispanic adolescent males to examine HPV vaccine coverage within the first few years after vaccine availability for males in the United States. The results will be useful for designing effective HPV vaccination programs for this population.
MATERIALS AND METHODS
We conducted a secondary analysis of publicly available data from the 2010 through 2012 National Immunization Survey-Teen (NIS-Teen).[20-22] The methodology of the NIS-Teen has been described in great detail and will be discussed briefly here. The NIS-Teen is an annual survey conducted by the Centers for Disease Control and Prevention (CDC) to monitor vaccination rates among individuals aged 13 years to 17 years in the United States. Data collection occurs in all 50 states, the District of Columbia, and the US Virgin Islands.
The CDC uses a complex stratified sampling strategy to obtain a national probability sample of adolescents aged 13 years to 17 years for the NIS-Teen. For 2010, the survey used a random digit-dialed sampling frame that consisted of landline telephones, whereas for 2011 and 2012 a dual-frame sampling approach with independent random digit-dialed samples of landline and cellular telephone sampling frames was used.[20-22] For households with >1 adolescent aged 13 years to 17 years, one adolescent is randomly chosen as the index adolescent. Data collection for the NIS-Teen consists of 2 phases: 1) a telephone survey with parents of the adolescents; and 2) a mailed survey to the adolescents' health care providers. Data obtained from provider records are the basis for the NIS-Teen vaccination estimates.[13, 24, 25]
Excluding participants from the US Virgin Islands, data sets included 19,257 adolescents from 2010 (household response rate of 58.0%), 23,564 adolescents from 2011 (household response rate of 57.2% for landline households and 22.4% for cellular households), and 19,199 adolescents from 2012 (household response rate of 55.1% for landline households and 23.6% for cellular households). These data sets represent all years with HPV vaccination data available for males at the time of analyses. We report data on 4238 Hispanic adolescent males from these data sets (all participants included had provider-verified HPV vaccination data). The NIS-Teen established Hispanic ethnicity by asking parents whether adolescents were Hispanic or Latino.
The National Center for Health Statistics Research Ethics Review Board approved NIS-Teen data collection, and the NIS-Teen obtained informed consent from all participants. Analysis of deidentified data from the survey is exempt from the federal regulations for the protection of human research participants. The Institutional Review Board at The Ohio State University determined this study was exempt from review.
We examined HPV vaccine initiation (receipt of at least 1 dose of the HPV vaccine) as the primary outcome variable because few males in the United States have received any doses of the HPV vaccine. For descriptive purposes, we also examined HPV vaccine completion (receipt of all 3 doses).
We examined parents' intent to get their sons the HPV vaccine within the next year among parents whose sons had not received any doses of the HPV vaccine (ie, unvaccinated). The NIS-Teen assessed intent by asking these parents, “How likely is it that (TEEN) will receive HPV shots in the next 12 months?” Response options included “not likely at all,” “not too likely,” “not sure/don't know,” “somewhat likely,” and “very likely” (coded as 1-5). Parents who gave 1 of the first 3 responses then indicated the main reason why their sons would not receive the HPV vaccine within the next year. Parents could indicate multiple reasons for this open-ended item. The CDC coded responses and then created a dichotomous variable for each main reason for use in analyses (1 indicates the reason was reported, 0 indicates the reason was not reported).
The NIS-Teen assessed various characteristics of sons, parents, and households (Table 1). Son characteristics included age, race (because Hispanic is an ethnicity and not a race), if they visited a health care provider within the previous year, health care coverage, and if they currently lived in the state in which they were born (ie, geographic mobility). We examined geographic mobility because relocation may disrupt continuity of care. Parent characteristics included mother's age, education level, and marital status. If someone other than the mother completed the parent survey, this individual provided information regarding the mother. Parents indicated if they had ever received a health care provider recommendation to get their sons the HPV vaccine. We examined whether parents completed the NIS-Teen telephone survey in English or Spanish (ie, preferred language) as a proxy measure of acculturation. We acknowledge that acculturation is a complex construct, but language preference is a commonly used proxy for acculturation that correlates with acculturation scales or is a domain within several such scales.
Table 1. Characteristics of Parents and Their Hispanic Adolescent Sons From the NIS-Teen: 2010 Through 2012 (n=4238)a
No. (Weighted %)
Abbreviations: HPV, human papillomavirus; NIS-Teen, National Immunization Survey-Teen.
Totals may not sum to stated sample size due to missing data. Percentages may not sum to 100% due to rounding. Frequencies were not weighted.
Currently lives in state where born
Visited health care provider within previous y
Health care coverage
Mother's age, y
Mother's marital status
Language of NIS-Teen interview
Received provider recommendation to get son HPV vaccine
Above poverty, ≤$75,000
Above poverty, >$75,000
No. of children in household
Region of residence
Household characteristics included poverty status (based on US Census Bureau poverty thresholds[20-22]), number of children aged <18 years residing in the household, and region of residence in the United States (Northeast, Midwest, South, or West). Unlike previous analyses of NIS-Teen data,[15, 27] we were not able to examine parents' awareness of HPV and the HPV vaccine and adolescents' eligibility for the Vaccines for Children (VFC) program because these variables were not included in the 2012 public use NIS-Teen data set. The VFC program is a federal program that provides vaccines free of charge to children who might not otherwise be vaccinated because of an inability to pay (those who are uninsured, underinsured, etc).
We examined descriptive statistics for all outcome variables. We used binary logistic regression to identify correlates of HPV vaccine initiation (our primary outcome). We entered variables with a P value <.10 in bivariate analyses into a multivariate model, which produced adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs). Lastly, we determined if parents' intent to vaccinate (linear and binary logistic regression) and reasons for not intending to vaccinate (binary logistic regression) differed by the parents' preferred language because these outcomes differed by preferred language in our prior research on Hispanic females.
We combined multiple years of NIS-Teen data for analyses using recommended methods and applied appropriate sampling weights in determining percentages and effect estimates.[20-22] We used procedures for analyzing complex survey data in SAS statistical software (version 9.2; SAS Institute Inc, Cary, NC). Statistical tests were 2-tailed with a critical alpha of .05.
Most sons were aged 13 years to 15 years (62.4%), white (86.1%), lived in the state in which they were born (70.1%), and had visited a health care provider within the previous year (75.2%) (Table 1). The majority of mothers were at least aged 35 years (86.0%) and did not have a college degree (81.6%). Nearly one-half of parents (47.5%) completed the NIS-Teen telephone survey in Spanish. Only 18.2% of parents had received a recommendation from a health care provider to get their sons the HPV vaccine, although receipt of a recommendation increased each year (4.3% in 2010, 14.1% in 2011, and 24.3% in 2012; P<.0001).
HPV Vaccine Uptake
Overall, 17.1% of Hispanic adolescent males had received at least 1 dose of the HPV vaccine. Initiation increased each year, with 2.8% initiation in 2010, 14.9% initiation in 2011, and 31.7% initiation in 2012 (Fig. 1). Although only 5.5% of Hispanic adolescent males overall had completed the 3-dose HPV vaccine series, completion increased each year (<0.1% in 2010, 2.7% in 2011, and 12.9% in 2012). The yearly increases in both initiation and completion were statistically significant (all P<.0001).
Correlates of HPV Vaccine Initiation
In multivariate analyses (Table 2), initiation was higher in 2011 (OR, 4.22; 95% CI, 2.25-7.92) and 2012 (OR, 10.61; 95% CI, 5.78-19.47) compared with 2010. Initiation was higher among sons whose parents had received a provider recommendation to vaccinate compared with those whose parents had not (53.3% vs 9.0%; OR, 8.77 [95% CI, 6.05-12.70]). Initiation was also higher among sons who had visited a health care provider within the previous year (OR, 2.42; 95% CI, 1.39-4.23). Initiation was lower among sons from households that were above the poverty level and had an income >$75,000 compared with sons from households that were below the poverty level (OR, 0.47; 95% CI, 0.23-0.95).
Table 2. Correlates of HPV Vaccine Initiation (Receipt of at Least One Dose of the HPV Vaccine) Among Hispanic Adolescent Males: 2010 Through 2012 (n=4238)a
No. Initiated/Total No. in Category (Weighted %)
Bivariate OR (95% CI)
Multivariate OR (95% CI)
Abbreviations: 95% CI, 95% confidence interval; HPV, human papillomavirus; NIS-Teen, National Immunization Survey-Teen; OR, odds ratio.
Totals may not sum to stated sample size due to missing data. Frequencies were not weighted. The multivariate model did not include variables with em-dashes (—). The multivariate model included data on 3782 Hispanic adolescent males due to missing data for potential correlates.
Intent to Vaccinate and Reasons for Not Intending to Vaccinate
Parents with unvaccinated sons reported a moderate intent to vaccinate within the next year (mean, 2.96; standard error [SE], 0.04). Approximately 45.7% of these parents indicated their sons were “somewhat likely” or “very likely” to receive the HPV vaccine within the next year, 14.2% were not sure, and 40.2% indicated vaccination was “not too likely” or “not likely at all.” Parents whose preferred language was Spanish reported a much higher intent to vaccinate (mean, 3.52; SE, 0.05) compared with parents whose preferred language was English (mean, 2.54; SE, 0.06) (P<.0001) (Fig. 2). Approximately 61.2% of Spanish-speaking parents indicated their sons were “somewhat likely” or “very likely” to receive the HPV vaccine within the next year, compared with only 33.9% of English-speaking parents (P<.0001).
The most common main reasons for parents not intending to vaccinate their sons within the next year were lack of knowledge (23.6%), believing vaccination is not needed or not necessary (22.5%), and not having received a provider recommendation (22.0%) (Table 3). Compared with English-speaking parents, Spanish-speaking parents were more likely to indicate lack of knowledge (32.9% vs 19.9%) and not having received a provider recommendation (32.2% vs 17.7%) as a main reason (both P<.05). Conversely, English-speaking parents were more likely to indicate believing vaccination is not needed or not necessary (27.2% vs 10.6%), son not sexually active (11.2% vs 3.5%), their child is male (7.5% vs 2.2%), and concerns about vaccine safety and side effects (6.8% vs 3.1%) as a main reason (all P<.05).
Table 3. Main Reasons Why Parents Did Not Intend to Have Their Hispanic Adolescent Sons Receive the HPV Vaccine Within the Next Year: 2010 Through 2012 (n=1751)a
Parents' Preferred Language
Total No. (Weighted %)
English No. (Weighted %)
Spanish No. (Weighted %)
Abbreviation: HPV, human papillomavirus.
The table includes parents of unvaccinated sons who indicated they were “not likely at all,” “not too likely,” or “not sure/don't know” about getting their sons the HPV vaccine within the next year. The table does not include reasons that were reported by <2.0% of parents. Frequencies were not weighted. Reported P values were derived from binary logistic regression models that determined if each reason differed by parents' preferred language.
Lack of knowledge
Vaccination not needed or not necessary
Did not receive provider recommendation
Son not sexually active
Child is male
Vaccine safety concern/side effects
Son not appropriate age
Not a school requirement
The current study examined the early adoption of the HPV vaccine among a national sample of Hispanic adolescent males. According to NIS-Teen data, just under 20% of Hispanic adolescent males had initiated the HPV vaccine series and only approximately 5% had received all 3 doses. Despite this modest coverage overall, both initiation and completion increased substantially over the years examined (over 30% initiation and 12% completion in 2012). These increases were likely due in part to the different ACIP recommendations that were in place during these years. The ACIP initially provided a permissive recommendation for the HPV vaccine for males in October 2009, which was replaced by a stronger recommendation for routine administration in October 2011.9 The updated recommendation may have helped increase HPV vaccination by increasing provider recommendation for vaccination (which increased each year in the current study) and insurance coverage of the HPV vaccine for males. The VFC program and some private health insurance plans covered the HPV vaccine for males under the permission recommendation, but coverage by private health insurance plans has increased in recent years due to the updated recommendation and the Patient Protection and Affordable Care Act.[31, 32]
Despite the observed annual increases, interventions will likely be needed to maximize HPV vaccine coverage. Similar increases in HPV vaccination occurred among adolescent females in the first few years after vaccine availability, but increases have stalled in recent years.[33, 34] The results of the current study highlight potential leverage points and strategies for future interventions. The most promising strategy will be to ensure health care visits among Hispanic adolescent males and increase health care provider recommendations for vaccination during visits. Both of these factors were found to be correlated with HPV vaccine initiation in multivariate analyses, with provider recommendation being the strongest determinant (which is similar to the findings of previous studies[14, 15]). However, a majority of parents in the current study reported not having received a health care provider's recommendation to vaccinate, suggesting that many missed opportunities for recommending and administering the HPV vaccine are occurring during existing health care visits. As suggested by the President's Cancer Panel, reducing these missed opportunities will be critical for increasing HPV vaccine coverage.
Parents' preferred language, our proxy measure of acculturation, was found to be correlated with several outcomes examined. Spanish-speaking parents reported higher levels of intent to vaccinate their sons within the next year and different main reasons for not intending to vaccinate. These findings are similar to those of our prior analyses of Hispanic adolescent females. Lack of knowledge and lack of a provider recommendation were the most common main reasons for not intending to vaccinate among Spanish-speaking parents, whereas believing vaccination is not needed was the most common main reason among parents whose preferred language was English. These findings suggest that future HPV vaccine interventions for Hispanic males should be prepared to address different potential barriers to vaccination based on preferred language.
The results of the current study also suggested that HPV vaccine initiation was more common among the sons of parents whose preferred language was Spanish (P<.10 in multivariate analyses). This is somewhat surprising because past studies examining HPV vaccination among Hispanic individuals found lower HPV vaccine coverage among Hispanics with less US acculturation.[36, 37] The finding of the current study may be attributable to several factors, including differences between English-speaking and Spanish-speaking individuals in terms of health care use, attitudes and beliefs regarding the HPV vaccine, and VFC eligibility. Although we were not able to examine VFC eligibility, Spanish-speaking parents were more likely to be from households that were below the poverty level (which was correlated with HPV vaccine initiation in multivariate analyses) and to have sons without health insurance (both P<.05). Both factors may have made the sons of Spanish-speaking parents eligible for the VFC program. Future research using more sophisticated measures of acculturation is needed to further understand how acculturation (and which domains of acculturation) may affect HPV vaccination outcomes.
The current study had several important strengths, including a large sample of Hispanic adolescent males from throughout the United States, HPV vaccination data based on health care provider records, and examining variables that may be especially relevant to the Hispanic population (eg, parents' preferred language [a proxy for acculturation]). The correlations observed in the current study need to be verified in longitudinal studies, particularly to establish the temporal relationships between vaccination and correlates that can change over time (eg, poverty status). The NIS-Teen public use data sets did not contain information regarding country of origin among Hispanics (eg, Mexican, Cuban, etc) or VFC eligibility (not available for 201222). We believe it is important for these data to be available in future public use NIS-Teen data sets to allow for their inclusion in analyses.
Current HPV vaccine coverage among Hispanic adolescent males is modest but has increased substantially in recent years. Ensuring health care visits and increasing provider recommendations for vaccination at such visits will be important for continuing this increasing trend. Preferred language may also be important for increasing HPV vaccination, and future programs targeting this population need to consider how potential barriers to vaccination may differ by acculturation.
Funded by Cervical Cancer-Free America, via an unrestricted educational grant from GlaxoSmithKline. Additional support was provided by the National Cancer Institute (P30CA016058 and R25CA57726).
CONFLICT OF INTEREST DISCLOSURES
Drs. Reiter, Brewer, Paskett, and Smith have received research grants from Merck Sharp & Dohme Corporation. Dr. Brewer has received grants from GlaxoSmithKline, served on paid advisory boards, and served as a paid speaker for Merck Sharp & Dohme Corporation and received both personal fees and nonfinancial support. Dr. Smith has received unrestricted educational grants, served on paid advisory boards, and served as a paid speaker for GlaxoSmithKline.