Disclosures: The authors have no disclosures to report.
Human Papillomavirus Vaccine Awareness, Uptake, and Parental and Health Care Provider Communication Among 11- to 18-Year-Old Adolescents in a Rural Appalachian Ohio County in the United States
Article first published online: 8 JUL 2014
© 2014 National Rural Health Association
The Journal of Rural Health
Volume 31, Issue 1, pages 67–75, Winter 2015
How to Cite
Bhatta, M. P. and Phillips, L. (2015), Human Papillomavirus Vaccine Awareness, Uptake, and Parental and Health Care Provider Communication Among 11- to 18-Year-Old Adolescents in a Rural Appalachian Ohio County in the United States. The Journal of Rural Health, 31: 67–75. doi: 10.1111/jrh.12079
Acknowledgments: We would like to thank Ms. Jennifer Burns and Mr. John McCall of the County Children and Family First Council and Ms. Susie Frew and Mr. Nicholas Cascarelli of the County General Health District for their collaboration in conducting the study. We would also like to thank the middle school students and their parents for their participation in and support of the survey.
- Issue published online: 26 DEC 2014
- Article first published online: 8 JUL 2014
- HPV vaccine awareness;
- parental or health care provider communication;
- rural Appalachia;
This study examined human papillomavirus (HPV) vaccine awareness and uptake, and communication with a parent and/or a health care provider among 11- to 18-year-old male and female adolescents in an Appalachian Ohio county.
Five questions regarding the HPV vaccine were added to the 2012 Youth Risk Behavior Surveillance System (YRBSS) surveys administered to middle and high school students in the county. The YRBSS surveys are school-based, anonymous, and voluntary. The questions added were about vaccine awareness and uptake, and communication with a parent or health care provider about the vaccine.
Of the 1,299 participants, 51.9% were male and 90.3% were white. Overall, 49.2%, 23.5%, 19.2%, and 24.6%, respectively, reported vaccine awareness, uptake of at least 1 dose of the HPV vaccine, communication with a parent, and communication with a health care provider. Females and adolescents ≥15 years were significantly more likely to report awareness, uptake, and parental and provider communication than males and adolescents ≤14 years. Adolescents receiving any dose of the vaccine were significantly more likely to have had a parent (OR: 3.74; 95% CI: 2.30-6.06) or a health care provider (OR: 10.91; 95% CI: 6.42-18.6) discuss the vaccine than those who had not received any dose.
Despite the strong link between parental and health care provider communication and HPV vaccine uptake, the levels of communication remain low in this Appalachian population. These findings suggest the need for public health education programs targeting the health care providers, the parents, and the adolescents to improve awareness, knowledge, and HPV vaccine uptake.
In 2006, the Advisory Committee on Immunization Practices (ACIP) recommended routine vaccination of girls 11-12 years of age with 3 doses of human papillomavirus (HPV) vaccine, and catch-up vaccination for females aged 13-26 years in the United States. In 2011, the ACIP also recommended the vaccination of boys at 11-12 years of age with 3 doses of the quadrivalent HPV vaccine, and catch-up vaccination up to 26 years of age. After a 5-year increase in the vaccination coverage with at least one dose of any HPV vaccine in adolescent girls aged 13-17 years, the US vaccine coverage rate in 2012 stagnated near the 2011 level of 53.0%. The 3-dose vaccine completion rate for adolescent girls aged 13-17 years plateaued around 33% during 2010-2012. While data on HPV vaccination coverage among adolescent boys are limited, the national estimate of at least 1 dose of HPV vaccine uptake is around 10%.
The national data, however, do not adequately reflect a significant geographical disparity in HPV vaccination coverage rates, at least among adolescent girls. HPV vaccine initiation and completion rates in certain high cancer risk populations, such as the residents of the Appalachian region in the United States, are significantly lower than the national rates. Appalachia, a predominantly rural and medically underserved area, in general, has higher incidences of cervical and other HPV-related cancers than non-Appalachian regions. Between 1996 and 2008, the cervical cancer rates in West Virginia and the Appalachian region of Kentucky, the 2 adjacent Appalachian regions to Ohio, were 12.4 and 11.1 per 100,000 compared to the US rate of 7.7 per 100,000. The cervical cancer disparity is similar in Ohio where the state's Appalachian region has a significantly higher incidence of cervical cancer than the non-Appalachian region. Specifically, the cervical cancer incidence rate in Ohio Appalachia, an eastern and southeastern region consisting of roughly one-third of the counties in the state, was 10.9 per 100,000 during 1996-2008 compared to 8.1 per 100,000 in non-Appalachia Ohio. These statistics point to the cervical cancer disparities existing throughout the region, and highlight the importance of understanding the vaccination rates and barriers in these high-risk populations. This understanding is important for planning targeted public health programs to reduce the burden of HPV-related cancers in these populations.
Various factors, such as vaccine safety and efficacy concerns, lack of knowledge or misinformation about the vaccine, and financial and logistical issues have been shown to influence whether or not a child receives the HPV vaccine.[8-15] Moreover, previous studies have also shown that health care provider recommendation is one of the strongest predictors of HPV vaccine initiation and completion among adolescents.[8-15] Nationally, the proportion of parents reporting that a health care provider recommended the HPV vaccine for their adolescents remains low, especially for boys.[8, 9, 15] Limited data suggest that health care providers in Appalachia, particularly pediatricians, are even less likely to recommend HPV vaccination to their adolescent patients than those from non-Appalachian regions.
Although parents of minors give the consent to vaccinate, adolescents play an increasingly important role in the vaccination decision-making process.[17-19] The extent to which parents are having conversations about the HPV vaccine with their adolescent children is not well documented. Moreover, most knowledge and behavior studies about the HPV vaccine have queried parents only,[9, 15, 20] rather than including the adolescents, and the majority of studies that do ask the adolescents questions have focused primarily on girls.[17, 19, 21]
Now that the HPV vaccine has been approved and in use in the United States for females since 2006 and for males since 2009, it is important to determine how aware all adolescents are of the vaccine, and whether they are communicating with their parents and health care providers about the HPV vaccine. This study, therefore, has 2 purposes. The first is to examine the levels of adolescent HPV vaccine awareness, uptake, and parental and health care provider communication. The second is to assess the relationship between the parental communication and health care provider communication regarding the HPV vaccine, and the vaccine uptake from the 11- to 18-year-old male and female adolescent perspective in an Appalachian County in Ohio.
Materials and Methods
Study Design and Population
The study county is located in Northeast Ohio Appalachia and based on the following 2 definitions: either the majority or the entire country population is designated as rural. Seventy-one percent of the county population and 98.5% of the land area was designated as rural using the US Census Bureau's 2010 rural classification of populations living outside urban clusters of at least 2,500 people. Using the alternative rural definition as places outside census urban areas with populations greater or equal to 10,000, the entire county population was designated as rural. A secondary data analysis of the modified 2012 Middle and High School Youth Risk Behavior Surveillance System (YRBSS) surveys administered by the local county health department, and the County Family and Child First Council was performed to assess HPV vaccine knowledge, uptake, and parental and health care provider communication among middle (6th-8th grades) and high school (9th-12th grades) students. The 2 county agencies conduct the YRBSS survey every 3 years to assess the youth risk behaviors in the county for public health program planning purposes. The survey is self-administered, anonymous, and voluntary. Two weeks prior to survey administration in the classrooms, parents were sent a letter with an opt-out form should they not want their child to participate in the survey. Parents also had the option to review the survey in each school. Both public school systems in the county agreed to participate and were included in the survey. Of 722 middle and 1,027 high school students in the public school systems in the county, 593 (82.1%) and 706 (68.7%), respectively, participated in the survey. The study was approved by the Kent State University Institutional Review Board.
The 5 HPV-related questions included in the modified YRBS survey were: (1) Before today, had you ever heard of the cervical cancer or genital warts vaccine, HPV shot, HPV vaccine, Gardasil or Cervarix? (HPV awareness); (2) Has a doctor, nurse or other health care provider ever talked to you about HPV shots (vaccine)? (Health care provider communication); (3) Have your parents ever talked to you about HPV shots (vaccine)? (Parental communication); (4) Have you received the HPV shots (vaccine)? (HPV vaccine uptake); and (5) If you have received the HPV shots (vaccine), how many shots have you received? The survey instrument also contained demographic and health risk behavior questions.
The primary outcome of interest in the study was HPV vaccine uptake defined as having received at least one dose of either bivalent or quadrivalent HPV vaccine. To measure HPV vaccine uptake, participants were asked to respond “yes,” “no” or “don't know/not sure” to the question, “Have you received the HPV shots (vaccine)?” The possible responses to the HPV awareness, and parental and health care provider communication questions included “yes,” “no,” and “don't know/not sure” as well. Demographic characteristics measured included age, sex, grade, and race/ethnicity.
Overall and sex-specific descriptive analyses were performed for the demographic and HPV-related variables. Pearson's chi-square test was used to assess the difference in demographic and HPV-related factors between males and females, and the appropriate P values are reported. HPV uptake was dichotomized as “Yes” or “No” (“don't know/not sure” responses were excluded; n = 393) in analyses assessing the relationship of HPV uptake with the potential explanatory variables. Univariate analyses using the Pearson's chi-square test were performed to assess the relation of HPV uptake with the demographic characteristics, and parental and health care provider communication. Multivariable logistic regression models examined the overall and sex-specific relationship of HPV uptake with parental and health care provider communication while controlling for demographic variables. The adjusted odds ratios (OR) and associated 95% confidence intervals (CI) are reported. Data analysis was performed using SAS 9.3.1 (SAS Institute Inc., Cary, North Carolina).
Of 1,299 adolescents who completed the survey, 674 (51.9%) were male and 90.3% non-Hispanic white. Female respondents were significantly more likely to be white than male respondents (92% vs 88.7%; P = .046). Since only 3% of respondents were 11 years of age, they were combined with 12-year-olds in further analyses; thus, the 11- to 12-year-old age group included 16.7% of the total sample. Nine percent of respondents were 18 years of age, and they were combined with 17-year-olds for a total of 21.7% of the sample. Table 1 presents the overall and sex-specific demographic characteristics of the study sample.
|N (%)||n (%)||n (%)|
|1,299 (100)||674 (51.9)||625 (48.1)||P Value|
|11-12||217 (16.7)||101 (15.0)||116 (18.6)|
|13||204 (15.7)||111 (16.5)||93 (14.9)|
|14||196 (15.1)||97 (14.4)||99 (15.8)|
|15||184 (14.2)||89 (13.2)||95 (15.2)|
|16||216 (16.6)||115 (17.1)||101 (16.2)|
|17-18||282 (21.7)||161 (23.9)||121 (19.4)|
|6||191 (14.7)||96 (14.2)||95 (15.3)|
|7||210 (16.2)||112 (16.6)||98 (15.7)|
|8||192 (14.8)||90 (13.4)||102 (16.4)|
|9||202 (15.6)||103 (15.3)||99 (15.9)|
|10||176 (13.6)||95 (14.1)||81 (13.0)|
|11||203 (15.7)||106 (15.7)||97 (15.6)|
|12||123 (9.5)||72 (10.7)||61 (8.2)|
|White||1,173 (90.3)||598 (88.7)||575 (92.0)|
|Other||126 (9.7)||76 (11.3)||50 (8.0)|
|Know about HPV vaccine||<.0001|
|Yes||631 (49.2)||280 (42.1)||351 (56.8)|
|No||380 (29.6)||243 (36.5)||137 (22.2)|
|Not sure/don't know||272 (21.2)||142 (21.4)||130 (21.04)|
|Parents talked about HPV vaccine||<.0001|
|Yes||248 (19.4)||86 (13.0)||162 (26.3)|
|No||772 (60.4)||438 (66.3)||334 (54.1)|
|Not sure/don't know||258 (20.2)||137 (20.7)||121 (19.6)|
|Health care provider talked about HPV vaccine||<.0001|
|Yes||315 (24.6)||95 (14.4)||220 (35.6)|
|No||650 (50.8)||401 (60.5)||249 (40.4)|
|Not sure/don't know||314 (24.6)||166 (25.1)||148 (24.0)|
|Ever received HPV vaccine||<.0001|
|Yes||206 (16.2)||75 (11.5)||131 (21.3)|
|No||672 (52.9)||384 (58.6)||288 (46.7)|
|Not sure/don't know||393 (30.9)||196 (29.9)||197 (32.0)|
|Number of HPV doses received||<.0001|
|0||695 (57.0)||393 (62.3)||302 (51.3)|
|1||43 (3.5)||24 (3.8)||19 (3.2)|
|2||37 (3.0)||12 (1.9)||25 (4.2)|
|3||52 (4.3)||6 (0.9)||46 (7.8)|
|Don't know/not sure||393 (32.2)||196 (31.1)||197 (33.5)|
HPV Vaccine Awareness
In response to the question of whether they had ever heard of the HPV vaccine, overall, 49.2%, 29.6%, and 21.2% of respondents reported “yes,” “no,” and “don't know/not sure,” respectively. Girls were significantly more likely to report having heard of the HPV vaccine than were boys (P < .001; Table 1). Age was significantly associated with HPV vaccine awareness (P < .001). The proportion of adolescents who knew about the HPV vaccine increased from 17.8% in 11- to 12-year-olds to 27.0% in 13-year-olds and 47.7% in 14-year-olds. Among younger adolescents (≤14 years) girls were significantly more likely to report HPV awareness than boys (36.6% vs 24.0%; P = .0001). Almost two-thirds of older adolescents (≥15 years) reported being aware of the HPV vaccine (64.8%, 64.1%, and 68.4% for 15-, 16-, and 17- to 18-year-olds, respectively). Among adolescents in this age group, girls again were significantly more likely to report HPV awareness than boys (76.2% vs 57.3%; P < .0001).
Parental Communication Regarding HPV Vaccine
Overall, 19.4% of the adolescents indicated having a discussion with their parents about the HPV vaccine, and girls were 2 times as likely to report the parental communication than boys (P < .0001; Table 1). Older adolescents (≥15 years) were significantly more likely to report the parental communication (25.0% vs 13.2%; P < .0001) than younger adolescents (≤14 years). Among older adolescents, 36.1% of girls and 15.1% of boys reported a parent having discussed the HPV vaccine (P < .0001), while among younger adolescents only 16.0% of girls and 10.5% of boys reported parental communication regarding the vaccine (P = .117).
Health Care Provider Communication Regarding HPV Vaccine
Nearly a quarter (24.6%) of the adolescents indicated having a health care provider discuss the HPV vaccine with them; girls were almost 3 times as likely to report this discussion than boys (P < .0001; Table 1). Older adolescents (≥15 years) were significantly more likely to report a health care provider having discussed the HPV vaccine with them than younger adolescents (≤14 years) (34.0% vs 14.2%; P < .0001). Among older adolescents, 51.1% of girls and 18.9% of boys reported health care provider communication (P < .0001), while among younger adolescents 19.5% of girls and 8.9% of boys reported the communication (P < .0001).
HPV Vaccine Uptake
Receiving at least 1 dose of the vaccine was reported by 11.4% of boys and 21.3% of girls (P < .001; Table 1). When those reporting “don't know/not sure” were excluded from the analyses, the vaccine uptake rates for boys and girls were 16.3% and 31.3%, respectively (Table 2). Age was significantly associated with HPV uptake, with 15-year-olds reporting the highest rate (33.1%) and 11- to 12-year-olds reporting the lowest rate (13.5%). Girls were significantly more likely to have received at least 1 dose of the HPV vaccine than boys for every age (P < .0001). The rates of receiving at least 1 dose of the vaccine for girls were nearly double that of boys for both younger (24.9% for girls vs 13.4% for boys; P = .005) and for older (36.0% for girls vs 18.5% for boys; P < .0001) adolescents. Overall, the 3-dose vaccination completion rates were 1.4% for boys and 11.7% for girls. The completion rates were higher for the older adolescents and for girls than for younger adolescents and boys (older age group: 1.6% for boys and 13.9% for girls, P < .0001; younger group: 1.1% for boys and 8.9% for girls, P = .002).
|Received at Least 1 Dose of HPV Vaccine|
|n (%)||n (%)|
|Characteristics||206 (23.5)||672 (76.5)||P value|
|Male||75 (16.3)||384 (83.7)|
|Female||131 (31.3)||288 (68.7)|
|11-12||17 (13.5)||109 (86.5)|
|13||26 (21.5)||95 (78.5)|
|14||27 (21.8)||97 (78.2)|
|15||41 (33.1)||83 (66.9)|
|16||40 (25.2)||119 (74.8)|
|17-18||55 (24.6)||169 (75.5)|
|6||15 (12.4)||106 (87.6)|
|7||28 (25.2)||83 (74.8)|
|8||25 (19.5)||103 (80.5)|
|9||44 (34.4)||84 (65.6)|
|10||32 (24.2)||100 (75.8)|
|11||38 (24.5)||117 (75.5)|
|12||23 (22.8)||78 (77.2)|
|White||186 (88.7)||575 (92.0)|
|Other||20 (11.3)||65 (8.0)|
|Know about HPV vaccine||<.0001|
|Yes||150 (31.6)||325 (68.4)|
|No||32 (10.9)||262 (89.1)|
|Not sure/don't know||24 (22.2)||84 (77.8)|
|Parents talked about HPV vaccine||<.0001|
|Yes||121 (61.4)||76 (38.6)|
|No||65 (10.5)||556 (89.5)|
|Not sure/don't know||19 (32.8)||39 (67.2)|
|Health care provider talked about HPV vaccine||<.0001|
|Yes||148 (59.9)||99 (40.1)|
|No||33 (6.1)||505 (93.9)|
|Not sure/don't know||23 (25.6)||67 (74.4)|
Both parental and health care provider communication were significantly associated with HPV vaccine uptake in this population. A vaccinated adolescent was nearly 4 times more likely to report having spoken with a parent about the vaccine than an unvaccinated one. Similarly, a vaccinated adolescent was over 10 times more likely to report a discussion with a health care provider than an unvaccinated adolescent (Table 3). Vaccinated females were somewhat more likely to indicate that they had spoken with a health care provider (OR = 14.21, 6.47-31.25) than males were (OR = 9.23, 4.40-19.60).
|N = 835||n = 430||n = 405|
|Characteristic||Adjusted odds ratioa (95% confidence interval)|
|11-12||0.76 (0.37-1.57)||0.52 (0.15-1.80)||0.94 (0.37-2.40)|
|13-14||1.25 (0.76-2.06)||1.06 (0.50-2.23)||1.33 (0.67-2.63)|
|15||1.44 (0.80-2.60)||1.36 (0.50-3.71)||1.60 (0.76-3.61)|
|16-18||1.00 (ref)||1.00 (ref)||1.00 (ref)|
|Other||1.56 (0.63-3.86)||1.07 (0.26-4.37)||2.19 (0.58-8.23)|
|White||1.00 (ref)||1.00 (ref)||1.00 (ref)|
|Parents talked about HPV vaccine|
|Yes||3.74 (2.30-6.06)||4.80 (2.26-10.22)||3.24 (1.72-6.12)|
|Not sure/don't know||1.63 (0.78-3.40)||0.83 (0.22-3.12)||2.34 (0.92-5.98)|
|No||1.00 (ref)||1.00 (ref)||1.00 (ref)|
|Health care provider talked about HPV vaccine|
|Yes||10.91 (6.42-18.57)||9.23 (4.40-19.60)||14.21 (6.47-31.25)|
|Not sure/don't know||4.16 (2.09-8.30)||3.64 (1.24-10.72)||5.53 (2.11-14.46)|
|No||1.00 (ref)||1.00 (ref)||1.00 (ref)|
This study examined HPV vaccine awareness, parental, and health provider communication, and HPV vaccine uptake from the adolescent perspective in an Ohio Appalachian county post-ACIP recommendation for HPV vaccination for both males and females. It provides a unique view into these behaviors from the adolescent perspective and focuses on residents of a region with a variety of health disparities. In regard to parental and health care provider communication, our results support those of previous studies indicating that both are strong predictors of HPV vaccination in adolescents.[8-15] While these associations are expected, since minors must have parental approval for vaccination and most vaccines are given at a provider's office, the more salient findings of this study are the low rates of adolescents who reported having had a conversation about the vaccine with a parent or a provider and the low vaccine uptake rates for both males and females. Even though the influence of health care provider discussion is slightly higher in females than in males, this most likely reflects the lower rates of provider recommendation for males compared with females shown by other studies.[26, 27] The findings of this study support the importance of health care providers at clinical encounters discussing the HPV vaccination recommendation with adolescents and their parents starting at 11-12 years of age. In addition to the direct benefit of increased vaccine uptake, the parental and health care provider communication about the vaccine also presents a unique opportunity to actively engage the adolescents in their own health care decision making and to instill sound preventive practices in them.
Despite the growing evidence that health care provider recommendation is a strong predictor of HPV vaccine uptake among adolescents, health care providers are not regularly communicating about the vaccine with adolescent patients and their parents. In our study, only a quarter of the adolescents reported that a health care provider had ever discussed the HPV vaccine with them. Moreover, the reported health care provider communication was even lower for males (14.4%) and younger (≤14 years) adolescents (14.2%) in this population. The continued hesitancy on the part of health care providers to recommend the HPV vaccine, especially for younger adolescents, represents missed clinical opportunities for improving adolescent HPV vaccination coverage.
The reasons for low health care provider communication regarding HPV vaccination in adolescents observed in our study may be due to several factors identified in the studies of physicians nationally and within the Appalachian region.[16, 29] Nationally, physician characteristics such as specialty, age and ethnicity, and perceived barriers such as vaccine safety and efficacy concerns, hesitancy in discussing sexuality, and issues with cost and reimbursement have been found to be associated with the propensity to recommend the HPV vaccine to younger female adolescents. Compared to non-Appalachian pediatricians, Appalachian pediatricians are more likely to perceive their female adolescent patients to be at low risk for HPV infection and report greater difficulty in recommending the HPV vaccine to parents; thus, Appalachian pediatricians are less likely to encourage HPV vaccination than non-Appalachian pediatricians. These perceptions and barriers may be indicators of both the sociocultural environment and the characteristics of the health care providers in Appalachia.[30, 31] A previous study in Appalachia identified the HPV vaccine to be still associated with the belief that it encouraged sexual promiscuity and that young girls receiving the vaccine would be a focus of community gossip. Moreover, pediatricians practicing in Appalachia are significantly more likely to be racial or ethnic minorities (including foreign medical graduates). In the context of the prevailing social and cultural attitude toward the HPV vaccine, ethnic minority pediatricians practicing in a predominantly white population may be reluctant to broach the subject of HPV vaccination, especially for young girls. The low level of health care provider communication regarding the HPV vaccine in our study suggests the need for public health programs and interventions to not only reduce the community misperceptions and beliefs about the vaccine but also to increase the self-efficacy of the health care provider to communicate about the HPV vaccine.
We observed a low rate (19.4%) of adolescents who reported having discussed the HPV vaccine with their parents. Older adolescents (≥15 years) and females were significantly more likely to report having discussed the HPV vaccine with their parents. In this population, parents delaying or not having the conversation at all about the HPV vaccine with their children may reflect a general lack of awareness or knowledge about HPV, HPV-related diseases, and the risk associated with not vaccinating the adolescent. It may also reflect safety and effectiveness concerns about the HPV vaccine, social and cultural attitudes and beliefs regarding sexual behaviors and HPV, or a lack of focus on prevention. The fact that only 1 in 5 parents were reported as having discussed the HPV vaccine points to missing or failing programs and approaches to increase HPV education in this population, and the need to increase or improve public health messaging regarding HPV vaccination.
Improving and increasing community knowledge about the HPV vaccine should not only focus on health care providers and parents but also on the adolescents themselves. Previous studies have shown that adolescents both want to be,[17, 18] and think they should be, included in the vaccine decision-making process. Only half of the adolescents indicated that they knew about the HPV vaccine, indicating a major lack of awareness about the vaccine among adolescents in this population. For them to engage in a meaningful decision-making process about whether to and when to get the vaccine, they must be aware of the potential benefits it provides for their health. Moreover, the nearly one-third of respondents who stated that they were unsure whether or not they had ever received the HPV vaccine could indicate that many adolescents still are not involved in their medical decision making. These results highlight the opportunities for public health interventions focused on increasing HPV and HPV vaccine knowledge and awareness among adolescents. Such interventions have the potential to empower adolescents to engage in the vaccine decision-making process by initiating conversation with their parents and health care providers.
This study represents one of the first county-wide surveys of adolescent HPV vaccine-related behaviors included in the local YRBSS survey, thus providing the adolescent perspective on HPV vaccine-related behaviors. Other strengths include the high response rate, the inclusion of younger adolescents who are in the targeted age range for the vaccine, and the inclusion of males in a region with a high HPV-related cancer burden and low HPV vaccine coverage rates.[6, 7] Finally, the study results provide important population-level data on HPV vaccine-related knowledge and behaviors, and has implications for future research, policy, and practice considerations in the county and surrounding Ohio Appalachia.
In terms of limitations, the study was conducted in only 1 county in Appalachian Ohio; thus the generalizability to a wider region may be limited. The cross-sectional nature of this study precludes any conclusions related to sequence of events in terms of parental and health care provider communication, and vaccine uptake. It may be that the first time a health care provider communicated was at the time of vaccine uptake. This study also did not include a question on intention to get vaccinated, which could have provided an additional layer of information, especially for younger participants whose parents may have been delaying vaccination but still planning on it. However, because the HPV vaccine questions were necessarily added to an existing, and already somewhat lengthy, survey, it was decided that the 5 questions included were optimal to capture new information but still ensure that they would be answered.
Despite the consistent evidence that health care provider recommendation is a strong predictor of HPV vaccination and the ACIP recommendation of vaccination of both male and female adolescents starting at 11-12 years of age, health care provider communication about the HPV vaccine remains low in this Appalachian population. Moreover, parents are not discussing the topic with their adolescents, especially males and younger children, resulting in low vaccine uptake in this population. Our findings suggest the need for public health education programs targeting the health care providers, the parents, and the adolescents to improve awareness, knowledge, and HPV vaccine uptake.
- 1Quadrivalent human papillomavirus vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007;56(RR-2):1-24., , , , , .
- 2Centers for Disease Control and Prevention. Recommendations on the use of quadrivalent human papillomavirus vaccine in males—Advisory Committee on Immunization Practices (ACIP), 2011. MMWR Morb Mortal Wkly Rep. 2011;60(50):1705-1708.
- 3Centers for Disease Control and Prevention. Human papillomavirus vaccination coverage among adolescent girls, 2007-2012, and postlicensure vaccine safety monitoring, 2006-2013—United States. MMWR Morb Mortal Wkly Rep. 2013;62(29):591-595.
- 4Centers for Disease Control and Prevention. National and state vaccination coverage among adolescents aged 13-17 years—United States, 2011. MMWR Morb Mortal Wkly Rep. 2012;61(34):671-677.
- 22US Census Bureau. Census urban and rural classification and urban area criteria. Available at: www.census.gov/geo/reference/ua/urban-rural-2010.html. Accessed April 28, 2014.
- 23USDA Economic Research Service. Rural definitions. Available at: www.ers.usda.gov/datafiles/Rural_Definitions/StateLevel_Maps/OH.pdf. Accessed May 19, 2014.
- 24Centers for Disease Control and Prevention. Adolescent health and school health: questionnaires and item rationales. Available at: www.cdc.gov/healthyyouth/yrbs/questionnaire_rationale.html. Accessed March 26, 2014.
- 25Methodology of the youth risk behavior surveillance system. MMWR Recomm Rep. 2004;53(RR-12):1-13., , , et al.