Human Papillomavirus Awareness by Educational Level and by Race and Ethnicity

Key Points Question Does human papillomavirus (HPV) awareness differ by educational attainment and race and ethnicity? Findings In this cross-sectional study of the Health Information National Trends Survey (2017-2020) data among US adults, HPV awareness varied by educational level and by race and ethnicity. Among adults who were aware of HPV, knowledge that HPV causes cervical cancer differed by educational level and by race and ethnicity; less than one-third of the population knew HPV could cause noncervical cancers, which differed by educational level but not by race and ethnicity. Meaning These findings suggest that educational attainment and race and ethnicity should be considered when designing HPV campaigns to expand knowledge opportunities for HPV-related cancers prevention.


Introduction
Human papillomavirus (HPV) is the most common sexually transmitted infection in the US. 1 Persistent high-risk HPV type infections can lead to the development of cancer at multiple anatomical sites, including the cervix, anus, vulva, vagina, penis, and oropharynx. 2 Human papillomavirus vaccines protect against several carcinogenic HPV genotypes and constitute a wellresearched, evidence-based primary prevention strategy that has the potential to reduce many HPVdriven cancers.
[5] Sociodemographic characteristics, such as identifying with a historical racial and ethnic minority group or having a lower socioeconomic status, have been associated with less HPV awareness and knowledge. 6[13][14] Although many US-based studies report prevalence of HPV awareness and knowledge either by educational level alone [15][16][17] or race and ethnicity alone, 6,11,[18][19][20][21][22][23] few studies have attempted to disentangle the intersection of these highly colinear variables on HPV awareness and knowledge.
Intersectionality refers to the compounding effect of several social attributes that may result in widening disparities and inequalities. 24It is essential to recognize that race and ethnicity, although crucial factors, serve as proxies for many unmeasured social and structural variables.These variables may encompass factors such as access to health care, socioeconomic status, cultural influences, and systemic bias, which play a pivotal role in shaping individual awareness and knowledge related to HPV.
We estimated the weighted prevalence of HPV awareness, HPV vaccine awareness, and knowledge that HPV can cause cancer, by educational attainment, race and ethnicity, and the intersection of educational attainment and race and ethnicity during 2017 to 2020.As a secondary analysis, we assessed temporal trends across survey cycles to examine whether HPV awareness and knowledge by educational attainment and race and ethnicity have improved in recent years.

Data Source
We used self-reported data from the Health Information National Trends Survey (HINTS), obtained by merging HINTS-5 cycles 1 to 4 (January 26, 2017, to June 15, 2020).HINTS is a nationally representative survey that is administered by the National Cancer Institute through mailed questionnaires. 25Participants were chosen through a complex stratified, random sampling procedure among households from a nationwide list of addresses.The survey includes adults 18 years or older in the civilian, noninstitutionalized US population.HINTS collects information on the knowledge of, attitudes toward, and use of health-related information.Regarding HPV, the survey includes questions about HPV awareness, HPV vaccine awareness, and knowledge of HPV-related cancers.We restricted the analysis to cycles 1 to 4 because these surveys included overlapping questions on HPV awareness and knowledge.
HINTS was reviewed by the Westat Institutional Review Board and was deemed exempt from review and informed consent by the US National Institutes of Health Office of Human Subjects Research Protections.Our study used publicly available data with deindividualized information and followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Additional information on the HINTS survey design and methodology are found elsewhere. 25

Primary Outcomes
Our primary outcomes were (1) awareness of HPV and HPV vaccines and (2) knowledge that HPV causes cancers of the cervix, penis, anus, and oropharynx, as measured by questions in eTable 1 in Supplement 1. Specifically, HPV awareness was assessed by the question, "Have you ever heard of HPV?" while HPV vaccine awareness was assessed by the question, "Before today, have you heard of the cervical cancer vaccine or HPV shot?"Among those who had heard of HPV (ie, were aware of HPV), knowledge of HPV-related cancers was assessed by the question, "Do you think HPV can cause (a) cervical (b) penile (c) anal (d) oral cancer?"The questionnaire did not include questions pertaining to other HPV-associated cancers (eg, vulvar and vaginal cancer).All outcomes were dichotomized (yes vs no or not sure).

Sociodemographic Characteristics
Our main independent variables were (1) highest level of educational attainment (less than high school [<8 years of schooling or 8 through 11 years of schooling], high school graduate [12 years of schooling or completed high school], some college [including postsecondary vocational or technical schooling], and college degree or higher) and (2) self-reported race and ethnicity (Asian, Black, Hispanic, White, and other race or ethnicity [including American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and more than 1 race or ethnicity]) (eTable 1 in Supplement 1).We combined American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and more than 1 race or ethnicity into 1 group due to low sample sizes for these individual groups.We considered several sociodemographic characteristics self-reported by participants on the survey: age group (18-34, 35-44, 45-54, 55-64, 65-75, and Ն76 years), sex (male or female), annual household income (Յ$34 999, $35 000-$74 999, and Ն$75 000), marital status (married or living as married; divorced, widowed, or separated; and single), sexual orientation (heterosexual; gay, lesbian, or bisexual; and other), and insurance status (uninsured and insured).

Statistical Analysis
HINTS data were analyzed from December 12, 2022, to June 20, 2023.For all analyses, sampling weights were applied using the jackknife method to account for the complex sampling design of the survey. 25We described the distribution of sociodemographic characteristics stratified by educational attainment and by race and ethnicity.Weighted prevalence of HPV awareness and knowledge were calculated for the overall analytic population and stratified by educational attainment and by race and ethnicity.Analyses for each outcome were treated separately.Participants with missing data on educational attainment (2.8%) were excluded from the education-stratified analysis, and those with missing race and ethnicity data (10.2%)were excluded from the race and ethnicity-stratified analysis (eFigure 1 in Supplement 1).Because slightly over 10% of participants had missing race and ethnicity information, we conducted a sensitivity analysis, comparing characteristics of those with complete race and ethnicity information with all participants regardless of missing race and ethnicity data (eTable 2 in Supplement 1).The demographic characteristics were comparable between samples, indicating that our analysis did not have selection bias.
For the education-stratified analysis, weighted adjusted odds ratios (AORs) and 95% CIs were estimated using logistic regression, adjusting for confounders determined a priori, including age group, sex, marital status, and race and ethnicity.For the race and ethnicity-stratified analysis, AORs were calculated, adjusting for age group, sex, marital status, and educational attainment.To determine whether there was a linear association between educational attainment and HPV awareness and knowledge, P values for trend were calculated by treating educational attainment as a continuous variable.To determine whether there were significant differences in HPV awareness and knowledge across racial and ethnic groups, P values for heterogeneity were calculated using a Wald test.
To examine the intersection of educational attainment and race and ethnicity, we estimated weighted prevalence of HPV awareness, HPV vaccine awareness, and knowledge that HPV causes Last, we estimated temporal trends in HPV awareness and knowledge for all outcomes across the survey cycle for each educational level and race and ethnicity using logistic regression, treating survey cycle (year) as a continuous variable.Due to small sample sizes of participants obtaining an educational level of less than high school after stratifying by race and ethnicity, we grouped the last educational category as high school graduate or less for both the intersection analysis and the time trends analysis.Two-sided P < .05 was considered statistically significant.All analyses were conducted using Stata, version 17, software (StataCorp LLC).

Sociodemographic Characteristics
A total of 15 637 HINTS participants had data on educational attainment; of these, 51
Among adults who were aware of HPV, knowledge that HPV causes penile, anal, and oropharyngeal cancer was low and did not differ by racial and ethnic groups (eg, range for anal cancer, 21

Intersectionality of Educational Attainment and Race and Ethnicity
The interactions between educational attainment and race and ethnicity on HPV awareness, HPV vaccine awareness, and knowledge that HPV causes cervical cancer were not significant; however, disparities in HPV awareness and knowledge still existed across each intersection (Table 2).
Specifically, among each educational level, HPV awareness and HPV vaccine awareness differed by race and ethnicity, with the lowest awareness consistently among Asian individuals regardless of educational attainment (eg, 27.4% [95% CI, 14.0%-46.7%]for HPV awareness for those attaining a high school education or less); for example, among individuals with some college education, 38.0% (95% CI, 23.4%-55.1%) of Asian individuals were aware of HPV compared with 71.5% (95% CI, 68.5%-74.4%) of White individuals (P < .001for heterogeneity).Among each racial and ethnic group, lower levels of educational attainment were associated with less HPV awareness and HPV vaccine awareness; for example, among Hispanic individuals, 80.5% (95% CI, 75.8%-84.4%)with a college degree or higher were aware of HPV compared with 45.0% (95% CI, 39.7%-50.5%)with a high school education or less (P < .001for trend).Among adults who were aware of HPV, knowledge that HPV can cause cervical cancer differed by race and ethnicity among those with a college degree or higher (range, 77 a Data are from Health Information Trends Survey 5 cycles 1 to 4 (2017-2020).
b Indicates number of individuals with the outcome of interest (eg, responded "yes" to having heard of HPV)/total number of individuals in each population of interest for each outcome (eg, all Hispanic individuals who obtained a college degree or higher and responded to the HPV awareness question).
c Includes American Indian or Alaska Native, Native Hawaiian or Other Pacific Islander, and more than 1 race or ethnicity.
d Among individuals who were aware of HPV.

Figure 2 .AOR
Figure 2. Trends in Human Papillomavirus (HPV) Awareness and Knowledge by Educational Attainment and Race and Ethnicity, 2017 to 2020 Human Papillomavirus Awareness by Educational Level and by Race and Ethnicity Questions regarding penile, anal, and oral cancer were not included in the intersection analysis due to lack of power; the overall prevalence of knowledge that HPV causes noncervical cancers was low.The interaction between educational attainment and race and ethnicity on HPV awareness and knowledge outcomes was assessed using a Wald test, adjusting for age group, sex, and marital status.

Table 1 .
Sociodemographic Characteristics by Educational Attainment a for all cancer types (eg,21.5% [95% CI, 14.5%-30.6%] of individuals with less than high school compared with 30.7% [95% CI, 28.8%-32.6%] of those with a college degree or higher knew HPV can cause anal cancer) (P = .002fortrend).Across survey cycles, knowledge that HPV causes cervical cancer significantly declined over time for all educational levels, most notably for individuals with a high school education or less (AOR, 0.8 [95% CI, 0.7-0.9];P=.002fortrend).(Figure2).Knowledge that HPV causes penile, anal, and oropharyngeal cancer remained stable and low over time for all educational attainment levels (eFigure 2 in Supplement 1).