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Figure 1.  Knowledge of Human Papillomavirus (HPV) Infection, HPV Vaccination, and the Relationship Between HPV and Cancer
Knowledge of Human Papillomavirus (HPV) Infection, HPV Vaccination, and the Relationship Between HPV and Cancer

Participants responded yes to: Have you ever heard of HPV?”; “Before today, have you ever heard of the cervical cancer vaccine or HPV shot?”; and “Do you think HPV can cause cervical/oral/anal/penile cancer?”

aP < .05.

bP < .001.

Figure 2.  Receipt of Human Papillomavirus (HPV) Vaccine Recommendation From Health Care Professional to Vaccine-Eligible Persons or Those With Vaccine-Eligible Family Members
Receipt of Human Papillomavirus (HPV) Vaccine Recommendation From Health Care Professional to Vaccine-Eligible Persons or Those With Vaccine-Eligible Family Members

Participants responded yes to: “In the last 12 months, has a doctor or health care professional recommended that you or someone in your immediate family get an HPV shot or vaccine?”

aP < .001.

bP < .05.

1.
Walker  TY, Elam-Evans  LD, Yankey  D,  et al.  National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years: United States, 2017.  MMWR Morb Mortal Wkly Rep. 2018;67(33):909-917. doi:10.15585/mmwr.mm6733a1PubMedGoogle ScholarCrossref
2.
Holman  DM, Benard  V, Roland  KB, Watson  M, Liddon  N, Stokley  S.  Barriers to human papillomavirus vaccination among US adolescents: a systematic review of the literature.  JAMA Pediatr. 2014;168(1):76-82. doi:10.1001/jamapediatrics.2013.2752PubMedGoogle ScholarCrossref
3.
Finney Rutten  LJ, Davis  T, Beckjord  EB, Blake  K, Moser  RP, Hesse  BW.  Picking up the pace: changes in method and frame for the health information national trends survey (2011-2014).  J Health Commun. 2012;17(8):979-989. doi:10.1080/10810730.2012.700998PubMedGoogle ScholarCrossref
4.
FDA approves expanded use of Gardasil 9 to include individuals 27 through 45 years old [news release]. Silver Spring, MD: US Food & Drug Administration; October 5. 2018. https://www.fda.gov/news-events/press-announcements/fda-approves-expanded-use-gardasil-9-include-individuals-27-through-45-years-old?utm_campaign=10052018_PR_FDA+approves+expanded+use+of+Gardasil+9+to+include+individuals+27+through+45+years+old. Accessed August 7, 2019.
5.
Daley  EM, Vamos  CA, Thompson  EL,  et al.  The feminization of HPV: how science, politics, economics and gender norms shaped U.S. HPV vaccine implementation.  Papillomavirus Res. 2017;3:142-148. doi:10.1016/j.pvr.2017.04.004PubMedGoogle ScholarCrossref
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    Research Letter
    September 16, 2019

    Public Knowledge of Human Papillomavirus and Receipt of Vaccination Recommendations

    Author Affiliations
    • 1Center for Health Services Research, Department of Management, Policy and Community Health, UTHealth School of Public Health, Houston, Texas
    • 2Department of Pediatrics, Baylor College of Medicine, Houston, Texas
    • 3Massachusetts General Hospital Institute for Technology Assessment, Harvard Medical School, Boston
    • 4Clinical Cancer Center/Center for AIDS Intervention Research, Medical College of Wisconsin, Milwaukee
    • 5Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston
    • 6Center for Healthcare Data, Department of Management, Policy and Community Health, UTHealth School of Public Health, Houston, Texas
    JAMA Pediatr. 2019;173(11):1099-1102. doi:10.1001/jamapediatrics.2019.3105

    Human papillomavirus (HPV) vaccination coverage (48.6% in 2017) in the United States remains far below the Healthy People 2020 goal of 80%, and a 10% difference in coverage between boys (44.3%) and girls (53.1%) has been reported.1 Knowledge of HPV among vaccine-eligible individuals and their parents is critical to vaccine uptake. Furthermore, the recommendation to receive an HPV vaccine from health care professionals can help parents in their decision-making to vaccinate children.2 Therefore, we evaluated the national-level estimates of (1) HPV knowledge and (2) receipt of HPV vaccine recommendation from a health care professional.

    Methods

    We performed a cross-sectional analysis of the Health Information National Trend Survey (HINTS-5) data, cycles 1 (conducted between January and May 2017) and 2 (conducted between January and May 2018). Analysis was conducted from December 1, 2018, to February 29, 2019. HINTS is a nationally representative survey administered by the National Cancer Institute that collects data on health-related behaviors and knowledge among US adults.3 We evaluated questions regarding (1) knowledge of HPV, HPV vaccine, and the relationship between HPV and cervical, oral, anal, and penile cancers and (2) receipt of HPV vaccine recommendation from a health care professional among vaccine-eligible persons and those with vaccine-eligible family members. Given the current vaccination age eligibility criteria and the recent approval of the HPV vaccination for adults aged 27 to 45 years,4 the outcomes were estimated for 3 age groups: (1) age 18 to 26 years (vaccine-eligible), (2) age 27 to 45 years (vaccine-approved), and (3) 46 years and older (not eligible/approved). This study was deemed exempt from review by the institutional review board of the University of Texas Health Science Center because it uses publicly available deidentified data.

    Descriptive statistics were computed to describe HPV knowledge and receipt of an HPV vaccine recommendation. A survey-design adjusted Wald F test was used for bivariate analyses. All analyses were conducted using SAS software, version 9.4 (SAS Institute) and were adjusted for sample weights and the complex survey design. Statistical significance was assessed at 2-sided P < .05.

    Results

    A total of 2564 men and 3697 women responded to HPV knowledge questions in HINTS-5. Fewer men aged 18 to 26 years (vaccine-eligible) were knowledgeable about HPV (men: 53.6% [95% CI, 36.2%-71.0%] vs women: 80.3% [95% CI, 71.5%-89.1%]; P < .05) and the HPV vaccine (men: 52.7% [95% CI, 36.9%-68.4%] vs women: 79.0% [95% CI, 70.3%-87.8%]; P < .05) than women (Figure 1A). Overall, 60.1% (95% CI, 43.0%-77.2%) of men and 31.6% (95% CI, 21.4%-41.7%) of women in this age category did not know that HPV causes cervical cancer. In addition, 92.2% (95% CI, 87.1%-97.3%), 89.0% (95% CI, 82.7%-95.4%), and 84.7% (95% CI, 74.1%-95.2%) of men and 79.4% (95% CI, 68.6%-90.3%), 77.8% (95% CI, 66.5%-89.1%), and 77.6% (95% CI, 66.8%-88.4%) of women did not know that HPV causes anal, penile, or oral cancers, respectively.

    Among individuals aged 27 to 45 years, HPV and HPV vaccination knowledge was lower among men than women (Figure 1B): HPV (67.7% [95% CI, 62.3%-73.1%] vs 86.4% [95% CI, 82.7%-90.0%]; P < .001), HPV vaccination (56.1% [95% CI, 50.2%-62.0%] vs 81.0% [95% CI, 76.4%-85.5%]; P < .001). Over half of men and women did not know that HPV causes anal, penile, and oral cancers. The proportion of men vs women who were not knowledgeable about the relationship between HPV and cancers is as follows: cervical (47.4% [95% CI, 41.3%-53.5%] vs 23.9% [95% CI, 19.4%-28.5%]; P < .001), anal (79.4% [95% CI, 73.3-85.4] vs 75.2% [95% CI, 70.9%-79.6%]; P = 0.31), penile (80.5% [95% CI, 75.6%-85.4%] vs 72.0% [95% CI, 67.2-76.7]; P < .05), and oral (81.7% [95% CI, 77.3%-86.1%] vs 72.8% [95% CI, 68.5%-77.2%]; P < .05).

    A similar level of knowledge and significant sex differences were observed among individuals 46 years and older (Figure 1C). Notably, an overwhelming number of individuals in this age group were not knowledgeable about HPV and HPV vaccine. The proportion of men vs women not knowledgeable were: HPV (54.7% [95% CI, 51.2%-58.1%] vs 34.9% [95% CI, 32.3%-37.5%]; P < .001), HPV vaccine (55.2% [95% CI, 51.3%-59.1%] vs 30.4% [95% CI, 27.9%-32.9%]; P < .001), HPV and cervical cancer (65.6% [95% CI, 62.1%-69.2%] vs 45.7% [95% CI, 43.2%-48.1%]; P < .001), HPV and anal cancer (87.3% [95% CI, 84.9%-89.7%] vs 81.9% [95% CI, 79.6%-84.2%]; P < .001), HPV and penile cancer (84.7% [95% CI, 81.8%-87.5%] vs 78.9% [95% CI, 76.6%-81.3%]; P < .001), and HPV and oral cancer (86.4% [95% CI, 83.8%-88.9%] vs 80.2% [95% CI, 77.8%-82.5%]; P < .001).

    Results for receipt of HPV vaccine recommendations from a health care professional in the subgroup of vaccine-eligible persons or those with vaccine-eligible family members are presented in Figure 2. Overall, fewer men (19% [95% CI, 15.2%-22.8%]) than women (31.5% [95% CI, 28.1%-34.9%]) received an HPV vaccine recommendation (P < .001).

    Discussion

    Findings from this national survey revealed that men are less knowledgeable than women about HPV, HPV vaccination, and the relationship between HPV and cancer. Low HPV knowledge in men may be attributed to the message framing of HPV vaccination campaigns that historically have focused on cervical cancer prevention in women.5 Notably, more than 70% of US adults irrespective of their age and sex did not know that HPV causes oral, anal, and penile cancers.

    In particular, the lack of HPV knowledge among adults aged 27 to 45 years and 46 years and older is concerning given that adults in these age groups are (or will likely be) the parents responsible for making HPV vaccination decisions for their children. Effective communication between patients and clinicians regarding the importance of HPV vaccination for cancer prevention is crucial to address this issue. A limitation of our study is that the data are self-reported and may be prone to recall bias. In summary, educational campaigns that target both sexes and convey the benefits of HPV vaccination for cancer prevention are urgently needed to accelerate HPV vaccine initiation and completion in the United States.

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    Article Information

    Corresponding Author: Ashish A. Deshmukh, PhD, MPH, Center for Health Services Research, Department of Management, Policy and Community Health, UTHealth School of Public Health, 1200 Pressler St, RAS-E 329, Houston, TX 77030 (ashish.a.deshmukh@uth.tmc.edu).

    Accepted for Publication: June 25, 2019.

    Published Online: September 16, 2019. doi:10.1001/jamapediatrics.2019.3105

    Author Contributions: Dr Deshmukh had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Drs Sonawane and Deshmukh contributed equally to this work.

    Concept and design: Suk, Sonawane, Deshmukh.

    Acquisition, analysis, or interpretation of data: All authors.

    Drafting of the manuscript: Suk, Richards Montealegre, Sonawane, Deshmukh.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Suk, Sonawane.

    Obtained funding: Deshmukh.

    Administrative, technical, or material support: Nyitray, Schmeler, Deshmukh.

    Supervision: Sonawane, Deshmukh.

    Conflict of Interest Disclosures: Dr Deshmukh received consulting fees from Merck on unrelated projects outside the submitted work. No other disclosures were reported.

    Funding/Support: Research reported in this publication was supported by the National Cancer Institute of the National Institutes of Health (award R01CA232888).

    Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

    References
    1.
    Walker  TY, Elam-Evans  LD, Yankey  D,  et al.  National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years: United States, 2017.  MMWR Morb Mortal Wkly Rep. 2018;67(33):909-917. doi:10.15585/mmwr.mm6733a1PubMedGoogle ScholarCrossref
    2.
    Holman  DM, Benard  V, Roland  KB, Watson  M, Liddon  N, Stokley  S.  Barriers to human papillomavirus vaccination among US adolescents: a systematic review of the literature.  JAMA Pediatr. 2014;168(1):76-82. doi:10.1001/jamapediatrics.2013.2752PubMedGoogle ScholarCrossref
    3.
    Finney Rutten  LJ, Davis  T, Beckjord  EB, Blake  K, Moser  RP, Hesse  BW.  Picking up the pace: changes in method and frame for the health information national trends survey (2011-2014).  J Health Commun. 2012;17(8):979-989. doi:10.1080/10810730.2012.700998PubMedGoogle ScholarCrossref
    4.
    FDA approves expanded use of Gardasil 9 to include individuals 27 through 45 years old [news release]. Silver Spring, MD: US Food & Drug Administration; October 5. 2018. https://www.fda.gov/news-events/press-announcements/fda-approves-expanded-use-gardasil-9-include-individuals-27-through-45-years-old?utm_campaign=10052018_PR_FDA+approves+expanded+use+of+Gardasil+9+to+include+individuals+27+through+45+years+old. Accessed August 7, 2019.
    5.
    Daley  EM, Vamos  CA, Thompson  EL,  et al.  The feminization of HPV: how science, politics, economics and gender norms shaped U.S. HPV vaccine implementation.  Papillomavirus Res. 2017;3:142-148. doi:10.1016/j.pvr.2017.04.004PubMedGoogle ScholarCrossref
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