Human Vaccines & Immunotherapeutics
ISSN: 2164-5515 (Print) 2164-554X (Online) Journal homepage: http://www.tandfonline.com/loi/khvi20
Human papillomavirus vaccination among adolescents in Georgia Natasha L Underwood, Paul Weiss, Lisa M Gargano, Katherine Seib, Kimberly J Rask, Christopher Morfaw, Dennis Murray, Ralph J DiClemente, James M Hughes & Jessica M Sales To cite this article: Natasha L Underwood, Paul Weiss, Lisa M Gargano, Katherine Seib, Kimberly J Rask, Christopher Morfaw, Dennis Murray, Ralph J DiClemente, James M Hughes & Jessica M Sales (2015) Human papillomavirus vaccination among adolescents in Georgia, Human Vaccines & Immunotherapeutics, 11:7, 1703-1708, DOI: 10.1080/21645515.2015.1035848 To link to this article: http://dx.doi.org/10.1080/21645515.2015.1035848
Accepted author version posted online: 27 Apr 2015.
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Date: 14 November 2015, At: 09:24
RESEARCH PAPER Human Vaccines & Immunotherapeutics 11:7, 1703--1708; July 2015; © 2015 Taylor and Francis Group, LLC
Human papillomavirus vaccination among adolescents in Georgia Natasha L Underwood1,*, Paul Weiss2, Lisa M Gargano1, Katherine Seib1, Kimberly J Rask2, Christopher Morfaw3, Dennis Murray4, Ralph J DiClemente2, James M Hughes1, and Jessica M Sales2 1
Emory University School of Medicine; Atlanta, GA USA; 2Emory University; Rollins School of Public Health; Atlanta, GA USA; 3East Central Health District; Augusta, GA USA; 4 Georgia Regents University; Augusta, GA USA
Downloaded by [Monash University Library] at 09:24 14 November 2015
Keywords: attitudes, adolescent, HPV vaccine, Health Belief Model, Theory of Reasoned Action
Human papillomavirus (HPV) vaccination coverage for adolescent females and males remains low in the United States. We conducted a 3-arm randomized controlled trial (RCT) conducted in middle and high schools in eastern Georgia from 2011–2013 to determine the effect of 2 educational interventions used to increase adolescent vaccination coverage for the 4 recommended adolescent vaccines: Tdap, MCV4, HPV and influenza. As part of this RCT, this article focuses on: 1) describing initiation and completion of HPV vaccine series among a diverse population of male and female adolescents; 2) assessing parental attitudes toward HPV vaccine; and 3) examining correlates of HPV vaccine series initiation and completion. Parental attitude score was the strongest predictor of HPV vaccine initiation among adolescents (adjusted odds ratio (aOR): 2.08; 95% confidence interval (CI): 1.80, 2.39). Other correlates that significantly predicted HPV series initiation were gender, study year, and intervention arm. Parental attitudes remained a significant predictor of receipt of 3 doses of HPV vaccine along with gender, race, school type and insurance type. This study demonstrates that positive parental attitudes are important predictors of HPV vaccination and critical to increasing coverage rates. Our findings suggest that more research is needed to understand how parental attitudes are developed and evolve over time.
Introduction In 2006, the Advisory Committee on Immunization Practices (ACIP) recommended routine human papillomavirus (HPV) vaccination for females ages 9–26 after licensure of the quadrivalent vaccine in 2006.1 The quadrivalent vaccine was not licensed for males ages 9–26 until 2009, and ACIP did not provide a routine recommendation for HPV vaccination for males until 2011.2 Despite routine recommendations for males and females as well as numerous marketing and educational campaigns, vaccination rates remain low in the US. HPV vaccination rates are suboptimal compared to other adolescent vaccination rates and are well below the Healthy People 2020 goal of 80% coverage for all adolescent vaccines, both nationally and in Georgia where rates lag even further behind.3 In 2013, coverage of 13–17 y old females in the U.S initiating HPV vaccine series was 57.3% and 34.6% among males.4 Coverage of all 3 doses among US adolescent females was 37.6% and 13.9% among males.4 In 2013, coverage of 13–17 y old females in Georgia initiating the HPV series was 53.7% and 40.5% among males.5 Coverage of all 3 doses among Georgia adolescent females was 33.2% and 15.3% among males.5 Provider recommendations and positive parental attitudes have been shown as important predictors of parents’ decisions to
vaccinate their adolescent against HPV.6-8 Studies have found that among parents, low knowledge of HPV, low perceived susceptibility of adolescents to HPV/sexually transmitted infections, concerns about vaccine safety, and views that HPV vaccination leads to sexual activity were associated with reluctance to allow HPV vaccination.9-11 The objectives of this study were to 1) describe receipt of one and 3 HPV vaccine doses among a diverse population of male and female adolescents; 2) assess parental attitudes toward HPV vaccine; and 3) examine correlates of HPV vaccine series initiation and series completion among a sample of middle and high school adolescents. This study is unique in that it focuses on a racially and economically diverse sample of adolescents coming from a mix of urban and rural schools, whereas previous HPV studies with parents were conducted prior to ACIP recommendations for HPV vaccination of males, focused on female adolescents only, or relied primarily on health care facilities for recruitment.12-15
Results Demographic characteristics and vaccination uptake The majority of adolescents were African American (74.9%, n D 514) and female (53.1%, n D 364). Over half were covered
*Correspondence to: Natasha L Underwood; Email: [email protected] Submitted: 01/09/2015; Revised: 03/12/2015; Accepted: 03/25/2015 http://dx.doi.org/10.1080/21645515.2015.1035848
www.tandfonline.com
Human Vaccines & Immunotherapeutics
1703
Downloaded by [Monash University Library] at 09:24 14 November 2015
by Medicaid (59.8%, n D 410) and were enrolled in middle school (63.6%, n D 436) (Table 1). Only 48.5% (n D 333) of adolescents had received one dose of the HPV vaccine (Table 1). Among adolescents who received one dose, 61.9% (n D 206) completed 3 doses. Female adolescents were significantly more likely to have received the initial HPV dose than male adolescents (59.8% vs 36.1% respectively, P < 0.001) (data not shown). Among adolescents receiving one HPV dose (n D 333), females were significantly more likely to receive 3 doses compared to males (67.6% v 51.3% respectively, p D 0.003) (data not shown).
Parental attitudes toward HPV vaccine The average HPV attitude score was 3.8 out of a possible 6 (SD D 1.5) (Table 3) with higher attitude scores among parents who reported their adolescent received one HPV dose (mean D 4.5, SD D 1.1) compared to parents who reported their child did not receive one HPV dose (mean D 3.2, SD D 1.6) (95% CI [¡1.5, ¡1.1], t(669) D ¡11.99) (Table 3). Among parents who reported their adolescent received one HPV dose, there was no significant difference in parental HPV attitude score among Table 1. Participant demographics and characteristics data Responses ND686 n (%) Race Caucasian African-American Other Gender Female Male Mean age in years (SD) (at time of survey) Child’s insurance Private insurance Medicaid No insurance Middle school High school Prior receipt of vaccine 1 HPV dose 3 HPV doses among those who received 1 (nD333 ) If not received any HPV vaccine, intent to receive (nD351 ) Study Characteristics Intervention Arms Control Parent only Parent and adolescent Study Year Baseline Year 1 Year 2 Survey Method Phone Online
1704
111 (16.2) 514 (74.9) 61 (8.9) 364 (53.1) 322 (46.9) 14.2 (2.4)
233 (34.0) 410 (59.8) 42 (6.1) 436 (63.6) 250 (36.4) 333 (48.7) 206 (61.9)
216 (61.5)
Table 2. Application of the Health Belief Model (HBM) and Theory of Reasoned Action (TRA) Theoretical Construct
117 (17.1) 209 (30.5) 360 (52.5) 358 (52) 328 (48)
-My child is very likely to get HPV
Perceived Susceptibility *
Perceived Severity
-The HPV infection can cause a serious disease
Perceived Benefits*
-The HPV vaccine is very effective at preventing cervical cancer -Children should be vaccinated against HPV
Social NormsC
-Most people important to me think I should give my child a HPV vaccine -Most of the parents I know take their children for HPV vaccine.
* D Health Belief Model; C D Theory of Reasoned Action
adolescents who received 3 HPV doses and those that did not receive 3 doses (95% CI [¡0.4, 0.0], t(328) D ¡1.6) (Table 3). Correlates of HPV vaccine initiation and series completion In unadjusted analyses, correlates of HPV vaccine initiation included: child gender, intervention arm, study year, parental HPV attitude and belief score, and insurance type. In the adjusted model, parents in the 2 intervention groups were less likely to report their child receiving one HPV dose compared to those parents in the control group. Compared to parents in intervention arm 3 (parent and adolescent arm), parents in arm 1 (control arm) had twice the odds of reporting their child received an initial dose of HPV (aOR D 2.14, 95% CI [1.3, 3.4]) (Table 4). Across all 3 study arms, the odds of parents reporting receipt of one HPV dose at baseline increased to 1.76 during the final follow-up (Year 2) (aOR D 1.76, 95% CI [1.07, 2.89]). Parents with more positive attitudes about HPV vaccine had higher odds of reporting receipt of an initial dose of HPV vaccine compared to parents with lower HPV attitudinal scores (aOR D 2.08, 95% CI [1.80, 2.39]). The odds of female adolescents receiving one HPV dose was 3 times greater than male adolescents (aOR D 3.0, 95% CI [2.1, 4.3]) (Table 4). Table 3. Parental HPV attitude and belief score and differences by receipt of one HPV dose, 3 HPV doses and gender Characteristic
210 (30.6) 251 (36.6) 225 (32.8)
Item (True/False) *
Parental attitude score 1 HPV dose Yes No 3 HPV doses Yes No Gender Female Male
Human Vaccines & Immunotherapeutics
N
Mean (SD)
T-test value (p-value)
686
3.8 (1.5)
330 341
4.5 (1.0) 3.2 (1.6)
204 126
4.6 (1.0) 4.4 (1.1)
¡1.621 (p D 0 .10)
357 315
3.9 (1.5) 3.8 (1.5)
0.718 (p D 0 .47)
¡11.9 (P < 0.001)
Volume 11 Issue 7
Table 4. Correlates of receiving one HPV dose and 3 HPV vaccine doses 1 HPV Dose Unadjusted OR [95% CI]
Downloaded by [Monash University Library] at 09:24 14 November 2015
Variables Gender Male Female Race Caucasian African American Other School type Middle school High school Insurance Type Medicaid Private No Insurance Study Year Baseline Year 1 Year 2 Intervention Arm Control Parent-only Parent and adolescent HPV attitude and belief score
Ref 2.55 [1.87, 3.49]
p-value
3 HPV Doses
Adjusted OR [95% CI]*
Ref
ISSN: 2164-5515 (Print) 2164-554X (Online) Journal homepage: http://www.tandfonline.com/loi/khvi20
Human papillomavirus vaccination among adolescents in Georgia Natasha L Underwood, Paul Weiss, Lisa M Gargano, Katherine Seib, Kimberly J Rask, Christopher Morfaw, Dennis Murray, Ralph J DiClemente, James M Hughes & Jessica M Sales To cite this article: Natasha L Underwood, Paul Weiss, Lisa M Gargano, Katherine Seib, Kimberly J Rask, Christopher Morfaw, Dennis Murray, Ralph J DiClemente, James M Hughes & Jessica M Sales (2015) Human papillomavirus vaccination among adolescents in Georgia, Human Vaccines & Immunotherapeutics, 11:7, 1703-1708, DOI: 10.1080/21645515.2015.1035848 To link to this article: http://dx.doi.org/10.1080/21645515.2015.1035848
Accepted author version posted online: 27 Apr 2015.
Submit your article to this journal
Article views: 75
View related articles
View Crossmark data
Citing articles: 1 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=khvi20 Download by: [Monash University Library]
Date: 14 November 2015, At: 09:24
RESEARCH PAPER Human Vaccines & Immunotherapeutics 11:7, 1703--1708; July 2015; © 2015 Taylor and Francis Group, LLC
Human papillomavirus vaccination among adolescents in Georgia Natasha L Underwood1,*, Paul Weiss2, Lisa M Gargano1, Katherine Seib1, Kimberly J Rask2, Christopher Morfaw3, Dennis Murray4, Ralph J DiClemente2, James M Hughes1, and Jessica M Sales2 1
Emory University School of Medicine; Atlanta, GA USA; 2Emory University; Rollins School of Public Health; Atlanta, GA USA; 3East Central Health District; Augusta, GA USA; 4 Georgia Regents University; Augusta, GA USA
Downloaded by [Monash University Library] at 09:24 14 November 2015
Keywords: attitudes, adolescent, HPV vaccine, Health Belief Model, Theory of Reasoned Action
Human papillomavirus (HPV) vaccination coverage for adolescent females and males remains low in the United States. We conducted a 3-arm randomized controlled trial (RCT) conducted in middle and high schools in eastern Georgia from 2011–2013 to determine the effect of 2 educational interventions used to increase adolescent vaccination coverage for the 4 recommended adolescent vaccines: Tdap, MCV4, HPV and influenza. As part of this RCT, this article focuses on: 1) describing initiation and completion of HPV vaccine series among a diverse population of male and female adolescents; 2) assessing parental attitudes toward HPV vaccine; and 3) examining correlates of HPV vaccine series initiation and completion. Parental attitude score was the strongest predictor of HPV vaccine initiation among adolescents (adjusted odds ratio (aOR): 2.08; 95% confidence interval (CI): 1.80, 2.39). Other correlates that significantly predicted HPV series initiation were gender, study year, and intervention arm. Parental attitudes remained a significant predictor of receipt of 3 doses of HPV vaccine along with gender, race, school type and insurance type. This study demonstrates that positive parental attitudes are important predictors of HPV vaccination and critical to increasing coverage rates. Our findings suggest that more research is needed to understand how parental attitudes are developed and evolve over time.
Introduction In 2006, the Advisory Committee on Immunization Practices (ACIP) recommended routine human papillomavirus (HPV) vaccination for females ages 9–26 after licensure of the quadrivalent vaccine in 2006.1 The quadrivalent vaccine was not licensed for males ages 9–26 until 2009, and ACIP did not provide a routine recommendation for HPV vaccination for males until 2011.2 Despite routine recommendations for males and females as well as numerous marketing and educational campaigns, vaccination rates remain low in the US. HPV vaccination rates are suboptimal compared to other adolescent vaccination rates and are well below the Healthy People 2020 goal of 80% coverage for all adolescent vaccines, both nationally and in Georgia where rates lag even further behind.3 In 2013, coverage of 13–17 y old females in the U.S initiating HPV vaccine series was 57.3% and 34.6% among males.4 Coverage of all 3 doses among US adolescent females was 37.6% and 13.9% among males.4 In 2013, coverage of 13–17 y old females in Georgia initiating the HPV series was 53.7% and 40.5% among males.5 Coverage of all 3 doses among Georgia adolescent females was 33.2% and 15.3% among males.5 Provider recommendations and positive parental attitudes have been shown as important predictors of parents’ decisions to
vaccinate their adolescent against HPV.6-8 Studies have found that among parents, low knowledge of HPV, low perceived susceptibility of adolescents to HPV/sexually transmitted infections, concerns about vaccine safety, and views that HPV vaccination leads to sexual activity were associated with reluctance to allow HPV vaccination.9-11 The objectives of this study were to 1) describe receipt of one and 3 HPV vaccine doses among a diverse population of male and female adolescents; 2) assess parental attitudes toward HPV vaccine; and 3) examine correlates of HPV vaccine series initiation and series completion among a sample of middle and high school adolescents. This study is unique in that it focuses on a racially and economically diverse sample of adolescents coming from a mix of urban and rural schools, whereas previous HPV studies with parents were conducted prior to ACIP recommendations for HPV vaccination of males, focused on female adolescents only, or relied primarily on health care facilities for recruitment.12-15
Results Demographic characteristics and vaccination uptake The majority of adolescents were African American (74.9%, n D 514) and female (53.1%, n D 364). Over half were covered
*Correspondence to: Natasha L Underwood; Email: [email protected] Submitted: 01/09/2015; Revised: 03/12/2015; Accepted: 03/25/2015 http://dx.doi.org/10.1080/21645515.2015.1035848
www.tandfonline.com
Human Vaccines & Immunotherapeutics
1703
Downloaded by [Monash University Library] at 09:24 14 November 2015
by Medicaid (59.8%, n D 410) and were enrolled in middle school (63.6%, n D 436) (Table 1). Only 48.5% (n D 333) of adolescents had received one dose of the HPV vaccine (Table 1). Among adolescents who received one dose, 61.9% (n D 206) completed 3 doses. Female adolescents were significantly more likely to have received the initial HPV dose than male adolescents (59.8% vs 36.1% respectively, P < 0.001) (data not shown). Among adolescents receiving one HPV dose (n D 333), females were significantly more likely to receive 3 doses compared to males (67.6% v 51.3% respectively, p D 0.003) (data not shown).
Parental attitudes toward HPV vaccine The average HPV attitude score was 3.8 out of a possible 6 (SD D 1.5) (Table 3) with higher attitude scores among parents who reported their adolescent received one HPV dose (mean D 4.5, SD D 1.1) compared to parents who reported their child did not receive one HPV dose (mean D 3.2, SD D 1.6) (95% CI [¡1.5, ¡1.1], t(669) D ¡11.99) (Table 3). Among parents who reported their adolescent received one HPV dose, there was no significant difference in parental HPV attitude score among Table 1. Participant demographics and characteristics data Responses ND686 n (%) Race Caucasian African-American Other Gender Female Male Mean age in years (SD) (at time of survey) Child’s insurance Private insurance Medicaid No insurance Middle school High school Prior receipt of vaccine 1 HPV dose 3 HPV doses among those who received 1 (nD333 ) If not received any HPV vaccine, intent to receive (nD351 ) Study Characteristics Intervention Arms Control Parent only Parent and adolescent Study Year Baseline Year 1 Year 2 Survey Method Phone Online
1704
111 (16.2) 514 (74.9) 61 (8.9) 364 (53.1) 322 (46.9) 14.2 (2.4)
233 (34.0) 410 (59.8) 42 (6.1) 436 (63.6) 250 (36.4) 333 (48.7) 206 (61.9)
216 (61.5)
Table 2. Application of the Health Belief Model (HBM) and Theory of Reasoned Action (TRA) Theoretical Construct
117 (17.1) 209 (30.5) 360 (52.5) 358 (52) 328 (48)
-My child is very likely to get HPV
Perceived Susceptibility *
Perceived Severity
-The HPV infection can cause a serious disease
Perceived Benefits*
-The HPV vaccine is very effective at preventing cervical cancer -Children should be vaccinated against HPV
Social NormsC
-Most people important to me think I should give my child a HPV vaccine -Most of the parents I know take their children for HPV vaccine.
* D Health Belief Model; C D Theory of Reasoned Action
adolescents who received 3 HPV doses and those that did not receive 3 doses (95% CI [¡0.4, 0.0], t(328) D ¡1.6) (Table 3). Correlates of HPV vaccine initiation and series completion In unadjusted analyses, correlates of HPV vaccine initiation included: child gender, intervention arm, study year, parental HPV attitude and belief score, and insurance type. In the adjusted model, parents in the 2 intervention groups were less likely to report their child receiving one HPV dose compared to those parents in the control group. Compared to parents in intervention arm 3 (parent and adolescent arm), parents in arm 1 (control arm) had twice the odds of reporting their child received an initial dose of HPV (aOR D 2.14, 95% CI [1.3, 3.4]) (Table 4). Across all 3 study arms, the odds of parents reporting receipt of one HPV dose at baseline increased to 1.76 during the final follow-up (Year 2) (aOR D 1.76, 95% CI [1.07, 2.89]). Parents with more positive attitudes about HPV vaccine had higher odds of reporting receipt of an initial dose of HPV vaccine compared to parents with lower HPV attitudinal scores (aOR D 2.08, 95% CI [1.80, 2.39]). The odds of female adolescents receiving one HPV dose was 3 times greater than male adolescents (aOR D 3.0, 95% CI [2.1, 4.3]) (Table 4). Table 3. Parental HPV attitude and belief score and differences by receipt of one HPV dose, 3 HPV doses and gender Characteristic
210 (30.6) 251 (36.6) 225 (32.8)
Item (True/False) *
Parental attitude score 1 HPV dose Yes No 3 HPV doses Yes No Gender Female Male
Human Vaccines & Immunotherapeutics
N
Mean (SD)
T-test value (p-value)
686
3.8 (1.5)
330 341
4.5 (1.0) 3.2 (1.6)
204 126
4.6 (1.0) 4.4 (1.1)
¡1.621 (p D 0 .10)
357 315
3.9 (1.5) 3.8 (1.5)
0.718 (p D 0 .47)
¡11.9 (P < 0.001)
Volume 11 Issue 7
Table 4. Correlates of receiving one HPV dose and 3 HPV vaccine doses 1 HPV Dose Unadjusted OR [95% CI]
Downloaded by [Monash University Library] at 09:24 14 November 2015
Variables Gender Male Female Race Caucasian African American Other School type Middle school High school Insurance Type Medicaid Private No Insurance Study Year Baseline Year 1 Year 2 Intervention Arm Control Parent-only Parent and adolescent HPV attitude and belief score
Ref 2.55 [1.87, 3.49]
p-value
3 HPV Doses
Adjusted OR [95% CI]*
Ref
