JOURNAL OF WOMENS HEALTH

Volume 18, Number 10, 2009 Original Article

Mary Ann Liebert, Inc.
DOI: 10.1089=jwh.2008.1329

Human Papillomavirus Vaccine Uptake, Predictors

of Vaccination, and Self-Reported Barriers to Vaccination

Kathleen Conroy, M.D.,1 Susan L. Rosenthal, Ph.D.,2 Gregory D. Zimet, Ph.D.,3 Yan Jin, M.S.,4
David I. Bernstein, M.D., M.A.,5 Susan Glynn, B.A.,6 and Jessica A. Kahn, M.D., M.P.H.6

Abstract

Objective: To describe human papillomavirus (HPV) vaccine uptake, predictors of vaccination, and barriers to
vaccination in young women.
Methods: Participants were 1326-year-old girls and women recruited from an urban, hospital-based clinic.
Between June and December 2007, 6 months after they had completed a baseline survey, they were recontacted
to assess receipt of at least one HPV vaccine dose and barriers to receiving the vaccine. We assessed whether
demographic factors, gynecological history, and attitudes measured at baseline were associated with vaccination
at follow-up using logistic regression.
Results: Of the 262 women who completed the baseline study, 189 (72%) participated in this follow-up study. At
follow-up, 68 of 189 (36%) had received
1 HPV vaccine dose. Factors measured at baseline that predicted
vaccination 6 months later included insurance coverage for HPV vaccination (odds ratio [OR] 5.31, 95% confi-
dence interval [CI] 1.61-17.49) and the belief that ones parents, partners, and clinicians endorsed HPV vacci-
nation (OR 2.21, 95% CI 1.29-3.79); those with a history of an abnormal Pap test were less likely to have received
the vaccine (OR 0.30, CI 0.10-0.92). Of the 121 who were unvaccinated, 54 (45%) had not returned to the clinic
since the baseline study, 51 (42%) had returned but were not offered vaccine, and 15 (12%) had declined
vaccination.
Conclusions: Interventions to increase HPV vaccination rates in women in the catch-up age group for vacci-
nation should ensure that vaccine costs are covered, promote HPV vaccination as normative, and establish clinic-
based systems to prevent missed opportunities for vaccination.

Introduction HPV-18 among women who are not infected with those types
at the time of vaccination.3,4 Given that both high-risk HPV

H uman papillomavirus (HPV) is the most common

sexually transmitted infection (STI) in the United States,
with lifetime prevalence among women estimated at 80%.1
The Food and Drug Administration (FDA) approved a
quadrivalent vaccine against HPV in June 2006. Subsequently,
the Advisory Committee of Immunization Practices (ACIP)
recommended routine vaccination of girls 1112 years of age,
as well as catch-up vaccination of girls and women 1326
years of age, regardless of prior sexual experience.2 The vac-
cine is highly effective in preventing persistent HPV infection
and precancerous cervical lesions caused by HPV-16 and
and cervical cancer prevalence rates are higher among poor,
minority women in the United States,5,6 the vaccine has the
potential to either narrow or widen disparities in cervical
cancer, depending on vaccine access and uptake patterns
among women.
Studies conducted before and just after licensing of the
HPV vaccine suggested that adolescent and young adult
women generally found vaccination to be acceptable and that
gynecological history and beliefs about HPV vaccines were
associated with intention to receive the vaccine.7,8 Little is
known, however, about rates of HPV vaccination, predictors

1
Department of General Pediatrics, Boston Medical Center, Boston, Massachusetts.
2
Division of Adolescent and Behavioral Health, University of Texas Medical Branch at Galveston, Texas.
3
Division of Adolescent Medicine, Indiana University, Indianapolis, Indiana.
4
Department of Biostatistics, University of Cincinnati, Ohio.
5
Division of Infectious Diseases and 6Division of Adolescent Medicine, Cincinnati Childrens Hospital Medical Center, Cincinnati, Ohio.

1679
1680
of vaccination, and self-reported barriers to vaccination dur-
ing the first 2 years after vaccine licensing. It is especially
important to explore these factors among low-income, mi-
nority women because they are at relatively high risk for
HPV infection and for developing cervical cancer later in life.
In addition, special attention should be paid to predictors
of vaccination and barriers to vaccination in the age group
eligible for catch-up vaccination, as they may experience
specific barriers to vaccination, including lack of insurance
coverage.
Thus, we designed a longitudinal study of predominantly
low-income, minority, 1326-year-old girls and women with
the following aims: (1) to describe rates of HPV vaccination in
this sample approximately 1218 months after the quadriva-
lent HPV vaccine was licensed, (2) to identify which demo-
graphic, attitudinal, behavioral, and health systems-related
factors measured at baseline predicted actual vaccine receipt
at follow-up, and (3) to identify self-reported barriers to HPV
vaccination among those who had not received the vaccine at
follow-up.
Materials and Methods
The study sample comprised 1326-year-old girls and
women recruited from an urban, hospital-based teen health
center who had previously participated in a multisite baseline
study that assessed cervicovaginal HPV infection as well as
attitudes toward HPV vaccination.9 Inclusion criteria for the
baseline study included a history of sexual contact with a man
or a woman and ability to complete a survey in English or
Spanish. The participants provided written consent to par-
ticipate in the baseline study (a requirement for parental
consent was waived) and were asked if they were willing to be
contacted by phone at a later date to ask if they would be
interested in participating in a follow-up study. When par-
ticipants were recontacted for the follow-up study, verbal
consent was requested, and those who consented completed a
phone survey. The baseline cohort was enrolled between
November 2006 and May 2007. The follow-up study was
performed approximately 6 months after each participant was
enrolled in the original study, between June and December
2007. At the beginning of the follow-up study, the HPV vac-
cine had been available in the clinic for approximately
6 months (Fig. 1). This study was approved by the Cincinnati
Childrens Hospital Medical Center Institutional Review
Board.
The survey completed by participants at baseline assessed
demographic factors, gynecological history, risk behaviors,
HPV knowledge, beliefs about HPV and HPV vaccines, HPV
vaccination history, and both intention and self-confidence to
receive the HPV vaccine.9 Participants received written in-
formation about HPV infection and HPV vaccines. The phone
Recruitment for baseline study
6/06 7/06 8/06 9/06 10/06 11/06 12/06 1/07
Vaccine licensed by FDA Vaccine available in clinic
FIG. 1. Timeline: HPV vaccine licensing, vaccine availability, recruitment for baseline study, recruitment for follow-up
study.
CONROY ET AL.
survey conducted in this follow-up study assessed whether or
not the participant had received any doses of HPV vaccine
and, if so, dates of vaccination. All immunization dates were
confirmed by reviewing the state immunization registry, and
any discrepancies were resolved by chart review. Participants
were considered late for the second or third dose of the vac-
cine if the interval between the first and second doses was >4
months or if the interval between the second and third doses
was >6 months. Self-reported barriers to receiving the HPV
vaccine were assessed only among participants who had yet
to receive any doses of the HPV vaccine at the time of the
follow-up interview. These participants were asked whether
they had not returned to see the physician since enrollment,
had returned but not been offered the vaccine, or had been
offered the vaccine but did not receive it. Participants indi-
cating that they did not receive the vaccine when offered were
then asked why they did not. They were prompted from a list
of 10 possible reasons, including an open-ended response
category, and were allowed to select multiple reasons. Parti-
cipants who had received at least one dose of vaccine but were
late for their second or third vaccine doses (or both) were also
asked to report one or more reasons why they were unable to
get the vaccination on time; they were prompted from a list
of 8 possible reasons, including an open-ended response
category.
We used insurance information collected during the base-
line study to create a new variable indicating whether each
participant was likely to have coverage for the HPV vaccine
through either private insurance, Medicaid, or the Vaccines
for Children Program. Insurance plan information collected
at baseline was highly correlated with insurance informa-
tion collected at the time of the follow-up survey (r 0.71,
p < 0.0001).
The primary outcome variable was receipt of at least one
HPV vaccination, and the secondary outcome variables were
self-reported barriers to receiving at least one HPV vaccina-
tion. Exploratory outcomes included reasons why those who
had been offered the vaccine between the baseline and follow-
up study visits had not received it and reasons why partici-
pants had received a second or third dose late.
We first examined if demographic, attitudinal, and be-
havioral variables measured at baseline were associated with
receipt of at least one HPV vaccine dose at follow-up, using
chi-square analysis for dichotomous predictor variables and a
Wilcoxon rank-sum test for ordinal variables. Those variables
associated with vaccination at p < 0.05 were entered into a
multivariable logistic regression model to identify baseline
variables independently associated with receipt of the HPV
vaccine; a stepwise procedure was used for variable selection.
We found evidence for collinearity between age and the var-
iable measuring coverage for the HPV vaccine and, therefore,
did not include age in the multivariable model.
Recruitment for follow-up study
2/07 3/07 4/07 5/07 6/07 7/07 8/07 9/07 10/07 11/07 12/07
HPV VACCINE UPTAKE, PREDICTORS, AND BARRIERS
Results
Approximately 98% of those approached for the baseline
study at all sites agreed to participate.9 Of the 262 women who
enrolled in the baseline study at the teen health center, 257
(98%) agreed to be recontacted for a follow-up study, and 189
(72%) were both recontacted and agreed to participate in the
follow-up study. The baseline characteristics of the women
who participated in the follow-up study did not differ sig-
nificantly from those of women who did not (Table 1). Parti-
cipants in this study were predominantly black, their mean
age was 17.5 years, and the majority was insured by Medicaid
at the time of enrollment. Insurance rates varied by age: 90%
of those <18 years of age vs. 73% of those
18 years of age
reported having some type of insurance ( p < 0.01). Rates of
gonorrhea and Chlamydia infection were high, as expected in a
sample of urban, predominantly low-income young women,
but no participant reported HIV infection. We calculated that
127 (70.6%) of the sample had coverage for the HPV vaccine
through private insurance, Medicaid, or the Vaccines for
Children program.
At follow-up, 68 participants (36%) had received at least
one dose of the HPV vaccine, of whom 21 (31% of those
vaccinated) had received only one vaccine dose, 38 (56%) had
received two doses, and 9 (13%) had received three doses. Ten
of the 68 patients who had started the vaccination series did so
late enough in the follow-up period that they could not yet be
considered late for the second vaccine dose at the time of
follow-up. Of the remaining 58 patients, 26 (45%) were late for
their second dose of vaccine. Among those who received a
second vaccine, the mean interval between doses one and two
was 89 days (standard deviation [SD] 45 days, range 28209
days).
Bivariate associations among demographic, behavioral,
and attitudinal predictors and receipt of at least one HPV
vaccination are shown in Table 2. Factors associated with
vaccination included younger age, coverage for HPV vacci-
nation, use of a condom at last sexual intercourse, no history
of an abnormal Pap test, no history of pregnancy, and nor-
mative beliefs (the perception that parents, partners, and ones
clinician would approve of HPV vaccination). Intention to
receive the vaccine was not predictive of vaccination. In the
adjusted logistic regression model, coverage for vaccination
and normative beliefs predicted vaccination, and a history of
an abnormal Pap test was associated with reduced likelihood
of receiving the vaccine (Table 3). Insurance coverage for
vaccination was associated with more than five times the odds
of having received the HPV vaccine, and a one-unit increase in
the normative beliefs scale (e.g., from agree to strongly agree)
was associated with more than twice the odds of having re-
ceived the HPV vaccine.
Of the 121 participants who received no doses of the vac-
cine at follow-up, 54 (45%) reported they had not returned to
the clinic since the baseline visit, 51 (42%) had returned to the
clinic but had not been offered the vaccine, and 15 (12%) had
been offered the vaccine but did not receive it. Refusal of
vaccination because of concern about insurance coverage for
the vaccine was the most frequently reported reason for not
receiving the vaccine when offered (n 13, 86.7% of those
reporting reasons why they had refused vaccination). Of the
26 patients who were late to receive their second dose of
vaccine, 16 (61.5%) reported they forgot to make an ap-
1681
pointment or forgot to return for an appointment they made,
and 10 (38.5%) reported they did not know they needed ad-
ditional injections.
Discussion
In this study, we measured rates of HPV vaccination
among a diverse sample of low-income women eligible for
catch-up vaccination, identified attitudinal and behavioral
predictors of HPV vaccination, and documented self-reported
barriers to vaccination. Thirty-six percent of participants had
received at least one HPV vaccination at follow-up, compared
with 5% when the baseline study was conducted. In-
vestigators from the Centers for Disease Control and Pre-
vention (CDC) recently reported that surveillance systems in
six states demonstrated that HPV vaccination rates among
1118-year-old girls ranged from 6% to 15% in the third quarter
of 2007,10 and another U.S. survey demonstrated that 25% of
1317-year-old girls received at least one HPV vaccine in
2007.11 A single-center study examining rates of vaccination
of 1117-year-old girls who were recruited for participation
from a pediatric primary care clinic reported a vaccination
rate of 26%.12 The comparatively high vaccination rate in our
sample may be explained in part by participants receipt of
care at an adolescent clinic where clinicians were generally
supportive of HPV vaccination. In addition, subjects who are
willing to participate in a clinical study may tend to trust
clinicians, which in turn could correlate with agreement to
receive a vaccine recommended by their clinician. Delivery of
HPV vaccines in school-based settings may lead to higher
vaccination rates, as shown in one study from the United
Kingdom in which 71% of girls received at least one HPV
vaccine dose.13
Coverage of the cost of vaccination, defined as either hav-
ing insurance that covered the cost of vaccination or eligibility
for vaccination through Medicaid or the Vaccines for Children
Program, was the strongest predictor of HPV vaccination in
this cohort. Younger age was associated with higher vacci-
nation rates as well as higher rates of insurance coverage for
HPV vaccination. This relationship between age and insur-
ance coverage is consistent with U.S. population trends in
insurance rates: lifetime insurance rates are highest among
1314-year-olds but decrease to a nadir among young adults
aged 2324 years.14 Low-income adolescents are less likely to
be insured than higher-income adolescents across every age
group. Therefore, lack of insurance coverage may be an im-
portant barrier to HPV vaccination in low-income young
women eligible for catch-up vaccination.
Normative beliefsa measurement of the participants
belief that her medical provider, her parents, and others
would approve of her receiving the HPV vaccinewas the
only attitudinal predictor of vaccination in this study. These
findings are consistent with a number of studies demon-
strating that social norms predict both intention to be vacci-
nated and vaccination.1517 The importance of normative
beliefs in our study population suggests that campaigns for
catch-up HPV vaccination may be most successful if they in-
clude information about endorsement of HPV vaccination by
physicians and trusted individuals and focus on vaccination
as a social norm.
Failure to return to the physician within the study period
was the most common self-reported barrier to vaccination.
 Table 1. Characteristics of Young Women at Enrollment in Baseline Study,
Who Did or Did Not Participate in Follow-Up Studya

Participated in follow-up Did not participate in

study (n 189) follow-up study (n 73)

Mean (SD) n (%) Mean (SD) n (%) p value

Demographics and health history

Age, years 17.5 (2.3) 17.6 (1.8) 0.39
Race 0.53
Black 146 (79.4) 53 (74.6)
White 27 (14.7) 11 (15.5)
Other 11 (5.9) 7 (9.9)
Insurance type 0.73
Private 36 (22.9) 10 (19.6)
Medicaid 97 (61.8) 31 (60.8)
None 24 (15.3) 10 (19.6)
Coverage for vaccinationb 127 (67.2) 43 (64.2) 0.34
Prior sexually transmitted infection
Chlamydia 86 (46.5) 34 (47.9) 0.84
Gonorrhea 45 (24.3) 18 (25.4) 0.86
Trichomonas 45 (24.3) 18 (25.4) 0.86
Herpes 5 (2.7) 3 (4.2) 0.53
Warts 12 (6.5) 2 (2.8) 0.36
Any 101 (54.5) 36 (50.7) 0.58
Gynecological history
HPV positive, any type 132 (70.2) 53 (72.6) 0.70
Positive for at least one vaccine type HPV 62 (33.0) 24 (32.8) 0.99
History of abnormal Pap test 46 (29.1) 22 (36.1) 0.32
History of pregnancy 50 (27.2) 23 (32.4) 0.41
Behavioral history
Age at first sexual intercourse, years 14.6 (2.0) 14.5 (1.9) 0.72
Lifetime number of male sexual partners 0.69
1 36 (20.2) 11 (16.4)
24 81 (45.5) 26 (49.2)
59 40 (22.5) 21 (31.3)

10 21 (11.8) 9 (13.4)
One or more new male sexual partners, last 3 months 78 (43.1) 31 (47.0) 0.59
Condom use, last sexual intercourse 75 (48.4) 27 (45.0) 0.66
History of smoking 38 (20.8) 19 (28.4) 0.21
Knowledge and attitudes
Knowledge about HPVc 0.41 (0.22) 0.36 (0.24) 0.10
Perceived barriers to vaccinationd
Knowledge related 2.61 (1.23) 2.67 (1.18) 0.70
Practical 3.72 (0.87) 3.62 (0.84) 0.34
Safety related 3.87 (0.89) 3.85 (0.95) 0.95
Perceived benefits of vaccinatione
Protection of self and partner 3.45 (1.12) 3.49 (1.15) 0.74
Protection and safety 4.19 (0.80) 4.07 (0.91) 0.44
Fear of shotsd 2.93 (1.15) 2.96 (1.14) 0.86
Normative beliefsf 3.94 (0.86) 3.83 (0.84) 0.35
Perceived severity of HPV-related diseaseg 3.60 (0.98) 3.65 (0.82) 0.86
Self-efficacy to receive vaccineh 2.43 (1.20) 2.47 (1.27) 0.81
Intention to receive vaccinei 124 (67.7) 42 (67.8) 0.87
a
All characteristics measured at baseline.
b
Participant has coverage for HPV vaccine through a private insurance plan, Medicaid, or the Vaccines for Children program.
c
Mean score for scale measuring knowledge: range 01, with higher score representing better knowledge.
d
Mean scores for scales and subscales measuring perceived barriers and fear of shots: range 15, with higher score representing less
endorsement of the attitude (i.e., higher scale score for barriers related to safety indicates less concern with the safety of the vaccine).
e
Mean scores for scales and subscales measuring perceived benefits of vaccination: range 15, with higher score indicating stronger
endorsement of the attitude (i.e., higher scale score for benefits related to safety indicates that the participant believes more strongly that the
vaccine is safe).
f
Mean score for scale measuring normative beliefs (assesses participants perception that ones parents, provider, partner, and other
important people think the participant should get the HPV vaccine); range 15, with higher numbers indicating stronger perception that these
people think the participant should get the vaccine.
g
Mean score for scale measuring perceived severity: range 15, with higher score representing stronger endorsement of the severity of these
conditions.
h
Mean score for scale measuring self-efficacy: range 14, with higher score representing higher self-efficacy (self-confidence).
i
Participant self-report that she was extremely or somewhat likely to receive the HPV vaccine within the next year.

1682
HPV VACCINE UPTAKE, PREDICTORS, AND BARRIERS 1683

Table 2. Characteristics of Young Women at Enrollment in Baseline Study,

Who Did or Did Not Receive HPV Vaccinea

Vaccinated (n 68) Not vaccinated (n 121)

Mean (SD) n (%) Mean (SD) n (%) p valueb

Demographics and health history

Age, years 16.4 (1.9) 18.1 (2.3) <0.001
Race 0.98
Black 51 (78.4) 95 (79.8)
White 10 (15.4) 17 (14.3)
Other 4 (6.2) 7 (5.9)
Coverage for vaccinationc 61 (91.0) 66 (58.4) <0.001
Prior sexually transmitted infection
Chlamydia 26 (40.0) 60 (50.0) 0.19
Gonorrhea 15 (23.1) 30 (25.0) 0.77
Trichomonas 14 (21.5) 31 (25.8) 0.52
Herpes 0 (0) 5 (4.2) 0.16
Warts 4 (6.2) 8 (6.7) 1.00
Any 30 (46.2) 71 (59.2) 0.09
Gynecological history
HPV positive, any type 46 (68.7) 86 (71.1) 0.73
Positive for at least one vaccine type HPV 24 (35.8) 38 (31.4) 0.54
History of abnormal Pap test 10 (17.9) 36 (35.3) 0.02
History of pregnancy 11 (16.9) 39 (32.8) 0.02
Behavioral history
Age at first sexual intercourse, years 14.4 (1.7) 14.7 (1.7) 0.33
Lifetime number of male sexual partners 0.34
1 17 (28.3) 19 (16.1)
24 27 (45.0) 54 (45.8)
59 12 (20.0) 28 (23.7)

10 4 (6.7) 17 (14.4)
Any new sexual partners, last 3 months 30 (49.2) 48 (40.0) 0.24
Condom use, last sexual intercourse 31 (60.8) 44 (42.3) 0.03
History of smoking 10 (15.6) 28 (23.7) 0.20
Knowledge and attitudes
Average knowledge scale scored 0.40 (0.2) 0.41 (0.2) 0.74
Perceived barriers to vaccinatione
Knowledge related 2.4 (1.1) 2.7 (1.3) 0.3
Practical 3.7 (0.9) 3.7 (0.8) 0.70
Safety related 4.0 (0.8) 3.8 (0.9) 0.09
Perceived benefits of vaccinationf
Protection of self and partner 3.5 (1.0) 3.4 (1.2) 0.79
Protection and safety 4.3 (0.7) 4.1 (0.8) 0.1
Fear of shotse 2.8 (1.0) 3.0 (1.2) 0.20
Normative beliefsg 4.2 (0.7) 3.8 (0.9) 0.003
Perceived severity of HPV-related diseaseh 3.7 (1.0) 3.6 (1.0) 0.50
Self-efficacy to receive vaccinei 2.5 (1.2) 2.4 (1.2) 0.46
Intention to receive vaccine j 45 (71.4) 79 (65.8) 0.44
a
All characteristics measured at baseline.
b
p values in bold represent relationships significant at the p < 0.05 level.
c
Participant has coverage for HPV vaccine through a private insurance plan, Medicaid, or the Vaccines for Children program.
d
Mean score for scale measuring knowledge: range 01, with higher score representing better knowledge.
e
Mean scores for scales and subscales measuring perceived barriers and fear of shots: range 15, with higher score representing less
endorsement of the attitude (i.e., higher scale score for barriers related to safety indicates less concern with the safety of the vaccine).
f
Mean scores for scales and subscales measuring perceived benefits of vaccination: range 15 with higher score indicating stronger
endorsement of the attitude (i.e., higher scale score for benefits related to safety indicates that the participant believes more strongly that the
vaccine is safe).
g
Mean score for scale measuring normative beliefs (assesses participants perception that ones parents, provider, partner, and other
important people think the participant should get the HPV vaccine); range 15, with higher numbers indicating stronger perception that these
people think the participant should get the vaccine.
h
Mean score for scale measuring perceived severity: range 15, with higher score representing stronger endorsement of the severity of these
conditions.
i
Mean score for scale measuring self-efficacy: range 14, with higher score representing higher self-efficacy (self-confidence).
j
Participant self-report that she was extremely or somewhat likely to receive the HPV vaccine within the next year.
1684
Table 3. Adjusted and Unadjusted Logistic Regression Models Predicting Vaccination
Predictor variable
Age, years
Coverage for vaccine (yes vs. no)d
History of pregnancy
History of abnormal Pap test (yes vs. no)
Condom use last sexual intercourse (yes vs. no)
Normative beliefse
a
Items in bold are statistically significant at the p < 0.05 level.
b
Variables in the adjusted model included: coverage for vaccine, history of pregnancy, history of abnormal Pap test, condom use at last
sexual intercourse, and normative beliefs.
c
Age was not entered into the adjusted model because of evidence that age and coverage were collinear.
d
Participant has coverage for HPV vaccine through a private insurance plan, Medicaid, or the Vaccines for Children program.
e
Normative beliefs measured using a scale assessing participants perception that ones parents, provider, partner, and other important
people think the participant should get the HPV vaccine; scale range 15.
Vaccine recall and reminder systemsin which clinics contact
patients by mail or phone to remind them to make or keep
vaccine appointmentsare known to be effective in increas-
ing vaccination rates in both children and adults18 and might
be effective in increasing rates of HPV vaccination. Proactive
outreach to girls in the target age group for catch-up immu-
nization may be particularly important for HPV vaccination
efforts because the vast majority of young women initiate
sexual activity and are at high risk for acquiring HPV infection
during the years when they are eligible for catch-up vacci-
nation.19,20 In our sample, for example, 43% of girls reported
having a new sexual partner in the past 3 months. As vacci-
nation appears to have no therapeutic benefit in women al-
ready infected with vaccine-type HPV at the time of
vaccination,4 the individual and public health benefits of
vaccination in the catch-up age group will depend on
timely vaccination. Recall and reminder systems for vacci-
nation were not in place at the state, local, or clinic level at the
time of this study. Establishing such systems for young
women in this age group may help maximize both vaccina-
tion rates and the health benefits of vaccination.
The second most commonly cited reason for not getting
vaccinated was not being offered the vaccine despite return-
ing to the physicians office during the study period. A clini-
cian may not have recommended HPV vaccination during an
office visit if a participant was moderately or severely ill, in
which case vaccination is not recommended. In other cases,
however, a clinician may have missed an opportunity to
vaccinate a young woman seeking treatment for a mild illness
or another reason. Given the importance of timely vaccination
in this age group, office-based interventions may be helpful in
maximizing vaccination rates, for example, office-based pro-
cedures that identify patients eligible for vaccination.21,22
Other reasons clinicians do not recommend HPV vaccination
may have to do with their attitudes about the vaccine or
specific barriers to recommending the vaccine. In prelicensing
studies, providers reported largely positive attitudes about
recommending HPV vaccines.2326 However, little informa-
tion is available concerning actual clinician recommendations
for HPV vaccines. As clinician recommendation is one of the
most important predictors of vaccination,17,27,28 further in-
formation about clinicians attitudes, prescribing practices,
CONROY ET AL.
Unadjusted odds ratio Adjusted odds ratio
(95% confidence interval)a (95% confidence interval)a,b
0.64 (0.520.77) N=Ac
7.24 (2.8918.14) 5.31 (1.6117.49)
0.42 (0.200.89) 1.67 (0.574.87)
0.40 (0.180.88) 0.30 (0.100.92)
2.11 (1.074.19) 0.93 (0.392.21)
1.83 (1.242.68) 2.21 (1.293.79)
and barriers to vaccination will be helpful in designing in-
terventions to improve HPV vaccination recommendations.
Of the 121 subjects reporting barriers to vaccination, <5%
reported concerns about safety and efficacy, echoing pre-
licensing studies that reported high acceptability of an HPV
vaccine among young adults.29,30 Of the 10 subjects who re-
ported concerns about insurance as a reason for refusing
vaccine, 5 did in fact have insurance coverage for vaccination,
consistent with prior research demonstrating that recipients
of both private and public insurance plans may underestimate
their benefits.31 In addition to recall and reminder systems for
patients and providers, healthcare personnel should help
patients to understand their insurance benefits for vaccination
if concerns arise.
Contrary to our expectations, intention to receive the HPV
vaccine was not associated with having received the vaccine
at the time of follow-up. The previously published baseline
study in this same cohort examined the correlations among
demographic, behavioral, and attitudinal factors and inten-
tion to vaccinate at baseline.9 With the exception of history of
an abnormal Pap test, all the predictors found to be signifi-
cantly associated with intention to be vaccinated in the
baseline study were also predictive of actual vaccination in
this study. Given the short follow-up period and the fact that
90% of those not vaccinated had either not returned to the
physician or had not been offered the vaccine, it is likely that
many of those intending to receive the HPV vaccine simply
did not have the opportunity to do so during the follow-up
period. Studies with longer follow-up periods will likely be
necessary to definitively assess whether intention to receive
the vaccine predicts actual receipt of the vaccine.
Our study has several limitations. Participants were re-
cruited from a hospital-based adolescent primary care clinic
serving a racially and ethnically diverse, predominantly low-
income population. Generalization from this population is
limited both by the demographic composition of our sample
and their connection to clinical care. However, initial re-
cruitment took place during both ill visits and health main-
tenance visits, and the follow-up study did not require a
repeat clinical visit; thus, there was at least some variation in
terms of connectedness to care. Those who participated in the
follow-up study may differ from those who did not partici-
HPV VACCINE UPTAKE, PREDICTORS, AND BARRIERS
pate; however, there were no baseline characteristics that
differed in the two groups. The study sample consisted of
those previously enrolled in a study of attitudes about HPV
vaccines; thus, participants could have had inherently higher
interest in HPV vaccination or be more likely to get the vac-
cine. In addition, the barriers to vaccination in this study are
self-reported, and although they provide information about
the young womens perceived barriers, they are subject to
recall error. Finally, our study followed this population for
only 6 months after initial recruitment and, therefore, reports
relatively short-term predictors of vaccination. However,
conducting such a study soon after the HPV vaccine was li-
censed should provide useful preliminary information for the
timely design of interventions that address barriers and aim to
improve vaccination rates.
Conclusions
Our data suggest that strategies to ensure that those who
are eligible for catch-up immunization are vaccinated should
include attention to young womens attitudes about vacci-
nation and to the implementation of office-based procedures
to ensure that clinicians do not miss opportunities for vacci-
nation. Ensuring that all young women in this age group are
able to afford vaccination will help to avoid an increase in
existing racial and economic disparities in cervical cancer
mortality.
Disclosure Statements
K.C., Y.J., and S.G. have no conflicts of interest to report.
S.L.R. is a co-principal investigator with G.D.Z. on an
investigator-initiated grant from Merck and is a research con-
sultant for Merck. G.D.Z. is a research consultant for Merck
and a co-principal investigator on an investigator-initiated
grant from Merck. D.I.B. has received honoraria from Glaxo-
SmithKline, Alpha Vax, Vical, Medimmune, and Novartis, for
whom he has served as an advisor. He has received a royalty
from Glaxo-SmithKline for work on the rotavirus vaccine.
J.A.K. is a co-principal investigator on an NIH-funded study
of HPV vaccination of HIV-infected adolescents, for which
Merck is providing vaccine and immunogenicity testing.
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Address correspondence to:
Jessica A. Kahn, M.D., M.P.H.
Division of Adolescent Medicine
MLC 4000
Cincinnati Childrens Hospital Medical Center
3333 Burnet Avenue
Cincinnati, OH 45215
E-mail: Jessica.Kahn@cchmc.org