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Awareness and knowledge of HPV and HPV vaccination among adults ages 27–45 years
Vaccine xxx (xxxx) xxx
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Awareness and knowledge of HPV and HPV vaccination among adults ages 27–45 years Erika L. Thompson a,⇑, Christopher W. Wheldon b, Brittany L. Rosen c, Sarah B. Maness d, Monica L. Kasting e, Philip M. Massey f a
Department of Health Behavior and Health Systems, School of Public Health, University of North Texas Health Science Center, Fort Worth, TX, United States Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, PA, United States Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, OH, United States d Department of Health and Exercise Science, College of Arts and Sciences, University of Oklahoma, Norman, OK, United States e Department of Public Health, College of Health and Human Sciences, Purdue University, West Lafayette, IN, United States f Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, Philadelphia, PA, United States b c
a r t i c l e
i n f o
Article history: Received 22 October 2019 Received in revised form 14 January 2020 Accepted 17 January 2020 Available online xxxx Keywords: HPV Vaccine Adults Knowledge Awareness
a b s t r a c t Objective: Recent guidelines indicate adults 27–45 years old can receive the human papillomavirus (HPV) vaccine based on a shared-decision with their healthcare provider. With this expansion in recommendations, there is a need to examine the awareness and knowledge of HPV and HPV vaccination among this age group for cancer prevention. Methods: HINTS-5 Cycle-2 is a national survey of US adults, and was restricted to a complete case analysis of adults ages 27–45 years (N = 725). Sociodemographic, healthcare, and health information correlates were assessed for the outcomes of HPV awareness, HPV vaccine awareness, knowledge of HPV and cervical cancer, and knowledge of HPV and non-cervical cancers. Survey-weighted logistic regression models were conducted. Results: Most respondents were aware of HPV (72.9%) and HPV vaccination (67.1%). Respondents were more likely to be aware of HPV and HPV vaccination if they were female, had a higher level of education, and had previous cancer information seeking behaviors. Although there was widespread knowledge of HPV as a cause of cervical cancer (79.6%), knowledge of HPV as a cause of non-cervical cancers was reported by a minority of respondents (36.1%). College education was positively associated with cervical cancer knowledge (aOR = 4.62; 95%CI: 1.81–11.78); however, no significant correlates were identified for non-cervical HPV associated cancer knowledge. Conclusion: While more than half of adults ages 27–45 years are aware of HPV and HPV vaccination, there are opportunities to improve awareness and knowledge, particularly related to non-cervical cancers, as these are critical first steps toward shared decision-making for HPV vaccination in mid-adulthood. Ó 2020 Elsevier Ltd. All rights reserved.
1. Introduction An estimated 80% of people will be infected with human papillomavirus (HPV) in their lifetime [1]. Specific high-risk types of HPV are responsible for causing cancers. Specifically, oncogenic types of HPV are responsible for nearly 34,800 cases of cervical, anal, penile, vaginal, vulvar, and oropharyngeal cancers annually
⇑ Corresponding author at: 3500 Camp Bowie Blvd., Fort Worth, TX 76107, United States. E-mail addresses: [email protected] (E.L. Thompson), [email protected] (C.W. Wheldon), [email protected] (B.L. Rosen), [email protected] (S.B. Maness), [email protected] (M.L. Kasting), [email protected] (P.M. Massey).
in the United States (U.S.) [2]. There is an opportunity to prevent the majority of these cancers through the use of HPV vaccination. Currently, the HPV vaccine is routinely recommended for 11– 12-year-old adolescents with the opportunity for catch-up vaccination until age 26 [3]. Until recently, this has been the upper age limit recommended for HPV vaccination. In 2018, the Food and Drug Administration approved HPV vaccination for people ages 27–45 based on safety and efficacy of the vaccine. In June 2019, the Advisory Committee on Immunization Practices voted to permit the HPV vaccine as a shared clinical decision for people ages 27–45 years. This recommendation is based not only on safety and efficacy, but also vaccine effectiveness and cost-effectiveness [3].
https://doi.org/10.1016/j.vaccine.2020.01.053 0264-410X/Ó 2020 Elsevier Ltd. All rights reserved.
Please cite this article as: E. L. Thompson, C. W. Wheldon, B. L. Rosen et al., Awareness and knowledge of HPV and HPV vaccination among adults ages 27– 45 years, Vaccine, https://doi.org/10.1016/j.vaccine.2020.01.053
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As the United States continues to have suboptimal HPV vaccination rates among the target demographic of adolescents (68.1% of adolescents received at least one HPV vaccine dose in 2018) and similar trends among catch-up age young adults (14.5% of men and 45.7% of women received at least one HPV vaccine dose in 2016) [4,5], there is a significant proportion of adults that continue to be unvaccinated for HPV and lack protection from HPV-related cancers. According to the National Health Interview Survey 2017, 15.8% of women and 3.2% of men ages 27-to-45 years old had received at least one dose of the HPV vaccine [6]. Based on these guidelines, not all persons in this age group may need to be vaccinated, but rather have a conversation with their healthcare provider about the option to vaccinate. To facilitate these shared decision-making conversations, understanding adults’ awareness and knowledge of HPV vaccination may inform future interventions for this population. The Health Information National Trends Survey (HINTS) is sponsored by the National Cancer Institute (NCI) and collects nationally representative data about how the public uses cancer-related information [7]. This data source has been previously used to assess knowledge and awareness of HPV among an adult sample in the U.S. Several recent studies used HINTS to assess HPV knowledge and awareness focusing on racial and gender disparities, differences by sex, and overall national trends [8–10]. Previous studies using this dataset have found: women were more likely than men to have heard of HPV and HPV vaccine; and nonHispanic black and Hispanic participants were significantly less likely to have heard of HPV or HPV vaccine [8]. These findings illuminate disparities in HPV awareness, yet the mean age in the particular sample was 54 (SD = 16) [8]. Two additional studies of adults 18 and older indicated that men were less likely to be aware of HPV and HPV vaccine, as well as low overall awareness that HPV causes penile, oral and anal cancers [9,10]. Although these studies included adult participants, they did not focus specifically on adults in the age range of 27–45 years and did not include covariates of cancer health information seeking [8–10] or health insurance status [9,10]. A recent assessment of HINTS data found that men ages 27–45 were less knowledgeable about HPV compared to women; however, correlates of HPV awareness other than sex were not examined [11]. There is a need to examine a broad range of factors, specifically sociodemographic, healthcare status, and cancer health information seeking, associated with HPV and HPV vaccine awareness and knowledge among this specific age range of adults who may now be vaccine-eligible due to revised HPV vaccine guidelines. The purpose of this study was to assess the awareness and knowledge of HPV and HPV vaccination among a nationally representative sample of US adults ages 27–45, given the recent change in HPV vaccine recommendations, including covariates based on areas of demographics, cancer health information seeking and healthcare status. We hypothesized that adults who were ever considered vaccine-eligible (age 37 years or younger – within 11–26year age range since vaccine available) would have higher awareness and knowledge of HPV and HPV vaccination compared to adults ages 38–45 (i.e., those who were never eligible to receive the HPV vaccine). Similarly, we hypothesized that adults with a vaccine-eligible member of the household will have higher awareness and knowledge of HPV and HPV vaccination compared to adults without a vaccine-eligible member of the household.
this survey sampled U.S. adults ages 18 years and older, and had a response rate of 32.39%. The analytic sample was created by first limiting the full dataset (N = 3504) by the inclusion criteria (age = 27 to 45 years), which resulted in 744 eligible respondents. Measures. The outcome variables for this study were: awareness of HPV (‘‘Have you ever heard of HPV? HPV stands for Human Papillomavirus. It is not HIV, HSV, or herpes); awareness of HPV vaccination (‘‘A vaccine to prevent HPV infection is available and is called the cervical cancer vaccine or HPV shot. Before today, have you ever heard of the cervical cancer vaccine or HPV shot?); knowledge of HPV causing cervical cancer (‘‘Do you think HPV can cause cervical cancer?”); and knowledge of HPV causing noncervical cancers, including anal, penile, and oral cancers (‘‘Do you think HPV can cause [anal/penile/oral] cancers?”). Response options were yes, no, and not sure. Respondents were coded as yes for non-cervical cancers if they responded correctly to at least one of the items (anal, penile, and oral, respectively). The outcomes were dichotomized as yes or no/not sure. The analysis utilized three domains of predictor variables: demographics, healthcare, and cancer health information seeking. Demographic variables included: sex (female, male), marital status (married or living as married, single, previously married, single and never married), educational attainment (high school or less, some college, college), sexual orientation (heterosexual, lesbian/gay/bisexual (LGB), missing/declined), and race/ethnicity (Hispanic/ Latino, White, Black, Asian, Other/multi-racial). To assess familiarity with HPV vaccination, age was dichotomized to 27–37 years old and 38–45 years old, as persons in the 27–37 age category were eligible though may not have received the HPV vaccine in adolescence or young adulthood. Similarly, the measure of someone in the household being eligible for vaccination based on age (ages 9 to 27) was included (yes, no). Healthcare variables included: had health insurance (yes, no), and had a medical home (i.e., ‘‘. . .a particular doctor, nurse, or other health professional that you see most often?” yes, no). Finally, cancer health information seeking measures included: ever sought cancer information (yes, no), and sought cancer information on the Internet in the past year (yes, no). Analysis. SAS version 9.4 was used with survey-weighting procedures to adjust for household-level nonresponse and noncoverage biases [12]. Hot-deck imputation was used to replace missing responses for the following demographic variables: age, sex, educational attainment, race, and ethnicity [13]. There was minimal missing data on the remaining explanatory variables (1%), thus all analysis included only respondents with complete data on these variables (N = 725). A complete case analysis was used for the HPV-knowledge outcomes, resulting in<4% missing data for any given analysis. Awareness of HPV and HPV vaccination was assessed among the full analytic sample. To assess knowledge of HPV as a cause of cancer the sample was restricted to respondents who had previously heard of HPV (n = 577), since knowledge may be impacted by awareness of HPV. Crude odds ratios and 95% confidence intervals for each outcome and each correlate were estimated. Correlate variables with statistically significant (p < 0.05) independent effects were retained in the adjusted logistic regression models for each outcome variable. Odds ratios and 95% confidence intervals are reported.
3. Results 2. Material and Methods Sampling. This study used the HINTS 5, Cycle 2, which was administered from January to May 2018. Detailed survey methodology for this mailed survey can be found elsewhere [7]. Briefly,
Sample. Characteristics of the study sample are reported in Table 1. The sample was diverse with regard to sex, age, ethnoracial identity, and educational attainment. The majority were heterosexual (88.7%) and married or living as married (56.3%). Approximately half of respondents (50.3%) had an immediate fam-
Please cite this article as: E. L. Thompson, C. W. Wheldon, B. L. Rosen et al., Awareness and knowledge of HPV and HPV vaccination among adults ages 27– 45 years, Vaccine, https://doi.org/10.1016/j.vaccine.2020.01.053
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Table 1 Sample characteristics and awareness of HPV and HPV vaccination among men and women 27 to 45 years of age from the Health Information National Trends Survey, 2018 (N = 725). Total Sample
Aware of HPV (n = 563; 72.9%, SE = 2.5)
% (SE)
% (SE)
OR (95% CI)
AOR (95% CI)b
% (SE)
OR (95% CI)
AOR (95% CI)c
Demographics Sex Male Female
49.9 (2.2) 50.1 (2.2)
63.3 (3.5) 82.4 (2.8)
1.00 2.71 (1.73–4.24)
1.00 2.90 (1.74–4.87)
54.0 (4.0) 80.0 (3.2)
1.00 3.40 (1.90–6.09)
1.00 4.21 (2.08–8.54)
Age 27–37 years old 38–45 years old
50.7 (3.1) 49.3 (3.1)
75.2 (3.9) 70.5 (3.1)
1.00 0.78 (0.46–1.33)
68.3 (3.3) 65.9 (3.2)
1.00 0.90 (0.59–1.36)
Marital Status Married or living as married Single, previously married Single, never married
56.3 (2.6) 7.6 (1.0) 36.1 (2.6)
76.4 (2.9) 64.7 (6.7) 69.1 (5.6)
1.45 (0.75–2.82) 0.82 (0.36–1.89) 1.00
73.0 (2.7) 57.4 (6.7) 60.0 (6.0)
1.81 (0.95–3.42) 0.90 (0.42–1.92) 1.00
Educational Attainment High school or less Some college or equivalent College
25.4 (2.7) 33.9 (2.4) 40.7 (2.3)
45.0 (5.8) 83.6 (3.4) 81.2 (2.1)
1.00 6.21 (3.07–12.56) 5.29 (3.19–8.75)
35.8 (5.2) 78.8 (3.3) 76.6 (2.8)
1.00 6.65 (3.49–12.67) 5.87 (3.58–9.60)
Sexual Orientation Heterosexual LGB Missing/Declined
88.7 (2.0) 6.6 (1.9) 4.7 (1.1)
75.0 (2.6) 70.2 (22.2)
1.00 0.79 (0.03–20.41)
a
a
Race/Ethnicity Hispanic/Latino White Black Asian Other/multi-racial
19.8 (1.6) 56.5 (2.2) 13.0 (1.4) 7.2 (1.3) 3.5 (0.9)
68.9 76.5 70.8 47.9 95.4
Someone in Household Vaccine Eligible Age No 49.7 (2.8) Yes 50.3 (2.8)
(6.9) (3.9) (5.5) (9.1) (4.0)
0.68 1.00 0.74 0.28 6.33
(0.29–1.60) (0.36–1.54) (0.12–0.65) (0.51–79.40)
1.00 7.82 (3.89–15.72) 6.51 (3.46–12.25)
Aware of HPV vaccine (n = 524; 67.1%, SE = 2.3)
68.6 (2.3) 54.8 (17.4) 57.4 (12.6) 0.79 (0.31–1.99) 1.00 0.73 (0.35–1.53) 0.15 (0.06–0.36) 10.80 (0.71–163.75)
57.5 74.3 56.9 47.8 81.9
(7.0) (3.7) (6.7) (9.5) (11.1)
1.00 8.31 (3.49–19.76) 6.81 (3.45–13.44)
1.00 0.56 (0.12–2.58) a
0.47 1.00 0.46 0.32 1.56
(0.22–1.02) (0.23–0.92) (0.13–0.76) (0.32–7.73)
0.59 1.00 0.37 0.15 3.59
(0.27–1.30) (0.18–0.76) (0.06–0.39) (0.12–105.19)
70.5 (4.1) 75.2 (3.9)
1.00 1.27 (0.67–2.43)
64.3 (4.3) 69.8 (3.3)
1.00 1.28 (0.74–2.23)
10.8 (2.4) 89.2 (2.4)
65.8 (12.1) 73.8 (2.7)
1.00 1.46 (0.43–5.01)
59.2 (13.2) 68.1 (2.6)
1.00 1.47 (0.43–4.99)
44.3 (2.8) 55.7 (2.8)
63.8 (4.3) 80.2 (2.5)
1.00 2.29 (1.39–3.76)
1.00 1.85 (1.11–3.09)
60.6 (4.0) 72.3 (2.8)
1.00 1.70 (1.07–2.70)
1.00 1.09 (0.66–1.80)
Health information behaviors Sought cancer information (ever) No 55.6 (2.5) Yes 44.4 (2.5)
64.5 (3.3) 83.3 (3.9)
1.00 2.75 (1.43–5.28)
1.00 2.22 (1.14–4.35)
58.0 (3.5) 78.4 (4.0)
1.00 2.62 (1.40–4.92)
1.00 2.03 (1.08–3.82)
Sought cancer information on internet (past year) No 84.3 (2.0) 71.1 (2.9) Yes 15.7 (2.0) 82.5 (4.1)
1.00 1.92 (0.98–3.77)
65.4 (2.8) 76.2 (6.0)
1.00 1.69 (0.78–3.69)
Healthcare Had health insurance No Yes Medical home No Yes
Bold values indicate statistical significance (p < 0.05). a Estimate suppressed because it has relative standard error > 30% b Adjusted for sex, education, race/ethnicity, medical home, information seeking. c Adjusted for sex, education, race/ethnicity, medical home, information seeking.
ily member who was within the recommended age range for HPV vaccination (i.e., 9 to 27 years old). While most were insured (89.2%), just over half had a medical home (55.7%). A minority had ever sought cancer information from any source (44.4%) and a smaller proportion had looked for cancer information online within the previous year (15.7%). HPV Awareness. A majority of respondents were aware of HPV (72.9%; Table 1). Bivariate correlates of HPV awareness included female sex, Asian race, higher educational attainment, having a medical home, and engaging in cancer information seeking behavior. In the multivariable model, the following factors were positively associated with HPV awareness: female sex (AOR = 2.90; 95% CI: 1.74–4.87; referent = male sex), post high school education (AOR = 7.82; 95% CI: 3.89–15.72; referent = high school or less) or college education (AOR = 6.51; 95% CI: 3.46–12.25; referent = high school or less), medical home (AOR = 1.85; 95% CI: 1.11-3.09; referent = no), and previous cancer information seeking (AOR = 2.22;
95% CI: 1.14–4.35; referent = no). Factors negatively associated with HPV awareness included Asian race (AOR = 0.15; 95% CI: 0.06–0.36; referent = White). Respondent age and the presence of an age-eligible household member were not associated with HPV awareness as hypothesized. HPV Vaccine Awareness. Similarly, most respondents were aware of HPV vaccination (67.1%). Bivariate correlations of HPV vaccine awareness included female sex, race, higher educational attainment, engaging in cancer information seeking behavior, and having a medical home. In the multivariable model, the following factors were positively associated with HPV vaccine awareness: female sex (AOR = 4.21; 95% CI: 2.08–8.54; referent = male), post high school education (AOR = 8.31; 95% CI: 3.49–19.76; referent = high school or less), college education (AOR = 6.81; 95% CI: 3.45–13.44; referent = high school or less), and previous cancer information seeking (AOR = 2.03; 95% CI: 1.08–3.82; referent = no). Factors associated with lower HPV vaccine awareness included Asian
Please cite this article as: E. L. Thompson, C. W. Wheldon, B. L. Rosen et al., Awareness and knowledge of HPV and HPV vaccination among adults ages 27– 45 years, Vaccine, https://doi.org/10.1016/j.vaccine.2020.01.053
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(AOR = 0.15; 95% CI: 0.06–0.39; referent = White) and Black race (AOR = 0.37; 95% CI: 0.18–0.76; referent = White). Respondent age and the presence of an age-eligible household member were not associated with HPV vaccine awareness as hypothesized. HPV Knowledge. Although there was widespread knowledge of HPV as a cause of cervical cancer (79.6%), knowledge of HPV as a cause of non-cervical cancers was reported by a minority of respondents (36.1%; Table 2). When asked if HPV can cause different cancers, the distribution of ‘‘no” responses compared to ‘‘not sure” responses were larger for non-cervical cancers compared to cervical cancer: anal cancer (20.2% vs. 55.4%), penile cancer (19.1% vs. 51.5%), oral cancer (20.1% vs. 53.2%), and cervical cancer (2.3% vs. 18.1%). Among respondents who knew HPV can cause cervical cancer, 44.6% also knew that HPV was associated with oral, anal, or penile cancers. Bivariate correlates of HPV as a cause of cervical cancer knowledge included higher educational attainment and engaging in cancer information seeking behaviors; however,
only college education was positively associated with HPV as a cause of cervical cancer knowledge (AOR = 4.62; 95% CI: 1.81– 11.78; referent = high school or less). There were no factors associated with knowledge of non-cervical HPV associated cancers. Respondent age and the presence of an age-eligible household member were not associated with HPV knowledge as hypothesized. 4. Discussion This is one of the first studies in the U.S. to examine HPV and HPV vaccination correlates among 27–45 year olds within the context of the revised HPV vaccine guidelines. Overall, most adults were aware of HPV (73%) and two out of three adults were aware of HPV vaccination. However, HPV knowledge varied widely with a majority of participants identifying HPV’s link to cervical cancer and a minority identifying the link to non-cervical cancers. The
Table 2 Knowledge of HPV as a cause of cervical and non-cervical cancers among men and women 27 to 45 years who were previously aware of HPV, 2018 (N = 577; Health Information National Trends Survey). HPV causes cervical cancers (N = 471; 79.6%, SE = 2.8) % (SE)
OR (95% CI)
Demographics Sex Male Female
73.3 (4.5) 84.3 (3.4)
Age 27–37 years old 38–45 years old
AOR (95% CI)
HPV causes non-cervical cancers (N = 218; 36.1%, SE = 2.7) b
% (SE)
OR (95% CI)
1.00 1.96 (0.97–3.98)
35.0 (4.7) 36.9 (3.3)
1.00 1.09 (0.65–1.81)
79.3 (4.2) 79.9 (3.5)
1.00 1.03 (0.52–2.06)
38.4 (4.2) 33.3 (3.8)
1.00 0.80 (0.47–1.37)
Marital Status Married or living as married Single, previously married Single, never married
81.0 (3.4) 86.1 (4.5) 75.9 (6.1)
1.35 (0.58–3.16) 1.96 (0.67–5.77) 1.00
37.3 (3.9) 39.3 (9.7) 33.5 (4.5)
1.18 (0.69–2.02) 1.28 (0.51–3.21) 1.00
Educational Attainment High school or less Some college or equivalent College
59.8 (9.3) 76.5 (5.7) 88.7 (2.0)
1.00 2.19 (0.79–6.11) 5.27 (2.1–13.1))
23.2 (7.6) 33.2 (5.4) 42.4 (3.7)
1.00 1.64 (0.67–4.04) 2.43 (0.91–6.50)
Sexual Orientation Heterosexual LGB Missing/Declined Race/Ethnicity Hispanic/Latino White Black Asian Other/multi-racial
1.00 1.97 (0.70–5.57) 4.62 (1.81–11.78)
79.4 (2.7) 90.4 (4.3)
1.00 2.44 (0.81–7.31)
36.1 (2.8) 39.0 (10.8)
1.00 1.13 (0.44–2.94)
a
a
a
a
1.15 (0.54–2.45) 1.00 1.21 (0.48–3.07) 3.25 (0.95–11.1)
41.0 35.4 39.1 41.5
a
a
a
1.00 1.34 (0.61–2.94)
32.8 (3.8) 39.2 (4.7)
1.00 1.32 (0.73–2.38)
81.1 78.9 81.9 92.4
(4.6) (3.6) (5.6) (3.5)
a
Someone in Household Vaccine Eligible Age No 77.1 (4.5) Yes 81.9 (3.9)
(7.0) (3.3) (8.8) (11.7)
AOR (95% CI)
1.27 (0.65–2.48) 1.00 1.17 (0.52–2.62) 1.30 (0.45–3.72)
Healthcare Had health insurance No Yes
() 73.1 (11.0) 80.3 (3.0)
1.00 1.50 (0.40–5.62)
39.6 (15.5) 35.7 (2.8)
1.00 0.85 (0.20–3.54)
Medical home No Yes
77.0 (4.7) 81.3 (3.4)
1.00 1.30 (0.63–2.68)
31.8 (3.7) 38.8 (3.4)
1.00 1.36 (0.90–2.05)
Health information behaviors Sought cancer information (ever) No Yes
72.3 (3.9) 86.1 (3.7)
1.00 2.33 (1.06–5.08)
32.9 (3.6) 39.0 (3.8)
1.00 1.31 (0.83–2.07)
35.4 (3.1) 39.1 (7.0)
1.00 1.17 (0.60–2.30)
Sought cancer information on internet (past year) No 80.0 (2.9) Yes 78.3 (8.0)
1.00 0.91 (0.30–2.74)
1.00 2.03 (0.91–4.52)
Bold values indicate statistical significance (p < 0.05). a Estimate suppressed because it has relative standard error > 30%. b Adjusted for education and information seeking.
Please cite this article as: E. L. Thompson, C. W. Wheldon, B. L. Rosen et al., Awareness and knowledge of HPV and HPV vaccination among adults ages 27– 45 years, Vaccine, https://doi.org/10.1016/j.vaccine.2020.01.053
E.L. Thompson et al. / Vaccine xxx (xxxx) xxx
study’s hypotheses of age and having a vaccine-eligible household member being associated with more awareness and knowledge about HPV and HPV vaccination were not confirmed by this analysis. Rather, sex and socioeconomic factors were more consistent factors associated with awareness and knowledge. The diffusion of HPV-related information exhibits a few notable patterns in this nationally representative dataset of adults in the most recently expanded age licensure for HPV vaccination. Female sex was associated with awareness of HPV and HPV vaccination; however, among the subset of respondents who were previously aware of HPV, no differences by sex in HPV cancer knowledge were observed. This finding likely reflects the emphasis of HPV infection as a women’s health issue and the initial focus of HPV vaccination for the primary prevention of cervical cancer. Indeed, the HPV vaccine was licensed for girls and women in the U.S. several years before it was licensed for boys and men [14,15]. As such, much of the initial educational interventions to increase vaccination were targeted towards girls and parents of girls and highlighted only the benefits for women [16]. Similarly, knowledge of HPV-associated cancers that directly impact men was low among both men and women in this sample. This is consistent with previous research in this population. One study examining HPV-related knowledge among college students found that only 37% of women and 31% of men knew that HPV caused penile cancer [17]. Another study using HINTS data to compare men’s and women’s HPV-associated knowledge found no differences between sexes in regards to whether they knew HPV caused anal cancer (30% for men, 29% for women), penile cancer (27% for men, 15% for women), or oral cancer (32% for men, 29% for women) [18]. These findings indicate a clear and consistent lack of knowledge within this population and increasing their awareness of HPV and non-cervical cancers through evidence-based information is the first step to increase vaccine acceptance and uptake. Awareness of HPV-related information also differed by educational attainment. Adults with a college education were much more likely to be aware and knowledgeable about HPV and HPV vaccination regardless of their sex, age, race/ethnicity, and whether or not they had an immediate family member who was eligible for HPV vaccination. This finding suggests that the expanded age range for HPV licensing may increase disparities in HPV vaccine uptake in favor of the highly educated. Other studies including adults of a broader span of age ranges have also found educational attainment to be associated with HPV awareness [18–21]. Lower awareness and knowledge about HPV vaccination among those with lower educational attainment may reflect lack of exposure to relevant information about HPV or a higher burden of health literacy. To narrow the gaps in HPV and vaccine awareness and knowledge present in our findings (sex, race, educational attainment, and cancer information seeking behavior), the first step requires active diffusion of scientifically accurate information [22,23] through trusted, influential interpersonal channels [24]. Evidence suggests that using multiple channels (e.g., posters, infographics, websites, and social media) is most effective to increase awareness and knowledge within populations [25]. In particular, websites and social media have been shown to have a negative or positive impact, based on the messaging, on community’s vaccine perceptions [22,23,26]. In particular, given that our results showed HPV and vaccine awareness was associated with cancer information seeking behavior, public health officials must actively employ an integrated social media strategy (posting about upcoming events, blog posts, links to reputable websites, using keywords and hashtags, interactive content and games) and moving outside of traditional social media outlets to provide information comprehensively, not just to the information seekers. These findings should be considered in the context of its limitations. First, the sociodemographic data are self-reported measures,
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and may misidentify if a person has a vaccine-eligible household member. This measure is used as a proxy for a child who may be eligible to receive the vaccine; however, the respondent may not be the main decision-maker for the vaccine of this household member. The response rate for the survey was 32.4%; however, the survey-weighting procedures adjust for non-response bias. Additionally, these data were collected in January through May 2018 – immediately prior to the ACIP recommendation for adults ages 27–45. It may take several months for the information regarding this recommendation to diffuse within the target population. Finally, the study was limited by the sociodemographic predictor variables available in the HINTS dataset for analysis. 5. Conclusions The recent age expansion for HPV vaccination presents an important opportunity in the field of cancer prevention. While more than half of adults ages 27–45 years are aware of HPV and HPV vaccination, there are opportunities to improve awareness and knowledge, particularly related to non-cervical cancers, as these are critical first steps toward shared decision-making for HPV vaccination in mid-adulthood. Moreover, given the age range of the expansion guideline, many of these newly eligible individuals may themselves be parents of age-eligible children (i.e., 11– 12 year olds). Future work is needed to explore the potential pathways of decision-making and leverage points for vaccine uptake when both parent and child are eligible for the HPV vaccine. CRediT authorship contribution statement Erika L. Thompson: Conceptualization, Methodology, Writing original draft, Writing - review & editing. Christopher W. Wheldon: Conceptualization, Formal analysis, Methodology, Writing original draft, Writing - review & editing. Brittany L. Rosen: Conceptualization, Writing - original draft, Writing - review & editing. Sarah B. Maness: Conceptualization, Writing - original draft, Writing - review & editing. Monica L. Kasting: Conceptualization, Writing - original draft, Writing - review & editing. Philip M. Massey: Conceptualization, Writing - original draft, Writing - review & editing. Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Acknowledgement The authors would like to acknowledge the developers and administrators of the Health Information National Trends Survey – the National Cancer Institute. The present study reflects the analyses and interpretations of the authors, and do not reflect the views of the National Cancer Institute. References [1] Chesson HW et al. The estimated lifetime probability of acquiring human papillomavirus in the United States. Sex Transm Dis 2014;41(11):660–4. [2] Senkomago V et al. Human Papillomavirus-Attributable Cancers - United States, 2012–2016. MMWR Morb Mortal Wkly Rep 2019;68(33):724–8. [3] Meites E et al. Human papillomavirus vaccination for adults: updated recommendations of the advisory committee on immunization practices. MMWR Morb Mortal Wkly Rep 2019;68(32):698–702. [4] Walker TY et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years - United States, 2018. MMWR Morb Mortal Wkly Rep 2019;68(33):718–23.
Please cite this article as: E. L. Thompson, C. W. Wheldon, B. L. Rosen et al., Awareness and knowledge of HPV and HPV vaccination among adults ages 27– 45 years, Vaccine, https://doi.org/10.1016/j.vaccine.2020.01.053
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[5] Thompson EL, Rosen BL, Maness SB. Social determinants of health and human papillomavirus vaccination among young adults, National Health Interview Survey 2016. J Community Health 2019;44(1):149–58. [6] Kasting, M., et al. Baseline human papillomavirus vaccination prevalence prior to extended Food and Drug Administration licensure for adults 27-45 years old. in American Public Health Association. 2019. Philadelphia, PA. [7] Westat. Health Information National Trends Survey 5 (HINTS 5). 2018 [cited 2019 August 23]; Available from: https://hints.cancer.gov/docs/ methodologyreports/HINTS5_Cycle_2_Methodology_Report.pdf. [8] Adjei Boakye E et al. Approaching a decade since HPV vaccine licensure: Racial and gender disparities in knowledge and awareness of HPV and HPV vaccine. Hum Vaccin Immunother 2017;13(11):2713–22. [9] Osazuwa-Peters N et al. Not just a woman’s business! Understanding men and women’s knowledge of HPV, the HPV vaccine, and HPV-associated cancers. Prev Med 2017;99:299–304. [10] Wheldon CW et al. National trends in human papillomavirus awareness and knowledge of human papillomavirus-related cancers. Am J Prev Med 2019;56 (4):e117–23. [11] Suk R et al. Public knowledge of human papillomavirus and receipt of vaccination recommendations. JAMA Pediatr 2019;173(11):1099–102. [12] Rust KF, Rao JN. Variance estimation for complex surveys using replication techniques. Stat Methods Med Res 1996;5(3):283–310. [13] Andridge RR, Little RJ. A Review of Hot Deck Imputation for Survey Nonresponse. Int Stat Rev 2010;78(1):40–64. [14] Centers for Disease Control and Prevention. FDA licensure of quadrivalent human papillomavirus vaccine (HPV4, Gardasil) for use in males and guidance from the Advisory Committee on Immunization Practices (ACIP). MMWR. Morbidity and mortality weekly report 2010;59(20):630–2. [15] Markowitz LE et al. Quadrivalent Human Papillomavirus Vaccine: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2007;56(RR-2):1–24.
[16] Fu LY et al. Educational interventions to increase HPV vaccination acceptance: a systematic review. Vaccine 2014;32(17):1901–20. [17] Kasymova S, Harrison SE, Pascal C. Knowledge and awareness of human papillomavirus among college students in South Carolina. Infect Dis (Auckl) 2019;12. 1178633718825077. [18] McBride KR, Singh S. Predictors of adults’ knowledge and awareness of HPV, HPV-associated cancers, and the HPV vaccine: implications for health education. Health Educ Behav 2018;45(1):68–76. [19] Blake KD et al. Predictors of human papillomavirus awareness and knowledge in 2013: gaps and opportunities for targeted communication strategies. Am J Prev Med 2015;48(4):402–10. [20] Maness SB et al. HPV awareness, knowledge and vaccination attitudes among church-going african-american women. Am J Health Behav 2016;40(6):771–8. [21] Watkins KL et al. HPV awareness, knowledge and attitudes among older African-American women. Am J Health Behav 2015;39(2):205–11. [22] Nyhan B, Reifler J. Does correcting myths about the flu vaccine work? An experimental evaluation of the effects of corrective information. Vaccine 2015;33(3):459–64. [23] Nyhan B et al. Effective messages in vaccine promotion: a randomized trial. Pediatrics 2014;133(4):e835–42. [24] Kolff CA, Scott VP, Stockwell MS. The use of technology to promote vaccination: a social ecological model based framework. Hum Vaccin Immunother 2018;14(7):1636–46. [25] Cates JR et al. Evaluating a county-sponsored social marketing campaign to increase mothers’ initiation of HPV vaccine for their pre-teen daughters in a primarily rural area. Soc Mar Q 2011;17(1):4–26. [26] Betsch C, Sachse K. Dr. Jekyll or Mr. Hyde?(How) the Internet influences vaccination decisions: Recent evidence and tentative guidelines for online vaccine communication. Vaccine 2012;25(30):3723–6.
Please cite this article as: E. L. Thompson, C. W. Wheldon, B. L. Rosen et al., Awareness and knowledge of HPV and HPV vaccination among adults ages 27– 45 years, Vaccine, https://doi.org/10.1016/j.vaccine.2020.01.053
Contents lists available at ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
Awareness and knowledge of HPV and HPV vaccination among adults ages 27–45 years Erika L. Thompson a,⇑, Christopher W. Wheldon b, Brittany L. Rosen c, Sarah B. Maness d, Monica L. Kasting e, Philip M. Massey f a
Department of Health Behavior and Health Systems, School of Public Health, University of North Texas Health Science Center, Fort Worth, TX, United States Department of Social and Behavioral Sciences, College of Public Health, Temple University, Philadelphia, PA, United States Department of Pediatrics, Cincinnati Children’s Hospital, Cincinnati, OH, United States d Department of Health and Exercise Science, College of Arts and Sciences, University of Oklahoma, Norman, OK, United States e Department of Public Health, College of Health and Human Sciences, Purdue University, West Lafayette, IN, United States f Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, Philadelphia, PA, United States b c
a r t i c l e
i n f o
Article history: Received 22 October 2019 Received in revised form 14 January 2020 Accepted 17 January 2020 Available online xxxx Keywords: HPV Vaccine Adults Knowledge Awareness
a b s t r a c t Objective: Recent guidelines indicate adults 27–45 years old can receive the human papillomavirus (HPV) vaccine based on a shared-decision with their healthcare provider. With this expansion in recommendations, there is a need to examine the awareness and knowledge of HPV and HPV vaccination among this age group for cancer prevention. Methods: HINTS-5 Cycle-2 is a national survey of US adults, and was restricted to a complete case analysis of adults ages 27–45 years (N = 725). Sociodemographic, healthcare, and health information correlates were assessed for the outcomes of HPV awareness, HPV vaccine awareness, knowledge of HPV and cervical cancer, and knowledge of HPV and non-cervical cancers. Survey-weighted logistic regression models were conducted. Results: Most respondents were aware of HPV (72.9%) and HPV vaccination (67.1%). Respondents were more likely to be aware of HPV and HPV vaccination if they were female, had a higher level of education, and had previous cancer information seeking behaviors. Although there was widespread knowledge of HPV as a cause of cervical cancer (79.6%), knowledge of HPV as a cause of non-cervical cancers was reported by a minority of respondents (36.1%). College education was positively associated with cervical cancer knowledge (aOR = 4.62; 95%CI: 1.81–11.78); however, no significant correlates were identified for non-cervical HPV associated cancer knowledge. Conclusion: While more than half of adults ages 27–45 years are aware of HPV and HPV vaccination, there are opportunities to improve awareness and knowledge, particularly related to non-cervical cancers, as these are critical first steps toward shared decision-making for HPV vaccination in mid-adulthood. Ó 2020 Elsevier Ltd. All rights reserved.
1. Introduction An estimated 80% of people will be infected with human papillomavirus (HPV) in their lifetime [1]. Specific high-risk types of HPV are responsible for causing cancers. Specifically, oncogenic types of HPV are responsible for nearly 34,800 cases of cervical, anal, penile, vaginal, vulvar, and oropharyngeal cancers annually
⇑ Corresponding author at: 3500 Camp Bowie Blvd., Fort Worth, TX 76107, United States. E-mail addresses: [email protected] (E.L. Thompson), [email protected] (C.W. Wheldon), [email protected] (B.L. Rosen), [email protected] (S.B. Maness), [email protected] (M.L. Kasting), [email protected] (P.M. Massey).
in the United States (U.S.) [2]. There is an opportunity to prevent the majority of these cancers through the use of HPV vaccination. Currently, the HPV vaccine is routinely recommended for 11– 12-year-old adolescents with the opportunity for catch-up vaccination until age 26 [3]. Until recently, this has been the upper age limit recommended for HPV vaccination. In 2018, the Food and Drug Administration approved HPV vaccination for people ages 27–45 based on safety and efficacy of the vaccine. In June 2019, the Advisory Committee on Immunization Practices voted to permit the HPV vaccine as a shared clinical decision for people ages 27–45 years. This recommendation is based not only on safety and efficacy, but also vaccine effectiveness and cost-effectiveness [3].
https://doi.org/10.1016/j.vaccine.2020.01.053 0264-410X/Ó 2020 Elsevier Ltd. All rights reserved.
Please cite this article as: E. L. Thompson, C. W. Wheldon, B. L. Rosen et al., Awareness and knowledge of HPV and HPV vaccination among adults ages 27– 45 years, Vaccine, https://doi.org/10.1016/j.vaccine.2020.01.053
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As the United States continues to have suboptimal HPV vaccination rates among the target demographic of adolescents (68.1% of adolescents received at least one HPV vaccine dose in 2018) and similar trends among catch-up age young adults (14.5% of men and 45.7% of women received at least one HPV vaccine dose in 2016) [4,5], there is a significant proportion of adults that continue to be unvaccinated for HPV and lack protection from HPV-related cancers. According to the National Health Interview Survey 2017, 15.8% of women and 3.2% of men ages 27-to-45 years old had received at least one dose of the HPV vaccine [6]. Based on these guidelines, not all persons in this age group may need to be vaccinated, but rather have a conversation with their healthcare provider about the option to vaccinate. To facilitate these shared decision-making conversations, understanding adults’ awareness and knowledge of HPV vaccination may inform future interventions for this population. The Health Information National Trends Survey (HINTS) is sponsored by the National Cancer Institute (NCI) and collects nationally representative data about how the public uses cancer-related information [7]. This data source has been previously used to assess knowledge and awareness of HPV among an adult sample in the U.S. Several recent studies used HINTS to assess HPV knowledge and awareness focusing on racial and gender disparities, differences by sex, and overall national trends [8–10]. Previous studies using this dataset have found: women were more likely than men to have heard of HPV and HPV vaccine; and nonHispanic black and Hispanic participants were significantly less likely to have heard of HPV or HPV vaccine [8]. These findings illuminate disparities in HPV awareness, yet the mean age in the particular sample was 54 (SD = 16) [8]. Two additional studies of adults 18 and older indicated that men were less likely to be aware of HPV and HPV vaccine, as well as low overall awareness that HPV causes penile, oral and anal cancers [9,10]. Although these studies included adult participants, they did not focus specifically on adults in the age range of 27–45 years and did not include covariates of cancer health information seeking [8–10] or health insurance status [9,10]. A recent assessment of HINTS data found that men ages 27–45 were less knowledgeable about HPV compared to women; however, correlates of HPV awareness other than sex were not examined [11]. There is a need to examine a broad range of factors, specifically sociodemographic, healthcare status, and cancer health information seeking, associated with HPV and HPV vaccine awareness and knowledge among this specific age range of adults who may now be vaccine-eligible due to revised HPV vaccine guidelines. The purpose of this study was to assess the awareness and knowledge of HPV and HPV vaccination among a nationally representative sample of US adults ages 27–45, given the recent change in HPV vaccine recommendations, including covariates based on areas of demographics, cancer health information seeking and healthcare status. We hypothesized that adults who were ever considered vaccine-eligible (age 37 years or younger – within 11–26year age range since vaccine available) would have higher awareness and knowledge of HPV and HPV vaccination compared to adults ages 38–45 (i.e., those who were never eligible to receive the HPV vaccine). Similarly, we hypothesized that adults with a vaccine-eligible member of the household will have higher awareness and knowledge of HPV and HPV vaccination compared to adults without a vaccine-eligible member of the household.
this survey sampled U.S. adults ages 18 years and older, and had a response rate of 32.39%. The analytic sample was created by first limiting the full dataset (N = 3504) by the inclusion criteria (age = 27 to 45 years), which resulted in 744 eligible respondents. Measures. The outcome variables for this study were: awareness of HPV (‘‘Have you ever heard of HPV? HPV stands for Human Papillomavirus. It is not HIV, HSV, or herpes); awareness of HPV vaccination (‘‘A vaccine to prevent HPV infection is available and is called the cervical cancer vaccine or HPV shot. Before today, have you ever heard of the cervical cancer vaccine or HPV shot?); knowledge of HPV causing cervical cancer (‘‘Do you think HPV can cause cervical cancer?”); and knowledge of HPV causing noncervical cancers, including anal, penile, and oral cancers (‘‘Do you think HPV can cause [anal/penile/oral] cancers?”). Response options were yes, no, and not sure. Respondents were coded as yes for non-cervical cancers if they responded correctly to at least one of the items (anal, penile, and oral, respectively). The outcomes were dichotomized as yes or no/not sure. The analysis utilized three domains of predictor variables: demographics, healthcare, and cancer health information seeking. Demographic variables included: sex (female, male), marital status (married or living as married, single, previously married, single and never married), educational attainment (high school or less, some college, college), sexual orientation (heterosexual, lesbian/gay/bisexual (LGB), missing/declined), and race/ethnicity (Hispanic/ Latino, White, Black, Asian, Other/multi-racial). To assess familiarity with HPV vaccination, age was dichotomized to 27–37 years old and 38–45 years old, as persons in the 27–37 age category were eligible though may not have received the HPV vaccine in adolescence or young adulthood. Similarly, the measure of someone in the household being eligible for vaccination based on age (ages 9 to 27) was included (yes, no). Healthcare variables included: had health insurance (yes, no), and had a medical home (i.e., ‘‘. . .a particular doctor, nurse, or other health professional that you see most often?” yes, no). Finally, cancer health information seeking measures included: ever sought cancer information (yes, no), and sought cancer information on the Internet in the past year (yes, no). Analysis. SAS version 9.4 was used with survey-weighting procedures to adjust for household-level nonresponse and noncoverage biases [12]. Hot-deck imputation was used to replace missing responses for the following demographic variables: age, sex, educational attainment, race, and ethnicity [13]. There was minimal missing data on the remaining explanatory variables (1%), thus all analysis included only respondents with complete data on these variables (N = 725). A complete case analysis was used for the HPV-knowledge outcomes, resulting in<4% missing data for any given analysis. Awareness of HPV and HPV vaccination was assessed among the full analytic sample. To assess knowledge of HPV as a cause of cancer the sample was restricted to respondents who had previously heard of HPV (n = 577), since knowledge may be impacted by awareness of HPV. Crude odds ratios and 95% confidence intervals for each outcome and each correlate were estimated. Correlate variables with statistically significant (p < 0.05) independent effects were retained in the adjusted logistic regression models for each outcome variable. Odds ratios and 95% confidence intervals are reported.
3. Results 2. Material and Methods Sampling. This study used the HINTS 5, Cycle 2, which was administered from January to May 2018. Detailed survey methodology for this mailed survey can be found elsewhere [7]. Briefly,
Sample. Characteristics of the study sample are reported in Table 1. The sample was diverse with regard to sex, age, ethnoracial identity, and educational attainment. The majority were heterosexual (88.7%) and married or living as married (56.3%). Approximately half of respondents (50.3%) had an immediate fam-
Please cite this article as: E. L. Thompson, C. W. Wheldon, B. L. Rosen et al., Awareness and knowledge of HPV and HPV vaccination among adults ages 27– 45 years, Vaccine, https://doi.org/10.1016/j.vaccine.2020.01.053
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Table 1 Sample characteristics and awareness of HPV and HPV vaccination among men and women 27 to 45 years of age from the Health Information National Trends Survey, 2018 (N = 725). Total Sample
Aware of HPV (n = 563; 72.9%, SE = 2.5)
% (SE)
% (SE)
OR (95% CI)
AOR (95% CI)b
% (SE)
OR (95% CI)
AOR (95% CI)c
Demographics Sex Male Female
49.9 (2.2) 50.1 (2.2)
63.3 (3.5) 82.4 (2.8)
1.00 2.71 (1.73–4.24)
1.00 2.90 (1.74–4.87)
54.0 (4.0) 80.0 (3.2)
1.00 3.40 (1.90–6.09)
1.00 4.21 (2.08–8.54)
Age 27–37 years old 38–45 years old
50.7 (3.1) 49.3 (3.1)
75.2 (3.9) 70.5 (3.1)
1.00 0.78 (0.46–1.33)
68.3 (3.3) 65.9 (3.2)
1.00 0.90 (0.59–1.36)
Marital Status Married or living as married Single, previously married Single, never married
56.3 (2.6) 7.6 (1.0) 36.1 (2.6)
76.4 (2.9) 64.7 (6.7) 69.1 (5.6)
1.45 (0.75–2.82) 0.82 (0.36–1.89) 1.00
73.0 (2.7) 57.4 (6.7) 60.0 (6.0)
1.81 (0.95–3.42) 0.90 (0.42–1.92) 1.00
Educational Attainment High school or less Some college or equivalent College
25.4 (2.7) 33.9 (2.4) 40.7 (2.3)
45.0 (5.8) 83.6 (3.4) 81.2 (2.1)
1.00 6.21 (3.07–12.56) 5.29 (3.19–8.75)
35.8 (5.2) 78.8 (3.3) 76.6 (2.8)
1.00 6.65 (3.49–12.67) 5.87 (3.58–9.60)
Sexual Orientation Heterosexual LGB Missing/Declined
88.7 (2.0) 6.6 (1.9) 4.7 (1.1)
75.0 (2.6) 70.2 (22.2)
1.00 0.79 (0.03–20.41)
a
a
Race/Ethnicity Hispanic/Latino White Black Asian Other/multi-racial
19.8 (1.6) 56.5 (2.2) 13.0 (1.4) 7.2 (1.3) 3.5 (0.9)
68.9 76.5 70.8 47.9 95.4
Someone in Household Vaccine Eligible Age No 49.7 (2.8) Yes 50.3 (2.8)
(6.9) (3.9) (5.5) (9.1) (4.0)
0.68 1.00 0.74 0.28 6.33
(0.29–1.60) (0.36–1.54) (0.12–0.65) (0.51–79.40)
1.00 7.82 (3.89–15.72) 6.51 (3.46–12.25)
Aware of HPV vaccine (n = 524; 67.1%, SE = 2.3)
68.6 (2.3) 54.8 (17.4) 57.4 (12.6) 0.79 (0.31–1.99) 1.00 0.73 (0.35–1.53) 0.15 (0.06–0.36) 10.80 (0.71–163.75)
57.5 74.3 56.9 47.8 81.9
(7.0) (3.7) (6.7) (9.5) (11.1)
1.00 8.31 (3.49–19.76) 6.81 (3.45–13.44)
1.00 0.56 (0.12–2.58) a
0.47 1.00 0.46 0.32 1.56
(0.22–1.02) (0.23–0.92) (0.13–0.76) (0.32–7.73)
0.59 1.00 0.37 0.15 3.59
(0.27–1.30) (0.18–0.76) (0.06–0.39) (0.12–105.19)
70.5 (4.1) 75.2 (3.9)
1.00 1.27 (0.67–2.43)
64.3 (4.3) 69.8 (3.3)
1.00 1.28 (0.74–2.23)
10.8 (2.4) 89.2 (2.4)
65.8 (12.1) 73.8 (2.7)
1.00 1.46 (0.43–5.01)
59.2 (13.2) 68.1 (2.6)
1.00 1.47 (0.43–4.99)
44.3 (2.8) 55.7 (2.8)
63.8 (4.3) 80.2 (2.5)
1.00 2.29 (1.39–3.76)
1.00 1.85 (1.11–3.09)
60.6 (4.0) 72.3 (2.8)
1.00 1.70 (1.07–2.70)
1.00 1.09 (0.66–1.80)
Health information behaviors Sought cancer information (ever) No 55.6 (2.5) Yes 44.4 (2.5)
64.5 (3.3) 83.3 (3.9)
1.00 2.75 (1.43–5.28)
1.00 2.22 (1.14–4.35)
58.0 (3.5) 78.4 (4.0)
1.00 2.62 (1.40–4.92)
1.00 2.03 (1.08–3.82)
Sought cancer information on internet (past year) No 84.3 (2.0) 71.1 (2.9) Yes 15.7 (2.0) 82.5 (4.1)
1.00 1.92 (0.98–3.77)
65.4 (2.8) 76.2 (6.0)
1.00 1.69 (0.78–3.69)
Healthcare Had health insurance No Yes Medical home No Yes
Bold values indicate statistical significance (p < 0.05). a Estimate suppressed because it has relative standard error > 30% b Adjusted for sex, education, race/ethnicity, medical home, information seeking. c Adjusted for sex, education, race/ethnicity, medical home, information seeking.
ily member who was within the recommended age range for HPV vaccination (i.e., 9 to 27 years old). While most were insured (89.2%), just over half had a medical home (55.7%). A minority had ever sought cancer information from any source (44.4%) and a smaller proportion had looked for cancer information online within the previous year (15.7%). HPV Awareness. A majority of respondents were aware of HPV (72.9%; Table 1). Bivariate correlates of HPV awareness included female sex, Asian race, higher educational attainment, having a medical home, and engaging in cancer information seeking behavior. In the multivariable model, the following factors were positively associated with HPV awareness: female sex (AOR = 2.90; 95% CI: 1.74–4.87; referent = male sex), post high school education (AOR = 7.82; 95% CI: 3.89–15.72; referent = high school or less) or college education (AOR = 6.51; 95% CI: 3.46–12.25; referent = high school or less), medical home (AOR = 1.85; 95% CI: 1.11-3.09; referent = no), and previous cancer information seeking (AOR = 2.22;
95% CI: 1.14–4.35; referent = no). Factors negatively associated with HPV awareness included Asian race (AOR = 0.15; 95% CI: 0.06–0.36; referent = White). Respondent age and the presence of an age-eligible household member were not associated with HPV awareness as hypothesized. HPV Vaccine Awareness. Similarly, most respondents were aware of HPV vaccination (67.1%). Bivariate correlations of HPV vaccine awareness included female sex, race, higher educational attainment, engaging in cancer information seeking behavior, and having a medical home. In the multivariable model, the following factors were positively associated with HPV vaccine awareness: female sex (AOR = 4.21; 95% CI: 2.08–8.54; referent = male), post high school education (AOR = 8.31; 95% CI: 3.49–19.76; referent = high school or less), college education (AOR = 6.81; 95% CI: 3.45–13.44; referent = high school or less), and previous cancer information seeking (AOR = 2.03; 95% CI: 1.08–3.82; referent = no). Factors associated with lower HPV vaccine awareness included Asian
Please cite this article as: E. L. Thompson, C. W. Wheldon, B. L. Rosen et al., Awareness and knowledge of HPV and HPV vaccination among adults ages 27– 45 years, Vaccine, https://doi.org/10.1016/j.vaccine.2020.01.053
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(AOR = 0.15; 95% CI: 0.06–0.39; referent = White) and Black race (AOR = 0.37; 95% CI: 0.18–0.76; referent = White). Respondent age and the presence of an age-eligible household member were not associated with HPV vaccine awareness as hypothesized. HPV Knowledge. Although there was widespread knowledge of HPV as a cause of cervical cancer (79.6%), knowledge of HPV as a cause of non-cervical cancers was reported by a minority of respondents (36.1%; Table 2). When asked if HPV can cause different cancers, the distribution of ‘‘no” responses compared to ‘‘not sure” responses were larger for non-cervical cancers compared to cervical cancer: anal cancer (20.2% vs. 55.4%), penile cancer (19.1% vs. 51.5%), oral cancer (20.1% vs. 53.2%), and cervical cancer (2.3% vs. 18.1%). Among respondents who knew HPV can cause cervical cancer, 44.6% also knew that HPV was associated with oral, anal, or penile cancers. Bivariate correlates of HPV as a cause of cervical cancer knowledge included higher educational attainment and engaging in cancer information seeking behaviors; however,
only college education was positively associated with HPV as a cause of cervical cancer knowledge (AOR = 4.62; 95% CI: 1.81– 11.78; referent = high school or less). There were no factors associated with knowledge of non-cervical HPV associated cancers. Respondent age and the presence of an age-eligible household member were not associated with HPV knowledge as hypothesized. 4. Discussion This is one of the first studies in the U.S. to examine HPV and HPV vaccination correlates among 27–45 year olds within the context of the revised HPV vaccine guidelines. Overall, most adults were aware of HPV (73%) and two out of three adults were aware of HPV vaccination. However, HPV knowledge varied widely with a majority of participants identifying HPV’s link to cervical cancer and a minority identifying the link to non-cervical cancers. The
Table 2 Knowledge of HPV as a cause of cervical and non-cervical cancers among men and women 27 to 45 years who were previously aware of HPV, 2018 (N = 577; Health Information National Trends Survey). HPV causes cervical cancers (N = 471; 79.6%, SE = 2.8) % (SE)
OR (95% CI)
Demographics Sex Male Female
73.3 (4.5) 84.3 (3.4)
Age 27–37 years old 38–45 years old
AOR (95% CI)
HPV causes non-cervical cancers (N = 218; 36.1%, SE = 2.7) b
% (SE)
OR (95% CI)
1.00 1.96 (0.97–3.98)
35.0 (4.7) 36.9 (3.3)
1.00 1.09 (0.65–1.81)
79.3 (4.2) 79.9 (3.5)
1.00 1.03 (0.52–2.06)
38.4 (4.2) 33.3 (3.8)
1.00 0.80 (0.47–1.37)
Marital Status Married or living as married Single, previously married Single, never married
81.0 (3.4) 86.1 (4.5) 75.9 (6.1)
1.35 (0.58–3.16) 1.96 (0.67–5.77) 1.00
37.3 (3.9) 39.3 (9.7) 33.5 (4.5)
1.18 (0.69–2.02) 1.28 (0.51–3.21) 1.00
Educational Attainment High school or less Some college or equivalent College
59.8 (9.3) 76.5 (5.7) 88.7 (2.0)
1.00 2.19 (0.79–6.11) 5.27 (2.1–13.1))
23.2 (7.6) 33.2 (5.4) 42.4 (3.7)
1.00 1.64 (0.67–4.04) 2.43 (0.91–6.50)
Sexual Orientation Heterosexual LGB Missing/Declined Race/Ethnicity Hispanic/Latino White Black Asian Other/multi-racial
1.00 1.97 (0.70–5.57) 4.62 (1.81–11.78)
79.4 (2.7) 90.4 (4.3)
1.00 2.44 (0.81–7.31)
36.1 (2.8) 39.0 (10.8)
1.00 1.13 (0.44–2.94)
a
a
a
a
1.15 (0.54–2.45) 1.00 1.21 (0.48–3.07) 3.25 (0.95–11.1)
41.0 35.4 39.1 41.5
a
a
a
1.00 1.34 (0.61–2.94)
32.8 (3.8) 39.2 (4.7)
1.00 1.32 (0.73–2.38)
81.1 78.9 81.9 92.4
(4.6) (3.6) (5.6) (3.5)
a
Someone in Household Vaccine Eligible Age No 77.1 (4.5) Yes 81.9 (3.9)
(7.0) (3.3) (8.8) (11.7)
AOR (95% CI)
1.27 (0.65–2.48) 1.00 1.17 (0.52–2.62) 1.30 (0.45–3.72)
Healthcare Had health insurance No Yes
() 73.1 (11.0) 80.3 (3.0)
1.00 1.50 (0.40–5.62)
39.6 (15.5) 35.7 (2.8)
1.00 0.85 (0.20–3.54)
Medical home No Yes
77.0 (4.7) 81.3 (3.4)
1.00 1.30 (0.63–2.68)
31.8 (3.7) 38.8 (3.4)
1.00 1.36 (0.90–2.05)
Health information behaviors Sought cancer information (ever) No Yes
72.3 (3.9) 86.1 (3.7)
1.00 2.33 (1.06–5.08)
32.9 (3.6) 39.0 (3.8)
1.00 1.31 (0.83–2.07)
35.4 (3.1) 39.1 (7.0)
1.00 1.17 (0.60–2.30)
Sought cancer information on internet (past year) No 80.0 (2.9) Yes 78.3 (8.0)
1.00 0.91 (0.30–2.74)
1.00 2.03 (0.91–4.52)
Bold values indicate statistical significance (p < 0.05). a Estimate suppressed because it has relative standard error > 30%. b Adjusted for education and information seeking.
Please cite this article as: E. L. Thompson, C. W. Wheldon, B. L. Rosen et al., Awareness and knowledge of HPV and HPV vaccination among adults ages 27– 45 years, Vaccine, https://doi.org/10.1016/j.vaccine.2020.01.053
E.L. Thompson et al. / Vaccine xxx (xxxx) xxx
study’s hypotheses of age and having a vaccine-eligible household member being associated with more awareness and knowledge about HPV and HPV vaccination were not confirmed by this analysis. Rather, sex and socioeconomic factors were more consistent factors associated with awareness and knowledge. The diffusion of HPV-related information exhibits a few notable patterns in this nationally representative dataset of adults in the most recently expanded age licensure for HPV vaccination. Female sex was associated with awareness of HPV and HPV vaccination; however, among the subset of respondents who were previously aware of HPV, no differences by sex in HPV cancer knowledge were observed. This finding likely reflects the emphasis of HPV infection as a women’s health issue and the initial focus of HPV vaccination for the primary prevention of cervical cancer. Indeed, the HPV vaccine was licensed for girls and women in the U.S. several years before it was licensed for boys and men [14,15]. As such, much of the initial educational interventions to increase vaccination were targeted towards girls and parents of girls and highlighted only the benefits for women [16]. Similarly, knowledge of HPV-associated cancers that directly impact men was low among both men and women in this sample. This is consistent with previous research in this population. One study examining HPV-related knowledge among college students found that only 37% of women and 31% of men knew that HPV caused penile cancer [17]. Another study using HINTS data to compare men’s and women’s HPV-associated knowledge found no differences between sexes in regards to whether they knew HPV caused anal cancer (30% for men, 29% for women), penile cancer (27% for men, 15% for women), or oral cancer (32% for men, 29% for women) [18]. These findings indicate a clear and consistent lack of knowledge within this population and increasing their awareness of HPV and non-cervical cancers through evidence-based information is the first step to increase vaccine acceptance and uptake. Awareness of HPV-related information also differed by educational attainment. Adults with a college education were much more likely to be aware and knowledgeable about HPV and HPV vaccination regardless of their sex, age, race/ethnicity, and whether or not they had an immediate family member who was eligible for HPV vaccination. This finding suggests that the expanded age range for HPV licensing may increase disparities in HPV vaccine uptake in favor of the highly educated. Other studies including adults of a broader span of age ranges have also found educational attainment to be associated with HPV awareness [18–21]. Lower awareness and knowledge about HPV vaccination among those with lower educational attainment may reflect lack of exposure to relevant information about HPV or a higher burden of health literacy. To narrow the gaps in HPV and vaccine awareness and knowledge present in our findings (sex, race, educational attainment, and cancer information seeking behavior), the first step requires active diffusion of scientifically accurate information [22,23] through trusted, influential interpersonal channels [24]. Evidence suggests that using multiple channels (e.g., posters, infographics, websites, and social media) is most effective to increase awareness and knowledge within populations [25]. In particular, websites and social media have been shown to have a negative or positive impact, based on the messaging, on community’s vaccine perceptions [22,23,26]. In particular, given that our results showed HPV and vaccine awareness was associated with cancer information seeking behavior, public health officials must actively employ an integrated social media strategy (posting about upcoming events, blog posts, links to reputable websites, using keywords and hashtags, interactive content and games) and moving outside of traditional social media outlets to provide information comprehensively, not just to the information seekers. These findings should be considered in the context of its limitations. First, the sociodemographic data are self-reported measures,
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and may misidentify if a person has a vaccine-eligible household member. This measure is used as a proxy for a child who may be eligible to receive the vaccine; however, the respondent may not be the main decision-maker for the vaccine of this household member. The response rate for the survey was 32.4%; however, the survey-weighting procedures adjust for non-response bias. Additionally, these data were collected in January through May 2018 – immediately prior to the ACIP recommendation for adults ages 27–45. It may take several months for the information regarding this recommendation to diffuse within the target population. Finally, the study was limited by the sociodemographic predictor variables available in the HINTS dataset for analysis. 5. Conclusions The recent age expansion for HPV vaccination presents an important opportunity in the field of cancer prevention. While more than half of adults ages 27–45 years are aware of HPV and HPV vaccination, there are opportunities to improve awareness and knowledge, particularly related to non-cervical cancers, as these are critical first steps toward shared decision-making for HPV vaccination in mid-adulthood. Moreover, given the age range of the expansion guideline, many of these newly eligible individuals may themselves be parents of age-eligible children (i.e., 11– 12 year olds). Future work is needed to explore the potential pathways of decision-making and leverage points for vaccine uptake when both parent and child are eligible for the HPV vaccine. CRediT authorship contribution statement Erika L. Thompson: Conceptualization, Methodology, Writing original draft, Writing - review & editing. Christopher W. Wheldon: Conceptualization, Formal analysis, Methodology, Writing original draft, Writing - review & editing. Brittany L. Rosen: Conceptualization, Writing - original draft, Writing - review & editing. Sarah B. Maness: Conceptualization, Writing - original draft, Writing - review & editing. Monica L. Kasting: Conceptualization, Writing - original draft, Writing - review & editing. Philip M. Massey: Conceptualization, Writing - original draft, Writing - review & editing. Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Acknowledgement The authors would like to acknowledge the developers and administrators of the Health Information National Trends Survey – the National Cancer Institute. The present study reflects the analyses and interpretations of the authors, and do not reflect the views of the National Cancer Institute. References [1] Chesson HW et al. The estimated lifetime probability of acquiring human papillomavirus in the United States. Sex Transm Dis 2014;41(11):660–4. [2] Senkomago V et al. Human Papillomavirus-Attributable Cancers - United States, 2012–2016. MMWR Morb Mortal Wkly Rep 2019;68(33):724–8. [3] Meites E et al. Human papillomavirus vaccination for adults: updated recommendations of the advisory committee on immunization practices. MMWR Morb Mortal Wkly Rep 2019;68(32):698–702. [4] Walker TY et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years - United States, 2018. MMWR Morb Mortal Wkly Rep 2019;68(33):718–23.
Please cite this article as: E. L. Thompson, C. W. Wheldon, B. L. Rosen et al., Awareness and knowledge of HPV and HPV vaccination among adults ages 27– 45 years, Vaccine, https://doi.org/10.1016/j.vaccine.2020.01.053
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Please cite this article as: E. L. Thompson, C. W. Wheldon, B. L. Rosen et al., Awareness and knowledge of HPV and HPV vaccination among adults ages 27– 45 years, Vaccine, https://doi.org/10.1016/j.vaccine.2020.01.053