State-Level Public Awareness of HPV, HPV Vaccine, and Association With Cancer

Each year, an estimated 48 000 new cases of human papillomavirus (HPV)–associated cancers are diagnosed in the US,¹ with nearly 62% occurring in Midwestern and Southern states.² Awareness is a key psychosocial factor that drives the public’s adherence to preventive measures like HPV vaccination. This study quantifies awareness of HPV, the HPV vaccine, and its association with cancer across 50 states and Washington, DC.

Methods |

This cross-sectional study analyzed the 2017–2020 Health Information National Trends Survey (HINTS) 5, cycles 1 to 4, and the 2022 HINTS cycle 6; HINTS is a nationally representative survey of civilian noninstitutionalized populations.³ Adults 18 years and older were asked, “Have you ever heard of HPV?” and “Before today, have you ever heard of the cervical cancer vaccine or HPV shot?” Respondents who had heard of HPV were also asked, “Do you think HPV can cause oral cancer?” and “Do you think HPV can cause cervical cancer?” to understand their awareness of the link between HPV and cancers. Responses of “no” or “not sure” were classified as lacking awareness about HPV, the HPV vaccine, and that HPV causes cancers. Weighted proportions and 95% CIs were estimated using SAS SURVEY procedures (SAS Institute), and a 2-sided P < .05 was considered statistically significant. Additional methodological details are presented in the eMethods in Supplement 1. We followed STROBE reporting guidelines. The study used deidentified data and was deemed exempt by the institutional review board at the Medical University of South Carolina.

Results |

The final sample included 22 344 respondents (mean age, 49 years; 51.1% female). Nationally, 34.3% (95% CI, 33.2%−35.4%) of US adults were unaware of HPV, and 37.6% (95% CI, 36.5%−38.8%) lacked awareness of the HPV vaccine (Figure 1). Lack of HPV awareness exceeded 40% in 7 states, with a majority from the Midwest (Kansas, Nebraska, and Illinois) and the South (Mississippi, Arkansas, and Alabama). Similarly, more than 40% of individuals in 13 states, 9 from the Midwest (South Dakota, Kansas, and Illinois) and the South (Mississippi, South Carolina, Arkansas, Oklahoma, Florida, and Alabama), were unaware of the HPV vaccine. Among respondents who knew about HPV, nationally, 70.8% (95% CI, 69.2%−72.3%) and 28.3% (95% CI, 27.0%−29.6%) were unaware that HPV causes oral and cervical cancers, respectively (Figure 2). In 45 states and Washington, DC, more than 60% of individuals lacked awareness that HPV causes oral cancers. In comparison, the lack of awareness that HPV causes cervical cancer was less common (6.9%−57.4%).

Figure 1. Lack of Awareness of Human Papillomavirus (HPV) and HPV Vaccine Across 50 States and Washington, DC.

A, Participants were asked, “Have you ever heard of HPV?” with responses of “no” or “not sure” indicating participants’ lack of awareness. Information on this question was missing for 652 participants. B, Participants were asked, “Before today, have you ever heard of the cervical cancer vaccine or HPV shot?” with responses of “no” or “not sure” indicating participants’ lack of awareness. Information on this question was missing for 908 participants.

^aEstimates where the sample size was fewer than 25 may not be reliable and should be interpreted with caution.

^bEstimates where the relative standard error was greater than 30% may not be reliable and should be interpreted with caution.

Figure 2. Lack of Awareness That Human Papillomavirus (HPV) Can Cause Oral and Cervical Cancer Across 50 States and Washington, DC.

A, Participants who were aware of HPV were asked, “Do you think HPV can cause oral cancer?” with responses of “no” or “not sure” indicating participants’ lack of awareness. Information on this question was missing for 4467 participants. B, Participants who were aware of HPV were asked, “Do you think HPV can cause cervical cancer?” with responses of “no” or “not sure” indicating participants’ lack of awareness. Information on this question was missing for 198 participants.

^aEstimates where the sample size was fewer than 25 may not be reliable and should be interpreted with caution.

^bEstimates where the relative standard error was greater than 30% may not be reliable and should be interpreted with caution.

Discussion |

In this cross-sectional study, public awareness about HPV, HPV vaccination, and the link between HPV and cancers was overwhelmingly low, particularly in Midwestern and Southern US states. These findings are troubling because these regions have recently seen a marked rise in HPV-associated cancers.^4,5 Notably, the lack of HPV and HPV vaccine awareness in the Midwest and South is alarming, as a majority of states in these regions have suboptimal HPV vaccination rates.⁶ Awareness of the link between HPV and oral cancer is considerably lower than for cervical cancer. This may stem from the long-standing focus on cervical cancer in screening programs and early HPV vaccine campaigns, which targeted women. In contrast, oral cancer is likely to have received less public attention, contributing to the awareness gap.

The limitations of this study are the cross-sectional data, which preclude making causal inferences, the ecological nature of the analyses, and the limited sample for certain states. Despite these limitations, this study offers valuable insights into public understanding of HPV and related topics across US states. In conclusion, given the importance of timely HPV vaccination and the risk of early-life exposure, there is a critical need to enhance HPV awareness among adolescents, young adults, parents or caregivers, and pediatric and adult health care professionals.

Data Sharing Statement:

See Supplement 2.