Identifying HPV vaccination research priorities for the US

ABSTRACT

To guide researchers and funders, we sought to identify top priorities for research on increasing HPV vaccine coverage among US children ages 9–12 years. In Survey 1, 60 participants (researchers, health care professionals, and other stakeholders engaged in HPV vaccination research) viewed 57 research topics about increasing HPV vaccination coverage and provided additional topics. We integrated their suggestions into the list and condensed similar items to reach a list of 38 topics. In Survey 2, 230 participants identified their top ten research priorities. The top HPV vaccination research priorities and their corresponding themes were misinformation (chosen by 50% of respondents, from the theme of vaccine confidence), starting at age 9 years (48%, primary care), and single dose (48%, other). The top ten research priorities also included vaccine communication (40%, primary care), system-wide approach (39%, health system and payers), community settings (39%, alternative settings), immunization registries (38%, policy), geography and rurality (37%, populations), school mandates (37%, policy), and near elimination of HPV cancers (37%, other). The proportion of participants selecting topics within each theme varied between 15% for health system and payers to 32% for alternative settings. These research priorities highlight research areas likely to yield impactful strategies for increasing HPV vaccination. Focusing US HPV vaccine research on these topics can optimize resource allocation, inform evidence-based interventions, and support policymaking to enhance vaccine uptake.

Introduction

Persistent human papillomavirus (HPV) infection causes six cancers, including cervical cancer and oropharyngeal cancer. Prophylactic HPV vaccination reduces HPV infection, precancerous lesions, and cancers in both clinical trials and population studies.^1–3 However, despite being part of routine adolescent vaccination for almost two decades,^4,5 Only 57% of children ages 13–15 years were up-to-date on HPV vaccination,⁶ which is well short of the nation’s goal of 80%. Initiation at younger ages is more effective for cancer prevention,⁷ yet less than 5% of US adolescents start HPV vaccination at ages 9 or 10 years.⁸ Starting HPV vaccination at age 9 years is supported by both the American Academy of Pediatrics⁹ and the American Cancer Society.¹⁰

Many effective and promising interventions are available to increase HPV vaccination coverage by focusing on policy, clinics, and parents. Policies shown to increase HPV vaccine uptake include school-entry requirements and federal programs that fund vaccination.¹¹ Effective clinical changes include prompts, feedback on vaccination coverage,¹² training to improve provider communication,¹³ and vaccine standing orders.^14,15 Parent-focused strategies include reminder/recall,¹⁶ receipt of a provider recommendation,¹⁷ especially presumptive provider recommendations,^18–20 and some educational efforts.²¹ Many interventions are also multi-component and address multiple socioecological levels.²² However, studies often focus on white, female, and non-rural populations,²³ including underpowered studies that involve more diverse populations.²⁴

Prioritizing research topics ensures that limited resources target high-impact areas to address these gaps. The American Cancer Society (ACS) National HPV Vaccination Roundtable sponsored a one-day national meeting in 2016 to identify priorities for research on HPV vaccine uptake.²⁵ HPV vaccine delivery experts, including scientists, clinicians, and stakeholders in attendance identified and prioritized research topics. The top three priorities were social media and vaccine confidence, vaccine provider interventions, and healthcare system approaches. These priorities have been helpful to researchers and funders. With almost a decade elapsed since that meeting, we sought to identify current priorities for research on HPV vaccination coverage for US children ages 9–12 years.

Methods

Participants

Our study employed two rounds of surveys to solicit and then rank research topics on increasing HPV vaccine uptake in the US among children ages 9–12 years. The first survey presented 57 research topics from nine themes. We distributed the survey via e-mail with a flyer containing a QR code and website address for accessing the survey. We sent the e-mail to a listserv of individuals affiliated with the ACS National HPV Vaccination Roundtable, the HPV Cancer Center Consortium, National Cancer Institute-designated cancer centers, and the Association of American Cancer Institutes. Affiliates of these organizations include researchers, health care professionals, and people in health departments with deep knowledge of HPV vaccine implementation in the US. We also invited recipients to share the survey with their professional networks. We also promoted the survey during the National HPV Roundtable’s annual meeting via an announcement and flyers. Survey participants reviewed candidate HPV vaccine research topics and suggested additional topics.

We distributed the second survey using the same channels. Participants included those from the first round, as well as individuals affiliated with the Association of Immunization Managers, American Academy of Pediatricians, HPV vaccine quality improvement provider champions, state immunization coalitions, and subject matter experts in HPV vaccine research. Because we recruited convenience samples and participants could be affiliated with multiple organizations, it was not possible to calculate response rates for either survey.

Procedures

Both surveys were online and collected no identifiable data. The first-round survey was open for two weeks in October 2023, and the second-round survey was open for three weeks in January and February 2024. Participation was voluntary, and no compensation was provided. The University of North Carolina’s Institutional Review Board deemed this study as IRB-exempt.

Measures

First round

The first survey presented 57 HPV vaccination research topics, categorized into nine themes. We compiled these topics based on the previous nominations of research priorities gathered in 2016,²⁵ and feedback from an HPV Vaccination Roundtable working group of 10 experts in HPV vaccination. The survey instructed participants to suggest promising additional topics.

Second round

Based on thematic analysis of responses gathered from the first survey by two researchers, and following consensus among the working group members, we arrived at 38 topics with definitions, grouped into nine themes. The top 10 topics and definitions appear in Table 1, and the full list appears in Supplemental Table S1. To equally distribute potential order effects in the second survey, we randomized the order of both the themes and topics within each theme. The survey instructed participants to select up to 10 priority research topics. Additionally, the survey assessed demographic characteristics, professional affiliation with a roundtable or cancer center, years working in HPV vaccination, involvement in HPV vaccination, and any relationship with the manufacturer of HPV vaccine in the past 24 months.

Table 1.

Definitions of top 10 research topics.

Topic	Includes
Misinformation	How to effectively address inaccurate information and disinformation, identify misinformation, impact on uptake, encouraging vaccine literacy.
Starting at age 9	Impact of starting HPV vaccination at age 9 on uptake and acceptability, mitigating concerns about multiples vaccines at a single visit.
Single dose	Forecasting the impact of a possible ACIP to change to a single dose recommendation.
Vaccine communication	Presumptive recommendations and when to use them, how to address parent questions, motivational interviewing, acceptability of approach to diverse populations.
System-wide approach	Quality improvement leaders, information technology, and vaccine champions, health system-level changes, electronic health record prompts, vaccination in care plans for high-risk patients.
Community settings	School-located delivery, big box retailers, businesses not part of a primary care clinic, faith-based settings, community centers, mobile van, employer-sponsored clinics.
Immunization registries	Connecting to electronic health records, forecasting and age 9 prompts, simplifying vaccine doses documentation, identifying low uptake hotspots.
Geography and rurality	Rurality, differences among states, why pockets of vaccine hesitancy exist, addressing low coverage areas, ensuring supply in rural clinics and pharmacies.
School mandates	Impact of school vaccination requirements on vaccine uptake, spillover effects of mandates for vaccines other than HPV, impact of state requirements for schools to send information on vaccination to parents.
Near elimination	How the idea of near elimination of cervical cancer and other HPV cancers can motivate vaccination, reduction in HPV cancers and diseases including oropharyngeal cancer.

Note. Definitions of the 38 research topics appear in Supplemental Table S1.

Data analysis

We calculated frequencies and proportions to describe the respondents’ demographic and employment characteristics for both surveys. For survey two, we calculated the proportion of participants who nominated each research topic, and ranked the priorities based on these proportions. We also calculated the proportion of participants who nominated the topics in each research theme. We then stratified the topic rankings based on professional affiliation, involvement with HPV vaccination, and relationship to the vaccine manufacturer. Analyses used Stata version 18.0 (College Station, TX).

Results

The first survey to identify research topics received responses from 60 experts. Of these, 42% were involved in behavioral or social science research, 39% in advocacy, and 13% in patient care. Over half (56%) were members of a cancer center, and over one-third (35%) were affiliated with the ACS National HPV Vaccination Roundtable.

The second survey to prioritize research topics received responses from 230 experts. Around half of the participants were ages 30–49 years (55%), three-fourths were white (74%), and the majority had a graduate degree or higher (82%) (Table 2). Most were affiliated with the National HPV Vaccination Roundtable (27%), National Cervical Cancer Roundtable (11%), or a cancer center (36%). Most had spent at least 5 years working on HPV vaccination (60%). Half were involved in patient care (50%), followed by behavioral or social science research (36%), and implementation science research (36%). Most (82%) had no relationship with the vaccine manufacturer in the previous 24 months.

Table 2.

Respondent characteristics for survey round two (n = 230).

	n	%
Age
18–29 years	22	10%
30–39 years	61	27%
40–49 years	64	28%
50–59 years	49	22%
60+ years	30	13%
Race/ethnicity
White	171	74%
Black or African American	23	10%
Asian	21	9%
Hispanic, Latino, or Spanish	13	6%
Middle Eastern or North African	3	1%
Prefer not to say	7	3%
Education
High school or some college	11	4%
Bachelor’s degree	30	13%
Graduate degree	184	82%
Professional affiliation
National HPV Vaccination Roundtable	63	27%
National Roundtable on Cervical Cancer	26	11%
Cancer center	84	36%
None of these	99	43%
Years working in HPV vaccination
<1 year	10	4%
1–5 years	62	27%
6–10 years	56	25%
11–15 years	39	17%
16+ years	41	18%
Did not work in HPV vaccination	19	8%
Involvement in HPV vaccination
Behavioral or social research	82	36%
Implementation science research	77	34%
Other research (includes bench science)	11	5%
Patient care	116	50%
Advocacy	73	32%
Other	44	19%
Relationship with manufacturer of HPV vaccine
No relationship in last 24 months	188	82%
Paid consultant, speaker or travel	13	6%
Research grant recipient	12	5%
Employee	5	2%
Other	13	6%

The top HPV vaccination research priorities were misinformation (50% of participants selected this topic), starting at age 9 (48%), and single dose (48%) (Table 3, Supplemental Table S1). The remaining research priorities in the top ten were vaccine communication (40%), system-wide approach (39%), community settings (39%), immunization registries (38%), geography and rurality (37%), school mandates (37%), and near elimination of HPV cancers (37%). The proportion of participants selecting topics, averaged across themes, varied between 15% for the health system and payers theme to 32% for the alternative settings theme (Supplemental Table S2).

Table 3.

Prioritization of research topics on HPV vaccination of children ages 9–12 years in the US (n = 230).

Topic	Theme	Proportion of respondents who selected topic as a top priority
Misinformation	Vaccine confidence	50%
Starting at age 9	Primary care	48%
Single dose	Other	42%
Vaccine communication	Primary care	40%
System-wide approach	Health system and payers	39%
Community settings	Alternative settings	39%
Immunization registries	Policy	38%
Geography and rurality	Populations	37%
School mandates	Policy	37%
Near elimination	Other	37%
High-need populations	Populations	36%
Building community confidence	Vaccine confidence	33%
Pharmacies	Alternative settings	30%
Implementation strategies	Implementation science	30%
Dental offices	Alternative settings	27%
Multilevel interventions	Implementation science	27%
Polarization	Populations	26%
Community	Other	26%
Social media	Vaccine confidence	25%
Race and ethnicity	Populations	25%
Linking barriers to interventions	Implementation science	23%
Engaging providers	Implementation science	20%
Language and culture	Populations	20%
Nurses, medical assistants, front office staff	Primary care	20%
Auxiliary vaccination delivery	Primary care	17%
Insurance	Policy	16%
Stories	Vaccine confidence	16%
Payers	Health systems and payers	16%
Vaccine champions	Implementation science	16%
Reimbursement	Policy	15%
Tailoring	Vaccine confidence	12%
Incentives	Health systems and payers	10%
Vaccines per visit	Primary care	10%
Other policy changes	Policy	9%
Cost	Implementation science	8%
Quality standards	Health systems and payers	7%
COVID-19	Other	4%
Feedback	Health systems and payers	4%

Note. Higher rank indicates higher priority. Shading indicates top ten priorities. High need populations were populations with low HPV vaccination coverage or high HPV cancer rates.

The prioritization of the research topics was largely stable across participants’ professional affiliation (Table 4), by involvement with HPV vaccination (Supplemental Table S3), and relationship to the vaccine manufacturer (Supplemental Table S4). Consistently in the top ten were the topics of misinformation (overall rank: 1), starting at age 9 (overall rank: 2), and system-wide approach (overall rank: 5).

Table 4.

Ranking of research topics overall and by professional affiliation.

Topic	Overall(n = 230)	HPV Vaccination Roundtable (n = 63)	Cervical Cancer Roundtable (n = 26)	Cancer center (n = 84)	None of these (n = 99)
Misinformation	1	4	9	1	1
Starting at age 9	2	3	2	2	3
Single dose	3	6	6	11	2
Vaccine communication	4	7	16	4	6
System-wide approach	5	9	3	8	4
Community settings	6	10	7	5	5
Immunization registries	7	5	10	7	8
Geography and rurality	8	8	4	6	13
School mandates	9	1	13	9	7
Near elimination	10	2	1	14	10
High-need populations	11	11	8	12	9
Building community confidence	12	12	11	13	11
Pharmacies	13	17	17	3	17
Implementation strategies	14	14	12	16	12
Dental offices	15	13	5	17	15
Multilevel interventions	16	16	14	10	19
Polarization	17	19	15	20	14
Community	18	15	24	15	20
Social media	19	22	19	18	21
Race and ethnicity	20	21	18	19	18
Linking barriers to interventions	21	23	25	23	16
Engaging providers	22	18	20	25	22
Language and culture	23	20	21	21	27
Nurses, medical assistants, front office staff	24	27	30	24	23
Auxiliary vaccination delivery	25	24	22	28	25
Insurance	26	25	27	29	29
Stories	27	26	31	26	30
Payers	28	28	29	33	24
Vaccine champions	29	30	32	22	28
Reimbursement	30	31	28	27	26
Tailoring	31	32	37	30	31
Incentives	32	34	34	31	33
Vaccines per visit	33	29	33	34	32
Other policy changes	34	33	23	36	34
Cost	35	35	38	32	35
Quality standards	36	36	26	35	37
COVID-19	37	37	35	37	38
Feedback	38	38	36	38	36

Note. Higher rank indicates higher priority. Shading indicates top ten priorities overall. High need populations were populations with low HPV vaccination coverage or high HPV cancer rates.

Single dose (overall rank: 3) fell out of the top ten for individuals involved with behavioral, social, implementation science, and other research and those affiliated with cancer centers. Vaccine communication (overall rank: 4) fell out of the top ten for National Cervical Cancer Roundtable members and other researchers. Community settings (overall rank: 6) fell out of the top ten for people involved with advocacy. Immunization registries (overall rank: 7) fell out of the top ten for those with no relationship to the vaccine manufacturer. Geography and rurality (overall rank: 8) fell out of the top ten for those unaffiliated with a roundtable or cancer center and other researchers. Finally, near elimination (overall rank: 10) fell out of the top ten for people in behavioral, social, and implementation science research and those in patient care.

Topics that some groups pulled up into the top ten included high-need populations, building community confidence, pharmacies, implementation strategies, dental offices, and multilevel interventions. These topics rose from their overall ranks of 11 to 16.

Discussion

To support increasing HPV vaccination coverage among US children, we identified top priorities for new research. The top three priorities were addressing misinformation, starting HPV vaccination at age 9, and single dose vaccination, reaffirming prior foci and introducing new ones.²⁵ The priorities were largely stable across subgroups. These priorities for HPV research can help ensure that resources are focused on research areas in the US likely to have more impact. Moreover, prioritizing key HPV vaccine research areas can inform policymaking for existing vaccination programs.

Of the top ten research priorities we identified and those identified previously in 2016, both lists included rumors about HPV vaccination posted on social media (current topic name: misinformation), the impact of interventions working in rural areas (current topic name: geography and rurality), and the impact of connecting immunization information systems to electronic health records and including exchanging data bidirectionally (current topic name: immunization registries). The persistence of HPV vaccine misinformation as a top priority reflects both the growing body of research and the urgency of the issue. Misinformation and disinformation continue to fuel vaccine hesitancy through unfounded claims about HPV vaccination.²⁶ People often remember these alleged harms more than the proven benefits, leading to higher rates of HPV vaccine refusal and lower vaccination uptake.^27–29 To counter this, it is important to identify influential types and sources of HPV vaccine misinformation to design more effective interventions. Despite increased research attention, durable solutions remain limited, underscoring the need for new approaches.

Another top priority that persisted was HPV vaccination in rural areas. A narrative review by Brandt et al. (2021) concluded that interventions in rural settings were limited and said that more intervention research was needed in rural communities due to higher HPV-related cancer incidence and lower HPV vaccine uptake.³⁰ Additionally, recent work by Naavaal and colleagues highlighted HPV vaccination challenges in rural areas of Illinois, South Carolina, and Virginia, identifying promising practices to overcome these barriers.³¹ The third common priority between then and now is the use of electronic health reminders and prompts to promote HPV vaccine uptake. Electronic reminders to patients, parents, and providers are successful in improving HPV vaccination rates.^32,33

Newer HPV vaccine priorities included starting vaccination at age 9, which has received support as an effective way to improve vaccine coverage^34–38 and advancing vaccine communication through evidence-based approaches, such as the Announcement Approach.¹³ Using this method, providers and nursing staff discuss adolescent vaccination with parents using presumptive language, assuming they are ready to get HPV vaccine for the child.^13,39 System-wide approaches were also a top priority, encompassing established strategies to enhance HPV vaccine uptake such as engaging quality improvement leaders to support and prioritize HPV vaccination implementation;⁴⁰ integration of information technology tools like text messages, e-mails, electronic health record reminders, and social media campaigns into both clinical and system-based practices;⁴¹ and leveraging vaccine champions to scale HPV vaccination across healthcare systems.^40,42,43 Expanding HPV vaccine delivery in diverse community settings was another priority, including school-located programs,⁴⁴ big box retailers,⁴⁵ faith-based settings,⁴⁶ community centers,^47,48 mobile vans^49,50 and employer-sponsored clinics.⁵¹ Implementing HPV vaccine via school mandates⁵² and the idea of near elimination of cervical cancer were also identified as key priorities. Near elimination of HPV cancers aligns with the World Health Organization’s global initiative to eliminate cervical cancer as a public health issue (defined as fewer than 4 cases per 100,000 women per year in a country), current efforts are concentrated on reaching HPV vaccination coverage targets of 90% of girls by age 15.⁵³

The top ten priorities overall were remarkably stable across participant subgroups of affiliation, involvement, or relationship with the vaccine manufacturer. Some of the stability may be due to some overlap among the subgroups, but the findings also likely reflect meaningful alignment. Some priorities, such as single-dose vaccines, vaccine communication, community settings, immunization registries, geography and rurality, school mandates, and near elimination shifted out of the top ten for various subgroups. Topics that ranked in top ten for specific subgroups, but not overall, were high-need populations, building community confidence, pharmacies, implementation strategies, dental offices, and multilevel interventions. The emphasis on high-need populations reflects a focus on equity. The topic of building community confidence, sixteen overall, was among the top ten for participants involved in patient care and advocacy and other research. High prioritization among these two groups aligns with the goals of vaccine delivery, advocacy, and other research categories such as public health education, cancer prevention, community outreach, policy, and education; to enhance community confidence and increase vaccine uptake. It also suggests a greater willingness to focus HPV vaccination efforts on historically neglected minority communities, with the goal of building confidence and fostering greater uptake among these groups. Ultimately, the variation in priorities among different subgroups underscores the diverse focus areas and interests in HPV vaccination efforts and highlights the need for tailored strategies that address the specific priorities and concerns of each group.

Study strengths include building on past work in this area, surveying a broad range of experts, and randomizing the order of themes and topics. Study limitations include the modest sample sizes, which was due to the relatively limited number of experts in this area. Respondents may have been especially engaged and knowledgeable in this field, and thus may not reflect the broader communities of healthcare providers, policymakers, and researchers. Furthermore, the convenience sampling makes it not possible to calculate a response rate, leaving open the question of how representative these findings are. As such, they may be best thought of as expert opinion but not a broad consensus. Most study participants were white, the demographics of these research communities. A more inclusive approach in this research field could foster greater equity in setting HPV priorities and ensure that marginalized groups receive wider representation in HPV vaccination research. Finally, the priorities are for the US, leaving open the question of whether the same priorities would exist for other high-income countries and for low- and middle-income countries.

HPV vaccination research priorities will continue to evolve. Repeating the prioritization exercise in perhaps a decade could yield useful information. It may even be necessary sooner. The new explosion of vaccine misinformation in the US has caused many to reconsider a “back to the basics” of seeking to understand how to communicate the exceptional safety and effectiveness of HPV vaccine.

Our identified research priorities for increasing HPV vaccination coverage for children offer insights valuable for future funding and research decisions. With the current focus in the US on promoting initiation of HPV vaccine starting at age 9 years, prioritizing research is an important first step in strategically targeting interventions. These priorities can guide pediatricians and other physicians in advocating for evidence-based interventions, inform grant funding by the federal government and foundations, and support policies to reduce HPV cancers, particularly for underserved groups.

Biography

Noel T. Brewer is the Gillings Distinguished Professor in Public Health and a member of the Lineberger Comprehensive Cancer Center at the University of North Carolina. He has a PhD in health psychology from Rutgers University.

His research examines vaccination, tobacco use, medical screening, and other cancer-related health behaviors. Dr. Brewer advises the World Health Organization on the behavioral and social drivers of vaccination and serves on the United States of America National Verification Committee for the Elimination of Measles, Rubella, and Congenital Rubella Syndrome. He served as a voting member of CDC’s Advisory Committee on Immunization Practices. He advised the President’s Cancer Panel under two presidents, and has addressed the National Academies of Science, Engineering and Medicine multiple times. Dr. Brewer co-edited the FDA’s book, Communicating Risks and Benefits: An Evidence-Based User’s Guide.

Funding Statement

Dr. Tomar and Dr. Brewer’s time was funded by the National Cancer Institute [grant P01CA250989]. Dr. Brandt’s time was supported by the American Lebanese and Syrian Associated Charities of St. Jude Children’s Research Hospital. Additional funding sources for authors’ time include the National Cancer Institute [grant P30CA021765]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Cancer Institute or the National Institutes of Health.

Disclosure statement

In the past three years, Dr. Brewer has served as a voting member of CDC’s Advisory Committee on Immunization Practices and the USA National Verification Committee for the Elimination of Measles, Rubella, and Congenital Rubella Syndrome; served as a paid consultant to CDC, Merck, Moderna, Novavax, Sanofi, and World Health Organization; and held CDC grants. All Dr. Brewer’s activities were outside the submitted work. This research was completed while Dr. Saslow was employed by the American Cancer Society and Dr. Oliver was employed by the Icahn School of Medicine at Mount Sinai. Drs. Fisher-Borne, Oliver, and Saslow are currently employees of Merck Sharp & Dohme LLC, a subsidiary of Merck & Co., Inc.

Supplementary material

Supplemental data for this article can be accessed online at https://doi.org/10.1080/21645515.2025.2590263