Introduction
Parental awareness of the benefits of human papillomavirus (HPV) vaccine may be especially important in maximizing uptake among adolescent females.1 Although industry-sponsored television advertisements have been the most common source of information about HPV vaccine reported by parents in the United States,1–3 recommendations from children’s healthcare providers are especially influential in parental decisions about HPV vaccination for their daughters.4–6 Other information sources commonly reported by parents include family and friends,1, 3 Internet,1, 3 news stories1 and brochures.1, 3 Reported HPV vaccine information sources can differ by socioeconomic group, including gender, race, age, education and income.1 We hypothesize these differences could lead to disparities in vaccine uptake.1
While parents may ultimately learn about the vaccine from their daughters’ providers, one early source of information may be their daughters’ schools. At least 7 states (Indiana, Louisiana, Michigan, New Jersey, North Carolina, Texas, and Washington, as of October, 2009) have passed legislation requiring information about HPV vaccine be distributed to parents of adolescents through their schools.7 Whether school-based outreach to parents has been effective in raising awareness or encouraging vaccine uptake, to our knowledge, is largely unknown.
We examined characteristics of parents, their adolescent daughters, and households as potential correlates of HPV vaccine awareness and information sources, and associations of information sources with HPV vaccine initiation.
Methods
Participants were a population-based sample of 696 parents of 10–17 year old females in North Carolina. They completed the 2008 Child Health Assessment and Monitoring Program Survey (CHAMP) of caregivers for children under 18 years old, a follow-up survey to the Behavioral Risk Factor Surveillance System (BRFSS) survey of adults.8
The survey assessed parents’ HPV vaccine awareness with the question, “Have you ever heard of the HPV vaccine?” For parents who had heard of HPV vaccine, questions assessed whether they had heard about it from any of four possible sources: daughter’s school, daughter’s healthcare provider, drug company advertisement, and news stories or Web sites other than drug company advertisements. The survey assessed HPV vaccine initiation with the question, “Has (daughter’s name) had any shots of the HPV vaccine?”
We used bivariate logistic regression models to identify correlates of HPV vaccine awareness and information sources and entered statistically significant (p<0.05) predictors into multivariate logistic regression models. We evaluated the four sources of information about HPV vaccine as bivariate predictors of HPV vaccine initiation. Multivariate models for HPV vaccine uptake controlled for variables we previously identified as multivariate correlates of initiation.9 Analyses were weighted to reflect population characteristics of North Carolina8 and estimated odds ratios (ORs) and associated 95% confidence intervals (CIs).
Results
Most parents (91%) reported having heard of HPV vaccine. In multivariate analyses, parents were less likely to be aware of HPV vaccine if they were male, or had daughters who were non-Hispanic African American or other races/ethnicities than non-Hispanic white (Table 1). Vaccine awareness was higher among parents from households with incomes of $50,000 or higher versus under $50,000, or who reported having daughters already vaccinated against meningitis.
Table 1.
Awareness of HPV vaccine (n = 696)
| n | Weighted % | n aware | Weighted % | Bivariate OR (95% CI) | Multivariate OR (95% CI) | |
|---|---|---|---|---|---|---|
| Total | 696 | 100.0 | 632 | 91.0 | ||
| Parent Characteristics | ||||||
| Gendera,b | ||||||
| Female | 561 | 81.5 | 521 | 91.9 | ref. | ref. |
| Male | 135 | 18.5 | 111 | 85.0 | 0.48 (0.24–0.97)* | 0.20 (0.09–0.43)* |
| Relationship to childa,b | ||||||
| Biological parents | 607 | 88.3 | 560 | 91.5 | ref. | ref. |
| Step/adoptive parents | 39 | 5.3 | 35 | 93.7 | 1.31 (0.38–4.52) | 2.56 (0.65–10.03) |
| Other | 50 | 6.5 | 37 | 75.7 | 0.30 (0.13–0.67)* | 0.47 (0.18–1.24) |
| Female parent received HPV vaccinea | ||||||
| No/don’t know (DK=2) | 311 | 90.4 | 287 | 90.4 | ref. | -- |
| Yes | 38 | 9.6 | 37 | 96.1 | 2.49 (0.32–19.69) | -- |
| Flu vaccine in past yeara | ||||||
| No/don’t know (DK=2) | 458 | 66.2 | 410 | 88.9 | ref. | ref. |
| Yes | 238 | 33.8 | 222 | 94.0 | 2.25 (1.03–4.89)* | 2.33 (0.98–5.56) |
| Female parent most recent Pap testa | ||||||
| Not within last 3 years | 63 | 13.9 | 58 | 88.3 | ref. | -- |
| Within last 3 years | 384 | 86.1 | 357 | 91.6 | 1.20 (0.37–3.91) | -- |
| Beliefs about how frequently child should see doctorb | ||||||
| Less frequently than once per year/don’t know (DK=7) | 56 | 6.5 | 50 | 86.5 | ref. | -- |
| At least once per year | 640 | 93.5 | 582 | 90.9 | 1.65 (0.60–4.55) | -- |
| Daughter Characteristics | ||||||
| Age (years)b | ||||||
| 10–12 | 225 | 36.6 | 200 | 89.9 | ref. | -- |
| 13–15 | 271 | 35.7 | 242 | 87.8 | 0.87 (0.43–1.77) | -- |
| 16–17 | 200 | 27.7 | 190 | 95.1 | 2.49 (0.96–6.46) | -- |
| Race/Ethnicityb | ||||||
| Non-Hispanic White | 480 | 63.3 | 459 | 96.8 | ref. | ref. |
| Non-Hispanic African | 0.14 (0.07–0.30)* | 0.15 (0.06–0.35)* | ||||
| American | 113 | 22.9 | 91 | 80.9 | ||
| Other | 103 | 13.8 | 82 | 78.7 | 0.14 (0.06–0.30)* | 0.20 (0.09–0.45)* |
| School Typeb | ||||||
| Private/home schooled | 74 | 12.0 | 70 | 91.6 | ref. | -- |
| Public | 618 | 88.0 | 558 | 90.4 | 0.87 (0.26–2.97) | -- |
| Healthcare coverageb | ||||||
| No/don’t know (DK=1) | 49 | 6.5 | 36 | 71.7 | ref. | ref. |
| Yes | 647 | 93.5 | 596 | 91.9 | 4.76 (1.96–11.56)* | 1.52 (0.58–3.96) |
| Regular healthcare providerb | ||||||
| No/don’t know (DK=3) | 117 | 15.9 | 94 | 82.4 | ref. | ref. |
| Yes | 579 | 84.1 | 538 | 92.2 | 2.53 (1.29–4.96)* | 1.62 (0.69–3.80) |
| Preventive check-up in last 12 monthsb | ||||||
| No/don’t know (DK=7) | 148 | 19.9 | 124 | 86.4 | ref. | -- |
| Yes | 548 | 80.1 | 508 | 91.6 | 1.80 (0.90–3.59) | -- |
| Meningococcal vaccineb | ||||||
| No/don’t know (DK=7) | 278 | 39.6 | 237 | 85.5 | ref. | ref. |
| Yes | 418 | 60.4 | 395 | 94.0 | 2.57 (1.32–5.0)* | 2.61 (1.29–5.29)* |
| Household Characteristics | ||||||
| Number of children in householda | ||||||
| 1 | 328 | 28.7 | 299 | 89.9 | ref. | -- |
| ≥2 | 368 | 71.3 | 333 | 90.9 | 1.09 (0.57–2.11) | -- |
| Annual household incomea | ||||||
| <$50,000 | 280 | 38.8 | 237 | 82.5 | ref. | ref. |
| ≥$50,000 | 364 | 53.0 | 351 | 97.5 | 7.79 (3.70–16.39)* | 4.50 (1.81–11.21)* |
| Not reported | 52 | 8.2 | 44 | 85.1 | 1.26 (0.45–3.55) | 1.83 (0.44–7.66) |
| Highest education level in householdb | ||||||
| High school or less | 147 | 20.8 | 117 | 78.4 | ref. | ref. |
| Some college or more | 549 | 79.2 | 515 | 93.9 | 3.83 (1.92–7.65)* | 1.23 (0.54–2.80) |
| Geographic regiona | ||||||
| Western | 125 | 14.8 | 114 | 93.3 | ref. | -- |
| Piedmont | 343 | 58.2 | 321 | 92.1 | 0.84 (0.34–2.07) | -- |
| Eastern | 228 | 27.0 | 197 | 85.9 | 0.48 (0.21–1.13) | -- |
| Urbanicitya | ||||||
| Rural | 216 | 28.9 | 194 | 90.2 | ref. | -- |
| Urban | 480 | 71.1 | 438 | 90.8 | 0.91 (0.46–1.80) | -- |
Notes. HPV = human papillomavirus, OR = odds ratio, CI = confidence interval, ref. = referent group.
Percents may not sum to 100% due to rounding and weighting. Relationship to child “other” category includes grandmothers (n = 33), grandfathers (n=5), aunts (n = 5), uncle (n=1), sister or brother (n=3), and other guardians (n=3). Only female parents were asked about HPV vaccine (n = 349) and Pap test (n = 447). Daughter’s race/ethnicity “other” category includes Hispanic (n = 51), Native American or Alaskan Native (n = 19), Asian (n = 6), mixed race or ethnicity (n = 26), or did not indicate (n = 1). School type excludes 4 respondents with missing values.
Data collected during BRFSS survey.
Data collected during CHAMP survey.
p<0.05
Of parents who had heard of HPV vaccine, 64% had heard from drug company advertisements, 50% from their daughters’ healthcare providers, 50% from news stories or Web sites, and 9% from their daughters’ schools. In multivariate analyses, parents were more likely to have heard about HPV vaccine from their daughters’ healthcare providers if they had daughters 16–17 years old (OR=2.09, 95% CI:1.23–3.54, versus daughters aged 10–12), their daughters had received preventive check-ups in the last 12 months (OR=3.50, 95% CI: 1.97–6.24), or their daughters had received meningococcal vaccine (OR=1.64, 95% CI:1.07–2.52). Daughters’ schools were more likely to be information sources for parents of daughters who attended public schools (OR=4.88, 95% CI: 1.04–22.93). We found no correlates of having heard about the vaccine through drug company advertisements or through news stories and Web sites.
Similar to 2008 National Immunization Survey-Teen estimates for North Carolina (34%),10 31% of parents reported they had initiated HPV vaccination for their daughters. Of parents who had heard about the vaccine from their daughters’ healthcare providers, 46% had daughters who had started HPV vaccination (Table 2). In contrast, only 16% of parents who had not heard about HPV vaccine from their daughters’ healthcare providers had started vaccination for their daughters. The other three information sources were not associated with HPV vaccine initiation.
Table 2.
HPV vaccine initiation by source of information (n = 617)
| n initiated/total | Weighted % | Bivariate OR (95% CI) | Multivariate OR (95% CI) | |
|---|---|---|---|---|
| Drug company ad | ||||
| No | 81/217 | 37.7 | ref. | -- |
| Yes | 115/390 | 28.0 | 0.65(0.41–1.01) | -- |
| Healthcare provider | ||||
| No | 56/313 | 16.4 | ref. | ref. |
| Yes | 141/301 | 45.7 | 4.28(2.61–6.99)* | 2.87(1.69–4.87)* |
| News/Internet | ||||
| No | 105/303 | 34.4 | ref. | -- |
| Yes | 87/304 | 27.0 | 0.71(0.46–1.10) | -- |
| Daughter’s school | ||||
| No | 178/559 | 30.3 | ref. | -- |
| Yes | 18/50 | 41.4 | 1.60(0.77–3.36) | -- |
Note. HPV = human papillomavirus, OR = odds ratio, CI = confidence interval, ref. = referent group. Does not include respondents who did not know if they had heard about HPV vaccine from this source (drug company advertisement n=10; healthcare provider n=3; news/Internet n=10; and daughter’s school n=8). Multivariate model controlled for variables previously found to be associated with HPV vaccine initiation in this data set (daughter’s age, daughter’s preventive check-ups within the past 12 months, meningococcal vaccine for daughter, flu vaccine for parent, and urbanicity).9
p<0.05
Discussion
How parents of adolescent girls heard about HPV vaccine varied substantially in this population-based survey. While awareness was nearly universal among parents of white and higher income daughters, many parents of non-white or lower income daughters had not heard of HPV vaccine. Differential consumption of news about HPV vaccine is one potential explanation for differences in vaccine awareness.1 Most parents heard through drug company advertising, healthcare providers, and news stories, consistent with Hughes (2009) and other studies.1–3 However, information sources may differently affect parents’ awareness of HPV vaccine and, ultimately, their decisions to vaccinate their daughters. Researchers should identify media channels and vaccine messages that meet different needs of various audiences.
This study has important strengths, including a large, population-based sample of parents and examination of the association of sources of information with awareness and initiation of HPV vaccine. Study limitations include the self-reported vaccine initiation measure and the cross-sectional study design, which prevents us from inferring causal relationships. Generalizability of findings to parents living in other states will need to be established.
Our main finding was that healthcare providers were the only information source associated with parents’ vaccination of their adolescent daughters. Future campaigns promoting HPV vaccine should target healthcare providers, since results show they can be influential sources of information for parents. An additional important public policy finding was that less than one tenth of parents recalled vaccine information provided by their daughters’ schools, despite a statewide requirement that schools disseminate this information. Having heard of HPV vaccine through schools was not associated with vaccine initiation, but this may be due to the low number of parents who had heard through schools. Policymakers in North Carolina should explore effective ways to disseminate the required HPV information through schools.
Acknowledgments
This study was supported by grants from the Centers for Disease Control and Prevention (S3715-25/25), Cancer Control Education Program at Lineberger Comprehensive Cancer Center (R25 CA57726), and American Cancer Society (MSRG-06-259-01-CPPB). We thank Donna Miles, James Cassell, Harry Herrick, Bob Woldman and the staff at the North Carolina State Center for Health Statistics for their assistance.
Footnotes
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References
- 1.Hughes J, Cates J, Liddon N, Smith J, Gottlieb S, Brewer N. Disparities in How Parents Are Learning About the HPV Vaccine. Cancer Epidemiology, Biomarkers & Prevention February. 2009;18(2):363–372. doi: 10.1158/1055-9965.EPI-08-0418. [DOI] [PubMed] [Google Scholar]
- 2.Gerend MA, Weibley E, Bland H. Parental Response to Human Papillomavirus Vaccine Availability: Uptake and Intentions. Journal of Adolescent Health. 2009;45(5):528–531. doi: 10.1016/j.jadohealth.2009.02.006. [DOI] [PubMed] [Google Scholar]
- 3.Katz ML, Reiter PL, Heaner S, Ruffin MT, Post DM, Paskett ED. Acceptance of the HPV vaccine among women, parents, community leaders, and healthcare providers in Ohio Appalachia. Vaccine. 2009;27(30):3945–3952. doi: 10.1016/j.vaccine.2009.04.040. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Dempsey AF, Abraham LM, Dalton V, Ruffin M. Understanding the Reasons Why Mothers Do or Do Not Have Their Adolescent Daughters Vaccinated Against Human Papillomavirus. Annals of Epidemiology. 2009;19(8):531–538. doi: 10.1016/j.annepidem.2009.03.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Kahn JA, Ding L, Huang B, Zimet GD, Rosenthal SL, Frazier AL. Mothers’ Intention for Their Daughters and Themselves to Receive the Human Papillomavirus Vaccine: A National Study of Nurses. Pediatrics June. 2009;123(6):1439–1445. doi: 10.1542/peds.2008-1536. [DOI] [PubMed] [Google Scholar]
- 6.Gottlieb SL, Brewer NT, Sternberg MR, et al. Human Papillomavirus Vaccine Initiation in an Area with Elevated Rates of Cervical Cancer. Journal of Adolescent Health. 2009;45(5):430–437. doi: 10.1016/j.jadohealth.2009.03.029. [DOI] [PubMed] [Google Scholar]
- 7.National Conference of State Legislatures. HPV Vaccine: State Legislation. [Accessed January 13, 2010];NCSL Issues and Research. 2009 http://www.ncsl.org/default.aspx?tabid=14381#2009leg.
- 8.North Carolina State Center for Health Statistics. [Accessed January 6, 2010];2008 North Carolina CHAMP, Child Health Assessment and Monitoring Program Survey. 2009 http://www.schs.state.nc.us/SCHS/champ/designanddatacollection.html.
- 9.Reiter PL, Cates JR, McRee A-L, et al. Statewide HPV vaccine initiation among adolescent females in North Carolina. Sexually Transmitted Diseases. doi: 10.1097/OLQ.0b013e3181d73bf8. (in press) [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Centers for Disease Control and Prevention. National, State, and Local Area Vaccination Coverage Among Adolescents Aged 13--17 Years --- United States, 2008. Morbidity and Mortality Weekly Report. 2009 September 18;58(36):997–1001. [PubMed] [Google Scholar]