Abstract
Background.
Sexual minority women (lesbian, bisexual, and other women who have sex with women) are at risk for human papillomavirus (HPV) infection and HPV-related disease, demonstrating the importance of HPV vaccination for these women.
Methods.
We conducted an online survey of sexual minority women ages 18–45 from the United States (n=505) in October 2019, about two months after HPV vaccine recommendations were expanded to include ages 27–45. Multivariable Poisson regression identified correlates of HPV vaccine initiation (i.e., receipt of at least one HPV vaccine dose).
Results.
Overall, 65% of participants ages 18–26 and 33% of participants ages 27–45 had initiated the HPV vaccine series. Among participants ages 18–26, initiation was more common among those who had received a healthcare provider recommendation (RR=2.19, 95% CI: 1.64–2.93) or had disclosed their sexual orientation to their primary healthcare provider (RR=1.33, 95% CI: 1.07–1.65). Among initiators ages 27–45, a large majority (89%) reported receiving their first dose before turning age 27. Initiation was more common among participants ages 27–45 who had received a healthcare provider recommendation (RR=3.23, 95% CI: 2.31–4.53) or who reported greater perceived social support for HPV vaccination (RR=1.22, 95% CI: 1.05–1.40). Several reasons for not yet getting HPV vaccine differed by age group (ages 18–26 vs. ages 27–45; all p<0.05).
Conclusions.
Many sexual minority women, particularly those ages 27–45, remain unvaccinated against HPV. Findings provide early insight into HPV vaccine coverage among adult women and highlight key leverage points for increasing vaccination among this population.
Keywords: Human papillomavirus, HPV vaccine, Sexual orientation, Women
Introduction
Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States (US).1 Oncogenic HPV types cause nearly 26,000 cases of cancer (cervical, anal, penile, vaginal, vulvar, and oropharyngeal) annually in the US, and non-oncogenic HPV types cause nearly 300,000 cases of genital warts each year.2 Sexual minority women (i.e., lesbian, bisexual, and other women who have sex with women) are at risk for HPV infection and HPV-related disease. Research has shown that HPV can be transmitted between female partners,3 and many sexual minority women have current or past male partners from whom they could have acquired HPV.4 Indeed, recent work has shown that nearly 50% of sexual minority women were infected with at least one type of HPV and about 40% were infected with at least one oncogenic type.5 These prevalence estimates were similar to, or slightly higher than, those for heterosexual women.5 Although official incidence rates for HPV-related cancers among sexual minority women do not exist to the best of our knowledge, evidence suggests the burden of cervical cancer may be similar to or higher than that for heterosexual women.6
The Advisory Committee on Immunization Practices (ACIP) has recommended routine HPV vaccination for female adolescents ages 11–12 since 2006 and for male adolescents ages 11–12 since 2011, with catch-up vaccination for females ages 13–26 and for males ages 13–21.7,8 The Food and Drug Administration expanded the approved age range for use of HPV vaccine to age 45 in October 2018,9 and in August 2019, ACIP updated their recommendations to harmonize catch-up vaccination across genders for all persons through age 26 and also address vaccination among people ages 27–45.10 ACIP does not currently recommend catch-up vaccination for people ages 27–45, but instead recommends shared clinical decision-making regarding HPV vaccination.10 Shared clinical-decision making is recommended because, although the population benefit may be minimal for this age group, unvaccinated individuals might still be at risk for new HPV infection and benefit from vaccination.10 The recommended HPV vaccine series consists of two doses if the series is started before turning age 15 and three doses if it is started after turning age 15.11
Recent studies have examined HPV vaccine coverage among sexual minority women in the US.12–16 Data from these studies show that half or fewer of sexual minority women have received any doses of HPV vaccine, with vaccine coverage among these women often similar to, or lower than, vaccine coverage among heterosexual women.12–16 However, these studies focused predominantly on adolescents and young adult women through age 26. Given the recent update to HPV vaccine recommendations by ACIP,10 it is important to include adults in the expanded age range as well. The current study examines HPV vaccination among adult sexual minority women through age 45 in the US, and in doing so, provides some of the earliest data that we are aware of on vaccination among ages 27–45 since ACIP updated their recommendations.10
Materials and Methods
Study Design
In October 2019, about two months after the ACIP updated their recommendations for HPV vaccination,10 we conducted a cross-sectional study with individuals who: a) were cisgender female; b) were ages 18–45; c) either self-identified as lesbian/gay, bisexual, or queer; or reported having sex with a woman in the last three years; and d) lived in the US. We recruited all participants from an online survey panel that was constructed by a survey company, SSRS (Glen Mills, PA). The online panel is an opt-in panel that has members from throughout the US, and panel members are invited to complete self-administered online surveys on a regular basis in exchange for incentives (e.g., an electronic gift card).
For our study, we utilized a convenience sample from this online panel. Panel members who were potentially eligible for our study received a standard email invitation from SSRS to participate. The email invitation did not allude to the study’s eligibility criteria. Panel members who were interested then proceeded via weblink to complete a brief screener to confirm study eligibility (since the online panel is not specific to sexual minority women). Women who were confirmed eligible then provided informed consent prior to completing their survey. A total of 505 women from 45 states competed our online survey, with an average survey duration of about 15 minutes. The states with the largest number of participants were New York (n=44), California (n=40), Florida (n=38), Texas (n=36), and Pennsylvania (n=30). The Institutional Review Board at The Ohio State University determined this survey was exempt from review.
Measures
We developed survey items based on our previous HPV vaccine research.16–20
HPV Vaccination.
We assessed HPV vaccine uptake by asking participants how many doses of the HPV vaccine series they had received. Our primary outcome was HPV vaccine initiation (i.e., receipt of at least one dose of the HPV vaccine series). For participants who indicated vaccine initiation, subsequent items assessed how old they were when they received their first dose of the HPV vaccine series and the reasons why they got vaccinated. For the latter, participants could endorse multiple reasons from a predefined list.
Among participants who did not indicate vaccine initiation (i.e., unvaccinated), we assessed their willingness to get HPV vaccine under two conditions: 1) if it were free; and 2) if it cost $400 out of pocket (the contract price for the Centers for Disease Control and Prevention is about $140 per dose for adults21). Both willingness items used a 5-point scale with responses of “definitely not willing”, “probably not willing”, “not sure”, “probably willing”, and “definitely willing” (possible range=1–5). We also asked unvaccinated participants the reasons why they had not yet received HPV vaccine. Participants could endorse multiple reasons from a predefined list.
Correlates.
We assessed participants’ knowledge about HPV with 5 items and classified them as having either high knowledge (answered 4 or more knowledge items correctly) or low knowledge (answered 3 or fewer knowledge items correctly). Two additional questions (yes or no for each) assessed whether participants were aware that HPV vaccine: (a) is recommended for all people who are ages 11–26; and (b) can be given to people who are ages 27–45. The survey included a range of beliefs and attitudes about HPV and HPV vaccine, with each variable coded so that higher values indicate greater levels of that construct. Attitudes and beliefs about HPV included: perceived stigma associated with HPV infection22 (3 items, α=0.84, possible range=1–5); worry about getting HPV-related disease (2 items, α=0.82, possible range=1–4); perceived likelihood of getting HPV-related disease (2 items, α=0.71, possible range=1–4); and the perception that sexual minority women are at a lower risk for cervical cancer compared to heterosexual women (1 item, possible range=1–5). Attitudes and beliefs about HPV vaccine included: perceived effectiveness of HPV vaccine (2 items, α=0.63, possible range=1–5); perceived harms of HPV vaccine (1 item, possible range=1–5); and perceived unavailability of HPV vaccine (i.e., difficulty in finding a clinic to get vaccinated; 1 item, possible range=1–5). The survey also examined participants’ uncertainty about whether women their age should get HPV vaccine (1 item, possible range=1–5), perceived positive social norms of HPV vaccination among sexual minority women (1 item, possible range=1–5), perceived social support (i.e., if they believed people important to them would support them getting vaccinated; 1 item, possible range=1–5), and self-efficacy to talk with a doctor about HPV vaccine (1 item, possible range=1–5).
We examined if women had ever been told by a healthcare provider that they have an HPV-related disease (i.e., HPV infection, genital warts, or cervical cancer). We also asked participants if they had ever received a recommendation from a healthcare provider to get HPV vaccine and if they had any children who are at least 11 years old who have received HPV vaccine. The survey assessed participants’ disclosure and concealment of their sexual orientation to their primary healthcare provider,23 and their perceived discrimination in receiving healthcare (1 item, possible range=1–5).24 Additional demographic and health-related characteristics examined in this study are shown in Table 1.
Table 1.
Demographic and health-related characteristics of participants (n=505)
| n (%) | |
|---|---|
| Demographic Characteristics | |
| Age (years) | |
| 18–26 | 204 (40) |
| 27–45 | 301 (60) |
| Sexual identity | |
| Lesbian/gay | 116 (23) |
| Bisexual/other | 389 (77) |
| Race / ethnicity | |
| White, non-Hispanic | 304 (60) |
| African American, non-Hispanic | 68 (13) |
| Other | 132 (26) |
| Relationship status | |
| Single | 172 (34) |
| Dating | 95 (19) |
| Partner | 238 (47) |
| Education level | |
| High school degree or less | 146 (29) |
| Some college | 194 (38) |
| College degree or more | 165 (33) |
| Household income | |
| Less than $50,000 | 288 (57) |
| $50,000 or more | 217 (43) |
| Region of residence | |
| Northeast | 123 (25) |
| Midwest | 114 (23) |
| South | 182 (36) |
| West | 86 (17) |
| Health and Health Behaviors | |
| Health insurance | |
| No | 74 (15) |
| Yes | 423 (85) |
| Had a routine medical check-up in the last year | |
| No | 290 (57) |
| Yes | 215 (43) |
| Sex with a woman in the last 3 years | |
| No | 180 (36) |
| Yes | 325 (64) |
Note. Totals may not sum to stated sample size due to missing data. Percents may not sum to 100% due to rounding.
Data Analysis
We first calculated descriptive statistics for demographic and health-related characteristics for all participants. We used chi-square tests to compare women who self-identified as lesbian or gay with those who self-identified as bisexual or other on these characteristics. Given the recent inclusion of ages 27–45 in ACIP recommendations for HPV vaccine,10 we stratified regression analyses by age group (ages 18–26 and ages 27–45). Within each age stratum, we used Poisson regression with the sandwich estimator of variance to identify bivariate correlates of HPV vaccine initiation. Variables with p<0.05 in bivariate analyses were then entered into a multivariable Poisson regression model to produce adjusted risk ratios (RRs) and 95% confidence intervals (CIs). Due to a current lack of knowledge about correlates of HPV vaccination among sexual minority women (especially those ages 27–45), we opted for a model-building approach that was more exploratory in nature and relied primarily on empirical evidence, as opposed to being guided by a specific theory or existing subject matter. For each multivariable model, we examined tolerance and variance inflation factors (VIF) to assess the potential for collinearity. We considered a tolerance of 0.10 or less or a VIF of 10 or greater to be indicative of collinearity. Neither model showed signs of potential collinearity.
We conducted additional analyses among unvaccinated participants to examine reasons why they had not yet been vaccinated and their willingness to get HPV vaccine. We used chi-square tests to compare unvaccinated participants ages 18–26 to those ages 27–45 on reasons why they had not yet received HPV vaccine. We then used paired t-tests to compare willingness to get HPV vaccine if the vaccine were free and if it cost $400 out of pocket. Data were analyzed using Stata 15.1 (StataCorp; College Station, TX) and all statistical tests were two-tailed with a critical alpha of 0.05.
Results
Participant Characteristics
Forty percent of participants were ages 18–26 (Table 1). Most participants were non-Hispanic white (60%), dating or partnered (66%), and had at least some college education (71%). About 25% participants were from the Northeast, 23% from the Midwest, 36% from the South, and 17% from the West. About 23% of participants self-identified as lesbian or gay, and more than 60% reported having sex with a woman in the last three years. Most participants had some form of health insurance (85%), though fewer than half had a routine medical check-up in the last year (43%). Compared to women who self-identified as lesbian or gay, those who self-identified as bisexual or other had less education and were less likely to report having sex with a woman in the last three years (both p<0.05).
HPV Vaccine Coverage among Women Ages 18–26
Overall, 65% (133/204) of participants who were ages 18–26 had initiated the HPV vaccine series. Among initiators, 21% had received one dose, 20% had received two doses, 32% had received three doses, and 26% were unsure about the number of doses they had received. Most initiators (74%) reported receiving their first dose before the age of 18. The most frequently reported reasons for getting HPV vaccine among these ages were: a doctor recommended it (57%); they always get recommended vaccines (41%); to protect against cancer (29%); the benefits of getting vaccinated outweighed the risks (28%); and the vaccine has been shown to be effective (27%).
Several variables were correlated with HPV vaccine initiation in multivariable analyses (Table 2). Receipt of a provider recommendation was the strongest correlate of HPV vaccine initiation (RR=2.19, 95% CI: 1.64–2.93). Initiation was also more common among participants who reported greater self-efficacy to talk with a doctor about HPV vaccine (RR=1.13, 95% CI: 1.01–1.28), had health insurance (RR=1.50, 95% CI: 1.01–2.24), or had disclosed their sexual orientation to their primary healthcare provider (RR=1.33, 95% CI: 1.07–1.65). HPV vaccine initiation was less common among participants who perceived greater unavailability of the vaccine (RR=0.93, 95% CI: 0.86–0.99).
Table 2.
Correlates of HPV vaccine initiation among participants ages 18–26 (n=204)
| n | Initiated HPV vaccine series n (%) | Not Initiated HPV vaccine series n (%) | Bivariate RR (95% CI) | Multivariable RR (95% CI) | |
|---|---|---|---|---|---|
| Demographic Characteristics | |||||
| Age (years) | |||||
| 18–21 | 88 | 52 (59) | 36 (41) | ref. | -- |
| 22–26 | 116 | 81 (70) | 35 (30) | 1.18 (0.96–1.46) | -- |
| Sexual identity | |||||
| Lesbian/gay | 35 | 18 (51) | 17 (49) | ref. | -- |
| Bisexual/other | 169 | 115 (68) | 54 (32) | 1.32 (0.94–1.86) | -- |
| Race / ethnicity | |||||
| White, non-Hispanic | 97 | 66 (68) | 31 (32) | ref. | -- |
| African American, non-Hispanic | 33 | 22 (67) | 11 (33) | 0.98 (0.74–1.29) | -- |
| Other | 74 | 45 (61) | 29 (39) | 0.89 (0.71–1.12) | -- |
| Relationship status | |||||
| Single | 92 | 56 (61) | 36 (39) | ref. | -- |
| Dating | 47 | 33 (70) | 14 (30) | 1.15 (0.90–1.48) | -- |
| Partner | 65 | 44 (68) | 21 (32) | 1.11 (0.88–1.41) | -- |
| Education level | |||||
| High school degree or less | 75 | 41 (55) | 34 (45) | ref. | ref. |
| Some college | 81 | 58 (72) | 23 (28) | 1.31 (1.02–1.68)* | 1.15 (0.95–1.38) |
| College degree or more | 48 | 34 (71) | 14 (29) | 1.30 (0.98–1.71) | 1.05 (0.85–1.30) |
| Household income | |||||
| Less than $50,000 | 116 | 72 (62) | 44 (38) | ref. | -- |
| $50,000 or more | 88 | 61 (69) | 27 (31) | 1.12 (0.91–1.36) | -- |
| Region of residence | |||||
| Northeast | 58 | 39 (67) | 19 (33) | ref. | -- |
| Midwest | 43 | 30 (70) | 13 (30) | 1.04 (0.79–1.36) | -- |
| South | 73 | 42 (58) | 31 (42) | 0.86 (0.65–1.12) | -- |
| West | 30 | 22 (73) | 8 (27) | 1.09 (0.82–1.45) | -- |
| HPV and HPV Vaccine | |||||
| Knowledge about HPVa | |||||
| Low knowledge | 83 | 47 (57) | 36 (43) | ref. | ref. |
| High knowledge | 121 | 86 (71) | 35 (29) | 1.26 (1.01–1.56)* | 0.99 (0.83–1.18) |
| History of HPV-related disease | |||||
| No | 184 | 118 (64) | 66 (36) | ref. | -- |
| Yes | 20 | 15 (75) | 5 (25) | 1.16 (0.89–1.54) | -- |
| Knows HPV vaccine is recommended for people ages 11–26 | |||||
| No | 47 | 22 (47) | 25 (53) | ref. | ref. |
| Yes | 157 | 111 (71) | 46 (29) | 1.51 (1.09–2.08)* | 1.14 (0.89–1.46) |
| Received healthcare provider recommendation to get HPV vaccine | |||||
| No | 89 | 30 (34) | 59 (66) | ref. | ref. |
| Yes | 115 | 103 (90) | 12 (10) | 2.66 (1.97–3.58)** | 2.19 (1.64–2.93)** |
| Stigma of getting HPV infectionb,c | 204 | 4.06 (0.08) | 4.14 (0.09) | 0.96 (0.87–1.07) | -- |
| Worry about getting HPV-related diseaseb,d | 204 | 2.14 (0.08) | 2.15 (0.13) | 1.00 (0.89–1.11) | -- |
| Perceived likelihood of getting HPV-related diseaseb,e | 204 | 2.12 (0.05) | 2.25 (0.07) | 0.88 (0.74–1.04) | -- |
| Perceived lower risk of cervical cancer compared to heterosexual womenb,f | 204 | 2.88 (0.09) | 2.72 (0.09) | 1.06 (0.97–1.17) | -- |
| Perceived effectiveness of HPV vaccineb,g | 204 | 3.71 (0.07) | 3.46 (0.09) | 1.15 (1.01–1.30)* | 1.05 (0.95–1.17) |
| Perceived harms of HPV vaccineb,f | 204 | 2.92 (0.09) | 2.90 (0.10) | 1.01 (0.92–1.11) | -- |
| Perceived unavailability of HPV vaccineb,f | 204 | 2.39 (0.11) | 2.82 (0.12) | 0.88 (0.81–0.97)* | 0.93 (0.86–0.99)* |
| Uncertainty about whether women their age should get HPV vaccineb,f | 204 | 2.67 (0.11) | 2.72 (0.11) | 0.99 (0.91–1.07) | -- |
| Perceived social norms of HPV vaccination among sexual minority womenb,f | 204 | 3.69 (0.08) | 3.23 (0.08) | 1.24 (1.11–1.37)** | 1.04 (0.95–1.15) |
| Perceived social support for HPV vaccinationb,f | 204 | 4.26 (0.07) | 3.80 (0.10) | 1.27 (1.11–1.46)* | 1.00 (0.89–1.12) |
| Self-efficacy to talk with a doctor about HPV vaccineb,f | 204 | 4.25 (0.08) | 3.68 (0.11) | 1.29 (1.12–1.50)* | 1.13 (1.01–1.28)* |
| Health and Health Behaviors | |||||
| Health insurance | |||||
| No | 24 | 9 (38) | 15 (63) | ref. | ref. |
| Yes | 173 | 122 (71) | 51 (29) | 1.88 (1.11–3.18)* | 1.50 (1.01–2.24)* |
| Had a routine medical check-up in the last year | |||||
| No | 114 | 78 (68) | 36 (32) | ref. | -- |
| Yes | 90 | 55 (61) | 35 (39) | 0.89 (0.73–1.10) | -- |
| Sex with a woman in the last 3 years | |||||
| No | 79 | 46 (58) | 33 (42) | ref. | -- |
| Yes | 125 | 87 (70) | 38 (30) | 1.20 (0.96–1.49) | -- |
| Disclosure of sexual orientation to primary healthcare provider | |||||
| Provider definitely does not know | 74 | 34 (46) | 40 (54) | ref. | ref. |
| Provider might/probably/definitely knows | 130 | 99 (76) | 31 (24) | 1.66 (1.27–2.16)** | 1.33 (1.07–1.65)* |
| Concealment of sexual orientation from primary healthcare provider | |||||
| Never | 72 | 49 (68) | 23 (32) | ref. | -- |
| At least some of the time | 132 | 84 (64) | 48 (36) | 0.94 (0.76–1.15) | -- |
| Perceived discrimination in receiving healthcareb,f | 204 | 2.47 (0.12) | 2.49 (0.13) | 0.99 (0.92–1.07) | -- |
Note. Multivariable model included all variables associated at p<0.05 in univariable models. Dashes (--) indicate that variable was not included in the multivariable model. RR=risk ratio; CI=confidence interval; HPV=human papillomavirus; ref=reference group.
Measured by determining number of correct responses to five HPV knowledge items. High knowledge was defined as four or more correct responses and low knowledge was defined as three or fewer correct responses.
Means and standard deviations are reported for continuous variables. ORs for these variables are for a 1-unit increase.
3 item scale; each item had a 5-point response scale ranging from “strongly disagree” to “strongly agree” (coded 1–5).
2 item scale; each item had a 4-point response scale ranging from “not at all” to “a lot” (coded 1–4).
2 item scale; each item had a 4-point response scale ranging from “no chance” to “high chance” (coded 1–4).
1 item; 5-point response scale ranging from “strongly disagree” to “strongly agree” (coded 1–5).
2 item scale; each item had a 5-point response scale ranging from “strongly disagree” to “strongly agree” (coded 1–5).
p<0.05;
p<0.001
HPV Vaccine Coverage among Women Ages 27–45
Overall, 33% (99/301) of participants who were ages 27–45 had initiated the HPV vaccine series. Among initiators, 25% had received one dose, 17% had received two doses, 25% had received three doses, and 32% were unsure about the number of doses they had received. About half of initiators (49%) reported receiving their first dose before the age of 18, with 39% reported receiving their first dose between the ages of 18–26. Only 11% reported receiving their first dose at age 27 or older. The most frequently reported reasons for getting HPV vaccine among these ages were: a doctor recommended it (49%); to protect against cancer (40%); they always get recommended vaccines (32%); it would give them piece of mind (29%); and the benefits of getting vaccinated outweighed the risks (25%).
In multivariable analyses (Table 3), HPV vaccine initiation was more common among participants who had received a recommendation from a healthcare provider to get vaccinated (RR=3.23, 95% CI: 2.31–4.53) or who reported greater perceived social support for HPV vaccination (RR=1.22, 95% CI: 1.05–1.40). HPV vaccine initiation was less common among participants who were ages 40–45 compared to those who were ages 27–39 (RR=0.35, 95% CI: 0.20–0.62), as well as participants who reported greater uncertainty about whether women their age should get HPV vaccine (RR=0.89, 95% CI: 0.80–0.99).
Table 3.
Correlates of HPV vaccine initiation among participants ages 27–45 (n=301)
| n | Initiated HPV vaccine series n (%) | Not Initiated HPV vaccine series n (%) | Bivariate RR (95% CI) | Multivariable RR (95% CI) | |
|---|---|---|---|---|---|
| Demographic Characteristics | |||||
| Age (years) | |||||
| 27–39a | 228 | 92 (40) | 136 (60) | ref. | ref. |
| 40–45 | 73 | 7 (10) | 66 (90) | 0.24 (0.12–0.49)** | 0.35 (0.20–0.62)** |
| Sexual identity | |||||
| Lesbian/gay | 81 | 20 (25) | 61 (75) | ref. | -- |
| Bisexual/other | 220 | 79 (36) | 141 (64) | 1.45 (0.96–2.21) | -- |
| Race / ethnicity | |||||
| White, non-Hispanic | 207 | 60 (29) | 147 (71) | ref. | ref. |
| African American, non-Hispanic | 35 | 14 (40) | 21 (60) | 1.38 (0.87–2.18) | 1.08 (0.79–1.48) |
| Other | 58 | 25 (43) | 33 (57) | 1.49 (1.03–2.14)* | 1.19 (0.87–1.64) |
| Relationship status | |||||
| Single | 80 | 27 (34) | 53 (66) | ref. | -- |
| Dating | 48 | 22 (46) | 26 (54) | 1.36 (0.88–2.10) | -- |
| Partner | 173 | 50 (29) | 123 (71) | 0.86 (0.58–1.26) | -- |
| Education level | |||||
| High school degree or less | 71 | 19 (27) | 52 (73) | ref. | -- |
| Some college | 113 | 35 (31) | 78 (69) | 1.16 (0.72–1.86) | -- |
| College degree or more | 117 | 45 (38) | 72 (62) | 1.44 (0.92–2.25) | -- |
| Household income | |||||
| Less than $50,000 | 172 | 55 (32) | 117 (68) | ref. | -- |
| $50,000 or more | 129 | 44 (34) | 85 (66) | 1.07 (0.77–1.48) | -- |
| Region of residence | |||||
| Northeast | 65 | 23 (35) | 42 (65) | ref. | -- |
| Midwest | 71 | 19 (27) | 52 (73) | 0.76 (0.46–1.26) | -- |
| South | 109 | 39 (36) | 70 (64) | 1.01 (0.69–1.53) | -- |
| West | 56 | 18 (32) | 38 (68) | 0.91 (0.55–1.50) | -- |
| HPV and HPV Vaccine | |||||
| Knowledge about HPVb | |||||
| Low knowledge | 108 | 35 (32) | 73 (68) | ref. | -- |
| High knowledge | 193 | 64 (33) | 129 (67) | 1.02 (0.73–1.44) | -- |
| History of HPV-related disease | |||||
| No | 245 | 82 (33) | 163 (67) | ref. | -- |
| Yes | 56 | 17 (30) | 39 (70) | 0.91 (0.59–1.40) | -- |
| Knows HPV vaccine can be given to people ages | |||||
| 27–45 | |||||
| No | 157 | 39 (25) | 118 (75) | ref. | ref. |
| Yes | 144 | 60 (42) | 84 (58) | 1.68 (1.20–2.34)* | 1.00 (0.75–1.35) |
| Received healthcare provider recommendation to get HPV vaccine | |||||
| No | 231 | 40 (17) | 191 (83) | ref. | ref. |
| Yes | 70 | 59 (84) | 11 (16) | 4.87 (3.60–6.57)** | 3.23 (2.31–4.53)** |
| Stigma of getting HPV infectionc,d | 301 | 3.60 (0.10) | 3.58 (0.07) | 1.01 (0.87–1.18) | -- |
| Worry about getting HPV-related diseasec,e | 301 | 2.34 (0.10) | 1.88 (0.07) | 1.34 (1.16–1.54)** | 1.10 (0.95–1.28) |
| Perceived likelihood of getting HPV-related diseasec,f | 301 | 2.18 (0.06) | 2.06 (0.05) | 1.22 (0.96–1.54) | -- |
| Perceived lower risk of cervical cancer compared to heterosexual womenc,g | 301 | 2.82 (0.12) | 2.65 (0.07) | 1.11 (0.95–1.30) | -- |
| Perceived effectiveness of HPV vaccinec,h | 301 | 3.75 (0.08) | 3.43 (0.06) | 1.38 (1.13–1.69)* | 0.93 (0.77–1.12) |
| Perceived harms of HPV vaccinec,g | 301 | 2.91 (0.12) | 3.07 (0.07) | 0.90 (0.76–1.07) | -- |
| Perceived unavailability of HPV vaccinec,g | 301 | 2.46 (0.12) | 2.35 (0.07) | 1.07 (0.92–1.24) | -- |
| Uncertainty about whether women their age should get HPV vaccinec,g | 301 | 2.57 (0.12) | 3.15 (0.08) | 0.76 (0.66–0.87)** | 0.89 (0.80–0.99)* |
| Perceived social norms of HPV vaccination among sexual minority womenc,g | 301 | 3.46 (0.09) | 2.96 (0.05) | 1.62 (1.37–1.93)** | 1.08 (0.94–1.25) |
| Perceived social support for HPV vaccinationc,g | 301 | 4.21 (0.09) | 3.60 (0.07) | 1.57 (1.28–1.91)** | 1.22 (1.05–1.40)* |
| Self-efficacy to talk with a doctor about HPV vaccinec,g | 301 | 4.24 (0.09) | 4.01 (0.06) | 1.24 (1.00–1.52)* | 0.98 (0.81–1.18) |
| Health and Health Behaviors | |||||
| Health insurance | |||||
| No | 50 | 13 (26) | 37 (74) | ref. | -- |
| Yes | 250 | 86 (34) | 164 (66) | 1.32 (0.80–2.18) | -- |
| Had a routine medical check-up in the last year | |||||
| No | 176 | 69 (39) | 107 (61) | ref. | ref. |
| Yes | 125 | 30 (24) | 95 (76) | 0.61 (0.43–0.88)* | 0.81 (0.58–1.13) |
| Has child age 11 or older who has received HPV vaccine | |||||
| No | 273 | 92 (34) | 181 (66) | ref. | -- |
| Yes | 27 | 7 (26) | 20 (74) | 0.77 (0.40–1.49) | -- |
| Sex with a woman in the last 3 years | |||||
| No | 101 | 29 (29) | 72 (71) | ref. | -- |
| Yes | 200 | 70 (35) | 130 (65) | 1.22 (0.85–1.75) | -- |
| Disclosure of sexual orientation to primary healthcare provider | |||||
| Provider definitely does not know | 74 | 21 (28) | 53 (72) | ref. | -- |
| Provider might/probably/definitely knows | 227 | 78 (34) | 149 (66) | 1.21 (0.81–1.82) | -- |
| Concealment of sexual orientation from primary healthcare provider | |||||
| Never | 144 | 38 (26) | 106 (74) | ref. | ref. |
| At least some of the time | 157 | 61 (39) | 96 (61) | 1.47 (1.05–2.06)* | 1.24 (0.91–1.69) |
| Perceived discrimination in receiving healthcarec,g | 301 | 2.57 (0.13) | 2.11 (0.08) | 1.21 (1.08–1.36)* | 1.10 (0.97–1.24) |
Note. Multivariable model included all variables associated at p<0.05 in univariable models. Dashes (--) indicate that variable was not included in the multivariable model. RR=risk ratio; CI=confidence interval; HPV=human papillomavirus; ref=reference group.
Ages that would have been age 26 or younger when HPV vaccine was first recommended for females in the US in 20067.
Measured by determining number of correct responses to five HPV knowledge items. High knowledge was defined as four or more correct responses and low knowledge was defined as three or fewer correct responses.
Means and standard deviations are reported for continuous variables. ORs for these variables are for a 1-unit increase.
3 item scale; each item had a 5-point response scale ranging from “strongly disagree” to “strongly agree” (coded 1–5).
2 item scale; each item had a 4-point response scale ranging from “not at all” to “a lot” (coded 1–4).
2 item scale; each item had a 4-point response scale ranging from “no chance” to “high chance” (coded 1–4).
1 item; 5-point response scale ranging from “strongly disagree” to “strongly agree” (coded 1–5).
2 item scale; each item had a 5-point response scale ranging from “strongly disagree” to “strongly agree” (coded 1–5).
p<0.05;
p<0.001
Reasons for Not Getting HPV Vaccine
Among all unvaccinated participants, the most common reasons for not being vaccinated were lack of a doctor’s recommendation to get HPV vaccine (32%), only having sex with one partner (25%), not knowing enough about HPV vaccine yet (21%), being too old for HPV vaccine (16%), not having been to a doctor recently (15%), and not being sexually active (15%) (Table 4). Compared to unvaccinated participants ages 18–26, those ages 27–45 were more likely to indicate being too old (22% vs. 1%), already having an HPV infection (9% vs. 0%), or already having a lot of sexual partners (6% vs. 0%) as reasons for not being vaccinated (all p<0.05). Conversely, participants ages 27–45 were less likely to indicate not being sexually active (9% vs. 30%) or having never heard of the vaccine (9% vs. 18%) as reasons for not being vaccinated (both p<0.05).
Table 4.
Reasons why unvaccinated participants had not yet received HPV vaccine (n=273)
| Total (n=273) n (%) |
Ages 18–26 (n=71) n (%) |
Ages 27–45 (n=202) n (%) |
|
|---|---|---|---|
| My doctor did not recommend getting the vaccine | 86 (32) | 20 (28) | 66 (33) |
| I only have sex with one partner | 67 (25) | 17 (24) | 50 (25) |
| I don’t know enough about the vaccine yet | 58 (21) | 20 (28) | 38 (19) |
| I am too old | 45 (16) | 1 (1) | 44 (22)** |
| I have not been to a doctor recently | 42 (15) | 15 (21) | 27 (13) |
| I am not sexually active | 40 (15) | 21 (30) | 19 (9)** |
| I have never heard of the vaccine | 31 (11) | 13 (18) | 18 (9)* |
| It might be unsafe | 26 (10) | 4 (6) | 22 (11) |
| It costs too much | 25 (9) | 9 (13) | 16 (8) |
| I do not know where to get the vaccine | 25 (9) | 9 (13) | 16 (8) |
| I only have sex with women | 25 (9) | 7 (10) | 18 (9) |
| I already have HPV | 18 (7) | 0 (0) | 18 (9)* |
| I have already had a lot of sexual partners | 12 (4) | 0 (0) | 12 (6)* |
| My parents do not want me to get the vaccine | 7 (3) | 2 (3) | 5 (2) |
Note. Participants could indicate multiple reasons from a predefined list of potential reasons. p-values are from chi-square tests comparing participants ages 18–26 to those ages 27–45.
p<0.05,
p<0.001
Willingness to Get HPV Vaccine
Among unvaccinated participants ages 18–26, willingness to get HPV vaccine was higher if the vaccine were free (mean=4.17, SD=0.99) than if the vaccine cost $400 out of pocket (mean=2.04, SD=1.02, paired t=13.70, p<0.001). This included 78% definitely or probably willing to get vaccinated if the vaccine were free compared to only 8% if the vaccine cost $400 out of pocket. Among unvaccinated participants ages 27–45, willingness was also much higher if the vaccine were free (mean=3.81, SD=1.21) than if it cost $400 out of pocket (mean=1.68, SD=1.03, paired t=21.84, p<0.001). While 62% of participants ages 27–45 were definitely or probably willing to get vaccinated if the vaccine were free, only 6% were willing to do so if the vaccine cost $400 out of pocket.
Discussion
In this study among a national sample of adult sexual minority women in the US, we found that about two-thirds of those ages 18–26 and about one-third of those ages 27–45 had initiated the HPV vaccine series. Our estimate of initiation among women ages 18–26 is noticeably higher than those reported in past studies of sexual minority women in this age range, where estimates of initiation were less than 50%.12–16 This is likely due in large part to our more recent data collection, which allowed additional time for young adult women to become vaccinated and also allowed females who were vaccinated as adolescents in prior years to age into adulthood. Indeed, most of the young women in our study who had initiated the vaccine series indicated that they were adolescents when they received their first HPV vaccine dose.
To our knowledge, this study provides one of the first estimates of HPV vaccine initiation among women ages 27–45, regardless of sexual orientation, since ACIP updated their recommendations.10 Thus, findings from this study can help provide a “baseline” estimate that serves as a comparison for future efforts examining HPV vaccine coverage among women in this age range. Interestingly, just over 10% of women ages 27–45 reported receiving their first dose at age 27 or older. Although some of these women may have received HPV vaccine at an older age prior to the recent ACIP update (i.e., “off-label” use), it is also possible that they began the vaccine series in the few months between the ACIP update10 and data collection for our study. Vaccine initiation was particularly low among women ages 40–45 in our study. This is not surprising since women in this age range would have been beyond the upper age limit of 26 years old included in the original ACIP recommendations for HPV vaccine when they were issued in 2006.7 It is also worth noting that fewer than half of women ages 27–45 in our study were even aware that HPV vaccine can be given at these ages, and being “too old” was one of the most common reasons that women in this age range indicated for not being vaccinated. These results suggest that efforts are needed to educate women ages 27–45 about current vaccine recommendations and assess their communication preferences with healthcare providers about HPV vaccination. Such information can help increase their knowledge and help prepare them for the shared clinical decision-making regarding HPV vaccination that is recommended for this age group.10
The strongest correlate of HPV vaccine initiation among both younger and older women was receipt of a healthcare provider recommendation to get vaccinated, yet fewer than 40% of women in our study had ever received a provider recommendation to get HPV vaccine. This may help explain why the most common reason for not being vaccinated was lack of a doctor’s recommendation. Our findings reinforce previous work identifying the importance of a healthcare provider recommendation to HPV vaccine uptake25 and demonstrate that, moving forward, healthcare providers will continue to play a central role in vaccinating sexual minority women. This includes not only recommending HPV vaccine to age-eligible patients and participating in the shared clinical decision-making for ages 27–45, but also in creating welcoming spaces for sexual minority patients. Our results showed a positive association between disclosure of sexual orientation and HPV vaccine initiation among younger women, highlighting the importance of healthcare providers creating welcoming spaces26 in which patients are likely comfortable communicating information about their sexual orientation.
Our study identified additional factors that may be useful for increasing HPV vaccination among sexual minority women in the future. Modifiable factors included self-efficacy to talk with a doctor about HPV vaccine among younger women and perceived social support for HPV vaccination among older women. Self-efficacy and social support have been associated with HPV vaccination in past work27,28 and represent targets for future HPV vaccine interventions for sexual minority women. Lastly, our results underscore the importance of logistical factors (i.e., vaccine availability and cost). For younger women in our study, vaccine initiation was lower among those who perceived greater vaccine unavailability or did not have health insurance. Further, women of both age groups were much less willing to get HPV vaccine if it cost $400 out of pocket than if it were free. These results are similar to past studies16,18,29 and suggest that insurance coverage of HPV vaccine for adults may be critical for uptake, as it is among the most expensive vaccines.21 Currently, health insurance plans offered through the Health Insurance Marketplace and other private plans cover HPV vaccination for adults, though it is not clear what age range this includes.30,31 This information should be clarified and communicated to adults, along with referral to potential options for those without health insurance. For example, the Merck Patient Assistance Program provides HPV vaccine free of charge to individuals ages 19–45 without any health insurance who meet other eligibility criteria (e.g., income requirements).32
Study strengths include a national sample of sexual minority women, the examination of a wide range of potential correlates of HPV vaccine initiation, and the inclusion of women ages in the expanded age range for HPV vaccine administration based on the updated ACIP recommendations.10 Limitations include a cross-sectional design, the lack of a comparison group of heterosexual women with no recent history of sex with women, and lack of data on non-respondents. We recruited a convenience sample of women from an online survey panel, although the demographic characteristics of our participants are similar to those from other national samples of sexual minority women.33–35 The survey did not collect geographic information beyond state of residence (e.g., urban/rural status) or detailed information on sexual behaviors, which may affect women’s perceptions both of their risk of HPV infection and the benefits of HPV vaccination. We also relied solely on self-reported data on HPV vaccination, though previous research suggests that most adults can accurately report their vaccine initiation status.36
Conclusions
Many sexual minority women remain unvaccinated against HPV. This is particularly true for women ages 27–45, an age group that has just recently been included in HPV vaccine recommendations. Our results provide timely data on HPV vaccine coverage among sexual minority women and early insight into vaccine coverage among these older ages. To support effective shared clinical decision-making among these older ages, future research is needed on their information needs and communication preferences with healthcare providers about HPV vaccination. Study findings also identify additional key leverage points for increasing HPV vaccine coverage among sexual minority women in the future.
Funding:
This research is supported by the National Cancer Institute of the National Institutes of Health under Award Number T32CA163184. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Footnotes
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Conflicts of Interest: None of the authors have disclosures to report.
Declaration of interests
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.
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