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. Author manuscript; available in PMC: 2022 Apr 1.
Published in final edited form as: Vaccine. 2013 Apr 30;31(28):2937–2946. doi: 10.1016/j.vaccine.2013.04.041

Factors associated with human papillomavirus vaccination among young adult women in the United States

Walter W Williams a,*, Peng-Jun Lu a, Mona Saraiya b, David Yankey a, Christina Dorell a, Juan L Rodriguez b, Deanna Kepka c, Lauri E Markowitz d
PMCID: PMC8972189  NIHMSID: NIHMS1784564  PMID: 23643629

Abstract

Background:

Human papillomavirus (HPV) vaccination is recommended to protect against HPV-related diseases.

Objective:

To estimate HPV vaccine coverage and assess factors associated with vaccine awareness, initiation and receipt of 3 doses among women age 18–30 years.

Methods:

Data from the 2010 National Health Interview Survey were analyzed to assess associations of HPV vaccination among women age 18–26 (n = 1866) and 27–30 years (n = 1028) with previous HPV exposure, cervical cancer screening and selected demographic, health care and behavioral characteristics using bivariate analysis and multivariable logistic regression.

Results:

Overall, 23.2% of women age 18–26 and 6.7% of women age 27–30 years reported receiving at least 1 dose of HPV vaccine. In multivariable analyses among women age 18–26 years, not being married, having a regular physician, seeing a physician or obstetrician/gynecologist in the past year, influenza vaccination in the past year, and receipt of other recommended vaccines were associated with HPV vaccination. One-third of unvaccinated women age 18–26 years (n = 490) were interested in receiving HPV vaccine. Among women who were not interested in receiving HPV vaccine (n = 920), the main reasons reported included: not needing the vaccine (41.3%); concerns about safety of the vaccine (12.5%); not knowing enough about the vaccine (11.9%); not being sexually active (8.2%); a doctor not recommending the vaccine (7.6%); and already having HPV (2.7%). Among women with health insurance, 10 or more physician contacts within the past year and no contraindications, 74.5% reported not receiving HPV vaccine.

Conclusions:

HPV vaccination coverage among women age 18–26 years remains low. Opportunities to vaccinate are missed. Healthcare providers can play an important role in educating young women about HPV and encouraging vaccination. Successful public health and educational interventions will need to address physician attitudes and practice patterns and other factors that influence vaccination behaviors.

Keywords: Human papillomavirus, HPV vaccine, Cervical cancer, Pap smear, Vaccination, Adult vaccination

1. Introduction

Genital human papillomavirus (HPV) is the most common sexually transmitted infection in the United States and can cause cervical cancer, genital warts and other anogenital cancers. Quadrivalent and bivalent HPV vaccines were licensed for use in the United States in 2006 and 2009, respectively, and recommended for prevention of vaccine HPV-type-related cervical cancers and cancer precursors [1,2]. Routine HPV vaccination of females age 11 or 12 years is recommended [2] and vaccination of females age 13–26 years who have not been previously vaccinated [1,2]. Routine cervical cancer screening is generally recommended at age 21 to age 65 years for adult women, regardless of HPV vaccination status, although guidelines may differ from one another with regards to when to start, stop, how often to screen, and use of the conventional Pap test or liquid-based cytology [1,3–6].

Since HPV vaccine was recommended for use in females, estimates of vaccine coverage among young women have been published [7–12]. In previous reports factors associated with HPV vaccination in adult women (≥18) have included white race, higher education and income, having insurance, discussions with a healthcare provider about HPV vaccine, history of sexual activity, and receipt of other vaccines [7–11]. Concern about vaccine safety, doctors not recommending vaccination and cost have been barriers to HPV vaccination [8,12].

This study at four years following first licensure of HPV vaccine uses national data to update information among age-eligible adult women on associations of initiation and receipt of the complete three dose series.

2. Methods

We analyzed data from the 2010 National Health Interview Survey (NHIS) which collected data throughout the year using a design oversampling for Hispanics, blacks, and Asians to produce nationally representative samples. The 2010 NHIS sample adult core included questions about HPV infection, Pap testing, and HPV vaccination. The NHIS protocol was approved by the National Center for Health Statistics Research Ethics Review Board (ERB # 2009–16). Additional details about the 2010 NHIS are located at ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NHIS/2010/srvydesc.pdf. The study sample consisted of adult women age 18–26 years (n = 1866) and women age 27–30 years at the time of the survey (n = 1028) who were eligible for vaccination at the time of vaccine licensure. HPV vaccination was self-reported.

We selected covariates from coded survey questions to measure associations among previous HPV exposure, HPV vaccination, cervical cancer screening, and selected demographic, health care access and behavior characteristics. Below poverty was defined as a total family income of less than $22,314 for a family of four as identified by the U.S. Census Bureau [http://www.census.gov/hhes/www/poverty/data/threshld/thresh09.html.]

Weighted data were used to produce national estimates. SUDAAN was used to calculate point estimates and 95% confidence intervals (CIs) accounting for the complex sample design [13]. Respondents who answered “Don’t Know” or who refused to answer any question were excluded from the analysis. Chi-square tests were used to examine population distributions between age groups and T-tests were used to determine significance within strata with multiple levels. Statistical significance was defined as p < 0.05. Logistic regression was used to determine adjusted prevalence ratios (Risk Ratio) of ever having received HPV vaccination by selected demographic, access to care, and health behavior covariates. All variables selected were included in the multivariable model.

3. Results

3.1. Ever told had HPV, cervical cancer screening and awareness of HPV vaccine

Overall, women age 27–30 years were more likely to have been told they had HPV (12.3%) than were women age 18–26 years (8.5%) (p < 0.05). These women were more likely to have ever heard of HPV vaccine (91.4%) and to have received at least one dose of HPV vaccine (30.2%) than women who had not been told they had HPV (84.7% and 19.9%, respectively) (p < 0.05). Women age 18–26 and 27–30 years had similar likelihood of awareness of HPV vaccine (Table 1).

Table 1.

Demographic characteristics, health care access, and health behavior among women in the United States by awareness of HPV vaccine and receipt of at least one HPV vaccine dose – NHIS 2010.

Characteristic Age group Ever heard of HPV vaccine Ever had at least 1 HPV vaccine dose
18–20 years
 21–26 years
 18–26 years
 27–30 years
n % n % n % n % n % n %
Total 2894 72.8 2894 18.0
Age
 18–20a 492 22.6 492 74.1 492 34.9
 21–26 1374 46.2 1374 74.3 1374 17.5b
 18–26 1866 68.8 1866 74.2 1866 23.2b
 27–30 1028 31.3c 1028 69.7 1028 6.7b
Previous HPV exposure Ever been told had HPV
 Yes d d 116 10.8 134 8.5 90 12.3c 224 91.4b 224 30.2b
 Noa 360 96.4 969 89.2 1329 91.5 679 87.7 2008 84.7 2008 19.9
Cervical CA screening Never had PAP testa 207 46.7 180 13.1 387 24.2 74 5.9 461 58.5 461 21.8
Ever had PAP test Time since last PAP 285 53.3 1186 86.9 1471 75.8 950 94.1 2421 76.2b 2421 17.2
 ≤3y 278 52.2 1121 82.1 1399 72.2 875 86.8c 2274 77.3b 2274 18.1
 >3y d d 53 4.0 60 3.1 57 5.8 117 62.3 117 4.2b
Doctor recommended
 Yes 304 67.6 664 48.7 968 55.0 459 43.8c 1427 71.2 1427 19.8
 Noa 187 32.4 680 51.3 867 45.0 551 56.2 1418 74.9 1418 16.4
Race/Ethnicity
 Non-Hispanic whitea 240 61.8 664 60.5 904 60.9 472 62.1 1376 81.3 1376 20.3
 Non-Hispanic black 89 14.5 254 14.4 343 14.4 182 12.7 525 65.8b 525 16.5
 Hispanic 125 17.7 323 17.7 448 17.7 275 17.3 723 52.0b 723 12.4b
 Non-Hispanic Asian d d 95 4.8 116 4.1 78 6.1 194 60.6b 194 15.9
 Other d d 38 2.6 55 2.9 21 1.9 76 71.7 76 15.7
Marital status
 Marrieda d d 329 27.1 358 20.6 426 51.1c 784 69.5 784 7.6
 Other 462 92.7 1043 73.0 1505 79.4 600 48.9 2105 74.2b 2105 22.6b
Education
 Less than HSa 121 24.6 167 10.2 288 14.9 133 11.1c 421 54.4 421 15.8
 HS Grad/GED 146 28.2 313 22.3 459 24.3 211 20.6 670 62.8b 670 15.2
 Some college 222 47.1 551 40.6 773 42.7 344 32.1 1117 78.3b 1117 20.9
 College graduate d d 341 26.9 343 18.1 337 36.2 680 84.3b 680 17.4
Employment status
 Employed 233 50.4 863 66.0 1096 60.9 691 68.0c 1787 76.9b 1787 18.1
 Not employeda 259 49.6 511 34.0 770 39.1 337 32.0 1107 65.8 1107 18.0
Poverty level
 300%+ 76 29.2 307 32.7 383 31.6 353 44.9c 736 83.4b 736 21.6
 200% to <300% 60 17.6 208 18.8 268 18.4 151 16.4 419 78.3b 419 16.2
 100% to <200% 102 21.9 289 22.0 391 21.9 210 21.4 601 62.8 601 13.0
 <100%a 192 31.4 443 26.5 635 28.1 230 17.3 865 65.3 865 18.2
Immigration status
 Born in U.S.a 432 90.0 1145 86.3 1577 87.5 771 81.3c 2348 78.0 2348 19.3
Born outside U.S. and stayed d d 126 7.4 152 6.4 128 9.7 280 34.1b 280 7.5b
 in the US <10 years Born outside U.S. and stayed in the US >10 years 34 5.7 103 6.3 137 6.1 129 9.0 266 50.2b 266 14.2
Health insurance
 Private 237 53.6 649 52.1 886 52.6 554 60.0c 1440 81.3b 1440 21.2b
 Public 137 24.3 342 20.6 479 21.8 227 18.7 706 62.2 706 18.1b
 Nonea 115 22.1 378 27.4 493 25.6 242 21.3 735 63.2 735 11.0
Regular physician
 Yes 392 82.3 1036 75.9 1428 78.0 810 79.6c 2238 74.3b 2238 20.6b
 Noa 100 17.7 338 24.1 438 22.0 217 20.4 655 67.7 655 8.9
Seen physician or OB/GYN in past year
 Yes 360 76.8 1061 78.0 1421 77.6 820 81.1 2241 76.6b 2241 20.4b
 Noa 132 23.2 311 22.0 443 22.4 208 18.9 651 58.9 651 9.5
Other vaccination behavior One/more recommended lifetime vaccines
 Yes 401 85.2 1096 80.7 1497 82.2 765 77.8c 2262 77.2b 2262 20.7b
 Noa 86 14.8 268 19.3 354 17.8 254 22.2 608 54.0 608 6.7
Influenza vaccine in past year
 Yes 61 23.6 186 23.8 247 23.7 161 28.6 408 80.9b 408 29.2b
 Noa 240 76.4 627 76.2 867 76.3 466 71.4 1333 67.7 1333 12.0
Cigarette use
 Current smokera 72 15.8 269 19.0 341 17.9 217 22.5c 558 74.1 558 15.4
 Formersmoker d d 106 8.1 119 6.1 105 12.5 224 79.8 224 12.1
 Never smoked 407 82.2 999 72.9 1406 76.0 706 64.9 2112 71.7 2112 19.4
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a

Reference level.

b

p <0.05 by T test forcomparisons within each variable with the indicated reference level.

c

Significant difference between persons aged 27–30 years and persons aged 18–26 years (by chi-square test, p <0.05).

d

Estimates are not reliable due to small sample size (n <30) or relative standard error (RSE) is >0.3.

Among respondents age 18–20 years, 21–26 years, 18–26 years overall, and 27–30 years, 76.9%, 70.8%, 72.2% and 67.1%, respectively, reported a year or less since their most recent Pap test. Women age 27–30 years were more likely to have been screened for cervical cancer during the previous three years (86.8%) compared with women age 18–26 years (72.2%) (p < 0.05) (Table 1).

Ever having had cervical cancer screening (76.2%) and having had cervical cancer screening in ≤3 years (77.3%) were associated with awareness of HPV vaccine (p < 0.05). Non-Hispanic white women were more likely to have heard of HPV vaccine (81.3%) than were non-Hispanic black (65.8%), non-Hispanic Asian (60.6%), and Hispanic women (52.0%) (p < 0.05) (Table 1).

3.2. HPV vaccine initiation

Vaccine initiation (receipt of ≥1 HPV vaccine dose) and receipt of 3 doses by age group by a variety of characteristics are shown in Table 2. Overall, HPV vaccine initiation was higher in younger than in older age groups with 34.9% of women age 18–20 years, 17.5% of women age 21–26 years (23.2% of women age 18–26), and 6.7% of women age 27–30 years reporting receipt of at least 1 dose of HPV vaccine (Table 2). Only 1.3% of women ≥27 years reported having ever had at least 1 HPV vaccine dose. In bivariate analyses characteristics associated with receipt of at least 1 dose of HPV vaccine varied by age group. Characteristics associated with vaccine initiation among women age 18–20 and 21–26 years included non-Hispanic ethnicity, having private health insurance, having a regular physician, seeing a physician or obstetrician/gynecologist in the past year, and receipt of influenza and other recommended vaccines (Table 2). Among women age 18–26 years overall, other factors associated with receipt of at least 1 vaccine dose included not currently being married, income at or above 300% of the poverty level, and having either public or private health insurance (Table 2).

Table 2.

Receipt of at least one HPV vaccine dose and receipt of three doses among women in the United States, by age and selected characteristics – NHIS 2010.

Characteristic Age 18–20 Years Age 21–26 Years Age 18–26 Years Age 27–30 Years
Number HPV doses
At least 1 dose
% (95% CI)		 3 Dosesa
% (95% CI)		 At least 1 dose
% (95% CI)		 3 Dosesa
% (95% CI)		 At least 1 dose
% (95% CI)		 3 Dosesa
% (95% CI)		 At least 1 dose
% (95% CI)		 3 Dosesa
% (95% CI)
Total 34.9 (29.8, 40.3) 21.1 (17.0, 25.9) 17.5 (15.0, 20.3) 9.3 (7.4, 11.5) 23.2 (20.8, 25.8) 13.2 (11.2, 15.4) 6.7 (5.3, 8.4) 4.2 (3.2, 5.6)
Ever been told had HPV
 Yes b b 31.8 (21.9, 43.6)c 18.9 (11.0, 30.5) 34.1 (24.9, 44.8) 21.7 (13.7, 32.5) 24.0 (15.5, 35.2)c 18.6 (11.2, 29.3)c
 Nod 40.5 (34.5, 46.7) 24.8 (19.7, 30.8) 18.7 (15.5, 22.3) 9.6 (7.5, 12.2) 26.0 (23.0, 29.2) 14.7 (12.2, 17.6) 5.8 (4.3, 7.7) 3.5 (2.4, 5.3)
Cervical CA screening
 Never had PAP testd 34.9 (27.0, 43.9) 19.9 (13.6, 28.1) 5.3 (2.9, 9.7) 2.5 (1.0, 6.5) 24.2 (18.7, 30.6) 13.6 (9.5, 19.2) b b
 Ever had PAP test 34.9 (28.4, 41.9) 22.2 (16.9, 28.5) 19.3 (16.4, 22.6)c 10.2 (8.2, 12.7)c 22.9 (20.1, 26.0) 13.0 (10.9, 15.4) 7.0 (5.6, 8.9) 4.5 (3.3, 6.0)
Time since last PAP
 ≤3y 35.3 (28.8, 42.4) 22.3 (17.0, 28.7) 20.3 (17.3, 23.7)c 10.7 (8.6, 13.4)c 23.9 (21.0, 27.0) 13.5 (11.3, 16.0) 7.4 (5.8, 9.4) 4.7 (3.5, 6.2)
 >3y b b 2.8 (0.7, 9.9) 1.8 (0.3, 9.2) 4.2 (1.3, 12.4)c 3.3 (0.9, 11.8)c b b
Doctor recommended
 Yes 36.7 (30.2, 43.8) 21.8 (16.5, 28.2) 16.6 (13.1, 20.8) 9.1 (6.5, 12.6) 24.8 (21.3, 28.8) 14.3 (11.4, 17.8) 5.9 (3.9, 8.7) 3.2 (1.9, 5.2)
 Nod 31.2 (23.6, 39.9) 19.8 (13.7, 27.6) 18.5 (14.9, 22.7) 9.2 (6.7, 12.5) 21.5 (18.1, 25.5) 11.7 (9.1, 14.9) 7.3 (5.4, 9.9) 5.1 (3.4, 7.4)
Race/Ethnicity
 Non-Hispanic whited 38.0 (31.3, 45.2) 22.9 (17.5, 29.3) 19.6 (16.0, 23.7) 11.6 (8.8, 15.2) 25.7 (22.4, 29.3) 15.4 (12.5, 18.8) 8.5 (6.5, 11.0) 5.3 (3.8, 7.3)
 Non-Hispanic black 33.8 (22.0, 47.9) 16.2 (8.8, 27.8) 15.5 (10.3, 22.6) 3.2 (1.7, 6.1)c 21.5 (16.0, 28.3) 7.5 (4.6, 11.9)c 4.0 (1.8, 8.7)c 2.6 (0.9, 7.1)
 Hispanic 24.9 (17.2, 34.7)c 16.0 (9.5, 25.6) 12.7 (9.1, 17.5)c 6.4 (4.2, 9.7)c 16.7 (13.1, 21.1)c 9.6 (6.7, 13.5)c 2.7 (1.4, 5.0)c 1.6 (0.7, 3.8)c
 Non-Hispanic Asian b b b b 22.9 (13.9, 35.2) 17.4 (9.9, 28.7) b b
 Other b b b b 19.0 (10.2, 32.9) b b b
Marital status
 Marriedd b b 10.7 (7.7, 14.6) 5.7 (3.6, 9.0) 11.4 (8.2, 15.7) 5.2 (3.2, 8.1) 4.2 (2.6, 6.6) b
 Other 36.4 (31.1, 42.0) 22.7 (18.4, 27.8)c 20.0 (16.8, 23.6)c 10.6 (8.3, 13.4)c 26.3 (23.4, 29.4)c 15.2 (12.9, 17.9)c 9.3 (7.0, 12.1)c 6.7 (4.8, 9.2)
Education
 Less than HSd 29.2 (19.7, 40.8) 14.0 (7.4, 25.0) 10.6 (5.7, 18.7) 2.8 (1.2, 6.5) 20.7 (14.9, 27.9) 8.9 (5.0, 15.2) b b
 HS Grad/GED 33.9 (24.0, 45.4) 18.7 (11.5, 28.9) 10.4 (7.2, 14.6) 5.0 (3.0, 8.2) 19.3 (15.0, 24.6) 10.2 (7.1, 14.7) 4.5 (2.2, 9.0) 3.7 (1.7, 8.1)c
 Some college 38.6 (31.0, 46.8) 26.2 (19.9, 33.8)c 17.8 (13.9, 22.5) 8.1 (5.6, 11.4)c 25.3 (21.5, 29.6) 14.7 (11.8, 18.1)c 8.0 (5.4, 11.5)c 4.1 (2.3, 7.2)c
 College graduate b b 25.7 (19.9, 32.5)c 17.1 (12.3, 23.2)c 25.7 (19.9, 32.4) 17.1 (12.4, 23.2)c 8.4 (5.9, 11.9)c 6.0 (4.0, 8.9)c
Employment status
 Employed 35.5 (28.0, 43.9) 20.9 (15.1, 28.1) 19.0 (15.9, 22.5) 10.8 (8.5, 13.6)c 23.5 (20.2, 27.1) 13.6 (11.0, 16.6) 7.4 (5.6, 9.7) 5.4 (3.9, 7.4)
 Not employedd 34.3 (27.7, 41.5) 21.3 (15.7, 28.1) 14.6 (10.8, 19.5) 6.3 (3.8, 10.2) 22.8 (19.5, 26.6) 12.5 (9.8, 15.9) 5.1 (3.1, 8.1) b
Poverty level
 300%+ 54.4 (41.6, 66.6)c 33.0 (22.1, 46.1)c 21.3 (16.5, 27.0) 14.5 (10.1, 20.6)c 31.1 (25.6, 37.2)c 20.1 (14.9, 26.5)c 7.2 (4.9, 10.5) 4.1 (2.5, 6.7)
 200% to <300% 24.5 (13.4, 40.4) 15.1 (7.1, 29.4) 18.2 (12.2, 26.3) 6.6 (4.1, 10.7) 20.1 (14.5, 27.2) 9.2 (5.9, 14.1) 6.7 (3.5, 12.4) 4.0 (1.7, 9.1)
 100% to <200% 26.4 (18.2, 36.7) 17.7 (10.8, 27.8) 11.7 (8.0, 16.7) 5.3 (3.3, 8.5) 16.4 (12.6, 21.2) 9.3 (6.5, 13.1) 5.6 (2.9, 10.6) 4.5 (2.1, 9.4)
 <100%d 32.3 (24.2, 41.7) 16.8 (11.5, 23.9) 15.0 (11.4, 19.5) 6.7 (4.5, 10.0) 21.2 (17.3, 25.8) 10.4 (7.7, 13.7) 7.4 (4.1, 12.9) 4.3 (1.8, 9.7)
Immigration status
 Born in U.S.d 35.9 (30.5, 41.6) 22.5 (18.0, 27.6) 18.6 (15.7, 21.9) 10.0 (8.0, 12.5) 24.4 (21.8, 27.3) 14.2 (12.1, 16.7) 7.0 (5.4, 9.0) 4.5 (3.3, 6.2)
 Born outside U.S. and stayed in the US ≤10 years b b b b 9.9 (4.0, 22.6)c 2.0 (0.9, 4.3)c b b
 Born outside U.S. and stayed in the US >10 years 24.4 (9.4, 50.1) 11.9 (2.9, 37.4) 17.3 (10.1, 27.8) 8.3 (4.3, 15.6) 19.4 (12.6, 28.8) 9.4 (5.5, 15.7) b b
Health insurance
 Private 42.3 (34.9, 50.2)c 25.6 (19.5, 32.8)c 21.8 (18.1, 26.1)c 13.4 (10.4, 17.0)c 28.7 (25.0, 32.8)c 17.5 (14.3, 21.2)c 6.7 (4.9, 9.1) 4.4 (3.1, 6.3)
 Public 33.5 (24.0, 44.5)c 23.5 (15.9, 33.2)c 15.0 (10.1, 21.6) 6.0 (2.9, 12.0) 21.8 (17.0, 27.5)c 12.5 (8.7, 17.5)c 8.7 (5.2, 14.1) 5.5 (2.8, 10.4)
 Noned 18.2 (10.7, 29.4) 7.6 (4.1, 13.8) 11.4 (7.7, 16.5) 4.0 (2.5, 6.2) 13.3 (9.6, 18.2) 5.0 (3.5, 7.2) 4.9 (2.5, 9.4) b
Regular physician
 Yes 39.0 (33.4, 44.9)c 24.7 (20.0, 30.1)c 20.2 (17.2, 23.6)c 10.6 (8.4, 13.3)c 26.7 (24.0, 29.6)c 15.5 (13.2, 18.2)c 7.3 (5.6, 9.3) 4.4 (3.2, 6.0)
 Nod 16.0 (8.9, 27.0) 4.5 (1.9, 10.0) 8.9 (6.1, 12.8) 5.0 (3.1, 7.9) 10.8 (7.8, 14.7) 4.9 (3.2, 7.3) 4.3 (2.1, 8.7) 3.5 (1.6, 7.9)
Seen physician or OB/GYN in past year
 Yes 38.5 (32.5, 45.0)c 24.0 (19.1, 29.8)c 20.7 (17.7, 24.2)c 10.9 (8.7, 13.6)c 26.5 (23.6, 29.7)c 15.2 (12.8, 18.0)c 7.4 (5.7, 9.4)c 4.7 (3.4, 6.4)
 Nod 22.8 (14.6, 33.8) 11.4 (6.0, 20.4) 6.0 (4.0, 9.0) 3.5 (2.0, 6.1) 11.8 (8.4, 16.1) 6.2 (3.9, 9.5) 3.7 (1.9, 7.1) 2.4 (1.1, 5.2)
Other vaccination behavior One/more recommended lifetime vaccines
 Yes 39.7 (34.0, 45.7)c 23.8 (19.2, 29.2)c 19.6 (16.5, 23.0)c 10.7 (8.5, 13.3)c 26.4 (23.6, 29.5)c 15.1 (12.8, 17.8)c 7.5 (5.9, 9.6)c 4.5 (3.4, 6.1)
 Nod 7.2 (33, 15.1) 5.0 (2.0, 12.2) 8.7 (5.7, 13.1) 3.4 (1.7, 6.6) 8.3 (5.6, 12.2) 3.9 (2.3, 6.5) 3.9 (1.8, 8.0) 3.4 (1.4, 8.1)
 Influenza vaccine in past year
 Yes 65.4 (49.5, 78.5)c 37.6 (23.9, 53.7)c 28.3 (20.0, 38.3)c 15.7 (9.3, 25.3)c 40.8 (32.6, 49.5)c 23.1 (16.1, 31.9)c 8.1 (4.4, 14.5) 3.8 (1.4, 9.8)
 Nod 23.6(17.8, 30.7) 15.6 (10.8. 21.9) 10.5 (7.9, 13.9) 6.2 (4.4, 8.7) 15.0 (12.3, 18.1) 9.4 (7.3, 11.9) 5.0 (3.3, 7.6) 3.3 (2.0, 5.5)
Cigarette use
 Current smoked 40.3 (27.5, 54.6) 19.5 (11.0, 32.2) 12.7 (8.8, 18.0) 4.4 (2.5, 7.6) 20.7 (15.6, 26.9) 8.7 (5.8, 13.0) 6.2 (3.6, 10.4) 3.5 (1.6, 7.6)
 Former smoker b b 12.6 (7.5, 20.4) b 15.4 (9.7, 23.7) 8.7 (4.5, 16.1) 8.5 (4.3, 16.2) 5.1 (2.2, 11.1)
 Never smoked 33.8 (28.3, 39.7) 21.3 (16.8, 26.6) 19.3 (16.2, 22.7) 10.8 (8.5, 13.6)c 24.4 (21.7, 27.4) 14.6 (12.2, 17.3)c 6.5 (4.8, 8.6) 4.3 (3.0, 6.2)
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a

A small number may have received more than 3 doses.

b

Estimates are not reliable due to small sample size (n < 30) or relative standard error (RSE) is >0.3.

c

p < 0.05 by T test for comparisons within each variable with the indicated reference level.

d

Reference level.

Women age 18–26 years reporting >3 years since the last Pap test were less likely to have received at least 1 dose of HPV vaccine (4.2%) compared with women never tested (24.2%) or tested in ≤3 years (23.9%) (p < 0.05)(Table 2). Women age 21–26 years reporting having ever had a Pap test or ≤3 years since their last Pap test were more likely to have received at least 1 dose of HPV vaccine (19.3% and 20.3%, respectively) compared with women never tested (5.3%) (p < 0.05). Women age 18–26 years who were born outside the United States and had stayed in the United States ≤10 years (49.5% Hispanic, 23.4% non-Hispanic white, 17.8% non-Hispanic Asian, 8.7% non-Hispanic black) were less likely to have received at least 1 dose of HPV vaccine (9.9%) compared with women born in the United States (24.4%) or born outside the United States and residing in the United States >10 years (19.4%) (Table 2).

Among women age 27–30 years, having ever been told they had HPV and not currently being married were associated with receipt of at least 1 dose of HPV vaccine (Table 2). Non-Hispanic black and Hispanic women age 27–30 years were less likely to have received at least 1 dose of HPV vaccine (4.0% and 2.7%, respectively) compared with non-Hispanic white women (8.5%) (p < 0.05).

In multivariable analyses among women age 18–26 years, not currently being married, having a regular physician, seeing a physician or obstetrician/gynecologist in the past year, influenza vaccination in the past year, and receipt of other recommended vaccines were associated with receipt of at least 1 dose of HPV vaccine (Table 3).

Table 3.

Multivariable logistic regression and predictive marginal prevalence of women aged 18–26 years (n = 1866) who reported having ever received HPV vaccination, United States, by demographic and access-to-care variables, NHIS 2010.

Characteristic Adjusted vaccination coverage
% (95% CI)		 Prevalence ratio (Risk Ratio) (adjusted)
% (95% CI)		 p-Valuea
Previous HPV exposure Ever been told had HPV
 Yes 20.9 (10.0, 31.8) 0.9 (0.5–1.5) 0.555
 Nob 24.5 (20.4, 28.6) Referent
Cervical CA screening
 Ever had PAP test 23.6 (19.1, 28.1) 1.3 (1.0–1.9) 0.584
 Never had PAP testb 26.4 (17.6, 35.2) Referent
Doctor recommended
 Yes 24.3 (18.7,30.0) 1.0 (0.7–1.4) 0.961
 Nob 24.1 (18.5, 29.8) Referent
Race/Ethnicity
 Non-Hispanic whiteb 23.0 (18.0, 28.1) Referent
 Non-Hispanic black 24.9 (16.1, 33.8) 1.1 (0.7–1.6) 0.713
 Hispanic 30.7 (22.4, 38.9) 1.3 (0.9–1.9) 0.112
 Other 24.5 (13.3, 35.7) 1.1 (0.6–1.8) 0.811
Marital status
 Marriedb 11.2 (5.5, 16.9) Referent
 Other 27.3 (22.8, 31.8) 2.4 (1.4–4.2) <0.001
Education
 Less than HSb 26.8 (16.1, 37.5) Referent
 HS Grad/GED 23.4 (15.2, 31.6) 0.9 (0.5–1.5) 0.615
 Some college 25.0 (19.7,30.3) 0.9 (0.6–1.5) 0.762
 College graduate 21.5 (13.2, 29.8) 0.8 (0.5–1.4) 0.459
Immigration status
 Born in U.S.b 24.0 (20.0, 28.0) Referent
 Born outside U.S. and stayed in the US ≤10 years 11.9 (−0.5, 24.2) 0.5 (0.2–1.4) 0.143
 Born outside U.S. and stayed in the US >10 years 33.6 (21.0, 46.1) 1.4 (1.0–2.1) 0.115
Health insurance
 Private 27.8 (22.5, 33.0) 1.7 (1.0–3.0) 0.059
 Public 20.8 (12.7, 28.8) 1.3 (0.7–2.3) 0.435
 Noneb 16.4 (8.0, 24.8) Referent
Regular physician
 Yes 26.2 (22.0, 30.4) 1.9 (1.2–3.1) 0.005
 Nob 13.7 (7.2, 20.3) Referent
Seen physician or OB/GYN in past year
 Yes 25.4 (21.2, 29.6) 1.6 (1.0–2.7) 0.050
 Nob 15.8 (7.9, 23.7) Referent
Other vaccination behavior One/more recommended lifetime vaccines
 Yes 26.3 (22.1, 30.4) 2.7 (1.4–5.1) <0.001
 Nob 9.7 (3.7, 15.8) Referent
Influenza vaccine in past year
 Yes 40.0 (31.6, 48.4) 2.2 (1.6–2.9) <0.001
 Nob 18.3 (14.4, 22.1) Referent
Cigarette use
 Current smokerb 24.7 (16.4, 33.0) Referent
 Former smoker 20.1 (10.9, 29.2) 0.8 (0.5–1.4) 0.440
 Never smoked 24.6 (19.9, 29.2) 1.0 (0.7–1.5) 0.976
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a

p <0.05 by T test for comparisons within each variable with the indicated reference level. All the variables in the table were included in the model.

b

Reference level.

3.3. Receipt of 3 HPV vaccine doses

Among women age 18–26 years overall, 13.2% reported receipt of 3 HPV vaccine doses, including 21.1% of women age 18–20 and 9.3% of women 21–26. Only 4.2% of women 27–30 years reported receipt of 3 HPV vaccine doses (Table 2). Overall, 57.1% of those who initiated the series reported receipt of 3 HPV vaccine doses. Characteristics associated with receipt of 3 HPV vaccine doses for each age group are similar to those of women who initiated HPV vaccination. Among women age 18–26 years, black non-Hispanic women (7.5%) and Hispanic women (9.6%) were less likely to receive 3 doses of HPV vaccine compared with white non-Hispanic women (15.4%) (p < 0.05). Examination of age at last HPV vaccine dose among women who received 3 doses indicated that women in more recent age cohorts were getting the third dose at younger ages (data not shown).

3.4. Impact of insurance, having a regular doctor, and doctor visits on HPV vaccination

Among women age 18–26 years, those who had health insurance were more likely to have a regular physician (86.4%) than those without health insurance (53.3%) (p < 0.05) (Table 4). Those with a regular physician were more likely to be vaccinated than those who did not have a regular physician whether or not they had (28.7% versus 14.0%) or did not have health insurance (17.6% versus 8.4%) (p < 0.05) (Table 4).

Table 4.

Association of health insurance, having a regular doctor, doctor visit, and vaccine cost with HPV vaccination among U.S. women aged 18–26 – NHIS 2010.

Characteristic HPV vaccinationa
n		 % (95% Cl) % (95% Cl)
Health insurance
Yesb
Regular physician
Yesb 1247 86.4 (84.1, 88.5) 28.7 (25.4, 32.2)
No 210 13.6 (11.5, 15.9)c 14.0 (9.2, 20.8)c
No
Regular physician
Yesb 271 53.3 (47.9, 58.6)d 17.6 (11.7, 25.6)d
No 258 46.7 (41.4, 52.1)d 8.4 (5.3, 13.0)c
Yesb
Physician contacts within past year
Noneb 198 11.4 (9.5, 13.6) 15.9 (9.7, 24.9)
1 211 14.7 (12.8, 16.9) 20.8 (14.4, 29.2)
2–3 405 28.2 (25.2, 31.3)c 28.4 (23.3, 34.2)c
4–9 402 29.1 (26.1, 32.2)c 33.3 (27.3, 39.9)c
≥10 231 16.6 (14.2, 19.4) 24.9 (17.2, 34.6)
No
Physician contacts within past year
Noneb 198 37.8 (32.9, 43.0)d 4.9 (2.6, 9.3)d
1 86 16.2 (12.7, 20.4)c 24.7 (13.0, 41.8)c
2–3 126 22.8 (18.6, 27.6) 16.7 (10.1, 26.5)c,d
4–9 77 15.4 (11.8, 19.7)c,d e
≥10 40 7.8 (5.2, 11.7)c,d e
Health insurance (Unvaccinated women interested in getting HPV vaccine)
Yesb
Would get vaccine ifhad to pay $360–500
Yesb 73 23.8 (18.6, 29.9) f
No 258 76.2 (70.1, 81.4)c f
No
Would get vaccine ifhad to pay $360–500
Yesb e e f
No 125 85.5 (78.6, 90.5)c f
Health insurance (Unvaccinated women who would not pay $360–500 forthe HPV vaccine or for whom the main reason for not getting HPV vaccine was cost)
Yesb
Would get vaccine iffreeor lower cost
Yesb 259 97.7 (95.2, 98.9) f
No e e f
No
Would get vaccine iffreeor lower cost
Yesb 133 98.2 (93.1, 99.6) f
No e e f
Open in a new tab
a

Estimates based on the responses of participants in the respective categories who answered affirmatively to the question, “Have you ever received an HPV shot or vaccine?”

b

Reference level.

c

p < 0.05 by T test for comparisons within each variable with the indicated reference level.

d

p < 0.05 by T test for comparison with the same level of the variable within the “Health insurance = Yes” category.

e

Estimates are not reliable due to small sample size (n <30) or relative standard error (RSE) is >0.3.

f

Data not applicable. Includes unvaccinated women.

HPV vaccination was higher among women age 18–26 years who had health insurance and 2–3 (28.4%) or 4–9 physician contacts within the past year (33.3%) compared with women with health insurance and no physician contacts within the past year (15.9%) (p < 0.05) (Table 4). However, vaccination was lower among women without health insurance compared to those with insurance, regardless of the number of physician contacts within the past year. Among women age 18–26 who had 10 or more physician visits (n = 271), 37 (13.6%) were pregnant, a group for whom HPV vaccination is not recommended. Most (65.9%) of the remaining women reported no chronic health condition; the others reported chronic illnesses that are not contraindications for HPV vaccination, including asthma (6.5%), heart disease (6.5%), cancer (2.3%), liver disease (2.0%), diabetes (1.6%) and kidney disease (1.6%). Among those women for whom HPV vaccination is indicated who had health insurance and 10 or more physician contacts within the past year, 74.5% reported not receiving HPV vaccine (Table 4).

3.5. Interest in HPV vaccination

Among women age 18–26 years who had never had HPV vaccine or did not know or refused to provide this information (n = 1484), 33.0% said they would be interested in getting HPV vaccine (n = 490) and 62.0% said they would not be interested (n = 920). Among those who were interested in getting HPV vaccine, most (76.2–85.5%) indicated they would not get the vaccine if they had to pay full price (Table 4). Among women who were not interested in getting HPV vaccine, the main reasons reported included: not needing it (41.3%); concerns about vaccine safety (12.5%); not knowing enough about the vaccine (11.9%); not being sexually active (8.2%); the doctor not recommending the vaccine (7.6%); and already having HPV (2.7%). Of women not interested in HPV vaccination, only 2.6% cited the vaccine being too expensive as the primary reason; 2.3% indicated they were too old, 0.7% reported their spouse or family was against it, and 0.3% did not know where to get the vaccine. Reasons other than those cited here were reported by 10% of respondents. Nearly all of those unwilling to pay full price for HPV vaccination (97.7–98.2%) reported that they would get the vaccine if it were free or available at lower cost (Table 4).

4. Discussion

The findings of this study indicate that 4 years following the recommendation for routine vaccination at age 11 or 12 years and through age 26 for those not previously vaccinated, HPV vaccination remains low with initiation highest among women age 18–20 years. The finding of higher initiation levels at younger ages has been reported [8,9,11,14] and might reflect the knowledge, attitude and practices of the healthcare providers of young adult women [9], the social norms of young women and the perceptions and vaccine intentions of peers or significant others [15] or receipt of vaccine when eligible for the Vaccines for Children (VFC) Program (≤18) [9–11] but 18 or older at the time of the survey. Few women age 27–30 years at the time of the survey (age 24–26 years when HPV vaccine was licensed) or age ≥27 reported receiving at least 1 dose, indicating HPV vaccine initiation was low within 1–3 years after vaccine licensure and limited off-label use.

Our multivariable model was used mainly to control for confounding rather than to test a specific hypothesis or underlying causal model developed a prior. Findings from the model should be interpreted along with those from bivariate analyses. Women who had been told by a provider they had HPV were more likely to have ever heard of and received at least 1 HPV vaccine dose than women who had not been told they had HPV. This observation suggests that a discussion with a healthcare provider about HPV might have facilitated a conversation about HPV vaccine and the decision to vaccinate. As reported elsewhere [7–12,14,16], awareness of HPV vaccine and HPV vaccination were also associated with having health insurance, having a regular physician, seeing a physician or obstetrician/gynecologist in the past year, and receipt of influenza and other recommended vaccines. These findings are consistent with previous reports indicating that persons who have insurance coverage, a usual place for health care or medical home, and who seek medical care one or more times during the year are more likely to be vaccinated against influenza and receive other preventive services, compared with those who are uninsured and are without a usual place for healthcare [17,18]. Having a regular physician and seeing a physician provide opportunities for education about HPV, HPV vaccination and other prevention services [8,10–12,14,16].

The association of HPV vaccination with not currently being married might be related to a perception of greater risk for HPV infection among unmarried women, particularly those engaging in sexual activity [7,10,12]. The perception of greater risk is also likely among women who have had HPV infection. The perception of risk for HPV infection is important in gaining acceptance of HPV vaccination as well as allaying undue concerns about vaccination side effects [12]. Tailoring educational initiatives among women to increase their understanding of the risk of acquiring HPV infection and the safety of HPV vaccine might improve vaccine acceptance. The association of HPV vaccination with receipt of influenza or other recommended vaccines was a predictor of HPV vaccination in this and other studies [7,10,12,14]. This finding might indicate a positive attitude about preventive measures playing an important role in women’s decisions about HPV vaccination, the quality of their medical care or having providers who are more likely to vaccinate adults [7,11,12,14]. Recent Pap testing (≤3 years) was associated with initiating HPV vaccination and receiving 3 doses. The relationship of vaccine initiation with Pap testing in other studies has been mixed, with reports of no association of HPV vaccine initiation with recent Pap testing [8,10] and in another study cervical cancer screening and having abnormal Pap results being positive correlates of HPV vaccine initiation [14].

HPV vaccination was lower among women age 18–26 years without health insurance, illustrating the importance of insurance in the receipt of preventive services. Lack of medical insurance has been an important predictor of low adult vaccination [7–12]. While many health plans are providing coverage for HPV vaccination, the availability or the level of coverage can vary (http://www.cdc.gov/std/hpv/stdfact-hpv-vaccine-young-women.htm) The expanded enrollment in public and private insurance programs expected from provisions of the Affordable Care Act might improve access to health care services, including vaccination, for persons who were previously uninsured [19]. Health insurance coverage, however, although beneficial in improving access to health care services, might not be sufficient in itself to achieve optimal HPV vaccination. In this report, even among those with health insurance, 10 or more contacts with physicians within the past year and no contraindications, HPV vaccination was not optimal-as many as 74.5% reported not receiving HPV vaccine. Provider attitudes and practice patterns might be playing a role in determining which women are offered HPV vaccine [7,8,14]. Providers may not be knowledgeable about HPV vaccine recommendations, offering vaccination to eligible women in their practice, and may not be discussing topics such as health risks related to sexual behavior with their young female patients.

Similar to other reports [7,9–12,14,16,20], in our bivariate analysis we found that black race and Hispanic ethnicity were negative correlates of HPV vaccination among women age 18–26 and 27–30 years. Numerous factors might play a role in these racial and ethnic disparities, including differences in attitudes toward vaccination and preventive care, propensity to seek and accept vaccination, variations in likelihood that providers recommend vaccination, regional factors, and differences in quality of care received by racial/ethnic populations [11,14,21–31]. Differences in HPV vaccination coverage by race or ethnicity among women 18–30 years of age differ from those among girls 13–17 years of age. In 2011, HPV initiation was higher for black and Hispanic girls, 13–17 years of age, compared to whites; coverage with three HPV doses was higher for Hispanics compared to whites [32]. Increased vaccine access through the VFC program or risk-based approaches that base provider recommendations for HPV on the perceived level of the patient’s risk for cervical cancer might contribute to higher HPV initiation rates among blacks and Hispanics [33].

As reported here, the main reasons reported among women age 18–26 years who were not interested in getting HPV vaccine included not believing it was needed, concerns about vaccine safety, not knowing enough about the vaccine, and the doctor not recommending the vaccine, all factors amenable to changes in physician practice. Increasing activities to inform providers of their critical role in influencing vaccination is important. Efforts to decrease out of pocket expenses to pay for HPV vaccination are also important [10,34–36].

This study has limitations. First, vaccination in NHIS is self-reported and not validated by medical records so is subject to recall bias. Adult self-reported influenza and pneumococcal vaccination, however, have been shown to be sensitive and specific [37–40]. Validity studies of self-reported HPV vaccination among adult women have not been reported. Among adolescent girls, however, high levels of inaccuracy between actual HPV vaccination and self-report of vaccine receipt has been reported [41]. Second, multiple comparisons and a large number of statistical tests were performed. Without correction for multiple comparisons, an unidentifiable proportion of significant results might be spurious. Third, the vaccination status and characteristics of women not included in the NHIS are not known. Women not included are those who at the time of the survey were not living at home, such as those in the military or incarcerated.

HPV vaccination can reduce the burden of HPV-associated disease through primary prevention of HPV infection but coverage is suboptimal. Vaccination would be most effective when given before exposure to HPV through sexual contact. Healthcare providers have an important role to play in educating young women about HPV and encouraging vaccination. Successful interventions will need to address physician attitudes and practice patterns. Greater use of strategies demonstrated to improve vaccination coverage is important [21,22,35,36,42].

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