The human papillomavirus (HPV) vaccine was first approved in 2006, and more than 135 million doses have been administered ever since.1 Although the vaccine is safe and effective in preventing anogenital and oropharyngeal cancers, uptake remains suboptimal in the United States, falling short of the Healthy People 2020 goal of vaccinating 80% of 13- to 15-year-olds.2 Among the known barriers to HPV vaccine uptake, safety concerns have recently gained more attention during the COVID-19 pandemic, with a recent study reporting increase rate of HPV vaccine refusal due to safety concerns.3 However, it is unknown whether HPV vaccine refusal is specifically associated with COVID-19. We described the reasons for HPV vaccine refusal during COVID-19 pandemic in 2020 in the United States.
We analyzed the 2020 National Immunization Survey–Teen, a deidentified, publicly available, nationally representative, random-dial-digit telephone survey of parents/guardians of 13- to 17-year-olds in the United States. Data have been approved by the National Center for Health Statistics Research Ethics Review Board; hence, our analysis was exempt from institutional review board approval. Analytic data (n = 2,901) included only unvaccinated adolescents. Outcome of interest was reasons given by parents/guardians for HPV vaccine refusal, derived from unique responses to the survey question, “What is the main reason teen will not receive HPV shots in the next 12 months?” Parents/guardians of unvaccinated adolescents identified the primary reason for vaccine refusal from a list of 29 unique predefined reasons. For regression analyses, we only looked at the top five most frequently cited reasons “not needed or not necessary,” “safety/side effects concerns,” “not recommended,” “lack of knowledge,” and “child not sexually active.” Weighted prevalence rates of reasons for HPV vaccine refusal were estimated for the overall population. Next, five separate weighted multivariable logistic regression models were used to examine the association between adolescent and mother's sociodemographic and healthcare utilization factors, and the five most frequently cited reasons for refusal: “not needed or not necessary,” “safety/side effects concerns,” “not recommended,” “lack of knowledge,” and “child not sexually active.” All analyses were performed with SAS 9.4 survey procedures to account for the complex survey design of the NIS-Teens data. Tests were two tailed, and significance was set at P < 0.05.
Of the 29 unique reasons cited for HPV vaccine refusal, the five most frequently cited reasons were safety/side-effects concerns (24.8%), not necessary (16.1%), not recommended (11.4%), lack of knowledge (7.7%), and not sexually active (7.7%; Table 1 ). Less than 1% of parents/guardians cited COVID-19 as reason for HPV vaccine refusal. In the adjusted regression analyses of parents/guardians’ main reasons for HPV vaccine refusal, parents/guardians who cited safety/side-effects concerns were less likely to be non-Hispanic Black (adjusted odds ratio [aOR] = 0.32; 95% confidence interval [CI] 0.17, 0.61), or live below poverty line (aOR = 0.52; 95% CI 0.31, 0.86). Those who cited the vaccine was not recommended were more likely to be males (aOR = 2.27; 95% CI 1.37, 3.74), Hispanics (aOR = 2.16; 95% CI 1.29, 3.64), or mothers with high school diploma or less (aOR = 2.12; 95% CI 1.14, 3.94). Parents/guardians citing lack of knowledge as a reason for not vaccinating their adolescent child was associated with being non-Hispanic Black (aOR = 2.59; 95% CI 1.24, 5.40) or mothers with high school diploma or less (aOR = 2.45; 95% CI 1.06, 5.68; Table 1).
Table 1.
Sociodemographic factors associated with various reasons for HPV vaccine refusal, 2020 NIS-Teen (n = 2,901).
| Characteristics | Frequency (unweighted percent) | Adjusted odds ratios (95% confidence interval) |
||||
|---|---|---|---|---|---|---|
| Not necessary (n = 421) | Not recommended (n = 285) | Safety/side-effects (n = 731) | Lack of knowledge (n = 223) | Not sexually active (n = 196) | ||
| Adolescents | ||||||
| Age | ||||||
| 13 | 657 (23.2) | Reference | Reference | Reference | Reference | Reference |
| 14 | 632 (22.2) | 1.13 (0.65, 1.98) | 1.28 (0.63, 2.60) | 1.42 (0.94, 2.15) | 0.92 (0.48, 1.78) | 0.85 (0.37, 1.94) |
| 15 | 573 (17.9) | 1.02 (0.57, 1.82) | 1.06 (0.52, 2.14) | 1.51 (0.99, 2.31) | 0.91 (0.45, 1.83) | 1.17 (0.49, 2.77) |
| 16 | 525 (18.5) | 1.09 (0.60, 1.99) | 0.78 (0.36, 1.68) | 1.24 (0.80, 1.92) | 0.97 (0.47, 1.99) | 1.06 (0.44, 2.58) |
| 17 | 514 (18.3) | 1.87 (0.98, 3.57) | 0.75 (0.33, 1.69) | 1.62 (0.98, 2.70) | 0.91 (0.45, 1.83) | 0.86 (0.32, 2.33) |
| Gender | ||||||
| Female | 1255 (43.2) | Reference | Reference | Reference | Reference | Reference |
| Male | 1646 (56.8) | 0.70 (0.50, 1.00) | 2.27 (1.37, 3.74) | 0.69 (0.52, 0.93) | 0.94 (0.60, 1.47) | 0.85 (0.52, 1.40) |
| Race/ethnicity | ||||||
| Non-Hispanic White | 2000 (60.5) | Reference | Reference | Reference | Reference | Reference |
| Non-Hispanic Black | 200 (10.7) | 1.31 (0.66, 2.60) | 1.50 (0.65, 3.45) | 0.32 (0.17, 0.61) | 2.59 (1.24, 5.40) | 1.92 (0.86, 4.29) |
| Hispanic | 379 (19.5) | 0.67 (0.37, 1.24) | 2.16 (1.29, 3.64) | 0.63 (0.38, 1.02) | 1.60 (0.81, 3.17) | 2.01 (0.93, 4.33) |
| Non-Hispanic Other | 322 (9.5) | 1.22 (0.67, 2.21) | 2.04 (1.01, 4.09) | 0.59 (0.35, 0.99) | 1.29 (0.64, 2.59) | 1.39 (0.67, 2.89) |
| Poverty | ||||||
| Above poverty | 2465 (85.8) | Reference | Reference | Reference | Reference | Reference |
| Below poverty | 343 (14.2) | 1.25 (0.66, 2.39) | 1.18 (0.59, 2.37) | 0.52 (0.31, 0.86) | 0.61 (0.32, 1.16) | 2.69 (1.16, 6.22) |
| Number of doctor visits | ||||||
| ≥4 | 509 (13.1) | Reference | Reference | Reference | Reference | Reference |
| 2–3 | 926 (29.2) | 0.89 (0.53, 1.49) | 1.29 (0.69, 2.39) | 1.12 (0.75, 1.67) | 0.78 (0.39, 1.56) | 0.94 (0.44, 2.03) |
| 1 | 879 (33.0) | 1.16 (0.72, 1.86) | 1.16 (0.62, 2.17) | 0.64 (0.42, 0.96) | 0.59 (0.29, 1.21) | 1.39 (0.70, 2.75) |
| None | 568 (24.7) | 0.99 (0.56, 1.75) | 1.04 (0.51, 2.13) | 0.93 (0.57, 1.52) | 0.72 (0.33, 1.55) | 1.40 (0.62, 3.16) |
| Mother's | ||||||
| Children in the house | ||||||
| 1 | 1040 (31.6) | Reference | Reference | Reference | Reference | Reference |
| 2–3 | 1463 (55.6) | 0.76 (0.51, 1.12) | 0.65 (0.38, 1.10) | 1.67 (1.16, 2.39) | 0.93 (0.58, 1.49) | 1.19 (0.63, 2.23) |
| ≥4 | 398 (12.8) | 1.83 (1.03, 3.26) | 0.29 (0.13, 0.62) | 1.02 (0.61, 1.73) | 0.63 (0.27, 1.49) | 1.50 (0.69, 3.26) |
| Mother's age | ||||||
| ≤34 | 210 (8.0) | Reference | Reference | Reference | Reference | Reference |
| 35–44 | 1345 (44.3) | 0.87 (0.41, 1.88) | 0.59 (0.26, 1.36) | 0.76 (0.45, 1.30) | 1.22 (0.55, 2.70) | 0.86 (0.33, 2.23) |
| ≥45 | 1346 (47.7) | 0.98 (0.43, 2.25) | 0.70 (0.29, 1.69) | 0.75 (0.42, 1.32) | 2.07 (0.96, 4.48) | 1.17 (0.42, 3.28) |
| Marital status | ||||||
| Married | 2135 (65.1) | Reference | Reference | Reference | Reference | Reference |
| Not married | 766 (34.9) | 1.06 (0.70, 1.61) | 0.90 (0.53, 1.53) | 1.41 (0.95, 2.09) | 0.92 (0.54,1.56) | 0.49 (0.24, 1.01) |
| Education | ||||||
| College graduate | 1385 (42.0) | Reference | Reference | Reference | Reference | Reference |
| Some college degree | 902 (29.2) | 1.09 (0.72, 1.66) | 1.06 (0.61, 1.86) | 0.90 (0.64, 1.28) | 0.79 (0.45, 1.38) | 0.78 (0.37, 1.63) |
| High school graduate | 428 (21.8) | 0.82 (0.49, 1.38) | 2.12 (1.14, 3.94) | 0.85 (0.54, 1.34) | 1.37 (0.71, 2.65) | 0.62 (0.30, 1.29) |
| Less than high school | 186 (7.0) | 0.52 (0.20, 1.37) | 2.14 (0.96, 4.74) | 1.19 (0.61, 2.31) | 2.45 (1.06, 5.68) | 0.12 (0.02, 0.76) |
| Reasons/barriers (collapsed) | ||||||
| Not necessary | 421 (16.1) | |||||
| Not recommended | 285 (11.4) | |||||
| Safety/side-effects | 731 (24.8) | |||||
| Lack of knowledge | 223 (7.7) | |||||
| Not sexually active | 196 (7.7) | |||||
| COVID/pandemic | 19 (0.9) | |||||
| Other reasons | 876 (31.6) | |||||
HPV, human papillomavirus; NIS-Teen, National Immunization Survey–Teen.
Boldface indicates statistical significance (P < 0.05).
The purpose of this study was to describe the main reasons for non-vaccination of HPV vaccine among parents/guardians of unvaccinated adolescents. The five most common reasons for HPV vaccine refusal in the United States in 2020 made up about two-thirds of the reasons given by parents/guardians in this survey. Only 0.9% of parents/guardians cited COVID-19 pandemic as a reason for HPV vaccine refusal. Future research should use data collected after 2020 to evaluate if COVID-19 disinformation is contributing to parents’ refusal to get the HPV vaccine. We note with concern that after the demonstrable success of the HPV vaccine as a cancer-preventing vaccine, a proportion of parents/guardians continue to cite lack of knowledge and physician recommendation as primary reasons for vaccine refusal. Physicians should use clinical encounters as opportunities to educate parents and actively recommend the HPV vaccine.4 Doing so may decrease HPV vaccine misinformation and hesitancy.5
Our study is not without limitations. First is the cross-sectional nature of the survey, any change in intention to vaccinate was not recorded. Also, it is unknown whether some of the vaccine safety concerns are COVID related. Finally, there is non-response bias, although the use of weighting reduces this potential bias. In conclusion, our study showed that in 2020, 29 unique reasons were reported for refusing the HPV vaccine, with safety/side-effects concerns being the most cited reason and COVID-19 accounted for <1% of reasons given.
Author statements
Competing interests
N.O.-P. is a scientific advisor to Navigating Cancer. All other co-authors had no conflict to declare.
Funding
N.O.-P. reported receiving grants from the National Institute of Health/National Institute of Dental and Craniofacial Research (K0s1DE030916) outside of the submitted work.
References
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