Order 638034: review of literature portion for paper

A National Study of HPV Vaccination of Adolescent Girls: Rates, Predictors, and Reasons for Non-Vaccination

Laura M. Kester • Gregory D. Zimet •

J. Dennis Fortenberry • Jessica A. Kahn •

Marcia L. Shew

Published online: 23 June 2012

� Springer Science+Business Media, LLC 2012

Abstract Despite recommendations in the U.S. for routine

HPV vaccination of adolescent girls since 2006, rates of

vaccination continue to be low. This study reports vacci-

nation uptake, factors associated with vaccine uptake and

reasons for non-vaccination within a national sample of

adolescent females during 2010. Using a computer admin-

istered survey of a national sample of 501 mothers of

daughters 14–17 years old we assessed maternal reports of

HPV vaccination as well as socio-demographical factors,

maternal HPV exposures and reasons chosen for non-

vaccination. Reported HPV vaccination rates were slightly

over 50 % (51.1 %), with 38.3 % reporting completion of

all 3 doses. Socioeconomic and demographic factors were

not associated with vaccination initiation; however, Blacks

and Hispanics were less likely to complete vaccination. The

most common reasons for non-vaccination were concerns

about vaccine safety, danger to daughter, and provider non-

recommendation. Relatively poor HPV vaccine initiation

and only modest 3-dose completion continues to be a major

public health concern that requires continued efforts to

address identified predictors and reasons for non-vaccination.

Keywords HPV � Vaccination rates � Adolescent health behaviors � Sexually transmitted infections

Introduction

Human papillomavirus (HPV) vaccination can lead to

substantial reductions in the incidence of HPV infection

and HPV-related diseases, including anogenital cancers

and genital warts [1]. The introduction and licensing of the

quadrivalent HPV vaccine in 2006 and the subsequent

licensing of the bivalent vaccine in 2008 created opportu-

nities to counter the existing HPV disease burden [1, 2].

Given the high rates of HPV infection that occur shortly

after the initiation of sex and the vaccine’s ability to pre-

vent infection only prior to exposure, HPV vaccination has

been particularly targeted to young adolescents [3, 4].

Routine vaccination with either the bivalent or quadrivalent

vaccine has been recommended by the Centers for Disease

Control and Prevention’s (CDC’s) Advisory Committee for

Immunization Practices (ACIP) for adolescent females

ages 11–12, with catch-up vaccination for young women

13–26 years of age. However, 4 years post vaccination

licensure, at least half of the target population of adolescent

females had not initiated HPV vaccination [5, 6].

Various studies have assessed predictors of HPV vacci-

nation initiation and completion. The CDC reported most

recently that poverty was not a factor in HPV vaccination

initiation. On the other hand, poverty status and minority

group membership were found to be associated with lower

HPV vaccine completion rates [5, 6]. Other studies have

shown conflicting results for the significance of socio-

demographic factors in HPV vaccination initiation (e.g.,

parental education level, income level, insurance status)

[7–11]. Other factors that have been evaluated as predictors

of vaccine acceptance include maternal attitudes, such as:

knowledge of HPV, perception of daughter’s risk for HPV

acquisition, belief in vaccination benefits, degree of concern

about vaccine side effects, child’s age, social influences,

L. M. Kester (&) � G. D. Zimet � J. D. Fortenberry � M. L. Shew

Department of Pediatrics, Indiana University,

410 W. 10th Street, Suite 1001, Indianapolis, IN 46202, USA

e-mail: [email protected]

J. A. Kahn

Department of Pediatrics, Cincinnati Children’s Hospital

Medical Center, Cincinnati, OH, USA

123

Matern Child Health J (2013) 17:879–885

DOI 10.1007/s10995-012-1066-z

concern regarding post-vaccination sexual disinhibition,

physician’s recommendation, and parent’s personal expo-

sure to HPV infection [7, 9–14].

In light of the morbidity and mortality associated with

HPV disease as well as the disproportionately high HPV

disease burden in minority and uninsured women within

the United States, it is pivotal that we continue to evaluate

factors related to HPV vaccine initiation and completion.

Understanding the current trends of vaccination and

continuing to re-evaluate predictors of vaccination and

non-vaccination allows for the development of more

effective strategies designed to increase rates of HPV

vaccination and reduce future health disparities.

Objective

In 2010 we conducted a survey with a national U.S. sample

of mother-daughter pairs to assess the following aims: (1)

number of HPV vaccination doses received (0, 1, 2, or 3)

by each daughter in middle to late high school, age of

14–17 years, (2) to evaluate potential predictors of vacci-

nation initiation and completion, and (3) to survey mothers

whose daughters had not initiated vaccination to identify

reasons for non-initiation of HPV vaccination.

Research Methods

Sample Population

For this cross-sectional study, 501 mother-daughter pairs

were recruited from across the U.S. from a pre-formed

research panel developed by Knowledge Networks (KN)

[Menlo, CA]. This nationally representative panel was

acquired using random digit dialing methodology as well as

address-based sampling to include those households without

landline phones. To ensure adequate representation of

African American and Hispanic American households, an

oversampling of recruitment was performed in certain

Census-defined areas. For each survey administered, a ran-

dom sample was chosen from the existing panel. Surveys

were distributed via link-containing emails with reminder

emails and phone calls for non-responders to recruit well-

balanced, non-biased samples. All surveys through KN were

administered on-line. Those families without a home com-

puter or internet service were provided with a laptop com-

puter as well as free monthly internet access as compensation

for participating in the KN. For those families with existing

internet access, compensation points, redeemable for cash,

were given for each survey in which they participated.

Inclusion criteria for this study required the presence in

the home of a mother and daughter (between the ages of

14–17). Only one daughter per home, randomly selected,

was allowed to participate in the study; other siblings and

those mothers whose daughters did not consent to partici-

pate in the study were excluded from participation.

On initial recruitment of the study sample, 857 mothers

from the existing KN panel confirmed a 14–17 year old

daughter living in their household. Panel recipients were

given a brief description of the study, its purpose, and the

voluntary nature of participation in the study. Potential

participants were asked if they would be willing to par-

ticipate in a study seeking to understand why some ado-

lescents receive HPV vaccination and others do not. Initial

consent was obtained from 637 of these mothers (74.3 %).

If mothers agreed to participate, their daughters were then

asked if they were willing to consent to participate in the

study. Six hundred and twenty daughters consented

(97.3 %) representing 47 of the 50 states. Once consent had

been obtained from both mothers and daughters, the

daughters were allowed access to the online survey, which

was completed by all 620 adolescents (100 %). Once the

daughters had completed and submitted their surveys, the

mothers were then allowed access to complete the surveys

through their separate email account access. Five hundred

and one of the mothers (80.8 %) completed and submitted

the survey and were included in this study (Fig. 1). The

Fig. 1 Sample recruitment process

880 Matern Child Health J (2013) 17:879–885

123

surveys were distributed in this order to minimize the

mother’s influence on the daughters’ survey responses.

Institutional Review Board (IRB) approval was obtained

from the Indiana University prior to the beginning of the

study.

Data Collection

Each participant was assigned a separate email account to

which all communication was sent. Survey questionnaires

were completed in either English or Spanish. A total of

nine standard questions were utilized in this study, to assess

daughter and maternal socio-demographic factors (daugh-

ter’s age, daughter’s insurance status, daughter’s insurance

plan, maternal age, maternal racial identification, maternal

marital status, maternal education, maternal working status,

and maternal geographic location). Additional questions

were asked to assess maternal HPV-related exposures,

seeking whether the mother had any history of an abnormal

Pap test, history of a colposcopy, knowledge of a friend or

family member being diagnosed with cervical cancer, or a

personal history of cervical cancer.

The number of HPV vaccination doses received (0, 1, 2,

or 3) was obtained via maternal report. The mothers of

daughters who had initiated vaccination, were asked whe-

ther or not their healthcare provider discussed with them

that their daughter could receive HPV vaccination. They

were also asked to report the strength with which their

health care provider had recommended that their daughter

receive the vaccine (strongly recommended the vaccine,

recommended the vaccine, provided no recommendation,

recommended against the vaccine, or strongly recom-

mended against the vaccine).

Mothers of daughters who had not initiated vaccination

were asked to select one or more reasons for why their

daughters had not received the HPV vaccination; the

choices given to select from included: (1) We have not seen

a health care provider in a long time, (2) My healthcare

provider has not recommended the vaccine, (3) I think the

HPV vaccine could be dangerous to my daughter, (4) I

don’t have insurance or money to pay for the vaccine, (5) I

don’t believe the vaccine works, (6) I believe the vaccine

will have side effects, (7) I believe the vaccine will make it

easier for my daughter to have sex.

Data Analysis

Oversampling of African-Americans and Hispanics, which

was inclusive of Spanish-speaking, Latino panel members

was performed. Data was analyzed using census-based

post-stratification probability sampling weights provided

by KN to ensure nationally representative data estimates to

adjust for sample (including oversampled populations),

non-sample error, study design and survey non-response.

Bivariate analyses were conducted using SPSS Statistics

17.0 to examine factors associated with HPV vaccination

status. Chi-square analyses were performed for categorical

variables and analysis of variance tests were performed to

assess differences across vaccination status for household

income and age. Associations with a p value \0.05 were considered significant.

Results

A total of 501 mother-daughter dyads were enrolled in the

study from 47 states in the U.S. Given the high congruence

of daughters’ and mothers’ reported rates of vaccination

(Kappa = 0.96), only maternal surveys were analyzed in

this study and mothers’ reports of vaccination status were

used as the outcome for vaccination status. Maternal mean

age was 45 years. The mothers identified as White (59 %),

Hispanic (22 %), Black (14 %), and Other (5 %). Almost

all surveys were completed in English, except for 14

(2.8 %), which were completed in Spanish. Most mothers

had some college education, were working, and were

married (Table 1). In regards to maternal experience with

HPV related diseases, greater than one-third of the mothers

reported a history of an abnormal Pap smear, 26 % had

undergone a colposcopy, and 16 % either had cervical

cancer or had a friend or family member with cervical

cancer.

Half of the daughters had not received HPV vaccination

(49.9 %), 28 had received 1 dose (5.6 %), 28 had received

2 doses (5.6 %), and 192 had received all 3 doses of vac-

cine (38.3 %). Three mothers were unsure of how many

doses their daughters had received. Of those daughters that

had received 1 dose of HPV vaccination, 67.9 % were

greater than 5 months out from initial vaccination and for

those who had received 2 doses, 57.1 % were greater than

6 months out from their second dose administration.

Neither socio-economic/demographic factors (including

daughter’s insurance status, mother’s education level,

marital status, geographic location, or working status) nor

maternal HPV-related exposures were significantly corre-

lated with vaccine initiation. Although daughter’s race/

ethnicity was not found to be associated with initiation of

vaccination, Black and Hispanic girls were both signifi-

cantly less likely to complete the 3-dose series than non-

Hispanic White girls (p \ 0.001) (Table 2). For daughters who had initiated vaccination and had

received one or more vaccine doses (n = 248), 90 % of

their mothers (n = 223) reported that their healthcare

provider had discussed HPV vaccine with them, while only

10 % (n = 25) indicated that the health care provider had

not discussed the vaccine. Looking more closely at strength

Matern Child Health J (2013) 17:879–885 881

123

of provider recommendation, 88.9 % of those whose doctor

had ‘‘strongly recommended’’ the vaccine completed the

vaccination series compared with 71.3 % completion in

those whose doctors had only ‘‘recommended’’ the vaccine

(p = 0.013).

Mothers whose daughters had not initiated vaccination

were asked to select one or more reasons for non-vaccina-

tion. The top three reasons chosen were: concerns about

vaccine side effects, fear that the vaccine could be dangerous

to their daughter, and provider non-recommendation

(Table 3). There was only moderate overlap of mothers who

indicated concern about vaccine side-effect with those who

indicated concern that the vaccination could be dangerous

(Kappa = 0.34). Of the 90 non-vaccinating parents report-

ing concern about side-effects, only 52 also reported concern

about the vaccine being dangerous (57.8 %). Race and

ethnicity was not associated with any of the reasons for non-

vaccination.

Discussion

Results of this study are largely consistent with those of the

CDC’s most recent adolescent vaccination surveillance

report, despite the difference between our methodology and

the National Immunization Survey [6]. The strength of our

study compared to that of the CDC is that they utilized

random-digit-dialing for sample recruitment, while our

study utilized both random digit dialing as well as

addressed-based sampling to ascertain those individuals

without home phones. While our study used internet sur-

veying as compared to the CDC who used mailed surveys,

our methodology required that individuals be able and

willing to use the internet (which was placed in homes by

KN). In our study, we found that 51.1 % of our target

population initiated vaccination compared to 48.7 %

reported by the CDC. Additionally, we found that 38.3 %

completed the vaccine series compared to 32 % reported

by the CDC [6]. It is concerning that half of this age group

continues either delaying or not initiating vaccination.

Our data showed no evidence that socioeconomic/

demographic factors (maternal age, education, partner

status, working status, geographic location, race/ethnicity,

or daughter’s insurance status) were associated predictors

for the rates of HPV vaccination initiation. This set of

findings differs from other studies where insurance status,

income and parental education where found to be associ-

ated with vaccination initiation [11, 15].

Race/ethnicity was the only socioeconomic/demo-

graphic factor associated with 3-dose completion showing

consistent results with the CDC that Black and Hispanic

adolescents were significantly less likely to complete vac-

cination [6]. This finding has been consistent throughout

several other studies that found that adolescents who

racially identified as Black were less likely than those who

identified as White to complete the vaccine series [16–20].

Some studies have found that even when Blacks had higher

rates of initiation compared to Whites, they maintained

lower rates of 3-dose completion [11]. A recent study by

Chou et al. [19] found that practice location was a signif-

icant association with vaccination completion and that the

Table 1 Sample demographics reported by mothers

Socio-economic/demographic factors Frequency (N) Percent (%)

Daughter age

14 125 25

15 125 25

16 122 24

17 129 26

Maternal age

18–39 106 21.2

40–44 133 26.5

45–49 140 27.9

50? 122 24.4

Maternal racial background

White, non-Hispanic 297 59

Black, non-Hispanic 69 14

Other or 2? races, non-Hispanic 26 5

Hispanic 109 22

Maternal marital status

Married/partnered 422 84

Single 79 16

Maternal education

High school or less 93 18.6

Some college 198 39.5

Bachelor’s or higher 210 41.9

Maternal working status

Working 355 70.9

Non-working 146 29.1

Maternal geographic region

Northeast 71 14

Midwest 156 31

South 136 27

West 138 28

Daughter’s insurance status

Insured 473 94.4

Uninsured 27 5.4

Daughter’s insurance plan

Private 286 61

Medicaid 51 10.9

Self-pay 12 2.6

Other 56 11.9

Unknown 63 13.4

Refused 1 0.2

882 Matern Child Health J (2013) 17:879–885

123

combination of being a young woman, 11–17 years old, in

an urban practice was a significant predictor of failure to

complete vaccination. The etiology of this racial discrep-

ancy for vaccination is not clear, but may be related to

variability in access to care, cultural influences, or patient-

provider communication. Given the disproportionately

higher HPV disease burden and mortality rates amongst

Black and other minority populations it will be important to

better understand and address these lower rates of vacci-

nation completion [11, 17, 21–23].

Maternal HPV exposure was not found to be a statisti-

cally significant predictor of vaccination, a finding similar

to a study by Caskey et al. [24] that found no association

between history of an abnormal pap smear and vaccination.

This lack of association could signify that experience with

HPV related conditions does not ensure increased knowl-

edge and understanding of HPV infection, and therefore

may not motivate vaccination against HPV. Additionally,

there is also no assurance that individuals with friends or

family members with cervical cancer are aware of the

causal connection between HPV infection and cervical

cancer. We note that our findings differ from a previous

study that found daughters who received HPV vaccination

were fifty percent more likely to have mothers who had

received Pap tests, which they interpreted as being due to

mothers’ attitudes toward preventive measures. However,

when this same study looked at mothers’ STI exposure

history, which included HPV, they found that there was

only a slight association with daughters’ HPV vaccination

status and that the nature of this association was incon-

sistent across racial/ethnic groups [25].

Provider recommendation shows a strong correlation to

vaccination decisions. Previous studies have identified the

importance of provider recommendation in HPV vaccina-

tion [26, 27]. However, studies looking at strength of

physician recommendation have shown some physicians

continue to alter the strength of their recommendation

based on the age of the female patient [28]. One study

found that for girls 11–12 years of age, only 56 % of

physicians and 50 % of family physicians strongly rec-

ommended vaccination [28]. Another study found 60 % of

individuals who had not intended to vaccinate reported that

they had not received a provider recommendation [27]. In

our study, strength of provider recommendation was sig-

nificantly correlated with higher rates of vaccination

completion. Individuals whose providers ‘‘strongly rec-

ommended’’ vaccination as compared to those whose

providers ‘‘recommended’’ vaccination had higher rates of

completion. This could in part indicate that those providers,

who ‘‘strongly recommended’’ vaccination, were more

proactive about ensuring series completion. Additionally, it

may also represent a transfer of vaccine importance from

provider to patient, providing further motivation for parents

to ensure vaccination completion. Although other studies

have shown HPV vaccine recommendations to be influ-

enced by patient age, we found no relationship of provider

recommendation with age of the adolescent girls (data not

shown), which may be a function of the narrow age range

of our study sample [19]. These findings regarding strength

of provider recommendation and HPV vaccination high-

light the importance of educating physicians to provide

‘‘strong recommendations’’ for all individuals within the

vaccine age-targeted population [28].

Mothers, of daughters who had not initiated vaccination,

reported the most common reasons for non-vaccination

were provider non-recommendation, concern for vaccine

side effect, as well as concern that the vaccine could be

Table 2 Number of HPV vaccine doses received by racial/ethnic groups

Number of vaccination

doses received

White (non-Hispanic)

(n = 297)

N (%)

Hispanic

(n = 109)

N (%)

Black (non-Hispanic)

(n = 69)

N (%)

Other (non-Hispanic)

(n = 26)

N (%) a

0 b

147 (49.8) 59 (54.1) 40 (61.5) 10 (38.5)

1 or 2 29 (9.8) 23 (21.1) 8 (12.3) 1 (3.8)

3 119 (40.4) 27 (24.8)* 17 (26.2)* 15 (57.7)

* Hispanics and Blacks found to have a statistically significant lower rate of HPV vaccination completion compared to Whites (p \ 0.05) a

Due to small number and heterogeneity, this group was not included in analysis b

No statistical difference in HPV vaccination initiation rates

Table 3 Maternal chosen reasons for vaccination non-initiation

Reason for non-vaccination Frequency

chosen (N)

Percent of total

sample (%)

Concern for vaccine side effect 90 36.0

Concern for danger to daughter 90 36.0

Provider non-recommendation 86 34.4

Long lapse in doctor’s visit 29 11.6

Concern for increased ease for

daughter to have sex

19 7.6

Doubt of vaccine efficacy 33 6.6

Lack of insurance or finance 28 5.6

No response chosen 15 6.0

Multiple reasons could be selected by each mother

Matern Child Health J (2013) 17:879–885 883

123

dangerous to their daughter. Each of these reasons further

underscores the importance of the provider’s role in vac-

cine uptake, particularly with almost 50 % of the target

population having not initiated vaccination [5]. Other

studies have found a similar significance of provider

influence being crucial to vaccine acceptance [21]. Con-

tinued provider support throughout the vaccination process

is essential, particularly in recognizing that those who

postpone vaccination (or never receive the vaccine) lose

potential for protection once exposure to vaccine-related

HPV types has occurred.

A limitation of this study is that vaccination rates were

based solely on maternal reports and could not include

confirmation via medical records. However, congruence

between mother and daughter reports of vaccination was

found to be high, suggesting good reliability of the self-

report measure. Also, the consistency between our findings

and the results of the National Immunization Survey sug-

gests that self-reports were fairly accurate. A second lim-

itation is that our assessment of provider non-

recommendation as a reason for non-vaccination, does not

distinguish between a provider recommendations against

vaccinations compared to a complete omission of any

recommendation in either direction.

Conclusion

HPV vaccination provides a strong potential to improve

public health by decreasing HPV-related anogenital can-

cers and genital warts. Despite increases in vaccination

rates, half of the target population continues to remain

unvaccinated and completion rates lag in those populations

that are at highest risk for HPV disease morbidity. In light

of the recommendation for routine vaccination of young

women and the coverage of HPV vaccination by the

Vaccines for Children program, there is the potential to

greatly decrease HPV-related disease burden. However,

reduction in HPV-related diseases will require more uni-

form vaccination initiation and completion rates across

HPV naı̈ve populations and must occur prior to HPV

exposure. For individuals who have initiated vaccination,

further research is needed to better understand barriers to

vaccine completion, especially among minority adoles-

cents. Additionally, improved understanding of the reasons

chosen for non-vaccination, including vaccine safety and

provider non-recommendation may help improve efforts to

increase rates of vaccination. Recognizing that timing of

HPV vaccination is important and it is recommended prior

to sexual exposure, continued educational interventions

with physicians, patients and their parents regarding vac-

cine safety and vaccine efficacy are clearly needed.

Acknowledgments Funding support for this research was provided by NIH R56 A1079090-01A1.

Conflict of interest Kester, Laura: Has no financial disclosures. Zimet, Gregory: Investigator on grants funded through Merck’s

Investigator Initiated Studies Program. In the past year served as a

consultant to Sanofi Pasteur regarding attitudes about herpes vacci-

nation. Shew, Marcia: Investigator for Merck and Co. related HPV

vaccine trials. Kahn, Jessica: Co-PI of two clinical trials of HPV

vaccine in HIV-infected individuals; vaccine and immunogenicity

testing were provided by Merck. Fortenberry, J Dennis: Receives

compensation from American Social Health Association for contin-

uing lectures related to HPV vaccines.

References

1. Morbidity and Mortality Weekly Report (MMWR). (2007).

Quadrivalent human papillomavirus vaccine. CDC, 56(RR02), 1–24. www.cdc.gov/mmwr/preview/mmwrhtml/rr5602a1.htm.

2. Morbidity and Mortality Weekly Report (MMWR). (2010). FDA

licensure of bivalent human papillomavirus vaccine (HPV2,

Cervarix) for use in females and updated HPV vaccination rec-

ommendations from the Advisory Committee on Immunization

Practices (ACIP). CDC, 59(20), 626–629. www.cdc.gov/mmwr/ preview/mmwrhtml/mm5920a4.htm.

3. Morbidity and Mortality Weekly Report (MMWR). (2007).

QuickStats: Prevalence of HPV infection among sexually active

females aged 14–59 years by age group. National Health and

Nutrition Examination Survey, United States 2003–2004. CDC. www.cdc.gov/mmwr/preview/mmwrhtml/mm5633a5.htm.

4. Weaver, B., Shew, M., Qadadri, B., et al. (2011). Natural history

of multiple human papillomavirus infections in female adoles-

cents with prolonged follow-up. Journal of Adolescent Health, 48(5), 473–480.

5. Morbidity and Mortality Weekly Report (MMWR). (2010).

National, state, and local area vaccination coverage among adoles-

cents aged 13–17 years—United States, 2009. CDC, 59(32): 1018–1023. www.cdc.gov/mmwr/preview/mmwrhtml/mm5932a3.

htm?s_cid=mm5932a3_e%0d%0a.

6. Morbidity and Mortality Weekly Report (MMWR). (2011).

National and state vaccination coverage among adolescents aged

13 through 17 years—United States, 2010. CDC, 60(33). http:// www.cdc.gov/mmwr/preview/mmwrhtml/mm6033a1.htm.

7. Brewer, N. T., & Fazekas, K. I. (2007). Predictors of HPV vac-

cine acceptability: A theory-informed, systematic review. Pre- ventive Medicine, 45(2–3), 107–114.

8. Guerry, S. L., De Rosa, C. J., Markowitz, L. E., et al. (2011).

Human papillomavirus vaccine initiation among adolescent girls

in high-risk communities. Vaccine, 29(12), 2235–2241. 9. Smith, L., Brassard, P., Kwong, J., Deeks, S., Ellis, A., & Lev-

esque, L. (2011). Factors associated with initiation and comple-

tion of the quadrivalent human papillomavirus vaccine series in

an Ontario cohort of Grade 8 girls. BMC Public Health, 11(1), 645.

10. Fernández, M. E., Allen, J. D., Mistry, R., & Kahn, J. A. (2010).

Integrating clinical, community, and policy perspectives on HPV

vaccination. Annual Review of Public Health, 31, 235–252. 11. Dorell, C. G., Yankey, D., Santibanez, T. A., & Markowitz, L. E.

(2011). Human papillomavirus vaccination series initiation and

completion, 2008–2009. Pediatrics, 128(5), 830–839. 12. Barnack, J. L., Reddy, D. M., & Swain, C. (2010). Predictors of

parents’ willingness to vaccinate for human papillomavirus and

884 Matern Child Health J (2013) 17:879–885

123

physicians’ intentions to recommend the vaccine. Women’s Health Issues, 20(1), 28–34.

13. Allen, J. D., Othus, M. K. D., Shelton, R. C., et al. (2010).

Parental decision making about the HPV vaccine. Cancer Epi- demiology, Biomarkers and Prevention, 19(9), 2187–2198.

14. Brewer, N. T., Gottlieb, S. L., Reiter, P. L., et al. (2011). Lon-

gitudinal predictors of human papillomavirus vaccine initiation

among adolescent girls in a high-risk geographic area. Sexually Transmitted Diseases, 38(3), 197–204.

15. Pruitt, S. L., & Schootman, M. (2010). Geographic disparity, area

poverty, and human papillomavirus vaccination. American Journal of Preventive Medicine, 38(5), 525–533.

16. Widdice, L. E., Bernstein, D. I., Leonard, A. C., Marsolo, K. A.,

& Kahn, J. A. (2011). Adherence to the HPV vaccine dosing

intervals and factors associated with completion of 3 doses.

Pediatrics, 127(1), 77–84. 17. Schluterman, N., Terplan, M. S., Lydecker, A. D., & Tracy, J. K.

(2011). Human papillomavirus (HPV) vaccine uptake and com-

pletion at an urban hospital. Vaccine, 29(21), 3767–3772. 18. Gold, R., Naleway, A. L., Jenkins, L. L., et al. (2011). Comple-

tion and timing of the three-dose human papillomavirus vaccine

series among adolescents attending school-based health centers in

oregon. Preventive Medicine, 52(6), 456–458. 19. Chou, B., Krill, L. S., Horton, B. B., Barat, C. E., & Trimble, C. L.

(2011). Disparities in human papillomavirus vaccine completion

among vaccine initiators. Obstetrics & Gynecology, 118(1), 14–20. 20. Niccolai, L. M., Mehta, N. R., & Hadler, J. L. (2011). Racial/ethnic

and poverty disparities in human papillomavirus vaccination com-

pletion. American Journal of Preventive Medicine, 41(4), 428–433.

21. Society, A. C. (2010). Cancer facts and figures 2010. Alanta: American Cancer Society.

22. Bingham, A., Drake, J. K., & LaMontagne, D. S. (2009).

Sociocultural issues in the introduction of human papillomavirus

vaccine in low-resource settings. Archives of Pediatrics & Ado- lescent Medicine, 163(5), 455–461.

23. Kahn, J. A., Lan, D., & Kahn, R. S. (2007). Sociodemographic

factors associated with high-risk human papillomavirus infection.

Obstetrics & Gynecology, 110(1), 87–95. 24. Caskey, R., Lindau, S. T., & Alexander, G. C. (2009). Knowledge

and early adoption of the HPV vaccine among girls and young

women: Results of a national survey. Journal of Adolescent Health, 45(5), 453–462.

25. Chao, C., Slezak, J. M., Coleman, K. J., & Jacobsen, S. J. (2009).

Papanicolaou screening behavior in mothers and human papil-

lomavirus vaccine uptake in adolescent girls. American Journal of Public Health, 99(6), 1137–1142.

26. Gerend, M. A., Weibley, E., & Bland, H. (2009). Parental

response to human papillomavirus vaccine availability: Uptake

and intentions. Journal of Adolescent Health, 45(5), 528–531. 27. Dorell, C., Yankey, D., & Strasser, S. (2011). Parent-reported

reasons for nonreceipt of recommended adolescent vaccinations,

National Immunization Survey—Teen, 2009. Clinical Pediatrics, 50(12), 1116–1124.

28. Daley, M. F., Crane, L. A., Markowitz, L. E., et al. (2010). Human

papillomavirus vaccination practices: A survey of US physicians

18 months after licensure. Pediatrics, 126(3), 425–433.

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