FOR RAY WRITTER
Labala_la
similapapa2.pdf
Walden University ScholarWorks
Walden Dissertations and Doctoral Studies Walden Dissertations and Doctoral Studies
Collection
2018
Maternal Socioeconomic Status and Human Papilloma Virus Vaccine Uptake Shawn Lockett Walden University
Follow this and additional works at: http://scholarworks.waldenu.edu/dissertations
Part of the Public Health Education and Promotion Commons
This Dissertation is brought to you for free and open access by the Walden Dissertations and Doctoral Studies Collection at ScholarWorks. It has been accepted for inclusion in Walden Dissertations and Doctoral Studies by an authorized administrator of ScholarWorks. For more information, please contact [email protected].
Walden University
College of Health Sciences
This is to certify that the doctoral study by
Shawn Lockett
has been found to be complete and satisfactory in all respects, and that any and all revisions required by the review committee have been made.
Review Committee Dr. Peter Anderson, Committee Chairperson, Public Health Faculty
Dr. Hope King, Committee Member, Public Health Faculty Dr. Ronald Hudak, University Reviewer, Public Health Faculty
Chief Academic Officer Eric Riedel, Ph.D.
Walden University 2017
Abstract
Maternal Socioeconomic Status and Human Papilloma Virus Vaccine Uptake
by
Shawn Terrence Lockett
MPH, University of Oklahoma, 1999
BS, University of Oklahoma, 1993
Doctoral Study Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Public Health
Walden University
February 2018
Abstract
There are more than 79 million people in the U.S. currently infected with human
papillomavirus (HPV), with an estimated 14 million new infections annually. There is a
lack of knowledge about the maternal socioeconomic influences and uptake of the HPV
vaccine series. Infection with HPV can cause cervical cancer in women, and there are
over 11,000 cervical cancer diagnoses in the U.S. responsible for 4000 deaths annually.
Vaccination coverage to prevent HPV infection does not meet the Healthy People 2020
goals of an 80% vaccination rate in the U.S. In this study, associations were tested
between maternal SES variables and uptake of the HPV vaccine in male and female
adolescents ages 13-17 from 1,125 participants who lived within the estimation areas of
New York City, New York and Houston, Texas in 2014. The health belief model was
used as the theoretical framework for the study. This was a cross-sectional quantitative
study using multiple logistic regression analysis of 4 maternal predictor variables. It was
found that 3 of the variables (income, p > .05, education β = -.026, p > .05, and age β = -
.096, p > .05) were not significantly related to uptake of the HPV vaccine series, whereas
ethnicity was found to be significant (Non-Hispanic White β = .429, p = .029, Non-
Hispanic Black β = .587, p = .002, and Non-Hispanic Other β = .586, p =.011). Hispanics
were nearly 2 times more likely to be vaccinated than other groups. The potential social
change implications of this research are that public health workers can use the findings to
develop targeted interventions to increase HPV vaccination uptake and reduce the
incidence of cervical cancer.
Maternal Socioeconomic Status and Human Papilloma Virus Vaccine Uptake
by
Shawn Terrence Lockett
MPH, University of Oklahoma, 1999
BS, University of Oklahoma, 1993
Doctoral Study Submitted in Partial Fulfillment
of the Requirements for the Degree of
Doctor of Public Health
Walden University
February 2018
Dedication
This research is dedicated to my son, Donovan Edward Lockett (December 7,
2005 – 9 August 2013). Donovan’s death at age 7 was my inspiration for returning to
school to finish my long-term goal of completing a doctorate. I will always remember my
son and his positive effect on my life from the day of his birth. I was proud to be his
father.
To my other children, Kaitlynn, Veronica, and Alexander for their unconditional
love and support through years of moving to different countries, meeting new friends and
leaving old friends related to our transient lifestyle within the Department of State.
To my late grandmother, Henrietta Lockett who helped form my ethical compass
and has been guiding me these last 17 years from Heaven.
Acknowledgments
I would like to profusely thank my advisor and committee chair, Dr. Peter
Anderson, for his frank coaching and providing the support that I needed to finish my
Dr.PH study and research; for his considerable patience, sincerity, positive motivation,
and knowledge. His guidance fully supported me through all the research and writing of
my final study. The research process has humbled me, and I thank Dr. Anderson for his
steady mentorship as I navigated the arduous research process.
In addition to my advisor, I would like to thank my former spouse, Stephanie
Laxa Lockett for all her dedication, support, and space that she provided me while I
completed the Dr.PH program. She was indeed the foundation that I needed to complete
the program. I would also like to thank my parents: Warren and Pauline Langdon for
providing me the environment and guidance that allowed me to reach my goals.
My close friends also played a significant role in the completion of my Dr.PH
program. I would like to thank my friends, Les Landry, Joe Santos, Dale Rush and
Michael Voorhies for the emotional support and motivation they provided me.
Lastly, I would like to thank my Department of State medical colleagues, Dr.
Jennifer Tseng, Dr. Jason Coe, Dr. Barry Fisher, and Dr. Edward Miron who provided the
professional mentorship that kept me focused on achieving my goal.
i
Table of Contents
List of Tables .......................................................................................................................v
Section 1: Foundation of the Study and Literature Review .................................................1
Introduction ....................................................................................................................1
Problem Statement .........................................................................................................4
Purpose of the Study ......................................................................................................5
Research Question(s) and Hypotheses ...........................................................................5
Theoretical Foundation for the Study ............................................................................7
Nature of the Study ........................................................................................................9
Literature Review Search Strategy ..............................................................................11
Literature Review of Key Concepts .............................................................................12
Maternal Income ................................................................................................... 12
Maternal Education ............................................................................................... 18
Maternal Age ........................................................................................................ 25
Ethnicity ................................................................................................................ 27
Decisional Influences ...................................................................................................31
Critics and Differing Opinions.....................................................................................35
Definitions....................................................................................................................41
Assumptions .................................................................................................................43
Scope and Delimitations ..............................................................................................44
Scope and Delimitations ....................................................................................... 44
Significance and Potential for Social Change ..............................................................45
ii
Significance of Study ............................................................................................ 45
Social Change ....................................................................................................... 45
Summary ......................................................................................................................46
Conclusion ...................................................................................................................47
Section 2: Research Design and Data Collection ..............................................................48
Introduction ..................................................................................................................48
Research Design and Rationale ...................................................................................48
Methodology ................................................................................................................50
Study Population ................................................................................................... 50
Sampling and Sampling Procedures ............................................................................52
Access to Secondary Data ..................................................................................... 53
Instrumentation and Operationalization of Constructs ................................................54
Instrumentation ..................................................................................................... 54
Operationalization ................................................................................................. 55
Data Analysis Plan .......................................................................................................56
Research Question(s) and Hypotheses .........................................................................56
Threats to Validity .......................................................................................................58
Ethical Considerations .................................................................................................60
Human Subjects .................................................................................................... 60
Ethical Issues ........................................................................................................ 60
Summary ......................................................................................................................61
Section 3: Presentation of the Results and Findings ..........................................................63
iii
Introduction ..................................................................................................................63
Data Collection of Secondary Data Set .......................................................................64
Discrepancies ........................................................................................................ 65
Univariate Analysis ......................................................................................................70
Descriptive Characteristics of the Sample Population .......................................... 70
Bivariate Analysis ........................................................................................................74
Logistic Regression Analysis .......................................................................................78
Results 80
Research Question 1 ............................................................................................. 81
Research Question 2 ............................................................................................. 81
Research Question 3 ............................................................................................. 82
Research Question 4 ............................................................................................. 82
Summary ......................................................................................................................83
Section 4: Application to Professional Practice and Implications for Social
Change ...................................................................................................................85
Introduction ..................................................................................................................85
Concise Summary of Findings .....................................................................................85
Interpretation of the Findings.......................................................................................86
Ethnicity ................................................................................................................ 86
Maternal Age ........................................................................................................ 86
Maternal Income ................................................................................................... 87
Maternal Education ............................................................................................... 87
iv
Conceptual Framework ................................................................................................88
Limitations of the Study...............................................................................................89
Recommendations ........................................................................................................90
Implications for Professional Practice and Social Change ..........................................91
Professional Practice ............................................................................................. 91
Implications for Research ..................................................................................... 91
Positive Social Change ......................................................................................... 92
Conclusion ...................................................................................................................93
References ..........................................................................................................................95
v
List of Tables
Table 1. Health Belief Model...............................................................................................9
Table 2. Maternal Age .......................................................................................................71
Table 3. Maternal Income ..................................................................................................71
Table 4. Maternal Education ..............................................................................................72
Table 5. Ethnicity ...............................................................................................................72
Table 6. HPV Vaccine Series Uptake ................................................................................73
Table 7. Estimation Area of Residence ..............................................................................73
Table 8. Gender of Child ...................................................................................................73
Table 9. Crosstabulation Ethnicity and HPV Vaccine Uptake .........................................75
Table 10. Crosstabulation Maternal Age and HPV Vaccine Uptake .................................75
Table 11. Crosstabulation Maternal Education and HPV Vaccine Uptake .......................76
Table 12. Crosstabulation Maternal Income and HPV Vaccine Uptake ...........................77
Table 13. Logistic Regression Results for Maternal Education, Maternal Age,
Maternal Race/Ethnicity, and Maternal Income as Predictors of Teens’
HPV Vaccine Series Uptake ..................................................................................80
1
Section 1: Foundation of the Study and Literature Review
Introduction
The genital human papillomavirus (HPV) is the most common sexually
transmitted disease in the United States (Centers for Disease Control and Prevention
[CDC], 2013). There are more than 79 million people in the United States currently
infected with HPV, and an estimated 14 million new infections occur every year (CDC,
2014a). Infection with HPV can cause cervical cancer in women and is the second
leading cause of cancer deaths in women worldwide (CDC, 2013).
The first HPV vaccine, Gardasil, was a significant step forward in the fight
against cervical cancer. Gardasil, introduced in June 2006, immunized against HPV
serotypes 6 and 11, plus the oncogenic HPV serotypes 16 and 18 (CDC, 2015a). A
second vaccine, Cervarix, introduced in 2007, also immunized against the oncogenic
HPV serotypes 16 and 18 (CDC, 2013). Collectively, Gardasil and Cervarix, both of
which are a three-shot vaccination series, immunized adolescent females to the serotypes
that account for 70% of cervical cancers (van Keulen et al., 2013). As previously stated,
Gardasil also immunized against non-oncogenic HPV serotypes 6 and 11, which cause
genital warts and which can affect men as well as women. Because of its efficacy against
genital warts and oncogenic strains of HPV, Gardasil has been the only vaccine approved
for use in both adolescent males and adolescent females since 2009 (U.S. Food and Drug
Administration, 2013). Cervarix is also approved for use in HPV infection and cervical
cancer prevention, but its use was restricted for use in females only (CDC, 2013).
2
In 2013, there were more than 6.2 million new HPV cases reported in the United
States, and HPV was responsible for over 11,000 new cases of cervical cancer
contributing to 4,000 deaths (Nettleman & Garcia-Chen, 2013). In 2014, there were an
estimated 14 million new HPV infections (CDC, 2014b). Furthermore, despite the release
of a safe, efficacious HPV vaccine in 2006, cervical cancer remains the second largest
killer of women worldwide (Crowcroft, Hamid, Deeks, & Frank, 2012; Union for
International Cancer Control (UICC), 2015). There has been some success against
cervical cancer as the incidences in the United States have significantly decreased since
the introduction of the Papanicolaou (Pap) test, or “Pap smear,” in 1941 (Techakehakij &
Feldman, 2008).
The Pap smear test enabled clinicians to screen for early-stage cervical cancer and
earlier detection of cervical tissue changes related to HPV infection. The result of the
screening test was earlier identification, intervention, and improved overall outcomes as
the mortality rate of cervical cancer in the United States decreased by 70% after the
introduction of the screening test (Techakehakij & Feldman, 2008). However, even
though there has been a significant improvement in the identification and treatment of
cervical cancer, it is still a significant burden to those affected by the disease (National
Institutes of Health, 2013). Both men and women can carry HPV, and together they
equally contribute to an epidemic that accounts for the most prevalent sexually
transmitted disease in the United States (Malkowski, 2014; Vanderpool, Van Meter
Dressler, Stradtman, & Crosby, 2015).
3
There are significant health disparities associated with race, ethnicity, and
SES(SES) regarding HPV vaccine uptake, which puts vulnerable groups at increased risk
of contracting cervical cancer (Btoush, Brown, Fogarty, & Carmody, 2015; Daniel-Ulloa,
Gilbert, & Parker, 2016). Researchers and public health officials have taken significant
steps over the years to study these disparities and improve intervention programs, but the
barriers remain, resulting in only a modest increase in the uptake of the HPV vaccine
(Schmidt & Parsons, 2014).
The potential for significant social change related to this study is based on the
evidence of an association between measurable maternal SES influences (maternal
income, maternal education) and uptake of the HPV vaccine series. Public health officials
and researchers could potentially use the results of the research to reduce the burden of
cervical cancer in women through the enhancement of vaccination programs contributing
to the decreased incidence of a significant health disparity for women.
Section 1 is an introduction to the subject of cervical cancer and its impact on
morbidity and mortality. I introduce the HPV vaccine series and its role in decreasing the
incidence of HPV infection, as HPV infection is a precursor to the development of
cervical cancer. I then describe the study, beginning with a discussion of the problem
addressed by the research, followed by a statement of the purpose of the study. I also
introduce the research questions and demonstrate how this research filled the gap in the
existing literature.
4
Problem Statement
There is a lack of knowledge about the maternal socioeconomic (SES) influences
and the voluntary uptake of the HPV vaccine series. Due to multifactorial issues, there
has been resistance to the uptake of the HPV vaccine (Navarro-Illana, Aznar, & Díez-
Domingo, 2014). Apte, Pierre-Joseph, Vercruysse, and Perkins (2015) reported that in the
United States, 57% of female adolescents and 34% of male adolescents initiated the HPV
vaccine series in 2013. The percentage of vaccinated male and female participants has
grown in recent years but does not meet the Healthy People 2020 goals of 80% (Savoy,
2014). Additionally, according to one study, over 30% of females and more than 50% of
males did not complete the series of three vaccinations (Apte et al., 2015). Lastly, there
was evidence of family influences decreasing the uptake of the HPV vaccine series for
their adolescent children. Cullen, Stokley, and Markowitz (2014) concluded that
increasing parent education could increase uptake of the vaccine. Attanasio and
McAlpine (2014) reported that the mother’s education level influenced the accuracy of
recall of HPV vaccinations given to their children. The lack of acceptance and subsequent
completion of the HPV vaccination series poses a continued public health threat, and
more research was needed to improve intervention programs, remove barriers, and
increase confidence in the safety and efficacy of the HPV vaccine (Savoy, 2014). Other
than research performed by Musto et al. (2013), which analyzed school-based service
delivery models based on the SES status of schools, there are limited studies in recent
literature addressing the associations between maternal SES influences and the voluntary
uptake of the HPV vaccine series. In my research, I tested for such associations to gain
5
knowledge that researchers and public health officials could use to potentially enhance
educational programs designed to improve vaccination rates, increase prevention, and
reduce the overall incidence of cervical cancer. The problem statement for this study is as
follows: There is a lack of knowledge about the maternal socioeconomic influences and
the voluntary uptake of the HPV vaccine series. In this study, I sought to identify an
association between measurable maternal SES influences and uptake of the HPV Vaccine
based on the responses by participants of the 2014 National Immunization Survey-Teen
(NIS-Teen).
Purpose of the Study
In this cross-sectional quantitative research study, I investigated the association
between maternal SES variables and uptake of the HPV vaccine in female and male
adolescents, aged 13-17, based on postal codes within the city of Columbus, Ohio. I
included additional variables to observe for associations with maternal age and ethnicity.
Research Question(s) and Hypotheses
The objective of this research study was to explore the association between
maternal SES and uptake of the HPV vaccine series. The research questions were as
follows:
RQ1: What is the association between maternal income and uptake of the HPV
vaccine series in male and female adolescents aged 13-17 in communities with
postal codes in the Columbus, Ohio metropolis?
H01: No association exists between maternal income and uptake of the HPV
vaccine series in male and female adolescents aged 13-17 after controlling for
6
ethnicity and maternal age based on postal codes in Columbus, Ohio.
Ha1: An association exists between maternal income and uptake of the HPV
vaccine series in male and female adolescents aged 13-17 after controlling for
ethnicity and maternal age based on postal codes in Columbus, Ohio.
RQ2: What is the association between maternal education and uptake of the HPV
vaccine series in male and female adolescents aged 13-17 in the postal codes
within the Columbus, Ohio metropolis?
H02: No association exists between maternal education and uptake of the HPV
vaccine series in male and female adolescents aged 13-17 in the postal codes
within the Columbus, Ohio metropolis.
Ha2: An association exists between maternal education and uptake of the HPV
vaccine series in male and female adolescents aged 13-17 in the postal codes
within the Columbus, Ohio metropolis.
RQ3: What is the association between maternal age and uptake of the HPV
vaccine series in male and female adolescents aged 13-17 in communities with
postal codes in the Columbus, Ohio metropolis?
H03: There is no association between maternal age and uptake of the HPV
vaccine series in male and female adolescents aged 13-17 in communities
with postal codes in the Columbus, Ohio metropolis.
Ha3: There is an association between maternal age and uptake of the HPV
vaccine series in male and female adolescents aged 13-17 in communities
with postal codes in the Columbus, Ohio metropolis.
7
RQ4: What is the association between ethnicity and uptake of the HPV vaccine
series in male and female adolescents aged 13-17 in the postal codes within the
Columbus, Ohio metropolis?
H04: There is no association between ethnicity and uptake of the HPV vaccine
series in male and female adolescents aged 13-17 in the postal codes within
the Columbus, Ohio metropolis.
Ha4: There is an association between ethnicity and uptake of the HPV vaccine
series in male and female adolescents aged 13-17 in the postal codes within
the Columbus, Ohio metropolis.
Theoretical Foundation for the Study
The theoretical framework for this study was the health belief model (HBM). The
HBM was developed in the 1950s by psychologists in the U.S. Public Health Service to
determine the rationale of people to not participate in programs that prevent and detect
disease (Skinner, Tiro, & Champion, 2015). In the 1950s, there was a widespread failure
of people to participate in screening and preventative programs for the early detection of
asymptomatic disease (Rosenstock, 1974). The HBM consists of five core constructs
proposed in order to influence an individual to perform a particular healthy behavior:
perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues
to action, and self-efficacy. The HBM has some limitations, most notably the low
predictive capacity (R2 < 0.21 on average) of existing HBM variables coupled with the
small effect size of individual variables (Orji, Vassileva, & Mandryk, 2012). The second
8
limitation of the HBM was the lack of clear guidance on its usage in combination and
relationship between the individual variables being studied (Orji et al., 2012). In my
study, I focused on the modifying factors that influence individual beliefs as defined
within the constructs of the HBM. As applied to this research, under the HBM, I would
evaluate my independent variables of maternal income, maternal education, and maternal
age to see if they significantly influence the dependent variable of uptake of the HPV
vaccine series through the constructs of the HBM. My rationale for using the HBM was
based on the hypothesis that differences in maternal SES and maternal age may have an
association with the uptake of the HPV vaccine series in communities defined by postal
codes in the Columbus, Ohio metropolis. The HBM was used in this study to look for an
association with measurable maternal modifying factors that may influence the uptake of
the HPV vaccine series by way of the HBM. Low SES has been associated with many
different disease processes (Goldberg, 2014). For example, research by Nicolai et al.
(2013) showed that higher rates of the precursors of cervical cancer, cervical
intraepithelial neoplasia grades 2, 2/3 and 3 (CIN2+) and adenocarcinoma in situ (AIS)
were associated with higher levels of poverty and occurred disproportionately among
Black residents. In this study, I focused on maternal SES factors by exploring potential
associations based on maternal income, maternal education, and maternal age, as well as
the ethnicity of the participants, through the analysis of secondary data derived from the
2014 NIS-Teen survey.
9
Table 1
Health Belief Model
Modifying Factors Individual Beliefs Action Maternal Income Perceived
susceptibility and severity
Mother’s belief that her child can get HPV and HPV can lead to cervical cancer
Uptake of HPV vaccine
Maternal Education
Perceived benefits Mother’s belief that vaccination of her child with the HPV vaccine series will prevent HPV infection and cervical cancer
Non uptake of the HPV vaccine series
Maternal Age Perceived Barriers Mother’s personal barriers to vaccinate her children (i.e., insurance coverage, cost, knowledge about disease or vaccine)
Ethnicity Cues to Action Strategies to activate mother’s readiness to vaccinate
Self-Efficacy Non-applicable after uptake of vaccine
Nature of the Study
This was a cross-sectional quantitative study in which I investigated the
association between maternal income, maternal education, maternal age and ethnicity,
and the outcome of the uptake of the HPV vaccine series. I analyzed the categorical
independent variables (maternal income, maternal education, maternal age and ethnicity)
with the categorical dependent variable (uptake of the HPV vaccine series). The most
appropriate method of statistical analysis for these variables was a multiple logistical
10
regression. My rationale for using multiple logistic regression was its appropriateness to
explore for a functional association between the independent variables and the dependent
variable. This statistical plan can be used to predict probabilities of an effect of multiple
independent variables on a categorical dichotomous dependent variable, and in some
circumstances multiple logistic regression can be used to make inferences about which
independent variables have a larger effect or stronger association with the dependent
variable (McDonald, 2014).
My study analyzed a secondary dataset that contains detailed information about
the uptake of the HPV vaccine series, maternal income, maternal education, maternal age,
and ethnicity by postal code. I defined the dependent variable, HPV vaccination uptake as
a dichotomous (yes/no) response on whether the male of female adolescents received at
least one dose of the vaccine. The independent variables were (a) maternal income
defined as the income reported by the respondents living within certain postal codes
within the Columbus, Ohio metropolitan area, (b) maternal education, (c) maternal age,
and (d) ethnicity. Maternal income was defined by total reported combined family
income, separated into the following groups: less than $20,000, $20,000 to $39,999,
$40,000 to $59,999, $60,000 to $75,000, and more than $75,000. I defined maternal
education by the highest level of education attained, separated into the following
categories: no high school diploma; high school graduate or GED; completed a
vocational, trade, or business school program; some college credit but no degree;
associate degree (AA, AS); bachelor’s degree (BA, BS, AB); master’s degree (MA, MS,
MSW, MBA); and doctorate (PhD, EDD) or professional degree (MD, DDS, DVM, JD).
11
Maternal age was measured by dividing the mothers’ age into the following groups: less
than 25 years old, 25-34 years old, 35-44 years, and 45+ years old. Ethnicity was
measured by the following six categories: White, Black/African-American, Native
American, Asian, Native Hawaiian, and Pacific Islander. The secondary dataset I used for
the study was the 2014 NIS-Teen. The rationale for the dataset was that it surveys HPV
vaccination, maternal education, and annual income. The 2013 NIS-Teen was an
instrument that researchers used to record the responses of over 18,000 households across
the United States (CDC, 2015c). For the purposes of my research, the 2014 NIS-Teen for
participants in Columbus, Ohio needed to be at least 1,188 participants based on
calculations using G*Power 3.1 Statistical Power Analysis for a logistic regression two-
tailed analysis with 0.95 power (1-β err prob; Faul, Erdfelder, Lang, & Buchner, 2007).
Since the NIS-Teen is an annual survey, there should be enough current information and,
therefore, less risk of the research being duplicated. Researchers used the NIS-Teen to
show at-risk groups for vaccine-preventable diseases (CDC, 2013).
Literature Review Search Strategy
I conducted a systematic literature search for pertinent research articles on the
factors affecting HPV vaccine uptake in different populations. Searches of several
databases, including Medline, Google Scholar, PubMed, Cinahl, and EBSCO resulted in
80 published articles relevant to the research. The keywords used in the search were
human papillomavirus vaccine, human papillomavirus vaccine and maternal income,
human papillomavirus vaccine and communities, human papillomavirus vaccine and
maternal education, and human papillomavirus vaccine and health belief model. I used
12
the search terms in various order to gather as many relevant articles to satisfy an
exhaustive search of literature that was less than five-years-old. The search for relevant
books and journal articles ranged from January 2011 to January 2016 unless otherwise
identified as an essential source for the development of the study.
Literature Review of Key Concepts
Key concepts noted during the exhaustive review of the literature concerning the
uptake of the HPV vaccine series were centered on maternal income, maternal education,
maternal age, and ethnicity. Below, I will highlight findings from previous research
regarding these key concepts that show tendencies relevant to my research.
Maternal Income
Higher income has been associated with increased uptake of the HPV vaccine
series. According to Link and Phelan (1995), money was a significant component of SES,
and the more money a person has, the better their health, with some exceptions. Musto et
al. (2013) investigated possible differences in HPV vaccine uptake in Calgary between
in-school and community delivery models and also whether SES contributed to the
phenomenon. Using 35,592 vaccination records the Calgary Zone Public Health
immunization database for all grades 5th through 9th-grade females for school years
2008–2011, logistic regression methods were used to examine the delivery system and
SES status on being vaccinated (Musto et al., 2013). The authors concluded that HPV
vaccination completion rates were 75% (95% confidence interval = 74.7%, 75.8%) for
females who received vaccination in school compared to 36% (95% confidence interval =
35.3%, 37.2%) for females who received the vaccination in the community (Musto et al.,
13
2013). Additionally, the researchers found that the participant's neighborhood SES was
related to the likelihood of being HPV vaccinated depended on the delivery model
available (Musto et al., 2013). Limitations of this study were that the authors used an
area-based material deprivation index as an alternative measure for individual SES as
individual SES reporting was not available (Musto et al., 2013). Based on the authors’
admission, the usage of this index may have potentially misclassified SES, and there may
be some misclassification bias (Musto et al., 2013). A strength of the research was the
linkage of postal code with the SES data was over 99% reducing the risk of selection bias
(Musto et al., 2013). Millen, Ginde, Anderson, Fang, & Camargo (2009) examined
knowledge and attitudes about HPV vaccine among emergency department patients if the
vaccine was mandatory. The researchers hypothesized that most women would be aware
of HPV, but few would know its association with cervical cancer or support mandatory
vaccinations (Millen et al., 2009). The researchers reported that one-third of those
surveyed had no knowledge of HPV, which correlated with recent U.S. survey data
concerning knowledge of HPV by women (Millen et al., 2009). Additionally, one-half of
patients surveyed supported state-administered mandatory HPV vaccination programs.
Participants were three times more likely to support mandatory programs based on the
knowledge of HPV being a sexually transmitted disease whereas cervical cancer
knowledge did not increase support for mandatory vaccinations (Millen et al., 2009).
However, the limitation of the study was that it had been conducted in a higher status
SES area within the Boston metropolis that was less ethnically diverse and more educated
than the more urban emergency departments (Millen et al., 2009). The authors asserted
14
that that lower SES areas would have less knowledge of HPV but never tested the
assertion (Millen et al., 2009). Another limitation was selection bias of the participants by
the investigators and participants, as people with certain medical conditions, such as
mental status changes were excluded from the study, as were non-respondents, which
could have affected the results of the survey (Millen et al., 2009). Cowburn et al. (2014)
tested for an association between insurance continuity and HPV vaccine use in a network
of federally qualified health facilities. Using retrospective electronic health record (EHR)
entries for females aged 9 to 26 from 2008 to 2010; the researchers categorized the
participants’ length of insurance in an ordinal fashion and studied HPV vaccine initiation
prevalence across the range of insurance coverages. They found that participants were
less likely to start the HPV vaccination series if they were insured less than 66% of the
time of the study, were 13 years or older, and belonged to an ethnic minority (Cowburn et
al., 2014). The authors concluded that disparities existed in the health facilities
researched in the study despite the fact that HPV vaccines are available to many of the
patients regardless of their ability to pay (Cowburn et al., 2014). Limitations of the
research included the potential for incomplete vaccination records if patients had received
immunizations outside of the network of facilities studied, which could have caused
underreported vaccination status especially in older children (Cowburn et al., 2014).
Btoush, Brown, Fogarty, and Carmody (2015) examined the prevalence and correlates of
HPV vaccination initiation among adolescents in low-income urban areas using
electronic health records from multisite community health centers in 2011. Their research
indicated that 27.4% of the adolescents and the study initiated HPV vaccination (Btoush
15
et al., 2015). Of those vaccinated, initiation was higher among males and higher among
Blacks than Hispanics (Btoush et al., 2015). HPV vaccination initiation was lower in
older adolescents, non-English speakers, and those who had received care from non-
pediatricians (Btoush et al., 2015). The limitations of the study are related to the 2009
inclusion of males in the U.S. Advisory Committee on Immunization Practices (ACIP)
recommendations and the 2011 data analysis published by the researchers in 2015. An
important finding was evidence of the lack of vaccination among patients of non-
pediatricians. Smith et al. (2011) reviewed the usage of the HPV vaccine in Ontario
where the government spent over 100 million dollars to offer free quadrivalent HPV
vaccinations to young females. The researchers using administrative and immunization
databases conducted a population-based retrospective study cohort study of females
eligible to receive the vaccination in selected cities in the Ontario province of Canada. Of
the females eligible for vaccination and living within the study boundaries, 1,425 (56.6%)
received at least one dose of the HPV vaccination, and less than half (48.2%) completed
the vaccination series (Smith et al., 2011). The researchers found no differences in health
utilization between vaccinated and unvaccinated females, except that females in the
lowest income quintile were less likely to receive HPV vaccine than the quintile above
(Smith et al., 2011). Additionally, HPV-vaccinated females were more likely to have
received other childhood vaccinations than their unvaccinated counterparts showing an
association of parents’ attitudes and vaccinations (Smith et al., 2011). HPV vaccine series
initiation and completion were not associated with age, health services utilization, or
medical history, although there was an association with low-income neighborhoods,
16
which were less likely to complete the vaccine series than the females living in middle-
income neighborhoods (Smith et al., 2011). Females residing in rural areas were more
likely to complete their series than females living in urban areas (Smith et al., 2011). A
limitation of a study was that school grade was not always available for review in the
databases, so the researchers used the birth year to identify eligible females. Another
limitation was that investigators did not have vaccination information after December 31,
2009, meaning that females received their vaccinations after this date may have been
misclassified (Smith et al., 2011). There was also the potential for misclassification of
health systems usage because the database used in the research did not capture care
received in clinics that did not update the database (Smith et al., 2011). Lastly, the
validity of using neighborhood income as a proxy for household income has not been
assessed (Smith et al., 2011). The researchers concluded that the females in the lower
SES groups were least likely to complete the HPV vaccination series suggesting that
future intervention programs be modified to enhance the delivery of the vaccine to this
vulnerable population (Smith et al., 2011).
The following research provides evidence that some programs like the Vaccines
for Children Program (VFC) may be having an impact in compensating for families
lacking resources regarding the HPV vaccine. Bednarczyk, Curran, Orenstein, and Omer
(2014) conducted a study of the atypical demographic patterns of HPV vaccine initiation
phenomenon. The researchers used the NIS-Teen data from 2008-2011 and used
regression analysis to calculate the average annual increase by sociodemographic
characteristics. The researchers found that HPV series initiation increased overall 16%
17
during the time evaluated (Bednarczyk et al., 2014). The researchers also found that since
2008, adolescents living below the poverty level had higher HPV vaccination initiation
than adolescents above the poverty level (Bednarczyk et al., 2014). There were also some
variations in HPV initiation by ethnicity as Hispanic adolescents were consistently higher
in initiation followed by Black and White adolescents (Bednarczyk et al., 2014). There
were also consistent findings when you compared ethnicity and poverty status and HPV
vaccination. All ethnic groups had higher initiation of the HPV vaccine series if they
were below the poverty level than groups above the poverty line (Bednarczyk et al.,
2014). The research was limited by the small samples of some ethnic groups (Bednarczyk
et al., 2014). Additionally, the researchers used a 4-level race/ethnicity which may have
overlooked some racial differences and poverty status (Bednarczyk et al., 2014). The
researchers concluded that more research was needed to explore provider
recommendation and sociodemographic factors. The researchers also found that the VFC
program may have had a larger impact than previously thought as all adolescents below
the poverty level were consistently higher initiators for the HPV vaccine series
(Bednarczyk et al., 2014).
My study overcame the limits of previous studies by analyzing maternal income
defined by postal code. Unlike the study by Musto et al. (2013) which used an area-based
material deprivation index, this study established maternal SES by reported income
within the boundaries of the postal codes of the participants. This method may provide
evidence of a maternal influence on the uptake of the HPV vaccine series based on
maternal income, a limitation found in the study by Musto et al. (2013). Additionally, this
18
study evaluated all postal codes within the Columbus, Ohio metropolis and provided a
broader, temporal, and more complete evidence of an association between maternal
income and uptake of the HPV vaccine series. My research examined maternal income in
an ordinal fashion based on the responses on the 2014 NIS-Teen survey. By analyzing a
broader range of maternal income and HPV uptake, this study overcomes the limitations
of Millen et al. (2009) and Btoush et al. (2015) which examined communities of higher or
lower income only. By examining more than only the polar extremes of income across
communities in the same region, there may be some valuable associations with maternal
income found that could enhance future HPV vaccine series intervention programs.
Lastly, this was a secondary data research conducted by using responses from the 2014
NIS-Teen. There were no limitations associated with the reviewing medical records of a
particular facility. As part of the NIS-Teen Survey, permission was obtained from parents
to survey the primary provider’s vaccination records, and NIS-Teen researchers had
verified the vaccine administration, thus minimizing the risk of recall bias from parents
on when and if their children received the HPV vaccine.
Maternal Education
Knowledge is a modifying factor of the HBM as knowledge can moderate
individual beliefs as well as health literacy (Phelan & Link, 2013; Skinner, Tiro, &
Champion, 2015). Health literacy can decrease the asymmetry of information given
through access to care thus influencing the avoidance of disease (Phelan & Link, 2013).
The following publications show some contradictory evidence of maternal education and
uptake of the HPV vaccine series. My study analyzed maternal knowledge as the variable
19
maternal education as reported on the 2014 NIS-Teen to explore for an association with
HPV vaccine series uptake.
Dorell et al. (2014) conducted research using the NIS-Teen data to correlate
parents who refuse or delay the HPV vaccine series for their children with other
vaccinations compared to parents who do not refuse or delay HPV vaccination. The
researchers used the parental attitudes module of the 2010 NIS-Teen survey which
included 1808 completed household interviews (Dorell et al., 2014). The researchers
separated the respondents into four groups based on answers about delaying or refusing
the HPV vaccination. The results showed that 10% delayed only 16.6% refused only, and
3.4% both delayed and refused (Dorell et al., 2014). The females in the delayed only
group tended to be White, from higher income homes and have mothers with college
degrees (Dorell et al., 2014). The major rationale for delaying or refusing the HPV
vaccination found through the analysis of the responses was related to knowledge or
vaccine necessity, vaccine safety, and access (Dorell et al., 2014). The research had some
limitations related to the random digit dialing aspect of the survey, and it was limited to
households with landlines. The study also had the risk of non-response bias, parental
recall, and incomplete vaccination records may also have affected the outcome (Dorell et
al., 2014). The researchers concluded that parental education about HPV might help
improve acceptance of the vaccine.
Additionally, Feiring et al. (2015) studied the parental influence on HPV vaccine
in Norway. In this research, the researchers examined parental education and income as a
factor in the uptake of the HPV vaccine. The researchers used a national immunization
20
registry to study the uptake of the HPV vaccine and the income and education of parents
of adolescent females. Norway offered the HPV vaccine to the public free of charge to all
12-year-old females since 2009 (Feiring et al., 2015). The researchers found an
association with high maternal education with a lower probability of initiation of the
vaccine series whereas lower education was associated was associated with the higher
likelihood of the initiation of the vaccine series (Feiring et al., 2015). Conversely, high
maternal income was found to be significantly associated with a higher probability of
initiating the HPV vaccine than lower maternal income (Feiring et al., 2015). Paternal
income and education were found to have the same associations with HPV vaccine
initiation, but weaker association than of the mothers (Feiring et al., 2015). The
researchers concluded that more research was needed to determine the factors responsible
for the socioeconomic differences so that interventions could target these differences
(Feiring et al., 2015). The limitations of this study included incomplete information on
vaccinations, income and immigrant education obtained abroad may not be as precisely
accounted for in the survey and may have affected results (Feiring et al., 2015). The
strength of the study was that it was a national registry covering the entire population of
Norway limiting selection bias (Feiring et al., 2015).
The previous studies showed an inverse association with education and
acceptance of the vaccine, but the research by Feiring et al. (2015) reinforced the
association between increased income and the uptake of the HPV vaccine while the study
by Dorell et al. (2014) showed the opposite. The following studies showed a different
association in regards to education and the uptake of the HPV vaccine. Yu et al. (2016)
21
examined the awareness, knowledge, and acceptability of the HPV vaccine in mothers of
teenage daughters in Shandong, China. The goal to study was to examine the variables of
awareness, knowledge, and acceptability of the vaccine in preparation for the
introduction of the HPV vaccine rollout in China. The researchers wanted to gather
information on attitudes regarding the HPV vaccine to provide evidence to inform health
educators and improve programs targeting this population. Researchers used a cross-
sectional approach using self-administered surveys on a population of 1850 mothers who
had daughters aged 9 to 17 attending schools in the region of Weihai, Shandong, China
(Yu et al., 2016). Researchers used 12 public schools grouped by school level and
location for the research. The mothers were asked to complete the survey of which
researchers collected 1592 surveys. Researchers excluded 14 questionnaires related to
logic errors for a total of 1578 mothers, 85.3% of those initially invited finished the study
(Yu et al., 2016). The findings of the research showed that 19.33% were aware of HPV
before the investigation n=305 (Yu et al., 2016). For the mothers who were aware of
HPV, 14.75% had no knowledge 58.69 % had low knowledge and 26.56% at higher
knowledge (Yu et al., 2016). Additionally, 26.49% mothers voiced a willingness to
accept the vaccination for their daughters n= 418. The authors used Chi-square tests for
analysis and identified five variables that were significantly associated with the
acceptance of the HPV vaccine. These areas found to be associated with acceptance of
the vaccine were daughter's age, maternal education, maternal occupation, household
income, and knowledge level (Yu et al., 2016). There was increased vaccine acceptability
associated with older daughters, higher income, and knowledge score (Yu et al., 2016).
22
The prevalent reasons for the refusal of the HPV vaccination were that mothers felt their
daughters were too young to have the risk of cervical cancer (30.95%); not sure about the
use of a new vaccine on their daughters (24.91%); and worried about the safety of the
vaccine (22.85%) (Yu et al., 2016). The limitations of the research were that the research
was conducted and in an economically developed city in China, and not a multi-center
study (Yu et al., 2016). Additionally, there was potential for response bias as the survey
was completed by the mothers who may have been influenced to give socially desirable
responses (Yu et al., 2016). The researchers concluded with the recommendation for the
prioritization of education to raise awareness and knowledge about HPV and the HPV
vaccine. As evidenced by the research, decreased knowledge was associated with poor
acceptance of HPV vaccination which was contrary to the research in Norway which
higher education was associated with decreased acceptance. However, the HPV vaccine
in Norway was available at the time of the study whereas the HPV vaccine was
unavailable in China and the research may not reflect the intentions of mothers once it is
available in China.
Researchers in Botswana conducted a cross-sectional survey on the HPV vaccine
with adults recruited from general medicine and HIV clinics in the capital of Botswana.
The goal of the researchers was to study the intentions of parents and adults to get the
HPV vaccine for their adolescent daughters. There were 376 participants in the study and
the researchers reported that 77% of the respondents were female, and their median age
was 37 years old (DiAngi, Panozzo, Ramogola-Masire, Steenhoff, & Brewer, 2011). The
participants had varying levels of education. 31% of participants completed up to primary
23
school level (6th grade), 41% of the participants have a secondary school education (high
school), and 28% of the participants had a tertiary education or above (DiAngi et al.,
2011). The income of the respondents showed that many of the participants were poor.
Many of the interviewees had no regular income (48%) or made less than 360 U.S.
dollars a month (29%). Geographically, over two-thirds (65%) of the participants
reported living within 30 kilometers of the capital. 83% of the respondents had children,
and 77% of the children of the participants had one or more daughters (DiAngi et al.,
2011). The results of the survey showed that in the population surveyed only 9% had ever
heard of the HPV vaccine before the study (DiAngi et al., 2011). Additionally, 88% of
the respondents said that they would definitely vaccinate their daughter, and they were
more likely to vaccinate if they had a lower education level or if they lived more than 30
kilometers outside the capital (DiAngi et al., 2011). The researchers concluded that
providing more information about HPV and a widely available HPV vaccine while
minimizing barriers would improve uptake in Botswana (DiAngi et al., 2011). The
limitations of the study were centered on the convenience sample of participants from
adults with health care access, and the oversampling of HIV-positive patients in the
sample may have confounded the results (DiAngi et al., 2011).
In South Africa, researchers studied the acceptability of the HPV vaccine in
educated participants attending a masters-level program in KwaZulu-Natal South Africa.
A cross-sectional self-administered anonymous survey was conducted on 146 participants
to test their knowledge of HPV and cervical cancer and whether they would accept the
HPV vaccination for their daughters. The researchers found that in this group that 74%
24
had heard of cervical cancer, but only 26.2% had ever heard of HPV (Hoque & Van Hal,
2014). The participants, after reading the information sheet on HPV and cervical cancer,
the intention to vaccinate their daughters increased from 88% to 97.2% (Hoque & Van
Hal, 2014). The majority of those surveyed (75.4%) believed that the vaccination should
be given before their daughters were aware of sexual activity (Hoque & Van Hal, 2014).
The group that declined to vaccinate tended to want more information on the safety of the
vaccination. The limitations of the study are that it only surveyed one university and
because of the education level of the participants, the results cannot be generalized to a
larger population (Hoque & Van Hal, 2014). A strength of the study was that the
participants, masters-level candidates and future leaders in their perspective fields, could
initiate societal changes through their leadership and knowledge of HPV and cervical
cancer (Hoque & Van Hal, 2014).
Markovitz, Song, Paustian, and El Reda (2014) also found that higher household
education was positively associated with both initiation and completion of the HPV
vaccination series but that higher household income was only positively associated with
completion. This discovery was noted during research of an association between maternal
preventive care utilization and HPV vaccine uptake by their adolescent daughters
(Markovitz et al., 2014).
My analysis of maternal education could contribute to previous research and help
deconflict some of the findings found in the past. This study could overcome some limits
of previous studies by showing maternal income across the population defined by postal
code. Additionally, because this research was on populations in areas within the same
25
metropolis, there may be some association with HPV vaccination uptake and maternal
education based on the community surveyed because secondary education i.e. beyond
high school education was not based on postal code, and the overlap of education and
community could show a tendency with HPV uptake. Unlike the study by Dorell et al.
2014), my research attempted to show an association with maternal education and uptake
across a defined area. My use of this method might provide some clearer evidence of a
correlation between maternal education and community influence based on postal code
and uptake of the HPV vaccine series. Feiring et al. (2015) researched a nationwide
database for a correlation between education, income, and uptake of the HPV vaccine
series. A major limitation in this research was incomplete vaccination information. My
research uses the 2014 NIS-Teen which allows researchers to query participants’
vaccination prescribers to verify vaccination information. Additionally, my research uses
the HBM methodology and examines maternal tendencies delineated by maternal income
delineated by postal code to search for an association between these variables.
Maternal Age
Maternal age could be a significant factor in the mother’s decision-making
process for the acceptance of HPV vaccine series in adolescent males and females. There
were no studies found that directly examined this phenomenon, but the variable was
discussed in a study conducted in Tanzania. Watson-Jones et al. (2012) conducted a case-
control study of the characteristics of the receivers and non-receivers of the HPV
vaccination in Tanzania as well as their rationale for not taking the vaccination.
Researchers utilized a randomized trial of HPV vaccinations in 134 primary schools.
26
Researchers randomized 67 of the schools to an age-based strategy and the other 67 to a
school-based strategy. A sample of 250 females who did not take the vaccine (cases) was
compared to a sample of 250 females who did receive the vaccine (controls). An analysis
of the responses the researchers determined that 53% did not get a dose of the vaccine
because they were absent from school on vaccination day, 40% because a parent refused,
and 1% because the girl refused (Watson-Jones et al., 2012). For the parent group that
received the vaccination, the common reasons for accepting the vaccination was
protection from cervical cancer (89%), health benefits (22%), and knowing someone who
had cancer (13%) (Watson-Jones et al., 2012). For the pupil group that received the
vaccination, the common reasons for accepting the vaccination was protection from
cervical cancer (91%), health benefits (24%), and parental wishes (21%) (Watson-Jones
et al., 2012). For the parent group that did not agree to the vaccination of their daughters,
the common reasons for not accepting the vaccination was concern over side effects
(40%), infertility (23%), or insufficient knowledge about the vaccine (22%) (Watson-
Jones et al., 2012). For pupil group that had not received the vaccination, the common
reasons for not accepting the vaccination was absent from school on vaccination day
(33%), both parents refused (24%), and concerns about side effects (22%) (Watson-Jones
et al., 2012). Further analysis of parents who refused vaccination of their daughters
showed a tendency to be older household members with less education (Watson-Jones et
al., 2012). In conclusion, Watson-Jones et al. (2012) recommended that sensitization
messages targeted at older and poor parents are crucial for vaccine acceptance in
Tanzania. The limitations of the study were related to potential selection bias as 60%
27
cases responded to the survey compared to more than 80% of the controls. This
deficiency could confound results and might not be representative of the non-receivers of
the HPV vaccine series.
Maternal age has not been adequately researched in recent literature. My study
provided new information about tendencies of the acceptance of the HPV vaccine and
mothers based on their age. This new information could provide insight for future
researchers to tailor interventions that target mothers of adolescent children to increase
HPV vaccination acceptance. Since this research was from secondary data obtained from
the 2014 NIS-Teen Survey, the limitation of selection bias seen in the study by Watson-
Jones et al. (2012) would not be a constraint because of the random digit dialing method
used to recruit participants of the survey.
Ethnicity
Blackman et al. (2013) compared and contrasted the knowledge and attitudes
toward the HPV and the vaccine within different cultures of African descent. The
researchers conducted a cross-sectional survey of African-Americans and Afro-
Caribbean’s living in the US and the Bahamas. The evidence indicated that there was a
significant difference between the two countries in knowledge about HPV and the HPV
vaccine. People from the Bahamas were significantly less knowledgeable about HPV and
the vaccine than African-Americans residing in the United States (Blackman et al., 2013).
Attitudes related to the vaccine were similar although Bahamians tended not to support
vaccination without parental consent versus African-Americans (80% to 57%) (Blackman
et al., 2013). Limitations of this study included a low response rate from Bahamian
28
parents on the rationale for the unwillingness to vaccinate their children compared to the
replies from African-Americans (Blackman et al., 2013). Luque, Raychowdhury, and
Weaver (2012) examined the provider’s perspectives of the VFC program for Hispanics
in rural Southern Georgia. The researchers performed structured interviews with
providers and focus groups with parents of Hispanic immigrant’s parents to understand
from the provider’s perspective the barriers to access and compliance of the HPV
vaccine. There were two focus groups of parents of females aged 9 to 18 years with
mothers and fathers in separate panels. Predominate barriers gathered from VFC
providers were related to: (1) low English proficiency of the parents; (2) Medicaid
reimbursement shortfalls; (3) mobile population creating difficulty completing a 3-dose
series over a 6-month span of time; (4) lack of transportation access; and (5) lack of
knowledge of the HPV vaccine (Luque et al., 2012). The limitations of the study include
a small sample size of parents for recruitment related to immigration status and Georgia’s
immigration law, and a media-driven controversy surrounding the HPV vaccine (Luque
et al., 2012). There were also limitations in the recruitment of VFC providers related to
contractual limitations on research participation (Luque et al., 2012). Ultimately, the
researchers concluded that inadequate insurance coverage by the VFC program was a
major barrier for not vaccinating adolescents with the additional reluctance to discuss
sexuality and lack of education about HPV and the vaccine (Luque et al., 2012). Kumar
and Whynes (2011) researched for an association between uptake, deprivation and ethnic
background that had been established in pilot research. Based on national immunization
programs in England, the HPV vaccine rates across the country were inconsistent and
29
varied by location, and the researchers sought to identify the factors explaining the
variation (Kumar & Whynes, 2011). The researchers analyzed published data of HPV
vaccination uptake, material deprivation, ethnic compositions of the different localities,
primary care access, and quality, and preventative services such as usage of cervical
screening and childhood immunization services. The analysis showed that ethnicity was
associated with attitudes towards cervical screening and other childhood vaccinations
while material deprivation and access to quality care were not significant (Kumar &
Whynes, 2011). The researchers found that ethnicity, childhood immunizations, and
usage of preventive and primary care and cervical screening were predictive of the uptake
of the HPV vaccine (Kumar & Whynes, 2011). The researchers also found an association
with increased material deprivation independent of race and lower access to quality care
with the decreased uptake of the HPV vaccine. The limitations of the study were related
to the data only tracked the first two doses of the HPV vaccine and the unavailability of
the data to the boundaries within the localities researched (Kumar & Whynes, 2011).
Lechuga, Swain, and Weinhardt (2011) performed a generalizability study to investigate
the strongest predictors of the mother’s intentions to vaccinate their daughters across
three cultural groups: Hispanic, non-Hispanic White and African American. The
researchers recruited a convenience sample of 150 mothers, 50 from each cultural group
from public health clinics in Milwaukee, Wisconsin and assessed their personal and
normative predictors of intentions to vaccinate their daughters (Lechuga et al., 2011). The
convenience sample of 150 mothers was drawn from Women Infant and Children (WIC)
federal program clinics at one of the four clinics in the Milwaukee, Wisconsin
30
metropolis. The research results indicated that the predictors of HPV vaccine intentions
varied by cultural group and that culture moderated the influence of norms on intentions
(Lechuga et al., 2011). Additionally, researchers discovered that in their attempt to
control for demographic differences through the recruitment of mothers enrolled in the
WIC program, that there was a significant amount of variability in insurance status
(Lechuga et al., 2011). Hispanic mothers in the study were more likely to be uninsured
and only have a high school education compared to both White and African American
mothers (Lechuga et al., 2011). The perceptions about the vaccine varied based on each
cultural group. For example, the non-Hispanic White mothers had the perception at the
vaccine would lead to increased sexual risk-taking, African American mothers believed
that the vaccine would cause a decrease in protective behaviors such as screening
(Lechuga et al., 2011). Hispanic mothers were more influenced by social norms as it was
a significant contributor to health decision-making (Lechuga et al., 2011). The limitations
of the research stem from the use of a small convenience sample, thus limiting the
generalizability of the results. Additionally, the varying levels of health insurance and
education within the small sample of mothers may have confounded the results. Lastly,
the intention to vaccinate was researched, not the initiation and completion of the HPV
vaccination series (Lechuga et al., 2011).
As noted above, there was much research on racial differences and HPV vaccine series
uptake. My research overcame some limitations of previous research because it was
examining a cross-section of populations defined not by race or ethnicity, but
socioeconomic status. Previous studies such as Blackman et al. (2013) and Luque,
31
Raychowdhury, and Weaver, (2012) examined specific ethnic groups for an association
with HPV vaccine uptake. My study does not specifically seek racial or ethnic groups,
but all social demographics confined to individual postal codes defined by maternal
income in Columbus, Ohio. My research might add new information to the field
concerning maternal influence via SES, regardless of race or ethnicity, and the uptake of
the HPV vaccine series.
Decisional Influences
The overall premise of the HBM was that people are likely to adopt a health
protective behavior if they believe: that they are susceptible to disease or condition; the
condition could have serious consequences; the remedy for the problem could eliminate
or reduce the susceptibility or severity of the problem; there are benefits to taking action;
and that the perceived costs are outweighed by the benefit of the action (Skinner et al.,
2015). These beliefs, shaped by modifying factors such as age, gender, ethnicity,
personality, socioeconomics, and knowledge may moderate an individual’s beliefs and
subsequent actions (Skinner et al., 2015). The constructs of the HBM collectively affect
behaviors, but precise relationships, weighting, or the combination of variables cannot be
delineated into action in the individual (Skinner et al., 2015). In adult women under 26
years of age, the decision to initiate the HPV vaccination series depends on their personal
choice to get the immunization. The forces that influence initiation or rejection of the
vaccination series vary person to person but have been studied by several researchers.
Harper et al. (2014) studied decisional satisfaction associated with HPV vaccination.
Researchers performed a prospective survey of urban college women aged 18 to 26 years
32
old about their HPV vaccination experience. The result of the study showed personal
satisfaction was very high regardless of the participant’s decision to accept or reject the
vaccination (Harper et al., 2014). There was variance in the initiation of the vaccine
based on perceived value of the vaccination by the participants. Participants who saw the
value of the vaccination as a method to prevent cervical cancer were more significantly
associated uptake than those who perceived the vaccination as a preventive measure for
genital warts (Harper et al., 2014). Additionally, the authors concluded that based the
participant’s responses targeting those who are neutral to HPV vaccination are a more
effective group to engage than those with high satisfaction to reject vaccination (Harper
et al., 2014). The limitations of the research are related to half the population had already
made a choice to receive at least one dose of the HPV vaccine series (Harper et al., 2014).
Additionally, within the decisional framework of the study, the researchers did not offer
the choice of no vaccination to the participants, so it was unknown how not having that
option might affect the results (Harper et al., 2014).
Knowledge and awareness of a disease process can influence parental choices to
vaccinate their children. Trim et al. (2011) conducted a systematic review of critical
surveys about HPV to understand how knowledge, attitudes, and behaviors were
influenced before and after the FDA release of HPV vaccination. The authors compared
the findings of previous research which studied parental knowledge attitudes and
behaviors towards the HPV vaccine. Additionally, the authors studied the factors that
influenced the decision to vaccinate their children. The authors used published articles
printed between the years 2001 and 2011. The findings from the research showed some
33
knowledge trends that changed throughout the study. Researchers found that parental
awareness of HPV increased in 2008 and 2009. Parental awareness of the HPV vaccine
increased in 2007 from 14% aware of the HPV vaccine in 2006 to 59% aware of the HPV
vaccine in 2007 and awareness continued to rise into 2008, but dropped slightly by 2010
(Trim et al., 2011). Behavior trends also fluctuated during the study as parents began
vaccinating their children after the 2006 release of the quadrivalent HPV vaccine,
reaching its peak in 2009 and 2010. For attitude trends, the highest percentage of parents
who intended to vaccinate their children peaked at 86% in 2005, the year before the HPV
vaccine release (Trim et al., 2011). Parental intent to vaccinate their children gradually
rose from 67% in 2007, and 80% 2008, but declined slightly over the last three years of
the study (Trim et al., 2011). There were also barriers for parents to accept the HPV
vaccine for their children. Parental knowledge of the HPV vaccine was a significant
factor in the acceptance of the vaccine for their children. In the review of the research, the
authors found evidence that in 37% of the studies reviewed, concerns about the safety of
the HPV vaccine were the parent's primary barrier with additional concerns about the
potential for side effects (Trim et al., 2011). Parents wanted more information to make an
informed decision was cited in 25% of the studies from the analysis. Conversely, parents
who were concerned about the risk of cancer in their child were more likely to accept the
HPV vaccination for their child (Trim et al., 2011). Parents differed in their attitudes on
when the vaccine should be given. In 19% of the studies reviewed by the researchers
showed a trend not to vaccinate if the parent believed that their child was too young for
the HPV vaccination (Trim et al., 2011). Earlier initiation to sex in adolescents related to
34
the HPV vaccine was also a barrier for parents. In 25% of the studies, researchers
examined parental concerns about increased risky sexual behaviors in adolescents after
vaccination (Trim et al., 2011). Research performed by Smith, Kaufman, Strumpf, and
Lévesque (2015) and Zimet et al. (2013) included in the review showed no evidence of
increased sexuality post-HPV vaccination. The strengths of the research were that it
included the knowledge, attitudes, and behaviors from a large number of parents from
several countries (Trim et al., 2011). The limitation of the research was the lack of the
ability to validate parental responses (Trim et al., 2011). The authors concluded based on
their analysis that parents wanted more information and reassurance from their providers
that the HPV vaccine was safe to give to their children (Trim et al., 2011). The parental
decisional findings by Trim et al. (2011) were similar to the findings of the research
conducted by Hofman et al. (2013). Hofman et al. (2013) studied parent's decision-
making strategies through focus groups in the Netherlands. The researchers used four
focus groups of primarily Dutch parents (one urban and two rural) and one group of
Turkish parents, who represented the largest ethnic minority in the Netherlands. All of
the parents in each group had at least one daughter between the ages of 8 and 15. The
researchers concluded post analysis of the parental responses that many parents felt
uneasy about HPV vaccination. The concern was related to the safety and the
effectiveness of the HPV vaccine (Hofman et al., 2013). The common theme from the
analysis was child protection motivation, and with some of the parents, the motivation
was to vaccinate whereas there were also some parents who were motivated to protect
their daughter by not vaccinating (Hofman et al., 2013). The strength of the research was
35
that it provided information about parental attitudes and decisional strategies about HPV
uptake before the vaccine was discussed in the media. The limitations of the research
were that most of the participants in the focus groups were mothers. The other limitation
was related to the sample size of Turkish parents group as there were too few Turkish
parents studied to compare to Dutch parents (Hofman et al., 2013).
My research provided new information concerning decisional influences for HPV
vaccination based on the responses of parents in communities defined by postal code. The
variables of maternal income, maternal education, and maternal age could provide
additional insight of the decisional influences of parents in communities of various SES
by way of the health belief model. Maternal SES and maternal age could be contributing
influences for parent’s decisions to vaccinate adolescent males and females with the HPV
vaccine based on the core constructs of the health belief model.
Critics and Differing Opinions
Bresse, Goergen, Prager, and Joura (2014) researched the cost effectiveness and health
impact of universal vaccination against HPV in Austria. The focus of the study was to
note the cost savings of preventing cancers caused by HPV 16/18 in a cohort of 9-year-
old males and females (Bresse et al., 2014). The authors concluded that with vaccination,
the HPV-related cancer burden would decrease by 71% over 100 years (Bresse et al.,
2014). This total includes not only cervical cancers but also anal, penile and
oropharyngeal cancers (Bresse et al., 2014). Additionally, Crowcroft et al. (2012)
concluded that high vaccine coverage improves communities, reduces absolute risk, and
increase equity. Their research computed the comparative risks for invasive cervical
36
cancer in a population or subgroup before and after the implementation of a vaccination
program. A simple static multi-sensitivity analysis was completed to compare the relative
risk of HPV infections that would lead to invasive cervical cancers if they were not
prevented or detected (Crowcroft et al., 2012). The researchers evaluated 3,793,902
scenarios and in 63.9% of the considered scenarios; HPV vaccination would lead to a
better population outcome regardless of the effectiveness of the vaccine (Crowcroft et al.,
2012). A limitation in the research by Crowcroft et al. (2012) was not estimating the prior
probability distribution for their parameters as Bayesian methods require. A limitation of
both these studies was that according to Ruiz et al. (2012) there are other prevalent strains
of oncogenic HPV other than HPV 16/18 and would not be covered by the present
vaccine. Currently, there are 12 known oncogenic strains of HPV
(16/18/31/33/35/39/45/51/52/56/58/59) (Ruiz et al., 2012).
Usage of the HPV vaccine in males has been a recommendation in the United
States since 2009, but usage in males had only recently achieved approval in Canada in
2015. The National Advisory Committee on Immunizations in Canada recommended that
males aged 9-26 receive the HVP vaccination series (Smith et al., 2015). In 2009, the
ACIP recommended that males receive the HPV vaccine aged 9-26 but subsequently
modified the initiation age in males to ages 11-26 in 2011 (CDC, 2011). The current
recommendation by ACIP for HPV vaccination is routine vaccination at age 11 or 12
years with HPV4 or HPV2 for females and with HPV4 for males; the vaccination series
can be started beginning at age nine years (CDC, 2014a). There were additional studies
using the NIS-Teen survey data for analysis,
37
A different approach for the prediction of HPV vaccine uptake was done by (Hechter et
al., 2013), who studied the maternal use of preventative care and history of sexually
transmitted disease as a predictor of uptake of HPV vaccine in adolescent males. This
innovative study linked maternal information with electronic medical records of males
aged 9-17 enrolled in a health maintenance organization (HMO) in Southern California.
Based on the various criteria conducted during the study, the researchers found some
interesting results useful for future research. For example, there was an association
between the initiation of HPV vaccine in males if they received the seasonal influenza
vaccine (Hechter et al., 2013). Additionally, males whose mothers received Pap testing
were more likely to receive the HPV vaccine than males whose mothers without a history
of genital papillomatosis were more likely to receive HPV vaccine (Hechter et al., 2013).
The authors concluded that maternal use of preventive health services might influence
HPV vaccination uptake in males (Hechter et al., 2013). Rahman, Laz, McGrath, and
Berenson (2014) found a similar association with the uptake of the HPV vaccination in
older adolescent females who received a seasonal influenza vaccination.
Some researchers argued that the disparity of HPV vaccinations may be related to
underreporting due to parental recall. Attanasio & McAlpine (2014) implied that parental
recall might inaccurately depict HPV uptake rates. The researchers evaluated parental
recall of HPV vaccination compared to clinical records while also evaluating social
characteristics of the accuracy by the parents surveyed. Researchers used data from the
2009-2010 NIS-Teen. The NIS-Teen survey consists of household interviews and a
provider-completed immunization history to compare responses to patient records. The
38
results showed parental underreporting of HPV uptake associated non-White, lower
household income, and lower education attained adolescent mothers (Attanasio &
McAlpine, 2014). Limitations of the study were related to the timing of the change the
ACIP recommendations for the HPV vaccination for males and the survey depended on
households that participated that also had a complete provider report (Attanasio &
McAlpine, 2014). This research showed that parental recall might cause a significant
limitation in vaccine coverage studies because some parents based on multiple
sociodemographic factors underreported the number of HPV vaccinations given to their
adolescent teen (Attanasio & McAlpine, 2014).
Malkowski (2014) studied the gender impact of the rollout of the HPV vaccine by Merck
Pharmaceuticals in 2006. The initial promotion of Gardasil presented a solution for a
woman-only issue despite the evidence that HPV infected both men and women
(Malkowski, 2014). The author implied that the initial advertisements for the vaccine
focus were not on the soon to be released vaccine nor did it inform the public of anything
related to the sexual transmission of HPV (Malkowski, 2014). The second advertisement
campaign was more focused on the teenage target audience, this time; the focus of the ad
campaign was on the vaccine and the disease without mentioning the mode of
transmission of the virus or even the virus itself (Malkowski, 2014). The third
advertisement campaign launched four years after the initial advertisement offering, and
the target audience was women. Merck used personal testimonies of people infected with
HPV a different tactic from previous campaigns where they targeted women not yet
exposed to the virus. Women in this campaign were portrayed to be the guardians of
39
public health despite the fact that HPV virus infects both males and females (Malkowski,
2014). Through analysis of all three campaigns, the researcher concluded that Merck
targeted a specific audience and persuaded them to assume a disproportionate burden for
a public health problem that affects men and women (Malkowski, 2014). The author
recommended a retooling of efforts to deconstruct parts of the message to repackage
HPV and the disease process as a more inclusive disease that does not solely place the
burden of protection on women (Malkowski, 2014). There are several theories in the field
of HPV vaccine uptake research. Most of these theories have been used in research to
determine the leading barriers to the uptake of the vaccine (Savoy, 2014). The most
common reasons for decreased uptake are knowledge of the vaccine, cost of the vaccine,
safety, efficacy, and risks of increased promiscuity. Savoy (2014) theorized that the
infrequent visits to the doctor as adolescents than as toddlers for vaccinations to be a
possible cause for the lack of vaccinations. Another rationale considered for decreased
uptake was the parental fear the vaccination would lead to promiscuity which various
researchers have evaluated (Savoy, 2014). Smith, Kaufman, Strumpf, and Lévesque
(2015) evaluated a cohort of over 260,000 females and found no evidence of perceived
promiscuity based on pregnancy and other sexually transmitted diseases. This study was
limited because it only evaluated females up to age 17 and the high attrition rate of the
survey as over 131,000 of the returned questionnaires was ineligible for the analysis
(Smith et al., 2015). Two years before this research, Zimet, Rosberger, Fisher, Perez, and
Stupiansky (2013) also investigated the promiscuity hypothesis and evaluated sexual risk
compensation related to HPV vaccination. The researchers reviewed several selected
40
published behavioral and social science articles on HPV vaccine acceptance and attitudes
and found no evidence of increased sexual risk-taking in adolescents taking the vaccine
(Zimet et al., 2013). Brown, Blas, Heidari, Carcamo, and Halsey (2013) evaluated
changes in sexual behavior and HPV knowledge after an education and vaccination
intervention in Peruvian female sex workers. The researchers noted that the participants
had a significant decrease in new clients over a 30-day period and utilized at least one
preventative strategy against other sexually transmitted infection upon the seven-month
follow-up survey (Brown et al., 2013). This evidence was corroborated by Zimet et al.
(2013), who came to similar conclusions in a study reviewed that was done on 13 to 21-
year-old females. Ruiz et al. (2012) hypothesized that proximity of first sexual experience
to menarche or the start of menstruation was associated with increased risk of cervical
intraepithelial neoplasia grade 2/3. In their research, they evaluated 1009 Colombian and
1012 Finnish females aged 16 to 23 that enrolled in an HPV vaccination trial that had
accurate data concerning the onset of menstruation and their first sexual experience. Of
the women included in the study, the statistics showed the mean age of menarche as 12.4
years, and the mean age of first sexual intercourse was 16 years (Ruiz et al., 2012). The
results of this study showed that women who had their first sexual intercourse less than
three years after menarche had a higher risk of cervical cytological abnormalities
compared to women who waited beyond three years after menarche (Ruiz et al., 2012).
Ruiz et al. (2012) concluded with the emphasis on the importance of primary prevention
through early vaccination and sexual education of adolescent females. The perception of
the HPV vaccine contributing to infertility was another hypothesis investigated by
41
researchers. Schuler, Hanley, and Coyne-Beasley (2014) researched parent’s concerns
about infertility as a barrier to accepting the HPV vaccine in adolescent males. 39% of
respondents reported that they were concerned about vaccine acquired infertility (VAI)
(Schuler et al., 2014). Additional analysis showed that this group had no less knowledge
than other parents surveyed indicating an increased need for conversations concerning the
side effects of the HPV vaccine to parents rather than having parents read the vaccine
information sheet (VIS) (Schuler et al., 2014).
This study provided new information that could impact future HPV vaccination
interventions. Based on the evidence discussed in the literature above, increasing the
uptake of the HPV vaccine series decreases the overall cervical cancer risk. As stated in
the research by Crowcroft et al. (2012) high HPV vaccination coverage improves
community health, increases equity, and reduces the absolute risk of cervical cancer. This
research added additional empirical evidence to support the development of future HPV
vaccination intervention programs by way of predicting tendencies of parents of
adolescent males and females to vaccinate their children with the HPV vaccine series
based on the theoretical concepts of the health belief model. My research enhanced
knowledge of decision-making based on maternal income, maternal education, and
maternal age.
Definitions
Cervical cancer: A type of cancer that begins in the cells lining the cervix at the
lower portion of the uterus (American Cancer Society, Inc., 2014). Cervical cancer is the
second most common female cancer worldwide, and there are nearly 500,000 cases per
42
year contributing to >250,000 deaths each year (Union for International Cancer Control
(UICC), 2015).
Human papillomavirus (HPV): Genital HPV is the most common sexually
transmitted infection (CDC, 2014c). There are over 100 HPV types identified, and there
are more than 40 HPV types that can infect the genital area (Hariri, Dunne, Saraiya,
Unger, & Markowitz, 2011). HPV types are classified by their association with cancer.
Non-oncogenic or low-risk strains of HPV can cause genital warts while oncogenic or
high-risk HPV can cause cervical cancer (Hariri et al., 2011).
HPV vaccine: Two vaccines are available to prevent persistent infection with
oncogenic strains of HPV. One vaccine is effective against four HPV strains, two high
risk, and two low risk and both vaccines are effective at protecting against the types that
cause 70% of cervical cancers (CDC, 2013; U.S. Food and Drug Administration, 2013).
Papanicolaou (Pap) test: A screening test for cervical cancer. The test looks for
abnormal cells on your cervix that could potentially turn into cancer. Early identification
of cancerous cells can improve the overall success of treatment. All women should start
getting regular Pap tests starting at age 21 (Techakehakij & Feldman, 2008).
Gardasil: The first HPV vaccine released in the United States in 2006. Gardasil
immunizes against HPV serotypes 6,11, 16 and 18 (U.S. Food and Drug Administration,
2013).
Cervarix: The second HPV vaccine released in the United States in 2009.
Cervarix immunizes against HPV serotypes 16 and 18 (CDC, 2010).
Maternal income: The value of the participant’s income reported on the NIS-Teen
43
survey by postal code.
Maternal education: The level of maternal educational reported by the 2014 NIS-
Teen survey participants (Centers for Disease Control and Prevention [CDC], National
Center for Immunization and Respiratory Diseases [NCIRD}, & National Center for
Health Statistics [NCHS], 2015).
Race: The 2014 NIS-Teen Survey defines race as White, Black or African
American, American Indian, Alaska Native, Asian, and Native Hawaiian (CDC, NCRID
and NCHS, 2015).
Ethnicity: The 2014 NIS-Teen Survey defines ethnicity as participants of
Hispanic or non-Hispanic origin (CDC, NCRID & NCHS, 2015).
Assumptions
This study was based on several assumptions. The most critical assumption was
that the instrument for data collection is valid and reliable based on the previous use of
the survey for HPV vaccination research. The NIS-Teen launched in 2006 provides the
most current, household, population-based, state and local area estimates of vaccination
coverage among children and teens using a standard survey methodology (CDC, 2016).
Additionally, there was the assumption that the random digit dial [RDD] sampling
method used to collect the NIS-Teen data resulted in a representative sample of telephone
households in Columbus, Ohio metropolitan area. Another assumption was that surveyors
collected data in a nonbiased manner and the participants provided the most honest and
accurate responses on the survey. The target audience for the NIS-Teen were adolescents
13-17 years living in households in the United States at the time of the survey. Lastly, it
44
was assumed the questions in the NIS-Teen survey are reliable and valid measures of
gathering information. This assumption was based on several years of use by the CDC
and in multiple previously published research studies. These assumptions are necessary to
conduct this research using this secondary data source. Due to the multiyear collection of
data by the National Immunization Survey (NIS), it was assumed that this source of data
was valid and reliable to be used in research. These assumptions are critical to the
research and to the analysis of the data provided so that conclusions can be made on the
population surveyed.
Scope and Delimitations
Scope and Delimitations
This study was limited to the analysis of selected SES variables and uptake of the
HPV vaccine series by postal code in the Columbus, Ohio metropolitan area. The
findings cannot be generalized to other vaccines. This survey data was limited by
information recall of parents who participated in the study. The sample population
interviewed for the 2014 NIS-Teen may not be generalizable to other populations. The
study did not analyze the variants of insurance coverage plans, or the state-related
variances in the VFC although some these variances may affect the conclusions and
should be considered for future research. Eligibility of the survey participants was
determined by the self-reporting by parents or guardians of adolescent children in the
household ages 13-17 years old via random digit dialing phone interviews. The NIS-Teen
is a large national representative sample that estimates vaccination coverage for the 50
States (CDC, 2016). Lastly, this research analyzed the responses from participants living
45
in the Columbus, Ohio metropolitan area and excluded postal codes not associated with
this location.
Significance and Potential for Social Change
Significance of Study
The significance of this research was that it could add potentially valuable
evidence that could contribute to the improvement of HPV intervention programs based
on maternal income and other selected SES variables examined in this study. Potential
evidence discovered through this research could enhance future researchers’
methodological approach to the implementation of community intervention programs by
tailoring HPV vaccination programs to fit selected communities based on maternal
income, education, maternal age, and ethnicity. Additionally, evidence found in the
analysis could potentially exclude some SES factors that were thought to influence the
uptake of the vaccine.
This research is an original contribution to field as there are many research studies
published exploring the barriers contributing to the decreased uptake of the HPV vaccine
series. None of the published contributions have explored maternal income, maternal
education and maternal age by community (defined by postal code) to explore for an
association within a community’s maternal SES status indicators and uptake of the HPV
vaccine series in adolescent females and males ages 13-17.
Social Change
The potential for significant social change related to this study was based on the
potential evidence of an association between uptake of the HPV vaccine series and
46
maternal influences as it relates to measurable maternal SES factors (maternal income
and maternal education). Such results of the research could potentially be used to reduce
the burden of cervical cancer in women through the enhancement of vaccination
programs contributing to the decreased incidence of a significant health disparity for
women. As a potential result of this research, more women could live longer and reach
their full potential through the improvement and enhancement of HPV vaccine series
interventions. Additionally, as a secondary result, this research could potentially change
the recommended screening schedule for cervical cancer screening decreasing the
frequency of exposure to invasive screening tests. Both men and women are reservoirs
for the HPV virus, universal HPV vaccination of all adolescents could lower the
incidence of HPV infection in women and the progression to cervical cancer.
Summary
HPV infection is the most common sexually transmitted infection (CDC, 2013).
HPV can progress to cervical cancer, and cervical cancer is responsible for over 4,000
deaths in the United States annually and a much higher burden worldwide, especially for
developing countries (American Cancer Society, Inc., 2014; Union for International
Cancer Control (UICC), 2015). To prevent cervical cancer, the enhancement of HPV
vaccination programs to meet the healthy people 2020 goal of 80% HPV infection is
critical (Savoy, 2014). HPV infection reduction can be accomplished by the use of
Gardasil, which is effective against HPV serotypes 6, 11, 16 and 18, and Cervarix, which
protects women from HPV types 16 and 18 (CDC, 2013; U.S. Food and Drug
Administration, 2013). The identification of additional barriers to HPV acceptance could
47
contribute to the continued improvement of vaccine intervention programs. The use of
the health belief model as the framework for the study may bring to light additional
measures to improve and enhance HPV vaccination programs. This study focused on
maternal SES factors by exploring for a correlation based on maternal income, maternal
education, as well as the maternal age of the participants through the analysis of the 2014
NIS-Teen survey data.
Conclusion
In conclusion, there was a gap in the literature for research exploring associations
between maternal community-level SES influences and the voluntary uptake of the HPV
vaccine series. Improving HPV vaccination rates among adolescents ages 13-17 was an
issue that must be addressed (Moss et al., 2014). The protection offered by this vaccine
can keep women from acquiring strains of oncogenic HPV that account for 70 % of all
cervical cancers in the U.S.(Harper et al., 2014). As both men and women are reservoirs
for the HPV virus, universal HPV vaccination of all adolescents could lower the
incidence of HPV infection and the progression to cervical cancer. The following chapter
provided the rationale behind the research design and data collection methods to reinforce
the significance and need of this scholarly project.
48
Section 2: Research Design and Data Collection
Introduction
The purpose of this doctoral study was to assess if there was an association
between maternal SES variables of income, education, age, and ethnicity and uptake of
the HPV vaccine in adolescent females and males ages 13-17 in Columbus, Ohio. In this
section, I explain my research design and the rationale for the choice of design. This
section also provides a comprehensive explanation of the methodology used for the study
in the event future researchers may want to replicate this research. Next, I elucidate my
choice of instrumentation, its purpose, and how I operationalized the constructs. Lastly, I
describe threats to validity and ethical procedures, to include the protection of data, and
close by summarizing the pertinent details in this section.
Research Design and Rationale
This was a cross-sectional quantitative observational research study in which I
explored associations between maternal socioeconomic influences based on income and
education and uptake of the HPV vaccine series. Additional analyses covered the
association between maternal age and ethnicity. The dependent variable in this study was
uptake of the HPV vaccine series, which I defined as a dichotomous (yes/no) response to
whether the adolescent (male or female) received at least one dose of the vaccine. The
four independent variables were maternal income, maternal education, maternal age, and
ethnicity. The first independent variable, maternal income, was defined as the income
reported by the respondents living within a certain postal code within the Columbus,
Ohio metropolitan area. The second independent variable, maternal education, was
49
defined by the highest level of education reported by the mother divided into the
following categories: no high school diploma; high school graduate or GED; completed a
vocational, trade, or business school program; some college credit but no degree;
associate degree (AA, AS); bachelor’s degree (BA, BS, AB); master’s degree (MA, MS,
MSW, MBA); and doctorate (PhD, EDD) or professional degree (MD, DDS, DVM, JD).
The third independent variable, maternal age, was defined by the mother’s age at the time
of survey completion divided into the following categories: 18-22, 23-27, 28-31, 31-36,
37-41, 42-45, and 46 and above. Ethnicity was measured by the following six categories:
White, Black/African-American, Native American, Asian, Native Hawaiian, and Pacific
Islander.
I chose a cross-sectional research design for this study. Cross-sectional design is
the predominate method for survey research and can be used sufficiently to examine
associations between properties and dispositions (Frankfort-Nachmias & Nachimas,
2008). There were no time or resource constraints related to using a cross-sectional
design approach, as the data analyzed was from a secondary analysis of the 2014 NIS-
Teen survey. Cross-sectional design was an optimal choice for this study as it allowed an
analysis of the dependent variables, uptake of the HPV vaccine series with multiple
independent variables, maternal income, maternal education and maternal age. By using
the cross-sectional design, the findings could be helpful in predicting outcomes based on
the SES variables analyzed in the study. The information gathered could enhance
intervention strategies based on any discoveries noted from the analysis of the SES
variables. A cross-sectional design was the best option because I was trying to elicit a
50
pattern of a relationship between the SES variables and uptake of the HPV vaccine series.
The statistical plan for my study was multiple logistical regression, which is used
when there is one categorical dependent variable and two or more independent variables
(McDonald, 2014). I chose multiple logistic regression because of its appropriateness for
seeking a functional association between the independent variables and the dependent
variable. This statistical plan can be used to predict probabilities of an effect of multiple
independent variables on a categorical dichotomous dependent variable and in some
circumstances can be used to make inferences about which independent variables have a
larger effect on or stronger association with the dependent variable (McDonald, 2014).
Methodology
In this section, I describe how I performed the research by defining the study
population, sampling techniques, access to secondary data, instrumentation,
operationalization of constructs, threats to validity, and ethical considerations.
Study Population
Columbus is the capital of the State of Ohio. The population of Columbus is
approximately 850,106 (Department of Commerce, 2016b). The target population for the
study was parents or guardians of adolescent teens who participated in the 2014 NIS-
Teen survey and live in the Columbus, Ohio metropolitan area. Since the participants of
the survey are asked specifically about HPV vaccine series uptake, I included all
participants of the survey who live in the geographic region when conducting the analysis
of the data. The sample size needed to be at least 1188 participants based on the
calculations using G*Power 3.1 Statistical Power Analysis for a logistic regression two-
51
tailed analysis with 0.95 power (1-β err prob; Faul et al., 2007). Optimally, if participants
resided across different postal codes, comparing uptake of the HPV vaccine series among
multiple SES variables would have improved the analysis. The target population for the
2014 NIS-Teen was adolescents aged 13–17 years living in non-institutionalized
households in the United States at the time of the interview (CDC, 2015b). Researchers
conduct the 2014 NIS-Teen concurrently with the 2014 NIS. The 2014 NIS-Teen
identified households containing one or more adolescents who was 13-17 years of age at
the time of the survey. Interviews were conducted with the household adults who were
the most knowledgeable about the teenager’s record of vaccinations (CDC, 2015b). Upon
completion of the survey and after obtaining consent from the parent or guardians of the
teenagers surveyed, the 2014 NIS-Teen surveyors also contacted the teenager’s
vaccination providers to request information on their vaccination records (CDC, 2015b).
The criteria for inclusion in this research study were as follows:
• Being an adolescent male or female between 13-17 years of age by the time of
the interview in 2014,
• Live in one of the Columbus, Ohio metropolitan postal codes
• The first HPV shot was received between 9 -17 years of age.
The ACIP recommends routine vaccination at age 11 or 12 years with HPV4 or
HPV2 for females and with HPV4 for males, although the vaccination series can be
started as early as age 9 (CDC, 2014b). For those unvaccinated at the routine age, the
vaccine is recommended for males aged 13 through 21 years and females aged 13
through 26 years who have not been vaccinated previously or who have not completed
52
the 3-dose series (CDC, 2014b).
Sampling and Sampling Procedures
The 2014 NIS -Teen Survey was used by surveyors to collect data from
households with adolescents 13-17 years and the teens’ vaccination providers (CDC,
2015). The NIS-Teen survey was conducted in two parts. The first part of the survey was
the random-digit-dialing (RDD) telephone survey of parents and guardians of randomly
selected households in all 50 states and the District of Columbia and the second part of
the survey was the survey of the teen’s vaccination providers (CDC, 2015). The NIS-
Teen surveyors obtained the consent to survey from the parents or guardians of eligible
teenagers so that contact could be made with their vaccination providers (CDC, 2015).
Researchers mailed a survey questionnaire to participants’ vaccine providers to perform a
check of their medical records (CDC, 2016). The goal of the mail survey of vaccination
providers was to confirm the accuracy and recall from the parents as compared to the
actual vaccination records and to assure the accuracy and precision of overall vaccination
coverage estimate (CDC, 2015c). The 2014 NIS-Teen survey included 59 geographic
strata for which vaccination coverage levels could be estimated, including seven mostly
urban cities and county areas (including the District of Columbia). Lastly, the remaining
52 estimation areas were either entire states or territories (including U.S. Virgin Islands
and Guam) or “rest of state” areas (CDC, NCRID & NCHS, 2015). According to CDC,
NCRID and NCHS (2015), this design makes it feasible to produce yearly predictions of
vaccine coverage levels for each state or territory (including U.S. Virgin Islands and
Guam) and for each of the seven sub-state estimation areas with a specified degree of
53
precision (a coefficient of variation of approximately 7.5%). Additionally, using the same
data collection methods and survey instruments researchers use the NIS-Teen to produce
results that are comparable to predict vaccination coverage levels among estimation areas
and through subsequent years (CDC, NCRID & NCHS, 2015). However, on the 2014
NIS-Teen survey, there was a change of the definition of adequate provider data (Reagan-
Steiner et al., 2015). As of 2014 on the NIS-Teen survey, adequate provider data was
achieved if the adolescent had vaccination history data from one or more of the named
vaccination providers or if the parent reported that the adolescent was completely
unvaccinated (Reagan-Steiner et al., 2015). Prior to 2014, there were more criteria
associated with the definition of adequate provider data, and it was based on a
comparison between provider reports of vaccination history and parental reports of
vaccination history, either by shot record report or recall (Reagan-Steiner et al., 2015).
This change means that future studies using the NIS-Teen survey data cannot be
compared to the previously published vaccine coverage estimates (Reagan-Steiner et al.,
2015).
Access to Secondary Data
The procedure to gain access to the 2014 NIS-Teen data was detailed at the CDC
website. The 2014 NIS-Teen public-use secondary dataset can be downloaded from this
website. In addition to the 2014 NIS-Teen dataset, users can download other pertinent
documents such as the readme file, data user's guide, household interview questionnaire,
provider-immunization history questionnaire data documentation, codebook and
frequencies, SAS input statements, and R Input Statements (CDC, NCRID & NCHS,
54
2015).
Permissions to use the 2014 NIS-Teen are clarified in the readme file. The
permissions for the use of data was strictly used only for the purpose of health statistical
reporting and analysis and any attempts to ascertain the identities of the participants were
prohibited by law (CDC, NCRID & NCHS, 2015). To comply with permissions for the
usage of the 2014 NIS-Teen, users of the data must be in compliance with the following:
1. Use the data in these data files for statistical reporting and analysis only.
2. Make no use of the identity of any person or establishment discovered
inadvertently and advise the Director, NCHS, of any such discovery (301-458-
4500)
3. Not link these data files with individually identifiable data from other NCHS
or non-NCHS data files (CDC, NCRID & NCHS, 2015).
Instrumentation and Operationalization of Constructs
Instrumentation
The NIS-Teen was launched in 2006. The target population for the NIS-Teen was
adolescents 13-17 years living in the United States at the time of the interview (CDC,
2015b). The NIS, developed in 1994 are a group of phone surveys used to monitor
vaccination coverage among children 19-35 months, teens 13-17 years, and flu
vaccinations for children 6 months-17 years (CDC, 2015b). The first NIS survey began in
April 1994 to examine vaccination coverage in the United States after measles outbreaks
in the early 1990s (CDC, 2015b). Researchers at the NCIRD of the CDC developed the
NIS by using a culmination of research experience using several different survey
55
methodologies (Zell et al., 2000). The NIS is an annual survey designed to provide
current and continuous estimates of vaccine coverage, provide reliable and valid
estimates of vaccination coverage in 78 separate areas (all 50 states, the District of
Columbia and 27 urban areas considered to be at risk of under-vaccination), provide
timely estimates, and produce estimates using reasonable resources (Zell et al., 2000).
Operationalization
Uptake of the HPV vaccine series: A person’s receiving one or more vaccinations
of the HPV vaccine series. This was the dependent variable. Based on the ACIP
recommendation, all participants of the HPV vaccination series are eligible to accept the
vaccine at 11-12 years of age but can be given as early as age 9 (CDC, 2014b). The
recommended age of initiation of the vaccine is well within the parameters of the NIS-
teen survey which gathers data of adolescents aged 13-17.
Maternal income: The household income reported based on the postal code of the
survey participants. Maternal income was measured by the income reported income per
postal code on the 2014 NIS-Teen survey. Maternal educational is measured by the
reported level of maternal educational reported during the survey by postal code.
Maternal education: The level of maternal education based on the postal code of
the survey participants, defined by the highest level of education attained, separated into
the following categories: no high school diploma; high school graduate or GED;
completed a vocational, trade, or business school program; some college credit but no
degree; associate degree (AA, AS); bachelor’s degree (BA, BS, AB); master’s degree
56
(MA, MS, MSW, MBA); and doctorate (PhD, EDD) or professional degree (MD, DDS,
DVM, JD).
Maternal age: The age of the mother at the time of survey participation. Maternal
age was measured by dividing the mothers’ age into the following groups: less than 25
years old, 25-34 years old, 35-44 years and 45+ years old.
Ethnicity: The grouping of the major divisions of humankind, having distinct
physical characteristics. Ethnicity was measured by dividing participants into the
following six categories: White, Black/African-American, Native American, Asian,
Native Hawaiian, and Pacific Islander.
Data Analysis Plan
I analyzed the 2014 NIS-Teen secondary data using SPSS® version 21 (IBM
Corp., 2016). I validated the analyses using the built-in validation functions in SPSS®
v.21. I conducted simple descriptive analyses of the variables. I recoded the identified
variables, categorized and manipulated them to fit the variables in line with the research
questions. I conducted normality testing and performed binary analyses, bivariate
analysis, followed by multiple logistic regression using SPSS® on the independent
variables to search for statistically significant associations with the dependent variable.
Research Question(s) and Hypotheses
The objective of this research study was to explore the association between
maternal SES and uptake of the HPV vaccine series. The research questions are as
follows:
Q1: what is the association between maternal income and uptake of the HPV
57
vaccine series in adolescent males and females 13-17 in communities with postal codes in
the Columbus, Ohio metropolis?
HO: there is no association exists between maternal income and uptake of the
HPV vaccine series in adolescent males and females 13-17 after controlling for ethnicity
and maternal age based on postal codes in Columbus, Ohio.
HA: There is an association exists between maternal income and uptake of the
HPV vaccine series in adolescent males and females 13-17 after controlling for ethnicity
and maternal age based on postal codes in Columbus, Ohio.
Q2: What is the association between maternal education and uptake of the HPV
vaccine series in adolescent males and females 13-17 in the postal codes within the
Columbus, Ohio metropolis?
HO: There is no association between maternal education and uptake of the HPV
vaccine series in adolescent males and females 13-17 in the postal codes within the
Columbus, Ohio metropolis
HA: There is an association between maternal education and uptake of the HPV
vaccine series in adolescent males and females 13-17 in the postal codes within the
Columbus, Ohio metropolis.
Q3: What is the association between maternal age and uptake of the HPV vaccine
series in adolescent males and females 13-17 in communities with postal codes in the
Columbus, Ohio metropolis?
HO: There is no association between maternal age and uptake of the HPV vaccine
series in adolescent males and females 13-17 in communities with postal codes in the
58
Columbus, Ohio metropolis
HA: There is an association between maternal age and uptake of the HPV vaccine
series in adolescent males and females 13-17 in communities with postal codes in the
Columbus, Ohio metropolis.
Q4: What is the association between ethnicity and uptake of the HPV vaccine
series in adolescent males and females 13-17 in the postal codes within the Columbus,
Ohio metropolis?
HO: There is no association between ethnicity and uptake of the HPV vaccine
series in adolescent males and females 13-17 in the postal codes within the Columbus,
Ohio metropolis.
HA: There is an association between ethnicity and uptake of the HPV vaccine series in
adolescent males and females 13-17 in the postal codes within the Columbus, Ohio
metropolis.
A cross-sectional design study using multiple logistical regression analysis was
performed to predict the most parsimonious model of HPV vaccine series uptake. The
variables of the study were measured by using responses from the 2014 NIS-Teen. This
research explored the association between SES variables of maternal income, maternal
education, maternal age and ethnicity in communities within communities of Columbus,
Ohio and uptake of the HPV vaccine series.
Threats to Validity
The data produced by the NIS are considered the gold standard for public health
surveillance on immunization rates. The NIS is one of the largest telephone surveys and
59
produces high-quality estimates of vaccine coverage in the United States (NORC at the
University of Chicago, 2016). Due to the method in which this survey was conducted,
and the theoretical framework the analysis, there are several external and internal threats
to validity involving the participants, location, and their reported income via postal code.
The analysis was performed on participants who completed the 2014 NIS-Teen in
communities within Columbus, Ohio metropolitan and the results are not generalizable to
different populations. There also could be a temporal association between the effects of
SES related to the length of time participants resided in the sampled postal codes. Newer
residents may not have the full effect of access or lack of access to money, knowledge,
prestige, power and supportive social networks where they were surveyed. This threat
was addressed by the random digit dialing sampling of selected households during the
survey. Additionally, there is evidence that parental reporting of vaccination statuses can
be inflated as compared to provider records (Lu, Dorell, Yankey, Santibanez, &
Singleton, 2012). The NIS-teen survey compares the vaccination status reports from
parents to the reports from the adolescent’s providers only when the parents or guardians
have given consent (CDC, 2015c). Lastly, up-to-date vaccine information, individual or
vaccine series was drawn from provider-reported data. There was no recheck of
households or reconciliation of data that might be different from the report of parents or
guardians, and the NIS-Teen surveyors do not re-contact households or providers to
attempt to reconcile potential discrepancies in provider-reported vaccination dates or to
resolve date-of-birth reporting errors (NORC at the University of Chicago, 2016).
60
Ethical Considerations
Human Subjects
I conducted the research using the 2014 NIS public-use data file for this
secondary data analysis study. The 2014 NIS -Teen staff and contractors are subject to
strict federal laws in regards to protecting the participants and the provider’s privacy
(CDC, 2015e). Employees working on the NIS are required to sign a legal document
saying that they will keep all information private as well as details the consequences of
the illegal disclosure of the information (CDC, 2015e). All information in the 2014 NIS-
Teen was collected under strict confidentiality and can be used only for research as
outlined in [Section 308(d) of the Public Health Service Act, 42 U.S. Code 242m(d), the
Privacy Act of 1974 (5 U.S. Code 552a), and the Confidential Information Protection and
Statistical Efficiency Act (5 U.S. Code)] (CDC, NCRID & NCHS, 2015). Prior to the
release of the public-use data file, the contents of file go through extensive review by the
NCHS Disclosure Review Board to ensure that participant privacy was protected as well
as the protection of data confidentiality (CDC, NCRID & NCHS, 2015). The information
collected in the NIS-Teen are used only for reporting of important statistical health
information in the United States and its territories, and the organization has taken
precautions to protect the privacy of individuals, families, and businesses participating in
the survey (CDC, 2015e).
Ethical Issues
During the data collection phase, many of the telephone numbers are randomly
selected by a computer so listed, and unlisted phone number receive phone calls
61
requesting permission to conduct the survey. Additionally, potential participants are
mailed a letter from the Director of the National Center for Immunization and
Respiratory Diseases, which describes the survey before a telephone interview was
conducted (CDC, 2015c). These steps were taken to protect participants’ confidentiality
and to make certain they understand that their participation was voluntary (CDC, 2015c).
Summary
In summary, this research was a cross-sectional quantitative study that explored
for a correlation between maternal socioeconomic influences and uptake of the HPV
vaccine series in the communities within the cities of Columbus, Ohio metropolis. By
using multiple logistic regression analysis, this study analyzed the dependent variables of
uptake of the HPV vaccination series with the independent variable of maternal income
measured by postal code. Additionally, the research analyzed the additional independent
variables of maternal education, and maternal age as well as ethnicity. There are several
threats to validity, but due to the RDD nature of gathering participants to be surveyed, the
threats to validity should be minimal. The research was ethical and should satisfy the
requirements of protecting the privacy of human subjects as all information in the 2014
NIS-Teen was collected under strict confidentiality and can be used only for research as
outlined in [Section 308(d) of the Public Health Service Act, 42 U.S. Code 242m(d), the
Privacy Act of 1974 (5 U.S. Code 552a), and the Confidential Information Protection and
Statistical Efficiency Act (5 U.S. Code)]. Additionally, the employees collecting
information for the 2014 NIS-Teen are under strict federal laws in regards to protecting
62
the participants and the provider’s privacy. The next section of this doctoral study
discussed the results and the findings of the research.
63
Section 3: Presentation of the Results and Findings
Introduction
The purpose of this study was to assess if there was an association between
maternal SES variables of maternal income and maternal education as well maternal age
and ethnicity and uptake of the HPV vaccine in adolescent males and females ages 13-17
based on postal codes within communities within the city of Columbus, Ohio. I provided
evidence of an association between maternal SES influences and uptake of the HPV
vaccine series. Four research questions were answered as a result of this study: (a) What
is the association between maternal income and uptake of the HPV vaccine series in
adolescent males and females 13-17 in communities with postal codes in the Columbus,
Ohio metropolis, and (b) What is the association between maternal education and uptake
of the HPV vaccine series in adolescent males and females 13-17 in communities with
postal codes in the Columbus, Ohio metropolis, and (c) What is the association between
maternal age and uptake of the HPV vaccine series in adolescent males and females 13-
17 in communities with postal codes in the Columbus, Ohio metropolis, and (d) What is
the association between ethnicity and uptake of the HPV vaccine series in adolescent
males and females 13-17 in communities with postal codes in the Columbus, Ohio
metropolis? The null hypothesis stipulated that there is no association between maternal
socioeconomic factors of income and education and uptake of the HPV vaccination
series, nor between the variables of age and ethnicity and uptake of the HPV vaccination
series in adolescent males and females 13-17 in communities with postal codes in the
Columbus, Ohio metropolis.
64
In this section, I present the results of a secondary data analysis. I analyzed the
2014 NIS-Teen secondary data using SPSS® version 21 (IBM Corp., 2016). I validated
the analyses using the built-in validation functions in SPSS® v.21. I conducted simple
descriptive analyses of the variables. I recoded the identified variables and categorized
and manipulated them to fit the variables in the research questions. I conducted normality
testing and performed binary analyses and bivariate analysis, followed by multiple
logistic regression using SPSS® on the independent variables to search for statistically
significant associations with the dependent variable. I conclude this section with a
summary of the findings from the data analysis.
Data Collection of Secondary Data Set
The annual NIS-Teen survey is conducted as an adjunct to the NIS. The overall
goal of the NIS is to estimate vaccination coverage rates among 19- to 35-month-old
children in the United States. The NIS uses a random digit dialing (RDD) telephone
survey to identify households with children aged 19 to 35 months and interviews the
adult who was the most familiar with the child’s vaccination history. When such a
household was identified, and the NIS interview was completed, the household was
further screened for the presence of 13- to 17-year-old adolescents. Households without
19- to 35-month-old children are not administered the NIS interview but are further
screened for the presence of a 13- to 17-year-old adolescent. If a household containing
one or more adolescents aged 13 to 17 years was identified, one of those adolescents was
randomly chosen from within the household, and the adult who was most knowledgeable
about the teen's vaccinations was interviewed. The household interviews for the 2014
65
NIS-Teen landline and cell-phone samples began on January 9, 2014, and ended on
February 8, 2015 (CDC, National Center for Immunization and Respiratory Diseases, &
National Center for Health Statistics, 2015). The samples were drawn independently from
RDD phone numbers from within the 58 selected geographical regions of the annual NIS.
Data obtained from the teen’s vaccine provider were collected from February 2014
through April 2015 for both landline and cell-phone sample sources. The response rates
for the 2014 NIS-Teen were as follows: resolution rate of 82.6%, screener completion
rate 87.2%, interview completion rate 83.8%, CASRO response rate 60.3%, and teens
with adequate provider data rate 57.1% (CDC, National Center for Immunization and
Respiratory Diseases, & National Center for Health Statistics, 2015).
Discrepancies
There were some discrepancies from the use of this secondary data set. Upon
review of the data, there were no specific methods to identify survey respondents by
postal code for the Columbus, Ohio metropolis. Additionally, I noted that the State of
Ohio (n = 754) did not have the required sample size to conduct multiple logistic
regression analysis. Based on this discrepancy, I modified my location of research into
two cities with differing levels of per capita income using the same methods I planned to
use in the research on Columbus, Ohio. My revised research plan analyzed New York
City, New York (n = 616) and Houston, Texas (n = 679). The combination of these cities
gave me a sample size of 1,295, which was adequate to perform multiple logistic
regression analysis. However, after reviewing the responses concerning HPV uptake for
the cities selected, I found that 170 respondents were unaware of HPV vaccine series
66
uptake in their adolescent teen and those respondents were excluded from the analysis.
The final sample size analyzed in this study was n = 1,125 which lowered the achieved
power to 0.939 power (1-β err prob) based on calculations using G*Power 3.1 Statistical
Power Analysis for a logistic regression two-tailed analysis from the original 0.95 power
(1-β err prob)(Faul et al., 2007). My study examined two large metropolitan areas with
vast differences in per capita income. In 2015, the per capita personal income (PCPI) in
New York City was $ 63,196 (Department of Commerce, 2017), whereas the PCPI in
Houston for 2015 was $36,913 (Department of Commerce, 2016a). The states that
encompass these cities have comparable HPV-related cervical cancer rates: New York at
7.57 and Texas at 8.27 per 100,000 (CDC, 2017). Both New York and Texas have the
highest cervical cancer rates for the United States. The change in my research plan
prompted a necessary change of my research questions.
My revised research questions are as follows:
Q1: What is the association between maternal income and uptake of the HPV
vaccine series in adolescent males and females 13-17 in communities within the cities of
New York City, New York and Houston, Texas?
HO: There is no association exists between maternal income and uptake of the
HPV vaccine series in adolescent males and females 13-17 after controlling for ethnicity
and maternal age within the cities of New York City, New York and Houston, Texas.
HA: There is an association exists between maternal income and uptake of the
HPV vaccine series in adolescent males and females 13-17 after controlling for ethnicity
and maternal age within the cities of New York City, New York and Houston, Texas.
67
Q2: What is the association between maternal education and uptake of the HPV
vaccine series in adolescent males and females 13-17 within the cities of New York City,
New York and Houston, Texas?
HO: There is no association between maternal education and uptake of the HPV
vaccine series in adolescent males and females 13-17 within the cities of New York City,
New York and Houston, Texas.
HA: There is an association between maternal education and uptake of the HPV
vaccine series in adolescent males and females 13-17 within the cities of New York City,
New York and Houston, Texas.
Q3: What is the association between maternal age and uptake of the HPV vaccine
series in adolescent males and females 13-17 in communities within the cities of New
York City, New York and Houston, Texas?
HO: There is no association between maternal age and uptake of the HPV vaccine
series in adolescent males and females 13-17 in communities within the cities of New
York City, New York and Houston, Texas.
HA: There is an association between maternal age and uptake of the HPV vaccine
series in adolescent males and females 13-17 in communities within the cities of New
York City, New York and Houston, Texas.
Q4: What is the association between ethnicity and uptake of the HPV vaccine
series in adolescent males and females 13-17 within the cities of New York City, New
York and Houston, Texas?
HO: There is no association between ethnicity and uptake of the HPV vaccine
68
series in adolescent males and females 13-17 within the cities of New York City, New
York and Houston, Texas.
HA: There is an association between ethnicity and uptake of the HPV vaccine
series in adolescent males and females 13-17 within the cities of New York City, New
York and Houston, Texas.
There were also some slight differences in my expectations in how the variables
were listed in the 2014 NIS-Teen data. The differences of the listing of the variables were
incorporated into the multiple logistic regression analysis. Maternal income was reported
on the 2014 NIS-Teen as: $0-$7500, $7501-$10000, $10001-$17500, $17501-$20000,
$20001-$25000, $25001-$30000, $30001-$35000, $35001-$40000, $40001-$50000,
$50001-$60000, $60001-$75000, and over $75000. Ethnicity was reported on the 2014
NIS-Teen as Hispanic, non-Hispanic White only, non-Hispanic Black only, and non-
Hispanic other + multiple race. Maternal education was reported on the 2014 NIS-Teen
as: less than 12 years education, 12 years of education, more than 12 years non-college
graduate, and college graduate. Maternal age was reported on the 2014 NIS-Teen as: less
than 34 years old, 35-44, and over 45 years. Lastly, HPV acceptance was reported on the
2014 NIS-Teen as Yes, No or I don’t know (CDC et al., 2015). The “I don’t know”
respondents were excluded from further analysis.
Additionally, there were other discrepancies from the use of this secondary data
as the NIS-Teen is a telephone survey and the results are weighted to be representative of
all children ages 19-35 months, and even with the statistical adjustments to account for
non-response and households without telephones, there may be some residual bias.
69
National estimates of vaccination coverage are precise, but state and local estimates
should be interpreted with caution because of limited sample size and widened
confidence intervals than for national estimates of vaccination coverage (CDC et al.,
2015).
The total sample, including the U.S. territory of Puerto Rico, contained
approximately 8.1 million telephone numbers (5.0 million landline and 3.1 million cell-
phone) and created household interviews for 38,703 teens (20,030 landline and 18,673
cell-phone), 21,057 of whom (11,353 landline and 9,704 cell-phone) had vaccine
provider data adequate to conclude whether the teen was current with the recommended
vaccination schedule (CDC et al., 2015). The NIS-Teen RDD telephone survey phase
used independent, quarterly samples of telephone numbers. Sampling frames for the NIS
were provided by Marketing Systems Group (MSG) and the target sample size of
completed interviews in each estimation area was designed to approximately achieve the
equal coefficient of 6.5% of the estimated vaccine coverage from provider reported
histories, given a true coverage parameter of 50% (CDC et al., 2015).
In order to best represent the general population, the 2014 NIS-Teen survey
weights for landline and cell-phone samples were combined in order to weight the full
population of teens aged 13 to 17 years. Teens that resided in landline-only households
(from the landline sample) and cell-phone-only households (from the cell-phone sample)
within the estimation areas were weighted to represent teens in landline-only and cell-
phone-only households. Additionally, because landline and cell-phone sampling frames
sometimes overlap in coverage of teens in landline and cell-phone dual-use households,
70
dual-users from both samples are combined based on the most effective number of teens
with completed household interview within each phone sample type (landline, cell-
phone), and were weighted to represent teens in dual-use households within each
estimation area. Lastly, teens who lived in houses without phones were excluded from the
dual-frame sample but were accounted for by using controls derived from combining the
2013 census population estimates and the public-use single year 2011 and the 2011-2013
American Community Survey (ACS) data for the United States and Puerto Rico. The
representation within the estimation areas was derived by using small area statistical
modeling techniques used by Blumberg et al. 2012. The modeled telephone estimates
were applied to the control total for the estimation area to approximate the control totals
by detailed telephone status within each estimation area. Additionally, sampling
variability was reduced, and precision of estimation was improved by trimming extreme
weights within an estimation area. RDD sampling weight values that surpassed the
median weight plus three times the interquartile range of the weights within an estimation
area were truncated to that threshold. This weight trimming prevented teens with
unusually large weights from having an unusually large effect on vaccination coverage
estimates (CDC et al., 2015).
Univariate Analysis
Descriptive Characteristics of the Sample Population
A total sample of 1295 respondents in the estimation areas of New York City,
New York (NYC) and Houston, Texas completed the 2014 NIS-Teen survey (NYC 522
and Houston 603). Of the 1,295 respondents, 170 responded that they did not know if the
71
teen had received any HPV vaccinations and were excluded from the analysis. Table 2-5
depict the sample sizes of the maternal SES variables that were evaluated in the study.
Table 2
Maternal Age
Age Groups Frequency Percent Valid
Percent Cumulative
Percent
<= 34 YEARS 80 7.1 7.1 7.1
35 TO 44 YEARS 410 36.4 36.4 43.6
>= 45 YEARS 635 56.4 56.4 100.0
Total 1125 100.0 100.0
Table 3
Maternal Income
Frequency Percent Valid
Percent Cumulative
Percent
$0 - $7500 35 3.1 3.1 3.1
$7501 - $10000 40 3.6 3.6 6.7
$10001 - $17500 74 6.6 6.6 13.2
$17501 - $20000 56 5.0 5.0 18.2
$20001 - $25000 58 5.2 5.2 23.4
$25001 - $30000 51 4.5 4.5 27.9
$30001 - $35000 38 3.4 3.4 31.3
$35001 - $40000 44 3.9 3.9 35.2
$40001 - $50000 55 4.9 4.9 40.1
$50001 - $60000 37 3.3 3.3 43.4
$60001 - $75000 60 5.3 5.3 48.7
$75001+ 436 38.8 38.8 87.5
DON'T KNOW 51 4.5 4.5 92.0
REFUSED 90 8.0 8.0 100.0
Total 1125 100.0 100.0
72
Table 4
Maternal Education
Frequency Percent Valid
Percent Cumulative
Percent
LESS THAN 12 YEARS
213 18.9 18.9 18.9
12 YEARS 192 17.1 17.1 36.0
MORE THAN 12 YEARS, NON- COLLEGE GRAD
217 19.3 19.3 55.3
COLLEGE GRADUATE
503 44.7 44.7 100.0
Total 1125 100.0 100.0
Table 5
Ethnicity
Frequency Percent Valid
Percent Cumulative
Percent
HISPANIC 352 31.3 31.3 31.3
NON-HISPANIC WHITE ONLY
409 36.4 36.4 67.6
NON-HISPANIC BLACK ONLY
231 20.5 20.5 88.2
NON-HISPANIC OTHER + MULTIPLE RACE
133 11.8 11.8 100.0
Total 1125 100.0 100.0
Tables 6-8 depict the sample sizes of HPV vaccine series uptake, the sample size of the
two communities sampled by the 2014 NIS-Teen survey and a summary depicting the
number of the males and females who received or did not receive the HPV vaccine.
73
Table 6
HPV Vaccine Series Uptake
Frequency Percent Valid
Percent Cumulative
Percent
YES 610 54.2 54.2 54.2
NO 515 45.8 45.8 100.0
Total 1125 100.0 100.0
Table 7
Estimation Area Of Residence
Frequency Percent Valid
Percent Cumulative
Percent
NYC 522 46.4 46.4 46.4
Houston 603 53.6 53.6 100.0
Total 1125 100.0 100.0
Table 8
Gender of Child
HPV YES
HPV NO
Total
Male
257 289 546
47.1% 52.9% 100%
Female 353 226 579
61% 39% 100%
Total
610 515 1125
74
Bivariate Analysis
A bivariate analysis of the respondents’ four SES variables and uptake of the
HPV vaccine series revealed a significant finding related to ethnicity. The other three
variables, maternal age, maternal education, and maternal income were found to be non-
significant. The complete results of all bivariate analyses are shown in the following
tables. I conducted a bivariate Pearson χ2 test of the crosstabulation on the variables of
HPV vaccination uptake and maternal age. HPV uptake and maternal age were not
significantly related, Pearson χ2 (2, N = 1125) = .751, p = .69. For HPV uptake and
maternal education, I also conducted a bivariate Pearson χ2 test of cross tabulation of the
variables of HPV vaccination uptake and maternal education. HPV uptake and maternal
education were also showed no significant relationship Pearson χ2 (2, N = 1125) = 4.06,
p = .25. For HPV vaccination uptake and ethnicity, I conducted a bivariate Pearson χ2
test of the crosstabulation of the variables of HPV Vaccination Uptake and ethnicity.
There was a significant pattern of association between HPV uptake and ethnicity, Pearson
χ2 (2, N = 1125) = 8.37, p = .039. The results of the analysis showed that there was a
significant relationship between uptake of the HPV vaccine series and ethnicity of the
respondents living within the estimation areas analyzed in the study. Lastly, an
independent-samples t-test was conducted to evaluate HPV vaccine uptake and maternal
income. The test was non-significant, t(982) = -1.38, p = .17. The patterns of association
between HPV vaccine uptake and the maternal demographic variables are seen below in
Tables 9-12.
75
Table 9
Crosstabulation Ethnicity of Sample and HPV Vaccine Uptake
Ethnicity* HPV Uptake Yes NO
Total
Hispanic 213 (60.5%) 139 (39.5%) White 213
(52.1%) 196 (47.9%)
409 (36.4%)
Black 116 (50.2%)
115 (49.8%)
231 (20.5%)
Other 68 (51.1%)
65 48.9%
133 (11.8%)
Total Responses to Survey for Maternal Ethnicity
610 (54%)
515 (46%)
*Indicates p <.05
Table 10
Crosstabulation Maternal Age of Sample and HPV Vaccine Uptake
Maternal Age HPV Uptake Yes NO
Total
<= 34 YEARS
41 (51.2%)
39 (48.8%)
409 (36.4%)
35 TO 44 YEARS
218 (53.2)
192 (46.8)
231 (20.5%)
>= 45 YEARS
351
(55.3%) 284
(44.7%)
133
(11.8%)
Total Responses to Survey for Maternal
Age
610 (54%)
515 (46%)
76
Table 11
Crosstabulation Maternal Education of Sample and HPV Vaccine Uptake
Maternal Education HPV Uptake Yes NO
Total
LESS THAN 12 YEARS
123 (57.7%)
90 (42.3%)
213 (19%)
12 YEARS
97 (50.5%)
95 (49.5%)
192 (17%)
12 YEARS, NON- COLLEGE GRAD
109 (50.2%)
108 (49.%)
217 (19%)
COLLEGE GRADUATE 281
(55.9%) 222
(44.1%) 503
(45%)
Total Responses to Survey for Maternal
Education
610
(54%) 515
(46%)
77
Table 12
Crosstabulation Maternal Income and HPV Vaccine Uptake
Maternal Income
HPV Uptake
Yes No Total
$0 - $7500 20 (57.1%) 15 (42.9%) 35 (3.6%)
$7501 - $10000 19 (47.5%) 21 (52.5%) 40 (4.1%)
$10001 - $17500
54 (73%) 20 (27%) 74 (7.5%)
$17501 - $20000
32 (57.1%) 24 (42.9%) 56 (5.7%)
$20001 - $25000
32 (55.2%) 26 (44.8%) 58 (5.9%)
$25001 - $30000
28 (54.9%) 23 (45.1%) 51 (5.2%)
$30001 - $35000
18 (47.4) 20 (52.6%) 38 (3.9%)
$35001 - $40000
27 (61.4%) 17 (38.6%) 44 (4.5%)
$40001 - $50000
27 (49.1%) 28 (50.9%) 55 (5.6%)
$50001 - $60000
18 (48.6%) 19 (51.4%) 37 (3.8%)
$60001 - $75000
20 (33.3%) 40 (66.7%) 60 (6.1%)
$75001+ 245 (56.2) 191 (43.8%) 436 (44.3%)
Total Responses to Survey for Maternal Income
610
(54%) 515
(46%) 1125
(100%)
78
Logistic Regression Analysis
Multiple logistic regression was performed on all four variables simultaneously
to analyze the predictors for uptake of the HPV vaccine series in the cities of New York
City, New York and Houston, Texas. The parsimonious analysis of each predictor
variable corresponds with each of the research questions reviewed later in the analysis.
In addition, sex of the child (male/female) and city of residence (New York
City/Houston) were included as control variables. The outcome variable was ‘Ever
received any HPV Vaccinations (yes/no).’ The main goal of the logistic analysis was to
determine the role of several critical predictors in explaining the dichotomous outcome
(yes or no HPV vaccination). The critical predictors were: maternal education, maternal
income, maternal age, ethnicity and uptake of the HPV vaccine series. City of residence
and child sex were also included, as mentioned above. Linearity of the continuous
variables with respect to the logit of the dependent variable was assessed via the Box-
Tidwell (1962) procedure. Based on this assessment, the sole continuous independent
variable, maternal income was found to be linearly related to the logit of the dependent
variable. The model containing all four independent variables (maternal income,
maternal education, maternal age, and ethnicity) as well as the two control variables
(child sex and city of residence) was statistically significantly related to HPV
vaccination uptake (χ2(8) = 34.867, p = .0005.
Pseudo- R2 (Nagelkerke) was .047. Uptake of the HPV vaccine series was
correctly classified for 58.1% of cases by the combination of variables in the logistic
79
regression equation. Sensitivity was 73.33%, specificity was 39.63%, positive predictive
value was 59.64%, and negative predictive value was 55.00%. Of the six predictor
variables, two were statistically significant: ethnicity and child sex. Non-Hispanic
Whites, Non-Hispanic Blacks, and Non-Hispanic Others all had approximately half the
odds to of being vaccinated than Hispanics (as shown in Table 13). Difference in odds
ratio when comparing the racial groups indicated that an increase in one unit of the
independent variable (0 for Hispanic to 1 for White patients, for example) decreases the
odds of receiving the HPV vaccine series such that Whites were 1.535 times – Exp(B) -
less likely to receive the HPV vaccine series than Hispanics. The reason that the
comparison was seen as a decrease in odds of receiving the HPV vaccine series despite
the fact that the beta value was positive was that the designation of the outcome variable
was (arbitrarily) coded in the reverse direction, with the “yes HPV” category represented
by a lower number (‘1’) than the “no HPV” category (‘2’). When comparing Black teens
to Hispanic teens, the odds of Blacks receiving the vaccine were 1.799 less likely than
Hispanics to receive the vaccine, and teens who were identified as multi-race or “other”
were 1.796 times less likely than Hispanics to receive the vaccine.
Maternal Income, Maternal Education and Maternal age were not significant
predictors of uptake of the HPV vaccine series as their associations with the dependent
variable were non-significant Maternal income β = .013, p > .05, Maternal Age β = -
.096, p > .05, and Maternal Education, β = -.026, p > .05. City of residence was not a
significant predictor of HPV vaccination, β = .004, p > .05.
80
Child sex was a significant predictor of HPV vaccination, β = -.571, p > .0005.
Females were more likely (61 percent of females) than males (47 percent of males) to
have received the HPV vaccination. The designation of female in the dataset was 2 and
the designation of male was 1, which explains the negative beta coefficient for this result.
Table 13
Logistic Regression Results for Maternal Education, Maternal Age, Maternal
Race/Ethnicity, and Maternal Income as Predictors of Teens’ HPV Vaccine Series
Uptake
Predictor Variable B SE p Odds Ratio
95 % Confidence Intervals for Odds Ratio
Lower Upper Ethnicity
White .453 .194 .02 1.535 1.046 2.254 Black .534 .187 .004 1.799 1.239 2.612
Multi- race/ Other .509 .227 .025 1.796 1.141 2.827
Maternal Age -.096 .112 .387 .908 .730 1.130 Maternal Education -.026 .07 .734 .974 .839 1.132 Maternal Income .013 .024 .595 1.013 .966 1.062 City of Residence .004 .003 .170 1.004 .998 1.010 Child Sex -.571 .131 .0005 .565 .437 .730 Note: For the categorical variable “ethnicity,” Hispanic is the reference category. The outcome variable was coded as 1-yes, 2-no in the dataset; sex was coded 1-male, 2- female in the dataset.
Results
One logistic regression analysis was conducted that tested the specific
associations between the variables in the research questions and the outcome variable,
HPV vaccination. The results of the overall logistic regression are seen in Table 13. Each
81
component of the equation, corresponding to the individual research questions, is
presented below.
Research Question 1
Logistic regression analysis was conducted to investigate the association between
maternal income and uptake of the HPV vaccine series in adolescent males and females
13-17 in communities within the cities of New York City, New York, and Houston,
Texas. The outcome variable of interest was uptake of the HPV vaccine series, and the
possible predictor variable was maternal income. The predictor variable, maternal income
was found to be non-significant β = .013, p > .05. Therefore, no statistically significant
association was found between maternal income and uptake of the HPV vaccine series in
adolescent males and females 13-17 in communities within the cities of New York City,
New York and Houston, Texas.
The null hypothesis that there is no association exists between maternal income
and uptake of the HPV vaccine series in adolescent males and females 13-17 after
controlling for ethnicity and maternal age within the cities of New York City, New York,
and Houston, Texas could not be rejected.
Research Question 2
A logistic regression analysis was conducted to investigate the association
between maternal education and uptake of the HPV vaccine series in adolescent males
and females 13-17 in communities within the cities of New York City, New York and
Houston, Texas. The predictor variable, maternal education was found to be non-
significant β = -.026, p > .05. Therefore, no statistically significant association was found
82
between maternal education and uptake of the HPV vaccine series in adolescent males
and females 13-17 in communities within the cities of New York City, New York and
Houston, Texas.
The null hypothesis that there is no association exists between maternal education
and uptake of the HPV vaccine series in adolescent males and females 13-17 after
controlling for ethnicity and maternal age within the cities of New York City, New York
and Houston, Texas could not be rejected.
Research Question 3
A logistic regression analysis was conducted to investigate the association
between maternal age and uptake of the HPV vaccine series in adolescent males and
females 13-17 in communities within the cities of New York City, New York and
Houston, Texas. The predictor variable, maternal age was found to be non-significant β =
-.096, p > .05. Therefore, no statistically significant association was found between
maternal age and uptake of the HPV vaccine series in adolescent males and females 13-
17 in communities within the cities of New York City, New York and Houston, Texas.
The null hypothesis that there is no association exists between maternal age and
uptake of the HPV vaccine series in adolescent males and females 13-17 within the cities
of New York City, New York, and Houston, Texas could not be rejected.
Research Question 4
A logistic regression analysis was conducted to investigate the association
between ethnicity and uptake of the HPV vaccine series in adolescent males and females
13-17 in communities within the cities of New York City, New York, and Houston,
83
Texas. The predictor variable, ethnicity was found to be significant: Non-Hispanic White
β = .429, p = .029, Non-Hispanic Black β = .587, p = .002, and Non-Hispanic Other β =
.586, p =.011. Therefore, the odds of Hispanic mothers reporting that their child had been
vaccinated were 1.535, 1.799, and 1.796 times that of Whites, African-Americans, and
those identified as multiracial or other race, was found between ethnicity and uptake of
the HPV vaccine series in adolescent males and females 13-17 in communities within the
cities of New York City, New York and Houston, Texas.
The null hypothesis that there is no association exists between ethnicity and
uptake of the HPV vaccine series in adolescent males and females 13-17 within the cities
of New York City, New York, and Houston, Texas was rejected. The evidenced
displayed in the above table suggested that the existence of a relationship between the
ethnicity and uptake of the HPV vaccine series was supported, hence rejecting the null
(Ho) hypothesis.
Summary
In summary, I presented the results of the 2014 NIS-Teen survey as it pertains to
uptake of the HPV vaccine series and maternal SES covariates. A total of 1125
respondents in the estimation areas of New York City, New York and Houston Texas
completed the survey. I used logistic regression analysis to evaluate the relationship
between the four variables of maternal income, maternal education, maternal age, and
ethnicity, and uptake of the HPV vaccine series in adolescent males and females 13-17 in
communities within the cities of New York City, New York and Houston, Texas. Based
on the results of the analysis, I found a statistically significant relationship between the
84
ethnicity and HPV vaccination uptake such that Hispanic teens were approximately twice
as likely to receive at least one dose of HPV vaccine series than teens from all other
ethnicities. The association between ethnicity and HPV vaccination uptake was
statistically significant; therefore, I rejected the null hypothesis. Bivariate analysis of
these variables also showed a relationship between ethnicity and HPV vaccination
uptake. Logistic regression analysis of the other three predictor variables (maternal
income, maternal education, and maternal age) resulted in a non-significant relationship;
therefore, I failed to reject the null hypotheses of these variables. In the next and final
section of the study, I discussed the findings of my research, their potential application to
professional practice, and the implications for social change.
85
Section 4: Application to Professional Practice and Implications for Social Change
Introduction
HPV vaccination coverage in the United States does not meet the Healthy People
2020 goals of an 80% vaccination rate. As a means to gather information that could
improve vaccination programs, I investigated the association between maternal SES
variables and uptake of the human papillomavirus (HPV) vaccine in male and female
adolescents ages 13-17 within the estimation areas of New York City, New York, and
Houston, Texas. The study was designed to provide evidence about maternal SES factors
and their association with HPV vaccine series acceptance. I conducted an analysis of
secondary data from the 2014 NIS-Teen public-use survey dataset. The analysis of the
secondary data was done using SPSS version 21 where univariate, bivariate and
multivariate analyses were done.
Concise Summary of Findings
By analyzing the 2014 NIS-Teen data, I found that ethnicity was a significant
predictor of being vaccinated with the HPV vaccine series. HPV uptake and ethnicity
were found to be significantly related, Pearson χ2 (2, N = 1125) = 8.37, p = .039. The
results of the analysis showed a significant relationship between uptake of the HPV
vaccine series and the ethnicity of the respondents living within the analyzed estimation
areas. The odds of Hispanic mothers reporting that their child had been vaccinated were
1.535, 1.799, and 1.796 times that of Whites, African-Americans, and those identified as
multiracial or other race, respectively. Additionally, a child’s sex was a significant
86
predictor of HPV vaccination, β = -.571, p > .0005. Males had lower odds of being
vaccinated compared to females.
Interpretation of the Findings
Ethnicity
Ethnicity was associated with HPV vaccination uptake in the cities of New York
City, New York, and Houston, Texas. This evidence confirmed the findings of
Bednarczyk et al. (2014), who noted that Hispanic adolescents were consistently higher
in the initiation of the HPV vaccine. Additionally, Kumar & Whynes (2011) found that
ethnicity, childhood immunizations, and usage of preventive and primary care and
cervical screening were predictive of the uptake of the HPV vaccine. Lastly, Lechuga et
al. (2011) indicated that the predictors of HPV vaccine intentions varied by cultural group
and that culture moderated the influence of norms on intentions. The evidence discovered
through my research illustrates a need for additional research to more clearly explain and
find further evidence of the association of ethnicity and the initiation of the HPV
vaccination series in order to improve HPV vaccination initiation across all racial/ethnic
groups.
Maternal Age
Maternal age was not associated with HPV vaccination uptake in the cities of
New York City, New York, and Houston Texas. This non-significant maternal age
association with HPV vaccination uptake disconfirmed the findings of Watson-Jones et
al. (2012), who found that parents who refused vaccination of their daughters tended to
be older household members with less education. As there were not many studies in the
87
literature examining maternal age as a predictor for HPV vaccine uptake, my research
results indicate a need for further research to elucidate the association or lack thereof
between maternal age and HPV vaccine uptake.
Maternal Income
Maternal income was not associated with HPV vaccination uptake in the cities of
New York City, New York, and Houston, Texas. This non-significant maternal income
association with HPV vaccination uptake in my study disconfirms other research. For
example, Musto et al. (2013) found that the participant's neighborhood SES was related
to the likelihood of being HPV vaccinated. Additionally, Bednarczyk et al. (2014) found
that since 2008, adolescents living below the poverty level had higher HPV vaccination
initiation than adolescents above the poverty level. These previous studies showed an
association with maternal income not found in my study but also conflicting maternal
income associations in regards to level of SES. My research extends the knowledge of
maternal income as a possible predictor variable of HPV vaccine uptake and justifies
further research on this variable. As found in the above mentioned studies, maternal
income was found to be inconsistently related to levels of HPV vaccine uptake.
Maternal Education
Lastly, maternal education was not associated with HPV vaccination uptake in the
cities of New York City, New York, and Houston, Texas. This non-significant
association between maternal education and HPV vaccine uptake disconfirms findings by
Dorell et al. (2014), who noted that females that delayed HPV vaccination tended to be
White, come from higher income homes, and have mothers with college degrees.
88
Similarly, Feiring et al. (2015) found an association between higher maternal education
and a lower probability of initiation of the vaccine series, whereas lower education was
associated with a higher likelihood of initiation of the vaccine series. Other studies,
however, suggested that a higher level of education was associated with increased uptake
of the HPV vaccine. Yu et al. (2016) found increased vaccine acceptability to be
associated with older daughters, higher income, and higher level of education. Cullen,
Stokley, and Markowitz (2014) also found that increasing parent education could increase
uptake of the HPV vaccine. My research disconfirms the overall association of maternal
education and HPV vaccine uptake found in these earlier studies. Based on these
contradictory findings in the literature, combined with my finding of a non-significant
association of maternal education and HPV uptake, I recommend further research to
expand knowledge about the role of maternal education as a predictor of HPV
vaccination uptake.
Conceptual Framework
Ethnicity, along with gender, age, personality, socioeconomics, and knowledge
can influence or moderate relationships between health beliefs and health behaviors
(Skinner et al., 2015). Applying the HBM to this study, I found evidence that ethnicity
was more associated with HPV vaccination uptake than the other SES variables
examined. According to the HBM constructs, the various sociodemographic variables of
age, sex, race, education or socioeconomic issues possibly moderate relationships
between health beliefs and health behaviors (Skinner et al., 2015). This concept seemed
consistent in my research as the modifying factor; ethnicity was a significant predictor of
89
HPV vaccine uptake. As this was a secondary data analysis, indirect analysis showed that
ethnicity could affect the perception of susceptibility to cervical cancer. More research is
necessary to directly test the perception of susceptibility to cervical cancer and the
potential moderation of the perception by ethnicity. According to (Skinner et al., 2015),
perceived susceptibility was a major component for the adoption of preventative health
behaviors. My study revealed that ethnicity was a significant factor predicting HPV
vaccination uptake in New York City, New York, and Houston, Texas. The effective use
of the HBM constructs during an HPV immunization program redesign could improve
HPV vaccination coverage across different ethnic groups and across different regions in
the United States. The effective tailoring of HBM construct-driven vaccination programs
towards communities and regions based on ethnic/racial cultural considerations and
barriers could provide a positive impact and enhance HPV vaccination coverage within
the broad range of diverse communities across the United States.
Limitations of the Study
The data used for this study was secondary data originally obtained as part of the
2014 NIS-Teen survey for immunization coverage estimates of 13-17-year-old adolescent
males and females in the United States. The findings of this study cannot be generalized
to the entire U.S. population as the study sample populations were only in the estimation
areas of New York City, New York, and Houston, Texas and not adequate to be fully
representative of the entire U.S. population. Secondary data can create limitations to a
study as well, as the data were not originally collected for the purpose of this research.
Another limitation of the study was that it was based solely on parental recall and if the
90
teen received at least one HPV vaccination. This study did not analyze whether the
respondent’s teen completed the HPV vaccination series. Lastly, this study did not
analyze responses from participants’ vaccine providers to confirm the accuracy and recall
from the parents as compared to the actual vaccination records and to assure the accuracy
and precision of overall vaccination coverage estimate.
Recommendations
My current secondary data analysis only looked at two estimation areas in the
states of New York, and Texas. To be more comprehensive in the research process, other
estimation areas should be quantitatively researched to compare or provide additional
information about maternal SES variables in different regions. Additionally, as this was a
secondary data analysis, further research using an HPV vaccine tailored instrument
grounded in the HBM constructs to analyze parents and medical providers’ responses
regarding maternal SES variables and uptake of the HPV vaccine is recommended.
Another consideration for further research would be in-depth interviews and focus group
discussions to qualitatively analyze participants’ responses. Evidenced by the
contradictions in maternal SES associations in previous research, more research is
necessary to improve the knowledge of maternal SES associations and to minimize or
even eliminate some of the contradictions. Lastly, a study using mixed methods,
qualitative and quantitative with responses gathered by the primary researchers
examining the same maternal SES variables could provide more information that could
further advance the goals of this research.
91
Implications for Professional Practice and Social Change
The study has shown that ethnicity could have a positive or negative effect on
HPV vaccination uptake in New York City, New York, and Houston, Texas. My study
examined researchable modifying factors of the HBM via secondary data analysis to look
at factors that may influence HPV vaccination uptake in large metropolitan areas in
States with high levels of cervical cancer.
Professional Practice
This study provides valuable information gathered through the process of
secondary data research. In regards to professional practice, the findings from this study
could be used to develop and test strategies to improve the uptake of the HPV vaccine
series across the different racial/ethnic groups. The findings of this research could also be
used in the development or the enhancement of culturally-sensitive educational programs
for parents and adolescent teens for use by primary care practitioners. The evidence
found in this study could be used to target the evidenced-based predictors, such as
race/ethnicity as seen in my study in HPV vaccine series educational programs. Lastly,
the evidence found in this study could be used to enhance the knowledge of primary care
health providers about the importance of race/ethnicity sensitive education and literature
to improve the HPV vaccination uptake within their patient populations.
Implications for Research
Findings from this research study showed that future researchers should attempt
to expand the knowledge of the impact of ethnicity on the uptake of the HPV vaccine
series. The study results also indicated that future research should be performed to
92
improve the knowledge and strength of the relationship between ethnicity and uptake of
the HPV vaccine series and to also examine possible regional influences as my study
looked at two cities with different levels of per capita income in different locations in the
United States. These results provided information that can further advance the field of
HPV vaccination research. The study depicted secondary data analysis as a low cost,
effective means of testing relevant hypotheses concerning HPV vaccination uptake and as
a means to explore for associations that may act as facilitators or barriers to HPV
vaccination. This analysis should be repeated to analyze other regions or States in the
U.S. to test the hypotheses of this study. A strength of this study was it was a low-cost
analysis of a public-use secondary data collected annually to check immunization
coverage across the U.S. within the 58 selected geographical regions of the annual NIS.
Positive Social Change
The research was conducted to narrow the gap of previous research concerning
maternal SES variables and their association with uptake of the HPV vaccine series. In
this study, ethnicity was a significant predictor of uptake of the HPV vaccine series, and
more predictive than maternal education, maternal age, and maternal income. As of a
result of this research, this information could contribute to the improvement of HPV
vaccination programs aimed at increasing the coverage to meet the Healthy People 2020
goals. Using these findings to redesign, supplement or enhance HPV vaccination
programs could ultimately reduce overall morbidity and mortality from cervical cancer in
the U.S.
93
Conclusion
The findings from this study revealed that: (a) there is an association between
ethnicity and uptake of the HPV vaccine series in adolescent males and females 13-17
within the cities of New York City, New York, and Houston, Texas, (b) there is not an
association between maternal income and uptake of the HPV vaccine series in adolescent
males and females 13-17 within the cities of New York City, New York, and Houston,
Texas, (c) there is not an association between maternal education and uptake of the HPV
vaccine series in adolescent males and females 13-17 within the cities of New York City,
New York, and Houston, Texas, and (d) there is no association between maternal age and
uptake of the HPV vaccine series in adolescent males and females 13-17 within the cities
of New York City, New York, and Houston, Texas. Vaccination to prevent HPV
infection and subsequent cervical cancers should remain a public health priority, and
more research is necessary to further enhance the knowledge gaps in the uptake of the
HPV vaccine series associations within different communities in the U.S. Additionally,
based on conflicting evidence found in previous research, there is a need for more
research to decrease the contradictory evidence found in the literature on HPV
vaccination acceptance. Although there have been significant improvements in the
identification and treatment of cervical cancer, it is still a significant medical and
financial burden for those affected with the disease. Cervical cancer is much more costly
to treat than to prevent through the uptake of the HPV vaccine series. The evidence found
in the study could be used to potentially enhance educational programs designed to
improve vaccination rates, increase prevention, and reduce the overall incidence of
94
cervical cancer. The use of the results to enhance HPV vaccination programs have the
potential for positive social change by way of improving the lives of individuals,
families, and communities by increasing HPV vaccination and reducing cervical cancer
in the U.S.
95
References
American Cancer Society, Inc. (2014). What is cervical cancer? Retrieved July 23, 2016,
from http://www.cancer.org/cancer/cervicalcancer/detailedguide/cervical-cancer-
what-is-cervical-cancer
Apte, G., Pierre-Joseph, N., Vercruysse, J. L., & Perkins, R. B. (2015). Could poor
parental recall of HPV vaccination contribute to low vaccination rates? Clinical
Pediatrics, 54(10), 987–991. https://doi.org/10.1177/0009922815590115
Attanasio, L., & McAlpine, D. (2014). Accuracy of parental reports of children’s HPV
vaccine status: implications for estimates of disparities, 2009-2010. Public Health
Reports (Washington, D.C.: 1974), 129(3), 237–244.
Bednarczyk, R. A., Curran, E. A., Orenstein, W. A., & Omer, S. B. (2014). Health
disparities in human papillomavirus vaccine coverage: Trends analysis from the
National Immunization Survey-Teen, 2008-2011. Clinical Infectious Diseases: An
Official Publication of the Infectious Diseases Society of America, 58(2), 238–
241. https://doi.org/10.1093/cid/cit707
Blackman, E., Thurman, N., Halliday, D., Butler, R., Francis, D., Joseph, M., … Ragin,
C. C. (2013). Multicenter study of human papillomavirus and the human
papillomavirus vaccine: Knowledge and attitudes among people of African
descent. Infectious Diseases in Obstetrics and Gynecology, 2013, 428582.
https://doi.org/10.1155/2013/428582
Bresse, X., Goergen, C., Prager, B., & Joura, E. (2014). Universal vaccination with the
quadrivalent HPV vaccine in Austria: Impact on virus circulation, public health
96
and cost-effectiveness analysis. Expert Review of Pharmacoeconomics &
Outcomes Research, 14(2), 269–281.
https://doi.org/10.1586/14737167.2014.881253
Brown, B., Blas, M. M., Heidari, O., Carcamo, C., & Halsey, N. A. (2013). Reported
changes in sexual behaviour and human papillomavirus knowledge in Peruvian
female sex workers following participation in a human papillomavirus vaccine
trial. International Journal of STD & AIDS, 24(7), 531–535.
https://doi.org/10.1177/0956462412473891
Btoush, R. M., Brown, D. R., Fogarty, S., & Carmody, D. P. (2015). Initiation of human
papillomavirus vaccination among predominantly minority female and male
adolescents at inner-city community health centers. American Journal of Public
Health, 105(11), 2388–2396. https://doi.org/10.2105/AJPH.2015.302584
Centers for Disease Control and Prevention. (2010). FDA licensure of bivalent human
papillomavirus vaccine (HPV2, Cervarix) for use in females and updated HPV
vaccination recommendations from the Advisory Committee on Immunization
Practices (ACIP). Retrieved July 24, 2016, from
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5920a4.htm
Centers for Disease Control and Prevention. (2011). Recommendations on the use of
quadrivalent human papillomavirus vaccine in males—Advisory Committee on
Immunization Practices (ACIP), 2011. Retrieved May 14, 2016, from
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6050a3.htm
Centers for Disease Control and Prevention. (2013). Vaccine information statement |
97
HPV Cervarix | VIS | CDC. Retrieved March 16, 2016, from
http://www.cdc.gov/vaccines/hcp/vis/vis-statements/hpv-cervarix.html
Centers for Disease Control and Prevention. (2014a). Human papillomavirus
vaccination: Recommendations of the Advisory Committee on Immunization
Practices (ACIP). Retrieved May 14, 2016, from
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6305a1.htm
Centers for Disease Control and Prevention. (2014b). STD Facts--Human papillomavirus
(HPV). Retrieved April 3, 2016, from http://www.cdc.gov/std/hpv/stdfact-
hpv.htm
Centers for Disease Control and Prevention. (2015a). Human papillomavirus (HPV)
infection--2015 STD treatment guidelines. Retrieved January 3, 2016, from
http://www.cdc.gov/std/tg2015/hpv.htm
Centers for Disease Control and Prevention. (2015b). National, regional, state, and
selected local area vaccination coverage among adolescents aged 13–17 years —
United States, 2014. Retrieved September 11, 2016, from
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6429a3.htm
Centers for Disease Control and Prevention. (2015c). About the National Immunization
Surveys. Retrieved April 5, 2016, from http://www.cdc.gov/vaccines/imz-
managers/nis/about.html
Centers for Disease Control and Prevention. (2016). NIS | About the National
Immunization Surveys | Vaccines | CDC. Retrieved July 19, 2016, from
http://www.cdc.gov/vaccines/imz-managers/nis/about.html
98
Centers for Disease Control and Prevention, National Center for Immunization and
Respiratory Diseases, & National Center for Health Statistics. (2015). 2014
National Immunization Survey - Teen.
Centers for Disease Control and Prevention, National Center for Immunization and
Respiratory Diseases, & National Center for Health Statistics. (2015b). National
Immunization Survey-Teen A User’s Guide for the 2014 Public-Use Data File.
Retrieved from
ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Dataset_Documentation/NIS/NIST
EENPUF14_DUG.pdf
Cowburn, S., Carlson, M., Lapidus, J., Heintzman, J., Bailey, S., & DeVoe, J. (2014).
Insurance continuity and human papillomavirus vaccine uptake in Oregon and
California federally qualified health centers. American Journal of Public Health,
104(9), e71–e79. https://doi.org/10.2105/AJPH.2014.302007
Crowcroft, N. S., Hamid, J. S., Deeks, S. L., & Frank, J. (2012). Human papilloma virus
vaccination programs reduce health inequity in most scenarios: a simulation
study. BMC Public Health, 12, 935–935. https://doi.org/10.1186/1471-2458-12-
935
Cullen, K. A., Stokley, S., & Markowitz, L. E. (2014). Uptake of human papillomavirus
vaccine among adolescent males and females: Immunization Information System
sentinel sites, 2009-2012. Academic Pediatrics, 14(5), 497–504.
https://doi.org/10.1016/j.acap.2014.03.005
Daniel-Ulloa, J., Gilbert, P. A., & Parker, E. A. (2016). Human papillomavirus
99
vaccination in the United States: Uneven uptake by gender, race/ethnicity, and
sexual orientation. American Journal of Public Health, 106(4), 746–747.
https://doi.org/10.2105/AJPH.2015.303039
Department of Commerce. (2016a). Houston, Texas. Retrieved from
https://www.bea.gov/regional/bearfacts/pdf.cfm?fips=48225&areatype=48225&g
eotype=4
Department of Commerce. (2016b). Population estimates, July 1, 2015, (V2015).
Retrieved January 8, 2017, from
//www.census.gov/quickfacts/table/PST045215/3918000
Department of Commerce. (2017). NYCdata: Per Capita Income. Retrieved June 2, 2017,
from http://www.baruch.cuny.edu/nycdata/income-taxes/per_cap.htm
Faul, F., Erdfelder, E., Lang, A.-G., & Buchner, A. (2007). G*Power 3:A flexible
statistical power analysis program for the social, behavioral, and biomedical
sciences. Behavior Research Methods, 39, 175–191.
Feiring, B., Laake, I., Molden, T., Cappelen, I., Håberg, S. E., Magnus, P., … Trogstad,
L. (2015). Do parental education and income matter? A nationwide register-based
study on HPV vaccine uptake in the school-based immunisation programme in
Norway. BMJ Open, 5(5), e006422. https://doi.org/10.1136/bmjopen-2014-
006422
Frankfort-Nachmias, C., & Nachimas, D. (2008). Research methods in the social sciences
(7th ed.). New York, NY: Worth Publishers.
Goldberg, D. S. (2014). The implications of fundamental cause theory for priority setting.
100
American Journal of Public Health, 104(10), 1839–1843.
https://doi.org/10.2105/AJPH.2014.302058
Green, S., & Salkind, N. J. (2014). Using SPSS for Windows and Macintosh: Analyzing
and understanding data (7th ed.). Upper Saddle River, NJ: Pearson Education.
Hariri, S., Dunne, E. F., Saraiya, M., Unger, E. R., & Markowitz, L. (2011). Human
Papillomavirus. In S. W. Roush & L. M. Baldy (Eds.), Manual for the
surveillance of vaccine-preventable diseases (5th ed.). Atlanta, GA: Centers for
Disease Control and Prevention.
Harper, D. M., Irons, B. B., Alexander, N. M., Comes, J. C., Smith, M. S., Heutinck, M.
A., … Ahern, D. A. (2014). Quantifying the decisional satisfaction to accept or
reject the Human Papillomavirus (HPV) vaccine: a preference for cervical cancer
prevention. Plos One, 9(2), e88493–e88493.
https://doi.org/10.1371/journal.pone.0088493
Hechter, R. C., Chao, C., Sy, L. S., Ackerson, B. K., Slezak, J. M., Sidell, M. A., &
Jacobsen, S. J. (2013). Quadrivalent human papillomavirus vaccine uptake in
adolescent boys and maternal utilization of preventive care and history of sexually
transmitted infections. American Journal of Public Health, 103(9), e63-68.
https://doi.org/10.2105/AJPH.2013.301495
Hofman, R., van Empelen, P., Vogel, I., Raat, H., van Ballegooijen, M., & Korfage, I. J.
(2013). Parental decisional strategies regarding HPV vaccination before media
debates: a focus group study. Journal of Health Communication, 18(7), 866–880.
https://doi.org/10.1080/10810730.2012.757390
101
IBM Corp. (2016). IBM SPSS Statistics for Macintosh, Version 24.0 (Version 24).
Armonk, NY: IBM Corp. Retrieved from http://www.ibm.com/support,
https://www-304.ibm.com/support/docview.wss?uid=swg21476197
Kumar, V. M., & Whynes, D. K. (2011). Explaining variation in the uptake of HPV
vaccination in England. BMC Public Health, 11, 172.
https://doi.org/10.1186/1471-2458-11-172
Lechuga, J., Swain, G. R., & Weinhardt, L. S. (2011). The cross-cultural variation of
predictors of human papillomavirus vaccination intentions. Journal of Women’s
Health (2002), 20(2), 225–230. https://doi.org/10.1089/jwh.2010.1993
Link, B. G., & Phelan, J. (1995). Social conditions as fundamental causes of disease.
Journal of Health and Social Behavior, Spec No, 80–94.
Lu, P., Dorell, C., Yankey, D., Santibanez, T. A., & Singleton, J. A. (2012). A
comparison of parent and provider reported influenza vaccination status of
adolescents. Vaccine, 30(22), 3278–3285.
https://doi.org/10.1016/j.vaccine.2012.03.015
Luque, J. S., Raychowdhury, S., & Weaver, M. (2012). Health care provider challenges
for reaching Hispanic immigrants with HPV vaccination in rural Georgia. Rural
and Remote Health, 12(2), 1975–1975.
Malkowski, J. (2014). Confessions of a pharmaceutical company: voice, narrative, and
gendered dialectics in the case of Gardasil. Health Communication, 29(1), 81–92.
https://doi.org/10.1080/10410236.2012.719178
McDonald, J. H. (2014). Multiple logistic regression - Handbook of Biological Statistics.
102
Retrieved January 28, 2017, from
http://www.biostathandbook.com/multiplelogistic.html
Millen, J. C., Ginde, A. A., Anderson, A. T., Fang, P., & Camargo, C. A. (2009).
Multicenter Study of Knowledge about Human Papilloma Virus and Attitudes
Among Emergency Department Patients. Journal of Pediatric and Adolescent
Gynecology, 22(6), 356–359. https://doi.org/10.1016/j.jpag.2009.03.001
Moss, J. L., Feld, A. L., O’Malley, B., Entzel, P., Smith, J. S., Gilkey, M. B., & Brewer,
N. T. (2014). Opportunities for increasing human papillomavirus vaccine
provision in school health centers. The Journal of School Health, 84(6), 370–378.
https://doi.org/10.1111/josh.12158
Musto, R., Siever, J. E., Johnston, J. C., Seidel, J., Rose, M. S., & McNeil, D. A. (2013).
Social Equity in Human Papillomavirus Vaccination: a natural experiment in
Calgary Canada. BMC Public Health, 13, 640. https://doi.org/10.1186/1471-2458-
13-640
National Institutes of Health. (2013). NIH Fact Sheets - Cervical Cancer. Retrieved April
11, 2016, from https://report.nih.gov/nihfactsheets/viewfactsheet.aspx?csid=76
Nettleman, M. D., & Garcia-Chen, V. (2013). Vaccinating Through a Lifetime: Adult
Priorities. South Dakota Medicine: The Journal of The South Dakota State
Medical Association, Spec no, 73–79.
NORC at the University of Chicago. (2016). National Immunization Survey (NIS) |
NORC.org. Retrieved October 9, 2016, from
http://www.norc.org/Research/Projects/Pages/national-immunization-survey.aspx
103
Orji, R., Vassileva, J., & Mandryk, R. (2012). Towards an Effective Health Interventions
Design: An Extension of the Health Belief Model. Online Journal of Public
Health Informatics, 4(3). https://doi.org/10.5210/ojphi.v4i3.4321
Phelan, J. C., & Link, B. G. (2013). Fundamental Cause Theory. In C. W. Cockerham
(Ed.), Medical Sociology on the Move: New Directions in Theory (pp. 105–125).
Dordrecht: Springer Netherlands. Retrieved from http://dx.doi.org/10.1007/978-
94-007-6193-3_6
Rahman, M., Laz, T. H., McGrath, C., & Berenson, A. B. (2014). Correlates of Human
Papillomavirus Vaccine Series Completion Among Young Adult Female
Initiators. Human Vaccines & Immunotherapeutics, 10(8), 2163–2167.
https://doi.org/10.4161/hv.29633
Reagan-Steiner, S., Yankey, D., Jeyarajah, J., Elam-Evans, L. D., Singleton, J. A., Curtis,
C. R., … Stokley, S. (2015). National, Regional, State, and Selected Local Area
Vaccination Coverage Among Adolescents Aged 13-17 Years - United States,
2014 (pp. 784–792). Atlanta, United States: U.S. Center for Disease Control.
Retrieved from
http://search.proquest.com.ezp.waldenulibrary.org/healthcomplete/docview/17041
78569/abstract/7D6D3B944448470CPQ/3
Rosenstock, I. M. (1974). Historical Origins of the Health Belief Model. Health
Education Monographs, 2(4), 328–335.
https://doi.org/10.1177/109019817400200403
Ruiz, Á. M., Ruiz, J. E., Gavilanes, A. V., Eriksson, T., Lehtinen, M., Pérez, G., …
104
Haupt, R. M. (2012). Proximity of first sexual intercourse to menarche and risk of
high-grade cervical disease. The Journal of Infectious Diseases, 206(12), 1887–
1896. https://doi.org/10.1093/infdis/jis612
Savoy, M. (2014). An opportunity for improvement: adolescent administration of the
human papillomavirus vaccine. Delaware Medical Journal, 86(2), 53–55.
Schmidt, S., & Parsons, H. M. (2014). Vaccination interest and trends in human
papillomavirus vaccine uptake in young adult women aged 18 to 26 years in the
United States: an analysis using the 2008-2012 National Health Interview Survey.
American Journal of Public Health, 104(5), 946–953.
https://doi.org/10.2105/AJPH.2013.301828
Schuler, C. L., Hanley, C. J., & Coyne-Beasley, T. (2014). Misconception: human
papillomavirus vaccine and infertility. Clinical Pediatrics, 53(2), 158–165.
https://doi.org/10.1177/0009922813504026
Skinner, C. S., Tiro, J., & Champion, V. L. (2015). The Health Belief Model. In K.
Glanz, B. K. Rimer, & K. Viswanath (Eds.), Health behavior: Theory, research,
and practice (5th ed., pp. 75–94). San Francisco, CA: John Wiley & Sons, Inc.
Smith, L. M., Brassard, P., Kwong, J. C., Deeks, S. L., Ellis, A. K., & Lévesque, L. E.
(2011). Factors associated with initiation and completion of the quadrivalent
human papillomavirus vaccine series in an Ontario cohort of grade 8 girls. BMC
Public Health, 11, 645–645. https://doi.org/10.1186/1471-2458-11-645
Smith, L. M., Kaufman, J. S., Strumpf, E. C., & Lévesque, L. E. (2015). Effect of human
papillomavirus (HPV) vaccination on clinical indicators of sexual behaviour
105
among adolescent girls: the Ontario Grade 8 HPV Vaccine Cohort Study. CMAJ:
Canadian Medical Association Journal = Journal De L’association Medicale
Canadienne, 187(2), E74–E81. https://doi.org/10.1503/cmaj.140900
Techakehakij, W., & Feldman, R. D. (2008). Cost-effectiveness of HPV vaccination
compared with Pap smear screening on a national scale: a literature review.
Vaccine, 26. https://doi.org/10.1016/j.vaccine.2008.09.036
Trim, K., Nagji, N., Elit, L., Roy, K., Trim, K., Nagji, N., … Roy, K. (2011). Parental
Knowledge, Attitudes, and Behaviours towards Human Papillomavirus
Vaccination for Their Children: A Systematic Review from 2001 to 2011,
Parental Knowledge, Attitudes, and Behaviours towards Human Papillomavirus
Vaccination for Their Children: A Systematic Review from 2001 to 2011.
Obstetrics and Gynecology International, Obstetrics and Gynecology
International, 2012, 2012, e921236. https://doi.org/10.1155/2012/921236,
10.1155/2012/921236
Union for International Cancer Control (UICC). (2015). Cervical Cancer Initiative (CCI) |
UICC. Retrieved December 3, 2015, from
http://www.uicc.org/programmes/cervical-cancer-initiative-cci/issue
U.S. Food and Drug Administration. (2013). Press Announcements - FDA Approves
New Indication for Gardasil to Prevent Genital Warts in Men and Boys - Gardasil,
October 16, 2009 [WebContent]. Retrieved March 16, 2016, from
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm187003.ht
m
106
Vanderpool, R. C., Van Meter Dressler, E., Stradtman, L. R., & Crosby, R. A. (2015).
Fatalistic Beliefs and Completion of the HPV Vaccination Series Among a
Sample of Young Appalachian Kentucky Women. The Journal of Rural Health :
Official Journal of the American Rural Health Association and the National Rural
Health Care Association, 31(2), 199–205. https://doi.org/10.1111/jrh.12102
van Keulen, H. M., Otten, W., Ruiter, R. A. C., Fekkes, M., van Steenbergen, J.,
Dusseldorp, E., & Paulussen, T. W. G. M. (2013). Determinants of HPV
vaccination intentions among Dutch girls and their mothers: a cross-sectional
study. BMC Public Health, 13, 111–111. https://doi.org/10.1186/1471-2458-13-
111
Watson-Jones, D., Tomlin, K., Remes, P., Baisley, K., Ponsiano, R., Soteli, S., … Hayes,
R. J. (2012). Reasons for Receiving or Not Receiving HPV Vaccination in
Primary Schoolgirls in Tanzania: A Case Control Study. PLOS ONE, 7(10),
e45231. https://doi.org/10.1371/journal.pone.0045231
Yu, Y., Xu, M., Sun, J., Li, R., Li, M., Wang, J., … Xu, A. (2016). Human
Papillomavirus Infection and Vaccination: Awareness and Knowledge of HPV
and Acceptability of HPV Vaccine among Mothers of Teenage Daughters in
Weihai, Shandong, China. PLOS ONE, 11(1), e0146741.
https://doi.org/10.1371/journal.pone.0146741
Zimet, G. D., Rosberger, Z., Fisher, W. A., Perez, S., & Stupiansky, N. W. (2013).
Beliefs, behaviors and HPV vaccine: correcting the myths and the
misinformation. Preventive Medicine, 57(5), 414–418.
107
https://doi.org/10.1016/j.ypmed.2013.05.013
- Walden University
- ScholarWorks
- 2018
- Maternal Socioeconomic Status and Human Papilloma Virus Vaccine Uptake
- Shawn Lockett
