Background Although physician recommendation is one of the strongest predictors of human papillomavirus (HPV) vaccination, it is unclear for whom physicians are recommending the vaccine. To help guide intervention efforts, this study investigated predictors of participant-reported physician recommendation for HPV vaccine among young adults in the USA.
Methods Women and men (N=223) aged 18–26 years were recruited online through Craigslist, a popular classified advertisements website. Ads were posted in the 25 largest US cities from September 2013 to March 2014. Participants completed a survey that assessed demographic and sociopolitical characteristics, sexual history, HPV vaccination history, and whether they had ever received a recommendation for HPV vaccine from a physician or healthcare provider.
Results Fifty-three per cent reported receiving a recommendation for HPV vaccine and 45% had received ≥1 dose of HPV vaccine. Participants who received a recommendation were over 35 times more likely to receive ≥1 dose of HPV vaccine relative to participants without a recommendation. Bivariable and multivariable correlates of provider recommendation were identified. Results from the multivariable model indicated that younger (aged 18–21 years), female, White participants with health insurance (ie, employer-sponsored or some other type such as military-sponsored) were more likely to report receiving a recommendation for HPV vaccine.
Conclusions Results suggest that physician recommendation practices for HPV vaccination vary by characteristics of the patient. Findings underscore the key role of the healthcare provider in promoting HPV vaccination and have important implications for future HPV vaccine interventions with young adults.
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Human papillomavirus (HPV) is a common sexually transmitted infection that can cause genital warts and anogenital and oropharyngeal cancers. In the USA, a quadrivalent HPV vaccine was approved for women aged 9–26 years in 2006 and for men of the same age in 2009. The quadrivalent vaccine protects against two oncogenic HPV types (16 and 18) responsible for most anogenital cancers and two non-oncogenic HPV types (6 and 11) responsible for most cases of genital warts.1 A bivalent vaccine that protects against HPV types 16 and 18 is also available for women only. The Advisory Committee on Immunization Practices (ACIP) currently recommends routine use of quadrivalent HPV vaccine for girls and boys aged 11 years or 12 years and catch-up vaccination for women aged 13–26 years and men aged 13–21 years, although men aged 22–26 may also be vaccinated.1 Vaccination could prevent thousands of HPV-related cancer deaths in the USA each year; however uptake of HPV vaccine has been low, particularly among young adults. As of 2012, only 34.5% of women and 2.3% of men aged 19–26 years had received at least one dose of HPV vaccine.2
One of the strongest predictors of HPV vaccination is provider recommendation.3 ,4 Nevertheless, little is known about characteristics that differentiate patients who receive versus do not receive a recommendation for HPV vaccine. A handful of studies suggest that provider recommendation practices for HPV vaccine vary by patient characteristics (ie, characteristics of the adolescent receiving the vaccine or the adolescent's mother). For example, physicians are more likely to recommend the vaccine to female than male adolescents.5 Additionally, non-Hispanic White patients are more likely to report receiving a recommendation for HPV vaccine than are racial/ethnic minorities, specifically non-Hispanic Black patients.6 Mothers’ education and health insurance status also predict provider recommendation such that mothers with a high school (vs college) degree and mothers without health insurance (vs employer-sponsored) are less likely to report receiving a recommendation.6 Other research suggests that the adolescent's age may affect provider recommendation practices. For instance, one study found that a significantly lower proportion of physicians strongly recommended HPV vaccine for 11–12-year olds relative to older adolescents (those age 13 years or older).7
As previous research has focused almost exclusively on adolescent girls and their mothers, the current study sought to identify predictors of provider recommendation for HPV vaccination among a national sample of young adult men and women. Focusing on this age group is important as young adults are at high risk for HPV infection.1 In addition to demographic factors we examined sociopolitical characteristics (eg, religious background, political orientation) and patient health factors (eg, sexual history, prior HPV infection) that are associated with HPV vaccine uptake and thus may predict provider recommendation practices.8 ,9
Participants and procedure
We recruited 246 participants through the ‘Volunteers’ section of Craigslist, a classified advertisements website for jobs, housing, and a variety of goods and services. Ads containing the survey link were posted in the 25 most populated cities in the USA. Ads were posted three times per week in one city at a time (as dictated by Craigslist rules) between September 2013 and March 2014. To encourage participation, participants were offered the chance to win one of two Amazon gift cards. We excluded individuals who did not meet the age requirement (18–26 years old; n=6), those who failed to complete the survey (n=16) or those that took the survey more than once (n=1), resulting in a final sample of 223. Respondent characteristics are provided in table 1.
After providing informed consent, participants completed a questionnaire assessing demographic characteristics (eg, age, gender), current health insurance coverage, sociopolitical characteristics (political affiliation, whether participants were raised with any specific religion, current religious preference), sexual history (whether they had ever had sex, number of lifetime sexual partners, HPV diagnosis history), provider recommendation for HPV vaccine and HPV vaccination status. Participants received a brief description about HPV and the HPV vaccine before answering questions about HPV vaccination. The questionnaire is available as a web only appendix.
Data analytical strategy
We used logistic regression analysis to examine the relationship between physician recommendation (yes/no) and HPV vaccine uptake (receipt of ≥1 dose vs no doses). We used bivariable logistic regression analysis to assess the relationship between physician recommendation and potential predictors (eg, demographic, sociopolitical and sexual history variables). Variables associated with physician recommendation at p≤0.10 were subsequently entered into a multivariable logistic regression analysis.
Forty-five per cent of participants received at least one dose of HPV vaccine and of those, 75% completed the three-dose series. A little over half (53%) reported that a physician or healthcare provider had recommended they should receive the HPV vaccine. Importantly, participants who reported receiving a provider recommendation were over 35 times more likely to have received ≥1 dose of HPV vaccine relative to participants who did not receive a recommendation, unadjusted OR=35.61, Wald=71.73, p<0.001, 95% CI (15.58 to 81.40) (data not reported in table 1).
Results of the bivariable and multivariable logistic regression analyses are given in table 1. At the bivariable level age, gender, race, education, health insurance coverage, political leaning, current religious preference and number of lifetime partners predicted physician recommendation. In the multivariable analysis age, gender, race and health insurance coverage emerged as independent predictors of physician recommendation.
Consistent with previous research,3 ,4 physician recommendation was a strong predictor of HPV vaccine uptake in this sample of young adult men and women. Moreover, important sociodemographic differences were observed among young adults who reported receiving versus not receiving a recommendation. Specifically, younger (aged 18–21 years), female, White participants with health insurance (ie, employer-sponsored or some other type such as military-sponsored) were more likely to report receiving a recommendation for HPV vaccine relative to older (aged 22–26 years), male, racial minority participants without health insurance. Findings underscore the key role of the healthcare provider in promoting HPV vaccination and have important implications for future HPV vaccine interventions with young adults.
Participant characteristics that independently predicted provider recommendation included age, gender, race and health insurance coverage. Previous studies suggest that physicians may be more comfortable recommending the HPV vaccine to older (ages 13–18 years) relative to younger (ages 11–12 years) adolescents.7 We found that participants aged 18–21 years were more likely to report receiving a recommendation than participants aged 22–26 years. Likewise, women were over 10 times more likely to receive a recommendation than were men. This finding was reflected in a recent study by Malo and colleagues10 who reported that relatively few physicians were regularly recommending HPV vaccine to their male patients. Low rates of provider recommendation among relatively older men in the current study could reflect the fact that ACIP's recommendation for routine vaccination of men did not occur until 2011 and the catch-up window for men only extends to age 21 years. White participants were over 2.5 times more likely to report receiving a recommendation than were racial minorities, a finding similar to one reported in a study of adolescent girls.6 Although we did not observe a relationship between participant race and health insurance coverage (data not reported), racial minorities often have poorer access to healthcare, which could translate into fewer opportunities to receive a recommendation for HPV vaccine. Consistent with this notion, we found that participants with health insurance (although not Medicaid), were more likely to report receiving a recommendation for HPV vaccine than uninsured participants.
Many of the sociodemographic characteristics associated with provider recommendation for HPV vaccine mirror those characteristics associated with HPV vaccine receipt.8 ,9 Beyond patients simply following the advice of their providers, one explanation for the similarity is that providers are recommending HPV vaccine to those patients they believe are most accepting of the vaccine. Physicians have limited time during clinical encounters and thus may be especially likely to recommend HPV vaccine to those patients they perceive are interested in receiving it. Recommendation practices could also be influenced by provider assumptions about who is most likely to benefit from vaccination, who is most likely to be able to pay for the vaccine and/or who has more favourable attitudes towards the vaccine, assumptions that could vary based on a patient's sociodemographic characteristics.5
In summary, this is one of the first studies to investigate participant-reported provider recommendation practices for HPV vaccine among a national sample of young adult men and women. Primary limitations include its small sample size, relatively low number of male participants, predominantly urban sample, use of self-reported provider recommendation, and use of volunteer participants. Despite these limitations, findings suggest that physician recommendation practices for HPV vaccination vary by characteristics of the patient. Differential recommendation practices could have important implications for public health, as recommending HPV vaccine more readily to some groups than others could contribute to disparities in HPV uptake. Additional research is needed to elucidate why physicians may differentially recommend HPV vaccine. Such information will be crucial for the development of future HPV vaccination interventions with healthcare providers.
This was a volunteer study, and had a lack of rural women participants.
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
- Data supplement 1 - Online supplement
Portions of this paper were presented at the 2015 Annual Meeting and Scientific Sessions of the Society of Behavioural Medicine in San Antonio, Texas.
Handling editor Jackie A Cassell
Contributors All authors made substantial contributions to the conception and design of the study. MAG and MAS oversaw the acquisition of data, analysed the data and collaborated in the writing of the manuscript. All authors assisted with the interpretation of the results and revised the manuscript critically for intellectual content.
Funding This research was supported by internal funding from the lead author's former institution.
Competing interests None declared.
Patient consent Obtained.
Ethics approval Human Subjects Committee at Florida State University (#2012.9497).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The lead author is willing to make data from this article available to interested individuals. Individuals should email the lead author explaining the nature of the request and describe how the data will be used.