Received: 22 September 2020
DOI: 10.1111/hir.12393
|
Revised: 14 June 2021
|
Accepted: 29 June 2021
ORIGINAL ARTICLE
Information seeking behaviour differences indicate which US
population groups lack information about human papilloma
virus and associated cancer risks
Bahareh Ansari MBA
Department of Information Science,
University at Albany-­State University of
New York, Albany, New York, USA
Correspondence
Bahareh Ansari, Department of
Information Science, University at
Albany-­SUNY, Draper Hall Room 015,
135 Western Ave, Albany, NY 12203,
USA.
Email: bansari@albany.edu
Abstract
Background: The majority of the US population have poor knowledge of cancers
related to human papillomavirus (HPV). Identifying best sources for communicating
this information can guide strategies to promote HPV vaccination.
Objectives: To assess the relationship between sources of health information and
individuals’ knowledge of HPV-­related cervical and oropharyngeal cancer.
Methods: This study conducts logistic regression on the most recent wave (2019) of
the Health Information National Trends Survey. Dependent variables are indicators
for self-­reported awareness that HPV causes (a) cervical cancer and (b) oropharyngeal cancer. The primary indicator is a variable for different sources of health information: The Internet, professional sources, print materials, friends/family and never
looked for health information.
Results: Being female, young, non-­
Hispanic White and having college education is associated with higher odds of knowing about HPV-­related cervical cancer.
Controlling for demographic factors, individuals using professionals and the Internet
are more likely to know that HPV causes cervical cancer (aOR: 2.65, 95% CI: 1.66,
4.25; aOR: 2.47, 95% CI: 1.75, 3.50, respectively) compared to those who have never
looked for health information. Similar results were found for HPV-­related oropharyngeal cancer.
Conclusion: Findings provide implications for targeted messaging through effective
channels to improve HPV vaccination uptake.
KEYWORDS
health literacy, information seeking behaviour, patient education, patient information, public health
I N T RO D U C T ION
Human papillomavirus infection (HPV) is a common virus
that spreads through intimate skin-­to-­skin contact, and clears
naturally in most cases, but a small fraction of HPV infections can persist and result in cancer (de Sanjosé et al., 2018).
There is ongoing research about the causal link between HPV
and different types of cancer (Kreimer et al., 2020; Saraiya
42
| © 2021 Health Libraries Group
et al., 2015), but there are established links between HPV and
six types of cancer including cervical cancer, vulvar, vaginal, penile, anal and oropharyngeal cancers (Forman et al.,
2012). In the United States, HPV is the most common sexually transmitted infection with 42 million infected persons in
2018 (Lewis et al., 2021), and an average of 34,800 HPV-­
attributable cancers reported annually during 2012–­
2016
(Senkomago et al., 2019).
wileyonlinelibrary.com/journal/hir
Health Info Libr J. 2023;40:42–53.
KNOWLEDGE OF HPV AND ASSOCIATED CANCERS
Human papillomavirus vaccination can prevent the HPV
infection and cancer (Brouwer et al., 2019; Meites et al.,
2016). HPV vaccination is probably most effective when
given to adolescent girls and boys. There is strong evidence
that HPV vaccines protect adolescent girls and young women
against cervical cancer (Morrison & Lasserson, 2018).
Additionally, the HPV vaccine in males seems to be effective in preventing genital warts and external genital lesions
(Bergman et al., 2019). A recent analysis shows that after the
introduction of the HPV vaccine for young females in 2006,
HPV vaccine-­
type prevalence has continued to decrease
among young females compared with years before vaccination (Rosenblum et al., 2021).
Despite the evidence on protective effects of the HPV
vaccine, uptake in the United States has been low, especially
in South and Midwestern states that generally have higher
rates of cervical cancer compared with Northeast and West
states (Hirth, 2019). A recent analysis of HPV vaccination
uptake shows that only 54% of US adolescents were up to
date in terms of HPV vaccination in 2019, and this percentage was significantly lower among those who live above the
poverty level in rural areas. This might indicate that HPV
vaccine disparity is driven by vaccine hesitancy rather than
lack of access (Elam-­Evans et al., 2020). Vaccine hesitancy
is determined by complex-­and context-­dependent factors
which vary from vaccine to vaccine, place to place and time
to time (Larson et al., 2014). There is currently limited evidence on effective interventions to deal with vaccine hesitancy (Machado et al., 2021).
Several interventions were implemented to increase HPV
vaccine awareness and uptake, including social marketing,
physician-­focused interventions and school-­based programs
(Niccolai & Hansen, 2015). However, barriers remain in
the acceptance of HPV vaccine. Some of these barriers include low-­perceived risk of HPV infection, concerns about
the vaccine's effect on sexual behaviour, vaccine cost, social
influences, irregular preventive care and mistrust in health
information from medical authorities (Cooper et al., 2017;
Holman et al., 2014; Nan et al., 2014). Although school entry
mandates have been effective in the uptake of other vaccinations, existing evidence suggests that school-­entry mandates
were not effective in HPV vaccination uptake (Cuff et al.,
2016; Pierre-­Victor et al., 2017). A systematic review of the
interventions to increase uptake of HPV vaccination shows
that there is strong evidence that educating adolescents and
their parents can improve vaccine acceptance, and there is
moderate evidence that providing health care providers with
education and personalised feedback can improve the uptake
(Abdullahi et al., 2020).
The important role of vaccine hesitancy in low rates of
vaccination uptake, and the existing evidence on the effectiveness of educational interventions can explain the importance
of available HPV information and the need to disseminate
| 43
Key Messages
• The majority of the US population do not know
that HPV can cause different types of cancers.
• Older age, racial/ethnic minority and lower education level are associated with disparities in the lay
public's gaps in HPV-­related knowledge.
• Controlling for demographic factors, professional
sources and the Internet can be effective channels
for disseminating information about HPV-­related
cancers.
• Health care providers should communicate the
scientific evidence on HPV-­related cancers in accessible language to all pre-­teen parents with specific attention to racial/ethnic minority groups.
• Information professionals should collaborate with
health care providers to help consumers use reliable online resources and professional advice,
with specific attention to particular demographic
groups.
this information through effective channels. Although the
majority of the US population has heard of HPV, they have
poor knowledge of the causal relationship between HPV and
cancer (Mcbride & Singh, 2018; Zavaski et al., 2019). One
determinant of low level of HPV knowledge could be the frequent changes of the federal recommendations in terms of
dosing schedule, age criteria and gender (Kim et al., 2021).
But it is also possible that the promotional campaigns have
not yet been successful in reaching adolescents and hesitant
parents and engaging them with high-­quality information in
effective formats.
Human papillomavirus information can be obtained from
a variety of sources, including the Internet, physicians, health
professionals, print materials such as newspapers, pamphlets,
brochures or magazines, and informal sources such as friends
and families. These sources may have different effects in
reaching and engaging different populations. For example, a
potentially effective channel to disseminate HPV information
to younger population could be through sharing educational
videos featuring health care providers on YouTube, or sharing
information memes and infographics on Instagram (Koskan
et al., 2021). Also, different habitual sources of health information can predict variations in persons’ knowledge about
health topics. For example, compared with those who saw
anti-­tobacco messages on passive media channels such as
television, individuals who were exposed to anti-­
tobacco
messages on active media channels such as social media were
more likely to believe that different tobacco products are addictive (Donaldson et al., 2017).
44
| Investigation of the relationship between HPV knowledge
and habitual sources of health information can identify the
best channels to effectively reach and engage those who have
not yet been convinced about the benefits of HPV vaccination. However, investigation of this relationship must take
into account demographic factors that could drive this association. For example, previous studies have found that men
were less likely to be aware of HPV and HPV vaccination
than women (Osazuwa-­peters et al., 2017), and non-­Hispanic
Black and Hispanic men and women had lower awareness
about HPV and HPV-­related cancers compared with their
White counterparts (Cooper et al., 2017; Ojeaga et al., 2019).
Moreover, older age, low-­educational attainment, and low income were among predicting factors of lower levels of HPV-­
related knowledge (Blake et al., 2015; Koshiola et al., 2009;
Mcbride & Singh, 2018). These demographic factors were
also associated with persons’ information seeking behaviour
(Kim & Kwon, 2010; Koch-­weser et al., 2010). Therefore,
it is possible that some of the variations in persons’ HPV-­
related knowledge can be explained by habitual sources of
health information (if any). To the best of my knowledge, no
study has investigated the potential association between individuals’ sources of health information and their HPV-­cancer
knowledge. This study aims to assess whether persons who
use different sources for obtaining health information have
varying knowledge of HPV-­related cervical and oropharyngeal cancer.
M ET H O D S
KNOWLEDGE OF HPV AND ASSOCIATED CANCERS
complex sampling method (HINTS, 2020). The final HINTS
5, Cycle 3 sample consists of 5438 respondents whose data
were collected in three modes: 3372 using a paper only questionnaire, 986 using a paper questionnaire with a web option,
and 1080 using a paper only questionnaire with a web option
that comes with bonus. This study tested for difference between the respondents, and found no significant differences
in HPV-­cancer knowledge between the groups of respondents using different modes of data collection. Therefore, all
respondents are included in this study, but because of missing data of the dependent variables, the final sample includes
3946 respondents in the regression model examining the oropharyngeal cancer knowledge, and 4024 respondents in the
regression model examining the cervical cancer.
Variables
Dependent variables
There are two dependent variables for knowledge about
whether HPV causes (a) cervical cancer and (b) oropharyngeal cancer. These are based on survey questions about
whether the respondent has heard about HPV, and among
those who answered in affirmative, whether they think HPV
can cause cervical cancer and oropharyngeal cancer. For simplification, the HINTS questions use the term “oral cancer”
instead of “oropharyngeal cancer”. In this manuscript, the
correct term (oropharyngeal cancer) is used.
Study design and data source
Independent variable
This study uses a cross-­sectional design based on the 2019
Health Information National Trends Survey (HINTS 5,
Cycle 3), which is a nationally representative repeated cross-­
sectional survey conducted by the National Cancer Institute
every few years. HINTS 5, Cycle 3 uses different modes of
data collection including a self-­administered mailed questionnaire, a web option mode which offers respondents
a choice between responding via paper or web, and a web
bonus mode which offers respondents a choice between responding via paper or web with an additional $10 incentive
for web respondents (HINTS, 2020).
The main independent variable is an indicator of the primary
source of health information, classified into five categories:
Internet, print sources (such as books, brochures), friends and
family, professionals (such as health care providers, cancer
organisation), and never looked for health information. This
is based on two survey questions “Have you ever looked for
information about health or medical topics from any source?”,
and among those who responded affirmative, “The most recent time you looked for information about health or medical
topics, where did you go first?” The current study treats this
variable as an indication of the frequency of the use of different sources. However, it is important to note that the first
source used on the most recent information-­seeking occasion is not a perfect index of information seeking behaviour.
Sources of information is usually complicated, and people
may use different sources for one query. Moreover, gathering
health information is not necessarily active, and sometimes
health information is gathered accidentally through available
sources such as mass media depending on how much people
trust these sources (Ruppel, 2016).
Sample
The HINTS uses a nationally representative, multi-­
stage
probability-­based sample of the civilian non-­institutionalised
adult population of the United States (aged 18 or older).
Targeted households are chosen from Marketing Systems
Group (MSG) of addresses in the United States, using a
KNOWLEDGE OF HPV AND ASSOCIATED CANCERS
Control variables
TABLE 1
Sample characteristics
N (%)a
Potential confounders are identified from the literature investigating demographic factors associated with HPV knowledge and the choice of health information sources. Factors
that may influence HPV knowledge include gender, race/ethnicity, income, education and marital status (Adjei Boakye
et al., 2017; Blake et al., 2015; Cooper et al., 2017; Mcbride
& Singh, 2018; Zavaski et al., 2019). Factors that may affect persons’ sources of information include age, education,
income, living in rural/urban areas (Befort et al., 2013; Koch-­
weser et al., 2010). Gender, age, race/ethnicity, marital status, household income and education are included as control
variables in the regression models.
Gender
Male
2236 (48.8)
Female
3073 (51.2)
Race/Ethnicity
Non-­Hispanic White
3054 (63.5)
Non-­Hispanic Black
677 (11.3)
Hispanic
730 (16.8)
Non-­Hispanic Asian
224 (5.3)
Other
165 (3.1)
Household income
Analytic methods
Descriptive statistics assess the overall level of knowledge that HPV causes cervical or oropharyngeal cancer.
Chi-­
square tests for bivariate analyses assess unadjusted
differences in the source of information by demographic
characteristic. Multivariate logistic regression models assess
the odds of knowing HPV causes cancer in persons with different sources of health information, adjusting for gender,
age, race, marital status, household income and education.
These predictors are included in the model because each
had significant unadjusted bivariate associations with the
source of information in the data. To account for the complex
multi-­stage sampling design of the survey, survey combined
weights (which combines all three modes paper-­only, web-­
option and web-­bonus), and jackknife variance estimation
method are used in all analyses (HINTS, 2020). Jackknife
method is a resampling method (similar to bootstrapping)
and it is chosen for variance estimation because it is compatible with the sample design and weighting procedure of the
HINTS. All analyses were performed using SAS version 9.4.
All statistical significance tests were two-­tailed with the significance level of p < 0.05.
<$20K
904 (18.5)
$20K–­$35K
614 (11.0)
$35K–­$50K
630 (13.5)
$50K–­$75K
848 (17.4)
>$75K
1802 (39.6)
Education
Less than High School
334 (7.0)
Completed High School
946 (23.4)
Some college
1591 (40.2)
College graduate
2481 (29.5)
Marital status
Married
2847 (55.7)
Never Married
882 (30.4)
Divorce/widow/separated
1538 (13.9)
Age
18–­34 years old
687 (24.3)
35–­49 years old
986 (24.5)
50–­64 years old
1668 (31.1)
≥65 years old
1961 (20.2)
HPV-­related cervical cancer knowledge
Know that HPV can cause cervical cancer
2660 (51.8)
Do not know (not sure) that HPV causes
cervical cancer
2387 (48.2)
HPV-­related oropharyngealb cancer knowledge
RE S U LTS
Table 1 summarises the characteristics of the HINTS5 cycle
3 sample, which shows an overall appropriate representation
of the US population. After adjusting for non-­response and
complex sampling design (using survey weights and jackknife
variance estimation method), the sample consists of 51.2%
female, 55.7% married and 24.3% between 18 and34 years
old. 63.5% of the sample are non-­Hispanic White, while
11.3% are non-­Hispanic Black, 16.8% are Hispanic and 5.3%
are non-­Hispanic Asian. This distribution is similar to the
US population which includes 60.1% non-­Hispanic White,
| 45
Know that HPV can cause oropharyngeal cancer
1096 (21.3)
Do not know (not sure) that HPV causes
oropharyngeal cancer
3846 (78.7)
a
Numbers represent the frequency of responses in each group, and percentages
are weighted column percentages that represent distribution of characteristics of
the sample.
b
Instead of oropharyngeal cancer, the term “oral cancer” is used in the survey.
13.4% non-­Hispanic Black, 18.5% Hispanic and 5.9% non-­
Hispanic Asian (U.S. Census Bureau, 2021); 29.5% of the
sample consists of college graduates (compared with 32.1%
of persons 25+ years old in the United States that have
46
| KNOWLEDGE OF HPV AND ASSOCIATED CANCERS
Bachelors’ degree or higher), and 39.6% live in households
with 75,000 dollars household income and higher (compared
with the median household income of 62,843 dollars in the
United States). Overall, there is a higher awareness of the
HPV-­cervical cancer relationship, compared with the HPV-­
oropharyngeal cancer relationship. Among respondents to
the cervical cancer question, 51.8% were aware that HPV
can cause cervical cancer, and among respondents to the oropharyngeal cancer question, 21.3% were aware that HPV can
cause oropharyngeal cancer.
TABLE 2
Table 2 shows the characteristics of the HINTS5 cycle
3 sample by the source of health information (frequencies
and weighted percentages of demographic characteristics
stratified by the primary source of health information, and a
chi-­square test to assess whether differences in demographic
characteristics by source of information are statistically
significant). Overall, all chi-­square tests show statistically
significant differences between demographic groups, and
some interesting relationships can be observed for some of
these demographic variables. For example, women were
Sample characteristics stratified by sources of health information
Total
Internet
a
Print
sources
Friends
family
Professionals
Never looked for
health information
N (%)
N (%)
N (%)
N (%)
χ2
p-­valueb
0.0005
N
N (%)
Male
1957
1073 (54.4)
110 (3.9)
55 (2.4)
290 (13.3)
429(26.0)
Female
2698
1584 (60.5)
140 (5.0)
93 (3.9)
395 (12.6)
486 (18.0)
Non-­Hispanic White
2750
1760 (63.8)
118 (3.7)
77 (2.9)
407 (13.0)
388 (16.6)
Non-­Hispanic Black
583
282 (44.7)
48 (5.5)
20 (2.4)
100 (16.6)
133 (30.8)
Gender
Race/Ethnicity
Hispanic
615
286 (49.1)
42 (6.3)
29 (6.0)
68 (7.0)
190 (31.5)
Non-­Hispanic Asian
196
119 (61.2)
6 (1.1)
2 (0.6)
20 (11.7)
49 (25.4)
Other
136
79 (50.7)
11 (8.0)
7 (2.1)
16 (25.5)
23 (13.7)
773
269 (41.3)
68 (5.4)
25 (1.5)
139 (13.9)
272 (37.9)
<0.0001
Household income
<$20K
$20K–­$35K
530
247 (47.3)
48 (6.2)
19 (3.7)
92 (16.6)
124 (26.2)
$35K–­$50K
545
302 (52.2)
22 (5.1)
27 (6.3)
94 (12.4)
100 (24.1)
$50K–­$75K
751
482 (66.2)
27 (3.2)
13 (1.3)
108 (10.8)
121 (18.6)
≥$75K
1614
1164 (68.4)
56 (3.0)
51 (3.7)
178 (12.9)
165 (12.1)
<0.0001
Education
Less than High School
266
49 (22.1)
25 (7.4)
11 (4.9)
54 (17.5)
127 (48.1)
Completed High
School
822
306 (41.7)
47 (4.0)
30 (2.5)
122 (11.7)
317 (40.2)
Some college
1401
769 (61.1)
86 (4.9)
46 (3.5)
248 (15.8)
252 (14.7)
College graduate
2147
1531 (73.4)
94 (3.3)
61 (3.1)
259 (9.5)
202 (10.7)
Married
2537
1589 (61.1)
123 (4.3)
77 (2.7)
349 (12.9)
399 (19)
Never Married
769
441 (55.4)
37 (3.2)
29 (4.1)
93 (12.6)
169 (24.7)
Divorce/widow/
separated
1318
614 (49.0)
89 (5.7)
40 (3.3)
243 (14.9)
332 (27.1)
18–­34 years old
606
399 (61.3)
16 (2.5)
34 (4.9)
55 (9.1)
102 (22.2)
35–­49 years old
850
596 (64.8)
21 (2.9)
22 (2.2)
65 (9.5)
146 (20.7)
<0.0001
Marital status
0.0017
Age
50–­64 years old
1473
899 (59.1)
62 (3.6)
38 (2.3)
199 (13.5)
275 (21.5)
≥65 years old
1711
761 (42.8)
150 (8.6)
52 (3.7)
366 (21.6)
382 (23.4)
<0.0001
a
Numbers represent the frequency of responses in each group, and percentages are weighted row percentages that represent distribution of characteristics in each group
of the source of health information.
b 2
χ p-­value is calculated using the survey weights with Jackknife Method (50 replicates) to account for complex sampling design.
KNOWLEDGE OF HPV AND ASSOCIATED CANCERS
more likely to use the Internet (60.5% of women compared
to 54.4% of men), and men were more likely to have never
looked for health information (26% of men compared to 18%
of women). Non-­Hispanic White and non-­Hispanic Asian respondents were more likely to use the Internet (63.8% and
61.2% respectively) than non-­Hispanic Black or Hispanic respondents (44.7% and 49.1% respectively). Print sources and
friends or family are used rarely for any group. Professionals
play a more important role as the information source of
non-­Hispanic Black and those with race/ethnicity other than
Hispanic, and non-­Hispanic White, Black, or Asian (this includes American Indian or Alaska Native, Native Hawaiian or
other Pacific Islander, and multiple races). Interesting inverse
relationships can be observed between household income/education and “never looked for health information”: the likelihood of never looking for health information decreases with
higher household income and higher education. The opposite can be observed for use of the Internet: the likelihood of
using the Internet increases with higher income/education.
Table 3 shows the unadjusted frequencies and weighted
percentages of self-­reported knowledge that HPV causes cervical and oropharyngeal cancer stratified by sources of health
information. Differences in knowledge were observed by the
source of information for both cervical cancer (p < 0.0001)
and oropharyngeal cancer (p < 0.0001). For example, among
those who use the Internet as the source of health information,
61.1% knew that HPV can cause cervical cancer and 23.7%
knew that HPV can cause oropharyngeal cancer. But among
those who use professional sources of health information,
53.0% knew about the HPV-­cervical cancer relationship and
27.7% knew about the HPV-­oropharyngeal cancer relationship. Among those who never looked for health information,
only 27.0% were aware of the HPV-­cervical cancer relationship and only 9.7% were aware of the HPV-­oropharyngeal
cancer relationship.
Tables 4 and 5 present odd ratios with confidence intervals from regression models comparing different sources
of health information, adjusted for age, gender, education,
marital status, household income and race/ethnicity. The adjusted odds of knowing about the HPV-­cervical cancer relationship is higher among women than men (adjusted odds
ratio (aOR) = 2.60, 95% CI: 1.96, 3.44). The adjusted odds
of HPV-­oropharyngeal cancer knowledge are not statistically
different between men and women (aOR = 1.24, 95% CI:
0.96, 1.60). There are differences by age group for knowledge
of cervical cancer. Individuals aged 65 and older have less
knowledge of HPV-­related cervical cancer, with the highest
knowledge among the 35–­49 age group (aOR = 2.14, 95%
CI: 1.59, 2.87). There is limited evidence for differences by
age group for knowledge that HPV causes oropharyngeal
cancer. Compared to individuals aged 65 and older, respondents aged 18–­34 and 35–­49 did not have statistically significant different odds of reporting this knowledge, but there
| 47
was a difference among persons aged 50–­64 compared to
those aged 65 and older (aOR = 1.31, 95% CI: 1.04, 1.66).
Compared with those who have less than high school education, those who have some college education, and college
graduates have higher odds of knowing about the HPV-­
related cervical cancer (some college education vs. less than
high school: aOR = 1.76, 95% CI: 1.01, 3.08; college graduates vs. less than high school: aOR=2.64, 95% CI: 1.39,
5.01). Among racial/ethnic groups, only non-­Hispanic Black
has significantly lower odds of HPV-­related cervical cancer
awareness compared with non-­Hispanic Whites (aOR=0.56,
95% CI: 0.37, 0.86).
After adjusting for age, gender, education, household
income, marital status and race/ethnicity, regression results
show significant higher adjusted odds of awareness about
HPV-­related cancers among those who use the Internet or
professional sources, compared with not looking for health
information. Those who use the Internet as the source of
health information are 2.47 times more likely to know that
HPV can cause cervical cancer (95% CI: 1.75, 3.50), and are
2.07 times more likely to know that HPV can cause oropharyngeal cancer (95% CI: 1.31, 3.26). Also, those who use professional sources of health information are 2.65 times more
likely to know that HPV can cause cervical cancer (95%
CI: 1.66, 4.25) and are 3.11 times more likely to know that
HPV can cause oropharyngeal cancer (95% CI: 1.72, 5.65).
However, the use of friends and family and print sources of
health information is not associated with significant higher
odds of HPV-­cancer knowledge.
DISCUSSION
HPV is a common sexually transmitted virus that can cause
different types of cancer in men and women. Knowing about
HPV-­
related cancers can encourage persons to vaccination and prevention of HPV infection and related cancers
(Rodriguez et al., 2020). HPV vaccination in the United States
is currently recommended to all pre-­teen boys and girls at age
of 11–­12 years old, as well as teens and young adults through
age 26 years who have not started or finished the HPV vaccine series (Centers for Disease Control and Prevention
[CDC], n.d.). Results of this study show that adjusted for demographic characteristics, persons who use sources such as
the Internet or professionals have significantly higher odds of
knowing that HPV causes cervical and oropharyngeal cancer,
compared to those who never looked for health information.
But individuals who use print sources (e.g. pamphlets and
brochures), or informal sources (e.g. friends and family) do
not have significantly different HPV knowledge than those
who never looked for health information. Furthermore, holding the source of health information constant, findings of the
current study suggest that being female, young, non-­Hispanic
48
| TABLE 3
KNOWLEDGE OF HPV AND ASSOCIATED CANCERS
Unadjusted self-­reported knowledge that HPV causes cervical and oropharyngeal cancer stratified by sources of health information
Source of health information in the most recent time
Total
a
N (%)
Internet
Print
sources
Friends
Family
Professionals
Never looked for
health information
N (%)
N (%)
N (%)
N (%)
N (%)
χ2
p-­valueb
<0.0001
HPV-­related cervical cancer knowledge
Know that HPV can cause
cervical cancer
2358
1645 (61.1)
93 (49.0)
71 (51.0)
309 (53.0)
240 (27.0)
Do not know or not sure that HPV
causes cervical cancer
2097
944 (38.9)
136
(51.0)
72 (49.0)
332 (47.0)
613 (73.0)
HPV-­related oropharyngeal c cancer knowledge
Know that HPV can cause
oropharyngeal cancer
962
666 (23.7)
41 (19.4)
24 (22.0)
143 (27.7)
88 (9.7)
Do not know or not sure that HPV
causes oropharyngeal cancer
3405
1878 (76.3)
184
(80.6)
116
(78.0)
477 (72.3)
750 (90.3)
<0.0001
a
Numbers represent the frequency of responses in each group, and percentages are weighted column percents that represent distribution of HPV knowledge for each
group of information source.
b 2
c
χ p-­value is calculated using the survey weights with Jackknife Method (50 replicates) to account for complex sampling design.
Instead of oropharyngeal cancer, the term “oral cancer” is used in the survey.
White and having college education is associated with higher
odds of knowing about HPV-­related cervical cancer, and
higher education and income are associated with higher odds
of knowing about HPV-­related oropharyngeal cancer.
Findings of this study suggest that HPV vaccination messages have not yet engaged some groups of the population including older parents, racial/ethnic minorities and those with
lower education. The decision-­making process of parents to
vaccinate their children consists of several steps: unaware of
the HPV vaccination, unengaged with the decision, undecided about vaccination, decided to vaccinate/not to vaccinate and vaccinate. A previous investigation of UK parents
shows that only a small percentage of parents have made their
decision to not get their children HPV vaccination, and most
parents are undecided and can be persuaded with convincing
presentation of information (Waller et al., 2020). The population groups with lower knowledge about HPV-­attributable
cancers may be at any of these decision-­making stages, and
disseminating accessible information through effective channels to parents at any of these stages can improve the rates of
vaccination uptake.
One promising channel for distributing HPV information
based on the current study's findings is the Internet. This finding is encouraging because dissemination of health messages
on the Internet requires lower cost and effort. Furthermore,
the Internet is an important source of information for adolescents and young adults who are the target population of HPV
prevention messages (Koch-­weser et al., 2010). However,
reliable sources of information on the Internet are not easily accessible to everyone. And, 17.3% of US households
do not have a broadband Internet subscription (U.S. Census
Bureau, 2021). Moreover, the Internet is also a great source
of misinformation, and might be a risky channel if reliable
websites are not consulted. For example, a recent study
found that stories of HPV vaccine-­related harms more often
come from social and traditional media, and hearing such
stories discourages parents from vaccinating their children
(Margolis et al., 2019). To counter these stories, some health
departments and health care groups work hard to disseminate
reliable information in accessible formats on their websites
(CDC, n.d.; Planned parenthood, n.d.). These sources may
be working well for knowledgeable health consumers who
know where to look for such information, but may be less
useful for those who are not motivated to look for health
information online, or those who do not know where they
can find reliable online health information. In general, individuals with lower education/health literacy, less trust in the
health care system, and more positive views about alternative
medicine are more susceptible to online health misinformation (Scherer et al., 2021). Helping these population groups
to find trusted sources of information by themselves may increase the chances of accepting vaccine messages and move
from undecided or unengaged to decide to get their children
vaccinated.
Another promising channels of disseminating HPV information, as findings of this study suggest, are professionals. This is consistent with previous studies that verified the
effectiveness of professional sources in communicating the
HPV knowledge (Cooper et al., 2017; Morales-­Campos &
Vanderpool, 2018), and suggested the patient-­provider communication as an important intervention for improving HPV
knowledge in the US population (Mcbride & Singh, 2018;
KNOWLEDGE OF HPV AND ASSOCIATED CANCERS
TABLE 4
| 49
Adjusted associations between sources of health information and knowledge of HPV-­related cervical cancer
HPV-­related cervical cancer knowledge
Joint test
p-­valueb
OR
CIa
Friends and Family vs. No active source
1.55
0.73
3.33
Internet vs. No active source
2.47***
1.75
3.50
Print sources vs. No active source
2.06
0.96
4.41
Professionals vs. No active source
2.65***
1.66
4.25
Non-­Hisp. Asian vs. non-­Hisp. White
0.54
0.29
1.02
Non-­Hisp. Black vs. non-­Hisp. White
0.56**
0.37
0.86
Hispanic vs. non-­Hisp. White
0.92
0.63
1.35
Others vs. non-­Hisp. White
1.28
0.49
3.37
$20K–­$35K vs. ≥$75K
0.74
0.46
1.22
$35K–­$50K vs. ≥$75K
0.66
0.43
1.01
$50K–­$75K vs. ≥$75K
0.86
0.59
1.24
<$20K vs. ≥$75K
0.57*
0.33
0.98
College graduate vs. Less than High School
2.64**
1.39
5.01
Completed High School vs. Less than High
School
0.87
0.47
1.61
Some college vs. Less than High School
1.76*
1.01
3.08
Divorce/widow/separated vs. Never married
0.98
0.65
1.50
Married vs. Never married
0.98
0.68
1.40
2.60***
1.96
3.44
<0.0001
18–­34 years old vs. ≥65 years old
1.91**
1.30
2.80
<0.0001
35–­49 years old vs. ≥65 years old
2.14***
1.59
2.87
50–­64 years old vs. ≥65 years old
1.757***
1.34
2.31
Source of health information
<0.0001
Race/ethnicity
0.0161
Income
0.2094
Education
<0.0001
Marital status
0.9907
Gender
Female vs. Male
Age
*p < 0.05, **p < 0.01, ***p < 0.001.
a
Confidence Intervals are calculated using the survey weights to account for complex sampling design and non-­response bias
b
Joint test p-­value is the result of type 3 analysis of effects which tests for the overall effect of a variable with multiple categories.
Wigfall et al., 2019). However, HPV communication is a
complex task for providers, as they have to initiate a conversation about children's sexual activities with the parents
of pre-­teens at very young ages. A recent review of provider
communication about HPV vaccination (Gilkey & McRee,
2016) shows that health care providers do not always endorse
HPV vaccine strongly, and perceiving parents as hesitant, or
perceiving patients to be low risk decreases the chance of
recommending HPV vaccine. Moreover, health care providers are less likely to discuss HPV vaccination with parents
of non-­Hispanic Black or Hispanic adolescents (Gilkey &
McRee, 2016). This is concerning as the current study finds
that health care providers are a more important source of
health information for non-­Hispanic Black population, and
would probably most benefit from unambiguous communication with health care providers.
More effective and easier provider communication with
racial/ethnic minority groups requires tailored culturally sensitive health messaging (Baezconde-­Garbanati et al., 2014).
Race, ethnicity, language and socioeconomic status are suggested to be correlated with health communication behaviours
such as cancer information seeking, attention to health in
the media and trust in cancer information (Viswanath &
Ackerson, 2011). This study confirms the need for provider
communication especially for non-­Hispanic Black population, as differences in HPV knowledge was persistent after
50
| TABLE 5
KNOWLEDGE OF HPV AND ASSOCIATED CANCERS
Adjusted associations between sources of health information and knowledge of HPV-­related oropharyngeal cancer
HPV-­related oropharyngeal cancer knowledge
OR
CIa
Joint test p-­valueb
Friends & Family vs. No active source
2.27
0.66
7.83
Internet vs. No active source
2.07**
1.31
3.26
Print sources vs. No active source
1.72
0.74
3.97
Professionals vs. No active source
3.11***
1.72
5.65
Non-­Hisp. Asian vs. non-­Hisp. White
0.62
0.34
1.11
Non-­Hisp. Black vs. non-­Hisp. White
0.66
0.41
1.07
Hispanic vs. non-­Hisp. White
1.27
0.73
2.21
Other vs. non-­Hisp. White
2.36
0.76
7.32
$20K–­$35K vs. ≥$75K
1.58
0.88
2.84
$35K–­$50K vs. ≥$75K
0.61
0.33
1.13
$50K–­$75K vs. ≥$75K
1.17
0.81
1.70
<$20K vs. ≥$75K
1.06
0.61
1.84
College graduate vs. Less than High School
2.50
0.97
6.45
Completed High School vs. Less than High
School
1.01
0.40
2.52
Some college vs. Less than High School
1.91
0.80
4.56
Divorce/widow/separated vs. Never married
0.97
0.63
1.50
Married vs. Never married
1.04
0.72
1.51
1.24
0.96
1.60
0.1045
18–­34 years old vs. ≥65 years old
1.21
0.80
1.85
0.1255
35–­49 years old vs. ≥65 years old
1.02
0.73
1.
50–­64 years old vs. ≥65 years old
1.31*
1.04
1.66
Source of health information
0.0059
Race/ethnicity
0.0485
Income
0.0161
Education
0.0021
Marital status
0.9195
Gender
Female vs. Male
Age
*p < 0.05, **p < 0.01, ***p < 0.001.
a
Confidence Intervals are calculated using the survey weights to account for complex sampling design and non-­response bias
b
Joint test p-­value is the result of type 3 analysis of effects which tests for the overall effect of a variable with multiple categories.
adjusting for the source of health information, and findings
show that provider communication is an important source of
health information among non-­Hispanic Black population.
However, this communication needs to be culturally sensitive, as perception of HPV-­related risks, and HPV vaccination is different among different groups (Pitts et al., 2017).
Tailored messages can target the specific perceptions and
cultural values of a population to have more lasting effect on
their knowledge and behaviour (Petty et al., 2009). Targeted
messaging to encourage African American parents toward
HPV vaccination may include acknowledgement of the historical mistreatment of government, health care providers
and pharmaceutical companies, using a clear language about
eligibility, side-­effects, risks, benefits (especially cancer prevention) and finally inclusion of diverse groups in terms of
age, gender and race in campaign efforts (Lama et al., 2021).
Findings of the current study have some implications for
information professionals. This study finds that use of different sources of health information predicts varying levels
of knowledge. Findings suggest that some population groups
require more assistance from information professionals including racial/ethnic minority groups, older individuals,
those with lower education or health literacy levels, and those
with no access to reliable Internet at home. Furthermore,
the information channel is important. Even after adjusting
for demographic characteristics associated with improved
KNOWLEDGE OF HPV AND ASSOCIATED CANCERS
knowledge, those who use the print sources or informal
sources such as friends and family are not better informed
than those who never look for the health information. These
results are consistent with previous studies that show seeking information from active sources such as the Internet or
professional sources engages individuals in the information
seeking process and may affect the extent to which they internalise the knowledge (Kelly et al., 2010; Petty et al., 2009).
Furthermore, engaging formats of health messages such as
narrative messaging with audio and video have suggested to
improve the effectiveness of HPV awareness messages (Nan
et al., 2016). Using such formats are possible through active
information sources, and therefore, can make them a better
source for dissemination of knowledge.
This study has several limitations that suggest areas for
future research. First, because of the cross-­sectional design of
this study and therefore the inability to demonstrate a temporal relationship, these results cannot be used to infer a causal
relationship between the source of health information and the
HPV knowledge. By controlling for demographic characteristics, this study rules out the possibility that demographic
factors may confound the relationship between the source of
health information and the HPV knowledge, but many unobserved factors remain that may confound the investigated
relationship. Second, the predictor variable used in this study
captures persons’ general sources of information which may
change over time and across different topics. Therefore, it is
hard to say whether respondents gained information about
HPV-­related cancer through this general source, or through a
couple of different sources. Future studies should use experimental design to further investigate the effectiveness of different information sources to improve HPV awareness, and
ultimately, vaccination uptake.
CO NC LU S IO N
Information about HPV-­
associated cancers have not yet
reached many individuals in the United States, and some
population groups are disproportionately affected including
racial/ethnic minorities, older people and those with lower
education levels. Older individuals are not the target audience of HPV information because they would not need this
information to vaccinate themselves or their children. But,
lack of knowledge among racial/ethnic minorities and those
with lower education is alarming, and confirms a need to
prioritise these groups for communication and messaging
around HPV, and HPV vaccination. The most effective channels for distributing this information are professionals and
the Internet. Both of these channels have advantages and disadvantages. Health care provider communication is a trusted
source for many population groups, but it is complicated
| 51
for health care providers to initiate the conversation about
sexually transmitted infections with pre-­teen parents. On the
other hand, the Internet provides opportunity for dissemination of information in engaging formats, but finding quality
information on the Internet can be challenging. To reach and
engage more people in the communication regarding HPV
vaccination, targeted messaging through effective channels
can provide the best result.
ACKNOWLEDGEMENTS
I am immensely grateful to Dr. Erika Martin for her comments on the earlier versions of the manuscript.
CONFLICT OF INTERESTS
None.
ORCID
Bahareh Ansari
R E F E R E NC E S
https://orcid.org/0000-0001-5064-6481
Abdullahi, L. H., Kagina, B. M., Ndze, V. N., Hussey, G. D., &
Wiysonge, C. S. (2020). Improving vaccination uptake among
adolescents. The Cochrane Database of Systematic Reviews (1).
Art. No, CD011895. https://doi.org/10.1002/14651​858.CD011​
895.pub2
Adjei Boakye, E., Tobo, B. B., Rojek, R. P., Mohammed, K. A.,
Geneus, C. J., & Osazuwa-­Peters, N. (2017). Approaching a decade since HPV vaccine licensure: Racial and gender disparities
in knowledge and awareness of HPV and HPV vaccine. Human
Vaccines & Immunotherapeutics, 13(11), 2713–­2722. https://doi.
org/10.1080/21645​515.2017.1363133
Baezconde-­Garbanati, L. A., Chatterjee, J. S., Frank, L. B., Murphy, S.
T., Moran, M. B., Werth, L. N., Zhao, N., de Herrera, P. A., Mayer,
D., Kagan, J., & O’Brien, D. (2014). Tamale Lesson: A case study
of a narrative health communication intervention. Journal of
Communication in Healthcare, 7(2), 82–­92.
Befort, C. A., Nazir, N., Engelman, K., & Choi, W. (2013). Fatalistic
cancer beliefs and information sources among rural and urban
adults in the United States. Journal of Cancer Education, 28(3),
521–­526. https://doi.org/10.1007/s1318​7-­013-­0496-­7.Fatal​istic
Bergman, H., Buckley, B. S., Villanueva, G., Petkovic, J., Garritty, C.,
Lutje, V., Riveros-­Balta, A. X., Low, N., & Henschke, N. (2019).
Comparison of different human papillomavirus (HPV) vaccine
types and dose schedules for prevention of HPV-­related disease
in females and males. Cochrane Database of Systematic Reviews
(11), CD013479. https://doi.org/10.1002/14651​858.CD013479
Blake, K. D., Ottenbacher, A. J., Rutten, L. J. F., Grady, M. A., Kobrin,
S. C., Jacobson, R. M., & Hesse, B. W. (2015). Predictors of
human papillomavirus awareness and knowledge in 2013: Gaps
and opportunities for targeted communication strategies. American
Journal of Preventive Medicine, 48(4), 402–­410. https://doi.
org/10.1016/j.amepre.2014.10.024.Predi​ctors
Brouwer, A. F., Eisenberg, M. C., Carey, T. E., & Meza, R. (2019).
Multisite HPV infections in the United States (NHANES 2003–­
2014): An overview and synthesis. Preventive Medicine, 123, 288–­
298. https://doi.org/10.1016/j.ypmed.2019.03.040
52
| Centers for Disease Control and Prevention [CDC]. (n.d.). Genital HPV
infection -­Fact sheet. Retrieved March 29, 2020, from https://
www.cdc.gov/std/hpv/stdfa​ct-­hpv.htm.
Cooper, D. L., Hernandez, N. D., Rollins, L., Akintobi, T. H., &
McAllister, C. (2017). HPV vaccine awareness and the association of trust in cancer information from physicians among males.
Vaccine, 35(20), 2661–­2667. https://doi.org/10.1016/j.vacci​
ne.2017.03.083.HPV
Cuff, R. D., Buchanan, T., Pelkofski, E., Korte, J., Modesitt, S. P., &
Pierce, J. Y. (2016). Rates of human papillomavirus vaccine uptake
amongst girls five years after introduction of statewide mandate in
Virginia. American Journal of Obstetrics & Gynecology, 214(6),
752.e1–­752.e6. https://doi.org/10.1016/j.ajog.2016.03.022
de Sanjosé, S., Brotons, M., & Pavón, M. A. (2018). The natural history of human papillomavirus infection. Best Practice and
Research: Clinical Obstetrics & Gynaecology, 47, 2–­13. https://
doi.org/10.1016/j.bpobg​yn.2017.08.015
Donaldson, E. A., Hoffman, A. C., Zandberg, I., & Blake, K. (2017).
Media exposure and tobacco product addiction beliefs: Findings
from the 2015 Health Information National Trends Survey
(HINTS–­FDA 2015). Addict Behavior, 72, 106–­113. https://doi.
org/10.1016/j.addbeh.2017.04.001.Media
Elam-­Evans, L. D., Yankey, D., Singleton, J. A., Sterrett, N., Markowitz,
L. E., Williams, C. L., Fredua, B., McNamara, L., & Stokley, S.
(2020). National, regional, state, and selected local area vaccination coverage among adolescents aged 13–­17 years -­United States,
2019. MMWR Morbidity & Mortality Weekly Report, 69(33),
1109–­1116. https://doi.org/10.15585/​mmwr.mm6933a1
Forman, D., de Martel, C., Lacey, C. J., Soerjomataram, I., Lortet-­
Tieulent, J., Bruni, L., Vignat, J., Ferlay, J., Bray, F., Plummer, M.,
& Franceschi, S. (2012). Global burden of human papillomavirus
and related diseases. Vaccine, 30(Suppl 5), F12–­23.
Gilkey, M. B., & McRee, A. L. (2016). Provider communication about HPV vaccination: A systematic review. Human
Vaccine & Immunotheraputics., 12(6), 1454–­1468. https://doi.
org/10.1080/21645​515.2015.1129090
HINTS. (2020). Overview of the HINTS cycle 3 survey and data analysis recommendations. https://hints.cancer.gov.
Hirth, J. (2019). Disparities in HPV vaccination rates and HPV prevalence in the United States: A review of the literature. Human
Vaccines & Immunotherapeutics, 15(1), 146–­155. https://doi.
org/10.1080/21645​515.2018.1512453
Holman, D. M., Benard, V., Roland, K. B., Watson, M., Liddon, N.,
& Stokley, S. (2014). Barriers to human papillomavirus vaccination among US adolescents: A systematic review of the literature.
JAMA Pediatrics, 168(1), 76. https://doi.org/10.1001/jamap​ediat​
rics.2013.2752
Kelly, B., Hornik, R., Romantan, A., Schwartz, J. S., Armstrong, K.,
DeMichele, A., Fishbein, M., Gray, S., Hull, S., Kim, A., Nagler,
R., Niederdeppe, J., Ramírez, S. A., Smith-­McLallen, A., & Wong,
N. (2010). Cancer information scanning and seeking in the general
population. Journal of Health Communication, 15(7), 734–­753.
https://doi.org/10.1080/10810​730.2010.514029.Cancer
Kim, D., Lee, H., & Kim, M. (2021). Overview of human papillomavirus vaccination policy changes and its impact in the United States:
Lessons learned and challenges for the future. Public Health
Nursing, 38(3), 396–­405. https://doi.org/10.1111/phn.12873
Kim, K., & Kwon, N. (2010). Profile of e-­Patients: Analysis of their cancer information-­seeking from a national survey. Journal of Health
KNOWLEDGE OF HPV AND ASSOCIATED CANCERS
Communication, 15(7), 712–­733. https://doi.org/10.1080/10810​
730.2010.514031
Koch-­weser, S., Bradshaw, Y. S., Gualtieri, L., & Gallagher, S. S. (2010).
The Internet as a Health Information Source: Findings from the
2007 Health Information National Trends Survey and Implications
for Health Communication. Journal of Health Communication,
15(3), 279–­293. https://doi.org/10.1080/10810​730.2010.522700
Koshiola, J., Finney-­Ruttenb, L., Moserc, R. P., & Hessed, N. (2009).
Knowledge of human papillomavirus. Journal of Health
Communication, 14(4), 331–­345. https://doi.org/10.1080/10810​
73090​28730​67.Knowl​edge
Koskan, A., Cantley, A., Li, R., Silvestro, K., & Helitzer, D. (2021)
College students’ digital media preferences for future HPV vaccine
campaigns. Journal of Cancer Education, Published on 02 May
2021. https://doi.org/10.1007/s1318​7-­021-­02022​-­1
Kreimer, A. R., Chaturvedi, A. K., Alemany, L., Anantharaman, D.,
Bray, F., Carrington, M., Doorbar, J., D'Souza, G., Fakhry, C.,
Ferris, R. L., Gillison, M., Neil Hayes, D., Hildesheim, A., Huang,
S. H., Kowalski, L. P., Lang Kuhs, K. A., Lewis, J., Lowy, D. R.,
Mehanna, H., … Brennan, P. (2020). Summary from an international cancer seminar focused on human papillomavirus (HPV)-­
positive oropharynx cancer, convened by scientists at IARC and
NCI. Oral Oncology, 108, 104736. https://doi.org/10.1016/j.oralo​
ncolo​gy.2020.104736
Lama, Y., Qin, Y., Nan, X., Knott, C., Adebamowo, C., Ntiri, S. O., &
Wang, M. Q. (2021). Human papillomavirus vaccine acceptability
and campaign message preferences among African American parents: A Qualitative Study. Journal of Cancer Education, 2, 1–­11.
https://doi.org/10.1007/s1318​7-­021-­02014​-­1
Larson, H. J., Jarrett, C., Eckersberger, E., Smith, D. M., & Paterson,
P. (2014). Understanding vaccine hesitancy around vaccines and
vaccination from a global perspective: A systematic review of published literature, 2007–­2012. Vaccine, 32(19), 2150–­2159. https://
doi.org/10.1016/j.vacci​ne.2014.01.081
Lewis, R., Laprise, J., Gargano, J., Unger, E. R., Querec, T. D., Chesson,
H. W., Brisson, M., & Markowitz, L. (2021). Estimated prevalence and incidence of disease-­associated human papillomavirus
types among 15-­to 59-­year-­olds in the United States. Sexually
Transmitted Diseases, 48(4), 273–­277. https://doi.org/10.1097/
OLQ.00000​00000​001356
Machado, A. A., Edwards, S. A., Mueller, M., & Saini, V. (2021).
Effective interventions to increase routine childhood immunization coverage in low socioeconomic status communities in developed countries: A systematic review and critical appraisal of
peer-­reviewed literature. Vaccine, 39(22), 2938–­2964. https://doi.
org/10.1016/j.vacci​ne.2021.03.088
Margolis, M., Brewer, N., Shah, P., Calo, W., & Gilkey, M. (2019).
Stories about HPV vaccine in social media, traditional media, and
conversations. Preventive Medicine, 118, 251–­256. https://doi.
org/10.1016/j.ypmed.2018.11.005
Mcbride, K. R., & Singh, S. (2018). Predictors of adults ’ knowledge and
awareness of HPV, HPV-­associated cancers, and the HPV vaccine
: Implications for health education. Health Education & Behavior,
45(1), 68–­76. https://doi.org/10.1177/10901​98117​709318
Meites, E., Kempe, A., & Markowitz, L. E. (2016). Use of a 2-­dose
schedule for human papillomavirus vaccination —­updated recommendations of the advisory committee on immunization practices.
MMWR. Morbidity and Mortality Weekly Report, 65, 1405–­1408.
https://doi.org/10.15585/​mmwr.mm6549a5
KNOWLEDGE OF HPV AND ASSOCIATED CANCERS
Morales-­Campos, D. Y., & Vanderpool, R. C. (2018). Examining differences in HPV awareness and knowledge and HPV vaccine
awareness and acceptability between U.S. Hispanic and island
Puerto Rican women. Journal of Health Disparities Research and
Practice, 10(3), 1–­18.
Morrison, J., & Lasserson, T. (2018). HPV vaccination: Balancing facts.
The Cochrane Database of Systematic Reviews, 6(ED000126),
https://doi.org/10.1002/14651​858.ED000126
Nan, X., Futerfas, M., & Ma, Z. (2016). Role of narrative perspective
and modality in the persuasiveness of public service advertisements promoting HPV vaccination. Health Communication, 32(3),
320–­328. https://doi.org/10.1080/10410​236.2016.1138379
Nan, X., Zhao, X., & Briones, R. (2014). Parental cancer beliefs and
trust in health information from medical authorities as predictors
of HPV vaccine acceptability. Journal of Health Communication,
19, 100–­114. https://doi.org/10.1080/10810​730.2013.811319
Niccolai, L. M., & Hansen, C. E. (2015). Practice-­and community-­based
interventions to increase human papillomavirus vaccine coverage:
A systematic review. JAMA Pediatrics, 169(7), 686–­692. https://
doi.org/10.1001/jamap​ediat​rics.2015.0310
Ojeaga, A., Alema-­Mensah, E., Rivers, D., Azonobi, I., & Rivers, B.
(2019). Racial disparities in HPV-­related knowledge, attitudes, and
beliefs among African American and White Women in the USA.
Journal of Cancer Education, 34, 66–­72. https://doi.org/10.1007/
s1318​7-­017-­1268-­6
Osazuwa-­peters, N., Adjei Boakye, E., Mohammed, K. A., Tobo, B. B.,
Geneus, C. J., & Schootman, M. (2017). Not just a woman’ s business ! Understanding men and women’ s knowledge of HPV, the
HPV vaccine, and HPV-­associated cancers. Preventive Medicine,
99, 299–­304. https://doi.org/10.1016/j.ypmed.2017.03.014
Petty, R. E., Barden, J., & Wheeler, S. C. (2009). The Elaboration
Likelihood Model of persuasion: Developing health promotions for
sustained behavioral change. In R. J. DiClemente, R. A. Crosby &
M. Kegler (Eds.), Emerging theories in health promotion practice
and research (2nd edn, pp. 185–­214). San Francisco: Jossey-­Bass.
Pierre-­Victor, D., Page, T. F., Trepka, M. J., Stephens, D. P., Li, T.,
& Madhivanan, P. (2017). Impact of Virginia's school-­
entry
vaccine mandate on human papillomavirus vaccination among
13–­17-­year-­old females. Journal of Womens Health, 26(3), 266–­
275. https://doi.org/10.1089/jwh.2016.5869
Pitts, M. J., Stanley, S. J., & Kim, S. (2017). College males’ enduring and novel health beliefs about the HPV vaccine. Health
Communication, 32(8), 995–­1003. https://doi.org/10.1080/10410​
236.2016.1196421
Planned parenthood. (n.d.). Human papillomavirus (HPV). Retrieved
March 29, 2020, from https://www.plann​edpar​entho​od.org/learn/​
stds-­hiv-­safer​-­sex/hpv
Rodriguez, S. A., Mullen, P. D., Lopez, D. M., Savas, L. S., & Fernandez,
M. E. (2020). Factors associated with adolescent HPV vaccination
in the US: A systematic review of reviews and multilevel framework to inform intervention development. Preventive Medicine,
131. https://doi.org/10.1016/j.ypmed.2019.105968
Rosenblum, H. G., Lewis, R. M., Gargano, J. W., Querec, T. D., Unger,
E. R., & Markowitz, L. E. (2021). Declines in prevalence of human
papillomavirus vaccine-­type infection among females after introduction of vaccine -­United States, 2003–­2018. MMWR Morbidity
and Mortality Weekly Report, 70(12), 415–­420. https://doi.
org/10.15585/​mmwr.mm7012a2
Ruppel, E. K. (2016). Scanning health information sources: Applying
and extending the comprehensive model of information seeking.
| 53
Journal of Health Communication, 21(2), 208–­216. https://doi.
org/10.1080/10810​730.2015.1058438
Saraiya, M., Unger, E. R., Thompson, T. D., Lynch, C. F., Hernandez, B.
Y., & Lyu, C. W. …, HPV Typing of Cancers Workgroup. (2015).
US assessment of HPV types in cancers: Implications for current and 9-­valent HPV vaccines. Journal of the National Cancer
Institute, 107(6), djv086. https://doi.org/10.1093/jnci/djv086
Scherer, L. D., McPhetres, J., Pennycook, G., Kempe, A., Allen, L. A.,
Knoepke, C. E., Tate, C. E., & Matlock, D. D. (2021). Who is
susceptible to online health misinformation? A test of four psychosocial hypotheses. Health Psychology, 40(4), 274–­284. https://doi.
org/10.1037/hea00​00978
Senkomago, V., Henley, S. J., Thomas, C. C., Mix, J. M., Markowitz, L. E.,
& Saraiya, M. (2019). Human papillomavirus-­attributable cancers -­
United States, 2012–­2016. MMWR Morbidity and Mortality Weekly
Report, 68, 724–­728. https://doi.org/10.15585/​mmwr.mm6833a3
U.S. Census Bureau (2021). Quick facts United States. Retrieved May
9, 2021, from https://www.census.gov/quick​facts/​fact/table/​US/
PST04​5219.
Viswanath, K., & Ackerson, L. K. (2011). Race, ethnicity, language,
social class, and health communication inequalities: A nationally-­
representative cross-­sectional study. PLoS One, 6(1). https://doi.
org/10.1371/journ​al.pone.0014550
Waller, J., Forster, A., Ryan, M., Richards, R., Bedford, H., & Marlow,
L. (2020). Decision-­making about HPV vaccination in parents
of boys and girls: A population-­based survey in England and
Wales. Vaccine, 38(5), 1040–­1047. https://doi.org/10.1016/j.vacci​
ne.2019.11.046
Wigfall, L. T., Sherman, L. D., Garney, W. R., Patterson, M. S., Montiel,
F. A., & Vadaparampil, S. T. (2019). Are health care providers
making the most of patient encounters to promote HPV vaccination among cigarette smokers? Patient Education and Counseling,
103(1), 180–­188. https://doi.org/10.1016/j.pec.2019.07.026
Zavaski, M. E., Hanske, J., Löppenberg, B., Cole, A. P., Hanna, N., Gupta,
S., Eswara, J. R., Preston, M. A., Kibel, A. S., Lipsitz, S. R., Sun,
M., Trinh, Q.-­D., & Meyer, C. P. (2019). Contemporary perceptions
of human papillomavirus and penile cancer: Perspectives from a national survey. Canadian Urological Association Journal, 13(2), 32.
AUTHOR BIOGRAPHY
Bahareh Ansari is a Ph.D. candidate in the department
of Information Science at the University at Albany, State
University of New York. Her research lies in the intersection of informatics areas including information seeking
behaviour, data analytics, data visualisation, and human-­
computer interaction, and areas including open data, public health and health information.
How to cite this article: Ansari, B. (2023).
Information seeking behaviour differences indicate
which US population groups lack information about
human papilloma virus and associated cancer risks.
Health Information & Libraries Journal, 40(1),
42–­53. https://doi.org/10.1111/hir.12393
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