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Examining Barriers to Obtaining HPV Vaccinations in Lincoln, Nebraska
by
Brianna Loeck
Bachelors of Arts in Human Relations, Doane College, 2013
Applied Research Project Paper
Submitted in Partial Fulfillment
of the Requirements for the Degree of
Master in Public Health
Concordia University, Nebraska
December 2014
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Abstract
Background: Human Papillomavirus (HPV) is the most common sexually transmitted
virus among men and women in the United States. There are two vaccines, Gardasil and
Cervarix that have been developed and are readily available. They are designed for
preventing HPV related cancers and reducing mortalities.
Aim: The aim of this study was to examine health care providers viewpoint on their
attitudes and beliefs regarding the HPV vaccine and their patients.
Methods: A quantitative study was conducted utilizing electronic surveys of which were
administered to medical professionals who are employed in health departments, hospitals,
clinics, and private practices in Lincoln, Nebraska.
Results: The results of this study showed there are barriers to obtaining the HPV
vaccination for young females and males. Results identified males were less likely to
obtain the full-recommended dosage of the vaccination compared to women.
Conclusions: The research gathered can assist parents and health care providers in
planning education for preteens and young women and men on the importance of the
vaccine. This study can help guide public health officials in increasing awareness,
developing new policies, and developing public health programs for HPV.
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Table of Contents
List of Figures ....................................................................................................................vv
Chapter 1: Introduction (Background) .................................................................................1
HPV Vaccine ......................................................... Error! Bookmark not defined.
Laws and Regulations related to the HPV vaccine ................................................. 2
Barriers to Obtaining the HPV Vaccine…………………………………………...4
Thesis Statement……………………………………………………………….….5
Purpose of the Study……...…………………………………………………….....6
Research Questions and Hypotheses……….……………………………………..6
Theoretical Base……….…………………………………………………………..7
Definition of Terms…………..……………………………………………………8
Assumptions...……………………………………………………………………..8
Limitations…….…………………………………………………………………..8
Delimitations…………...………………………………………………………….9
Significance of the Study………………………………….……………………....9
Summary and Transition………………………………………..…………………9
Chapter 2: Literature Review……………………………………………….……12
The HPV Vaccine………………………………………..………………………12
Laws and Regulations regarding the HPV Vaccine……………………….….….12
Barriers to Obtaining the HPV Vaccine……………………………..…….….….20
Summary…………………………………………..………………………….….25
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Chapter 3: Research Method………………………..…………………………………....26
Research Design and Approach…………………………..…….………….….…26
Setting and Sample……………………..……………………………….…….…26
Data Collection and Analysis……………………………………………….……27
Instrumentation and Materials……………………………………………….…..28
Protection of Human Participants…………………………………………...…...28
Chapter 4: Results…………...………..………………………………………………….30
Findings of Web-based Survey……..……………………..……………………..31
Results…………………..………………………………………………………..32
Hypothesis Testing………………………..……………………………………...35
Summary………….………..…………………………………………………….38
Chapter 5: Discussion, Conclusions, and Recommendations…………………………....39
Introduction……………………..………………………………………………..39
Discussion..…………………..…………………………………………………..39
Recommendations for Action………………….………..……………………….42
Limitations…..………………..………………………………………………….42
Recommendations for Further Study……………………………………….…....43
Conclusion……………….…..…………………………………………………..43
References………………………………………………………………………..45
Appendix A: Informed Consent……..……………………………………….…..48
Appendix B: Survey…………………………………………..……......………...49
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List of Figures
Figure 1. Number of years providers have worked in their area of specialty…….............31
Figure 2. Do providers have marketing materials in their waiting rooms on HPV/Cervical
Cancer?..............................................................................................................................32
Figure 3. Do providers believe they truly have a sufficient amount of time to educate their
patients on sex-related topics?........................................................................………..….33
Figure 4. Providers estimate the % of girls that obtain each vaccine………………..…..34
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Chapter 1: Introduction
Background
Unfortunately every man and woman may be at risk for some type of cancer,
whether it stems from genetics, poor hygiene, or unhealthy habits. One of the cancers that
women are at risk for is cervical cancer. According to the Mayo Clinic (2014), cervical
cancer is a cancer that “occurs in the cells of the cervix — the lower part of the uterus that
connects to the vagina. Various strains of the human papillomavirus (HPV), a sexually
transmitted infection, play a role in causing most cases of cervical cancer.” Several years
ago, cervical cancer was the most common cause of cancer death for women in the United
States.
Fortunately, over the past few decades, cervical cancer deaths have declined nearly
70% due to women receiving routine Pap tests (American Cancer Society, 2014),
however, the disease is still prevalent in many parts of the world in underdeveloped
countries such as Africa. Overall, cervical cancer kills around 270,000 women every year
worldwide (WHO, 2012). According to the CDC (2013) in 2010, 11,818 women were
diagnosed with cervical cancer and 3,939 women died from cervical cancer in the United
States. Due to women obtaining frequent pap tests, the incidence rates have decreased
1.9% per year and mortality rates have decreased 1.8% per year among all women in the
United States (CDC, 2013).
HPV Vaccine
Pap tests are not the only prevention measure needed for protection against HPV
and cervical cancer. The vaccines, Gardasil and Cervarix, are the only two current
vaccines available on the market. These vaccines are given in a sequence of three shots
over a 6-month period to protect against HPV infection that may lead to cervical cancer.
Gardasil was approved by the FDA in 2006 and can protect men and women from HPV
infections. “It protects against 4 types of the HPV virus, including the 2 viruses that cause
90% of genital warts” (The Nebraska Medical Center, n.d). Gardasil also protects cancers
of the anus, vagina, and vulva. Cervarix is the second HPV vaccine; it was approved by
the FDA in 2009 and protects women from HPV. Both of these vaccinations are
recommended for young girls and boys before they become sexually active in order for the
best protection.
Laws and Regulations Related to the HPV vaccine
Being that the HPV vaccine is recently new within the past decade, there is still
much debate on whether or not the HPV vaccine should be mandatory for girls and boys
in the United States. “The Advisory Committee on Immunization Practices (ACIP)
“recommends administering the vaccine to girls between 11 and 12 years of age, before
they become sexually active” (NSCL, 2014).
Currently, the debate is centered on school vaccine requirements. Since 2006,
“legislators in at least 42 states and territories have introduced legislation to: require the
vaccine, fund or educate the public or school children about the HPV Vaccine” (NCSL,
2014). At least 25 states and territories have passed legislation, including Colorado,
District of Columbia, Illinois, Indiana, Iowa, Louisiana, Maine, Maryland, Michigan,
Minnesota, Missouri, Nevada, New Mexico, New York, North Carolina, North Dakota,
Oregon, Puerto Rico, Rhode Island, South Dakota, Texas, Utah, Virginia, Washington and
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Wisconsin (NCSL, 2014). In the 2013-2014 legislation, only three states require the HPV
vaccine be mandated for school attendance; they were Kentucky, New York, and Virginia.
All three opted to require all girls and boys to obtain the vaccine before entering the 6th
grade (NCSL, 2014).
According to the Kaiser Family Foundation (KFF) (2014), there are currently four
federally funded programs that pay for vaccine recommendations such as Gardasil and
Cervarix:
1. Vaccines for Children (VFC) Program - This program pay for children ages 18
and under who are either Medicaid-eligible, uninsured, American Indian or Alaska
Natives, or underinsured (KFF, 2014).
2. Immunization grant program (section 317) - The CDC awards grants to state
and local public health agencies to assist with vaccine costs. This program can extend
coverage to children who do not qualify for the VFC program (KFF, 2014).
3. Medicaid - Women and men ages 19 and 20 are eligible for Medicaid coverage
of all recommended vaccines as a service in the Medicaid Early and Periodic Screening
Diagnosis and Treatment program (EPSDT). For adults 21 and older on Medicaid, vaccine
coverage is an optional benefit and is decided on a state-by-state basis (KFF, 2014).
4. Children’s Health Insurance Program (CHIP) - States with CHIP programs that
are separate from their Medicaid programs must cover recommended vaccines for
beneficiaries. State funds must be used because children enrolled in these programs are
not eligible for coverage under the federal Vaccines for Children Program (KFF, 2014).
Barriers to Obtaining the HPV Vaccine
Men and women are affected by HPV and cervical cancer throughout the world,
within the United States, and more specifically in Nebraska. According to the CDC
(2012) Nebraska has an incidence rate of 5.0–6.4 per 100,000. The positive aspect is that
Nebraska’s ranking is one of the lowest throughout the United States. Sadly, however, the
death rate for Nebraska is quite high compared to other states and is listed as 2.4–2.7 per
100,000 (CDC, 2012).
Unfortunately, the incidence of HPV and cervical cancer is still prevalent in
Nebraska. HPV continues to be a major public health issue in today’s world and it is
expected that one out of two sexually active people will contract HPV at some point in
their life. CDC (2013) mentions HPV vaccination rates are significantly low compared to
other recommended vaccines for young teens and adolescents.
The biggest impacts of HPV and cervical cancer fall under several health status
indicators such as poverty, education, and gender equity (WHO, 2014). Poverty is a factor
that may increase the prevalence of cervical cancer. Families or individuals that live in
poverty stricken communities may not have the resources or access to health facilities. If
they are receiving care but are classified as low-income, they may be struggling with
finances and medical bills in order to receive treatment.
According to the CDC, a recent study examining barriers of the HPV vaccine
among adolescents in the U.S, “health care providers often said parents’ concerns and the
cost of vaccination made it difficult to provide the HPV vaccine.” This information shows
that cost is one of the barriers for low-income families. For some parents cost is not the
barrier, but other reasons are. Some studies have indicated that parents need more
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information before vaccinating their children and that many parents and healthcare
providers did not see a need to vaccinate boys (CDC, 2014).
There is obviously a lack of education and the results from this study prove this is
a major barrier between health care providers and patients. Men and women can be the
carrier of the HPV virus and spread it to anyone he comes in sexual contact with. The
HPV vaccine Gardasil is safe and effective for males and prevents them against HPV
types that cause cancers and genital warts as well as spreading it to other males and
females.
Surveys were administered to physicians and other medical providers at hospitals,
physician practices, health departments, and clinics within Lincoln, Nebraska to examine
the limitations and/or barriers of identified by males and females when choosing not to get
HPV vaccine after it has been offered. This issued was examined from the providers’
viewpoint.
Thesis Statement
There are barriers and/or limitations for young men and women in Lincoln,
Nebraska to obtaining the recommended HPV vaccination that will prevent cervical
cancer; identifying these barriers will help public health programs focus their social
marketing programs to increase usage of these vaccines, which will, in turn, reduce the
rate of cervical cancer.
Purpose of the Study
Many young males and females who have not received the HPV vaccine may be at
great risk for contracting high risk HPVs, which may cause HPV-related cancers, genital
warts, and lead to cervical cancer. This survey will evaluate the barriers between medical
providers and patients. The purpose of the survey was to examine issues of education and
communication between physicians and female/male patients. By evaluating the results
from this survey, we learned what is and isn’t being discussed during visits. In turn, this
information can provide opportunities for increased education and awareness in medical
settings and educational institutions.
Research Questions and Hypotheses
The following research questions were posed.
1. Is age a relevant factor related to the willingness of physicians to discuss sexrelated topics?
2. Are the girls and boys receiving the vaccine obtaining the full-recommended
dosage?
3. When patients choose not to vaccinate, what is their reasoning?
4. Do providers feel they have an adequate amount of time to discuss and educate
their patients about sex-related topics?
The corresponding hypotheses related to these research questions are:
Hypothesis0: Age is not a relevant factor related to the willingness of physicians to
discuss sex-related topics.
Hypothesis1: Age is a relevant factor related to the willingness of physicians to
discuss sex-related topics.
Hypothesis0: Girls and boys who obtain the vaccine are not receiving the fullrecommended dosage.
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Hypothesis1: Girls and boys who obtain the vaccine are receiving the fullrecommended dosage.
Hypothesis0: Physicians believe patients do not see any barriers to obtaining the
vaccine.
Hypothesis1: Physicians believe patients see many barriers to obtaining the
vaccine.
Hypothesis0: Providers feel they do not have an adequate amount of time to discuss
and educate their patients about sex-related topics.
Hypothesis1: Providers feel they do have an adequate amount of time to discuss
and educate their patients about sex-related topics.
Theoretical Base
Much of the literature used in the study consisted of quantitative studies. Large
populations were studied to examine knowledge and perceived barriers of females and
males as well as assessing physicians’ communication and education regarding the HPV
vaccine. Quantitative studies provided information and a theoretical base for
understanding and describing why men and women are specifically not obtaining the
recommend HPV vaccine. Quantitative studies are based on deductive reasoning and
useful in testing theories and hypotheses and are helpful when trying to prove
generalizability.
Definition of Terms
Advisory Committee on Immunization Practices (ACIP): Is a group of medical and
public health experts that develops recommendations on how to use vaccines to control
diseases in the United States. The recommendations stand as public health advice that will
lead to a reduction in the incidence of vaccine preventable diseases and an increase in the
safe use of vaccines and related biological products (CDC, 2014)
Human Papillomavirus (HPV): A double-stranded DNA virus of the genus
Papillomavirus (species Human papillomavirus) that has numerous genotypes causing
various human warts (as the common warts of the extremities, plantar warts, and genital
warts) including some associated with the production of cervical cancer (MerriamWebster, 2014).
Assumptions
It is assumed that all participating medical providers were honest while completing
the surveys and completed the questions thoroughly and to the best of their knowledge.
Limitations
This study is limited due to its small sample size and low response rate. Another
limitation was the limited geographical area. This study could have been more
constructive if the population of interest was expanded. Instead of examining only
Lincoln, Nebraska, perhaps it would have been beneficial to survey all physicians in
Lancaster County or the state of Nebraska as a whole.
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Delimitations
The medical professionals were selected because the researcher wanted to examine
their viewpoint on HPV. The researcher chose not to survey the women and men of the
population who have received the HPV vaccine due to the fact that there are several
studies out there that have those findings. Electronic surveys were used for this study as
mailing surveys have an extremely low response rate and can end up being a very costly
study. Electronic surveys were used to gather the data because it makes it quick and
simple for the participants who already have busy lives themselves.
Significance of the Study
This particular study will provide necessary data to improve education and
communication between physicians and patients. By identifying the barriers that prevent
males and females from obtaining the HPV vaccine, public health professionals may be
able to enhance current programs already implemented or develop new health programs at
the local and/or national level to reduce the rate of specific HPVs and cervical cancer and
improve the health and well-being of the communities.
Summary and Transition
Cervical cancer is the second leading cause of death for women in the United
States. HPV is known to be the root cause of cervical cancer and stems from two specific
types of HPV, type 16 and type 18, which are responsible for nearly 70% of all cases
(National Cancer Institute, 2014). “More than half of sexually active people are infected
with one or more HPV types at some point in their lives” (National Cancer Institute,
2014). The high-risk types of HPV can be prevented by obtaining the recommended
vaccines, Gardasil and Cervarix. These vaccines became available and ready to be
received in 2006.
There has been much debate about making the HPV vaccine mandatory for girls
and boys throughout the United States. Currently, only three states require the HPV
vaccine for girls and boys entering the 6th grade. This ensures that all children are
receiving the vaccine before they become sexually active, which is the purpose of the
vaccine and guarantees protection against the high-risk strains that may cause cervical
cancer.
Poverty, education, and communication are a few of the main barriers between
patients and the HPV vaccine. Low-income families who do not have health insurance
and are not able to afford the vaccine for their children are at higher risk. Women, both
parents and young girls, lack the knowledge and education regarding HPV, cervical
cancer, and the recommended vaccine. Communication between parents, children, and
medical providers is another issue. The majority of patients look to their medical provider
for education and advice for prevention and health status. Are medical professionals doing
their job fully to ensure patients are educated and have the necessary information to make
their own decisions?
During Chapter 2, a review of the literature will be used to examine barriers on
HPV knowledge of men and women as well as barriers between patients and medical
providers. In Chapter 3, the methods of the study and the analysis will be described.
Chapter 4 will report the results and a thorough discussion of them will be included in
Chapter 5. Chapter 6 will discuss the conclusions that can be drawn from this study and
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the implications for public health. It is important to examine these topics to expand public
health programs locally, state, and nationally to improve knowledge, awareness, health,
and the well-being of all.
Chapter 2: Literature Review
Similar Studies
HPV is the most common sexually transmitted infection (STI) and the leading
cause of cervical cancer. The high-risk HPV types, 16 and 18, and cervical cancer are
preventable. There are ways to reduce the likelihood of contracting HPV such as limiting
the number of sex partners, using condoms, receiving Pap smears, and obtaining the
recommended vaccine. The U.S. Food and Drug Administration (FDA) approved of two
vaccines, Gardasil and Cervarix to protect against HPV infection before an individual
becomes sexually active. According to Cancer (2013), “data shows the HPV vaccinations
are safe and highly effective in preventing a lasting infection of the HPV types they
target.”
The literature review addresses three areas related to the HPV vaccine. The first
section addresses research studies identifying the HPV vaccine’s development,
effectiveness, and physicians intentions regarding vaccination. The second section
focuses on research related to policies and regulations related to the HPV vaccine. Lastly,
the third section discusses barriers to obtaining the HPV vaccine.
The HPV Vaccine
The HPV vaccine is key in preventing high risk HPVs that lead to cervical cancer.
It is recommended that girls and boys between the ages of 9–11 receive the vaccine in
order for full protection before they become sexually active. The purpose of this study
was to investigate HPV vaccination trends, interest, and reasons for non-vaccination in
young adult women (Schmidt & Parsons, 2014). Data was collected through the National
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Health Interview Survey within the United States between years 2008 and 2012 a total o
10,513 women, ages 18 to 26 years (Schmidt & Parsons, 2014).
The women were interviewed and asked a series of questions in relation to the
HPV vaccine, interests in the vaccine, and reasons for non-vaccination. First, the trends
of HPV vaccination from 2008 to 2012 files were examined. Second, unvaccinated
women were compared to non-vaccinated women in years 2008 and 2010 to examine their
interest.
Data analysis was conducted with SAS version 9.3 (Schmidt & Parsons, 2014). To
examine trends in the HPV vaccination uptake, estimated weight percentages, 95%
confidence intervals, and x2 tests for each survey were used (Schmidt & Parsons, 2014).
The results showed a substantial increase between 2008 data and 2012 data in HPV
vaccination among women. Vaccination rates increased from 11.6% to 34.1% (Schmidt &
Parsons, 2014). However, results also showed women with limited access to health care
were less likely to receive the vaccine. Women obtaining the HPV vaccinations doubled
within five years, but vaccine rates were still relatively low in 2012 at 34.1%.
There happened to be several limitations and weaknesses within this study. First,
all the information was self-reported and results may include bias. Second, no information
was available about whether respondents received the HPV vaccine recommendation from
their doctor. Third, the vaccines were approved in 2006 and recommended in 2007;
therefore trends were not examined before 2008 (Schmidt & Parsons, 2014).
The two vaccines currently on the market, Gardasil and Cervarix, have been
approved for prevention of HPV types 16 and 18. When these vaccines were placed on
the market, it “attracted reactions ranging from fervent approval to outright hostility”
(Mishra & Graham, 2012). The purpose of this study was to examine policy changes and
challenges for Canadian school-based immunization regarding the HPV vaccine from the
viewpoint of health care professionals (Mishra & Graham, 2012). The study was
conducted in Canada and the participants included six nurses, two public health officials,
six vaccinologists, and one health lawyer, for a total of 15 health professionals.
The nurses and health lawyer were recruited through posters via the Internet,
clinics, and hospitals. The vaccine scientists and public health officials were recruited
through emails. In depth, 30-60 minute interviews were conducted with the 15 health
professionals. These interviews were recorded sessions, which consisted of iterative
reading and discussion. The study lasted over a five-month period between September
2009 and January 2010 (Mishra & Graham, 2012).
The variables used were (1) defining HPV a risk, (2) between women: advocating
the ‘anti-cancer vaccine,’ and (3) needle anxiety and the ‘girl vaccine’ (Mishra & Graham,
2012). This data was analyzed by examined the “iterative reading, discussion, and critical
verification for corroboration, saturation, and differences” (Mishra & Graham, 2012).
Examining further into these interviews, it was proposed that these medical professionals
believe media had a strong influence on the way HPV and the vaccine were perceived
when it was first developed. One of the clinical scientists stated, “Before the vaccine was
available there was much lack of knowledge about HPV” (Mishra & Graham, 2012). A
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nurse stated there is much anxiety over needles and the pain they cause, so that is a barrier
for these young women to obtain the vaccine. The nurse states it is important for a
‘recovery period’ by rewarding juice and cookies. “Reward in the form of food disposes
the teenager to share information in a positive way with peers and is a most effective
vehicle for health promotion” (Mishra & Graham, 2012). This article did not list any
limitations within the study.
Unfortunately, healthcare providers face a major challenge providing information
to parents who believe the vaccine is ineffective and unsafe for their children. This is due
to the vaccine being relatively new on the market. Perhaps public health professionals
could make a new shift toward society’s aptitudes and beliefs towards this vaccine. If
these vaccine scientists of HPV took a step forward in the eye of the public and explained
the truth about the vaccine, it could diminish parents concerns and improve overall
immunity rates within the United States.
Parents are known to make decisions for their children when it comes to healthcare
and vaccinations, however, healthcare providers do have a major influence as well
regarding decision making of education and vaccinations. The purpose of this study was
designed to assess whether physicians would use the HPV vaccine as an opening to
communicate with 9–15 year-old female patients about sex (Askelson, Campo, Smith,
Lowe, Dennis & Andsager, 2011).
A midwest state in the U.S. was used for this particular study. A random sample
of 1,939 family practice, general practice, and pediatric physicians who were under the
age of 70 and lived in the state were surveyed. Surveys were mailed to the physicians and
asked questions regarding vaccination behavior and communication with female patients
between the ages of 9–15. The analyses were conducted using SPSS version 15. Chisquared tests, t-tests, correlations, and multivariate linear regression were implemented to
answer the research questions and test hypotheses (Askelson et al., 2011). In total, there
were 207 respondents to the survey. Out of the 207 participants, 54.1% were male and
45.4% were female. Results reported that physicians are more likely to talk about sex at
an earlier age when they vaccinate. Also, physicians reported they are willing to talk about
STD’s when they vaccinate against HPV (90.3%) followed by talking specifically about
HPV (89.4%) (Askelson et al., 2011).
This study assesses physicians’ intentions to talk about sex when they vaccinate
against HPV. The recommendation to vaccinate has the potential to encourage physicians
to discuss sex at a younger age in order for prevention of the high-risk HPVs. The
limitation of this study is due to a low response rate, which is typical for mailed surveys to
physicians. The researchers of this study believed a qualitative data collection method
such as interviewing the physicians would have beneficial for this particular study.
In summary, the HPV vaccine is key in preventing high risk HPVs that lead to
cervical cancer. It is recommended that girls and boys between the ages of 9–11 receive
the vaccine in order for full protection before they become sexually active. Based on the
literature review, there is still much concern on the HPV vaccine itself. Parents find there
is not enough research on this relatively new vaccine on the market and feel as though it is
not safe for their young children. More funding is in need of the HPV vaccine and virus
itself. Research will further examine into the disease and provide more knowledge and
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information that can be made available for the public.
Laws and Regulations Regarding the HPV Vaccine
The study examines HPV and cervical cancer in the Appalachian region within the
Unites States. The purpose of this study was to gain insight in HPV vaccine availability,
recommendations, costs, policies, and education materials being used in public health
departments (Katz, Retier, Kluhsman, Kennedy, Dwyer, Schoenberg, Johnson, Ely,
Roberto, Lengerich, Brown, Paskett & Dignan (2009). The study gathered data from
seven states within the Appalachian region in the United States: Kentucky, Maryland,
New York, Ohio, Pennsylvania Virginia, and West Virginia.
The intervention included interviews that took approximately 20 minutes to
complete and followed an interview guide asking several questions regarding HPV-related
health policy issues, vaccine availability, provider recommendations for vaccination, cost
and financial assistance for the vaccine, and HPV vaccine educational materials available
to patients at the health departments (Katz et al., 2009). Telephone interviews were
conducted between April and July 2008 with a representative from each health department
who had expert knowledge on the HPV vaccine.
Variables used in this study were content knowledge of HPV, supply and
availability of vaccines, costs, and education materials being used within health
departments. The data analysis was completed by the use of Behavioral Measurement
Shared Resources and entered into a database by scanning and verifying the electronic
documents (Katz et al, 2009). To calculate statistics such as means, standard deviations,
and percentages, SAS version 9.1 was used (Katz et al, 2009).
The final results showed 234 health departments completed the survey. Of the
health departments, 181 (77.3%) completed the survey through a representative and 53
(22.7%) was obtained from the Pennsylvania immunization database. In the health
departments, 99.1% reported receiving patient’s requests for the HPV vaccine and only
1% reported they do not provide the vaccine (Katz et al, 2009). Also, the supply of the
vaccine was reported to not meet the demand due to high costs. The findings from the
study provide information that can be used to evaluate existing policies, formulate new
policies, and to develop community-based interventions to improve HPV vaccine rates
among women living in Appalachia.
There were a few limitations within this study. First, the difference between
obtaining the data such as interviewing with a representative compared to using the
immunization database. The second limitation was being limited in time and using a
cross-sectional design, which did not capture changing HPV vaccine policy or availability.
Parents who have children between the ages 9 and 11 are more than likely still
paying for their children’s expenses and making decisions for their kids, especially when
it comes to health care and vaccines. This is specifically true for making decisions when it
comes to the HPV vaccine. The purpose of this study was to examine the effect of two
default policies on parents’ consent to have their adolescent sons hypothetically receive
HPV vaccine at school (Reiter, McRee, Pepper & Brewer, 2012)
A national sample of 404 parents of adolescent sons aged 11–17 years old
participated. The samples were members of an existing national panel of US households.
In 2010, over a two-month period, parents were invited to participate in an online survey
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via email. Parents’ consent was obtained prior to all surveys. Parents were asked to think
of this scenario, “Imagine that you just moved to a new state and your son is starting at a
new school. The school has a school health center where a trained professional gives
students basic health care” (Reiter et al., 2012). The study then described a default policy
for HPV vaccination that was: opt-in, opt-out, or neutral. It also described the
administration of the vaccine defined as the number of vaccines the son would receive:
HPV vaccine only or HPV vaccine along with two other recommended vaccines (Reiter et
al., 2012).
Variables used for this study were demographics and knowledge of content. “The
main outcome was whether parents consented to their sons hypothetically receiving HPV
vaccine at school” (Reiter et al., 2012). The data analysis was conducted by using chisquare tests to compare experimental conditions on demographics and two-tailed tests
were conducted by using SPSS version 17.0 to analyze the data (Reiter et al., 2012).
Results from this study showed parents who selected opt-in (75%) were more
likely to consent to their sons receiving the HPV vaccine at school compared to parents
that selected opt-out (52%) (Reiter et al., 2012). Results also identified parents who chose
their sons to receive the HPV vaccine with other recommended vaccines were more likely
compared to only receiving the HPV vaccine.
This study provided knowledge and information from a parents’ point of view
regarding the HPV vaccine for their sons. Obtaining parents’ consent to vaccination is
critical to the success of school-based vaccination programs. By assessing parents
attitudes may assist in implementing programs to increase knowledge and awareness of
HPV and the vaccine.
There were limitations within the study such as most participants were white with
a relatively high socioeconomic status. Second, data was not used for parents not wanting
their sons to receive the vaccine due to their low acceptance of their sons obtaining the
vaccine. Lastly, parents of daughters were not included in the study, which is an extremely
important aspect regarding the HPV vaccine.
HPV vaccination tends to be a controversial issue in today’s society. If mandating
HPV vaccination for school entry were to become final, this would increase the number of
females obtaining the vaccine and receiving protection against cervical cancer. Others
argue that HPV mandates are not appropriate because HPV is spread via sexual contact,
not by contagious disease like measles, so HPV vaccine should not be mandated into
school immunizations (NHII, 2008). Other concerns of mandating are conflicting with
personal beliefs and religions. If HPV became mandatory, this could violate citizens’
freedom as an individual residing in the United States.
Barriers to Obtaining the HPV Vaccine
It is important to assess the knowledge of HPV and the perceived barriers for
males and females. Prevalence rates continue to be a problem worldwide. By having the
knowledge and education on HPV and vaccines, many lives can be saved. The purpose of
this study was to examine the knowledge of HPV and perceived barriers to being
vaccinated against HPV (Dillard & Spear, 2010).
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The sample of this study was 396 undergraduate women attending Penn State
University in the fall term in 2008. Women were of the ages between 18 and 26 years of
all different races. The sample consisted of equal numbers of women from each class
level: freshman, sophomore, junior, and senior. The researchers gathered characteristics
of the sample such as age, class, and race. There were 18 true-false questions given to
assess the knowledge of HPV and the vaccine. Participants were contacted via email and
invited to partake in the online survey on “women’s vaccination decisions.”
Regression analyses were used to identify predictors of knowledge and barriers.
Results from the study showed that 96% of respondents have heard of HPV, however, a
large amount of participants were unaware that HPV was the direct cause of cervical
cancer and only half knew that HPV is the most common STD in the United States
(Dillard & Spear, 2010). Results also showed that nearly 35% of the sample believed that
men cannot contract HPV.
According to this study, there are several misconceptions regarding HPV and the
vaccine. The information gathered can assist in enhancing and improving public health
programs as well as educate medical professionals to increase awareness and knowledge
for young women. The limitations of this study displayed a relatively low response rate
and possibly some survey questions could have been revised such as, “The vaccination
protects against HPV and genital warts.” This question tends to be flawed and could have
been reworded because the vaccination only protects against the high-risk strains of the
virus. There are over 100 strains of HPV and the vaccination only protects a small group
of strains.
Many women have concerns about vaccines in general due to harmful side effects
and effectiveness. This is especially true regarding the HPV vaccine. This could be due
to a lack of knowledge and awareness about HPV itself and the vaccine to prevent the
high-risk strains that lead to the deadly disease, known as cervical cancer.
The purpose of this study is to investigate the areas of concerns women have
regarding the HPV vaccine (Chan, Kwan, Yao, Tam, Cheung & Ngan, 2012). The study
had a sample population of 1,450 women above the age of 18 located in Hong Kong. The
intervention was to examine women’s knowledge, beliefs on cervical cancer screening,
HPV infection, and vaccination.
The survey consisted of 63 questions and was divided up into six sections: cervical
cancer, cervical cancer screening, HPV infection, HPV vaccination, sexual practice, health
status, and demographics (Chan et al., 2012). Surveys were distributed to Chinese women
who attended Hong Kong Family Planning Association clinics and health centers between
the months of February and November 2007. There were several variables used within
this study such as age, education, income, marital status, and content knowledge of HPV
and the vaccination.
A data analysis was performed using SPSS version 6.1. This examined the
associations between the scores of each aspect of the vaccine and each demographic
characteristic (Chan et al., 2012). Out of the 1726 surveys, only 1450 completed them.
Results showed that women’s top three concerns about the HPV vaccine were:
effectiveness (54%), duration (44%), and long-term side effects (43.7) (Chan et al., 2012).
This is more than likely due to the fact that the HPV vaccine is still relatively new on the
23
market. There is still much confusion on the actual virus itself and whether it remains
with a person for life or it is able to be go away on its own.
Based off of the results, majority of women found television and newspapers to be
the best channels for educational purposes on HPV and cervical cancer prevention. This is
a good indicator that these channels should be targeted more with promotional messages
to reach out to the population. This study was considered to be the largest study
conducted on Chinese women regarding the HPV vaccine. However, the study was
limited to women who are 18 years or old and who live in Hong Kong. The authors
stated, “currently, population vaccination programs are targeted to girls aged 12–13 as the
vaccine should be best given before their first sexual experience to achieve optimal
effectiveness” (Chan et al., 2012).
Many people are unaware that men can be the carriers of HPV and spread it to
females, which then puts females at great risk for developing cervical cancer. The vaccine
Gardasil is recommended for boys from ages nine and up to 26 years of age. The purpose
of this study was to examine HPV vaccine uptake among male adolescents and to identify
vaccination predictors (Reiter, McRee, Pepper, Gilkey, Galbraith, & Brewer, 2013).
The sample of this study was a national sample of parents with sons aged 11–17
years of all difference races. The intervention was to have parents complete an online
survey to assess attitudes and beliefs about HPV vaccination for males. The survey at
baseline was over a two-month period, August and September 2010 with a follow up in
November 2011. The survey was emailed to 1,195 parents, however, only 752 responded,
and only 421 who had sons completed the survey.
Variables such as age, gender, demographics, predictors, outcomes, and
knowledge of content were used for this study. To examine HPV initiation between
baseline and follow up, logistic regression models were used to identify statistically
significant predicators (Reiter et al., 2013). The smaller data was identified by using
SPSS version 17.0 and using two-tailed tests.
Results showed that only 2% of sons had received any of doses of HPV vaccine at
baseline and by follow-up it had increased to 8% (Reiter et al., 2013). Though it is a small
increase, more males obtained the vaccine, which means more lives can be saved. Parents
also reported their main reasons for not vaccinating their sons. At baseline, only 11% felt
they did not know enough about the HPV vaccine, 10% reported not having received a
doctors’ recommendation to vaccinate, 4% believed the vaccine was too new, 6% had
concerns the vaccine was unsafe, and 3% reported their sons had not had a recent doctors
visit. The most shocking results reported that 23% of parents did not know boys could get
the HPV vaccine (Reiter et al., 2013).
It is important to remember that not only are females affected by HPV, but so are
males. They can be the carrier of this virus and spread it to their partners and put them at
risk. These findings may be helpful in improving HPV programs and campaigns to
increase the knowledge, awareness, and the amount of males receiving the vaccine. This
study did have a few limitations. One was the fact that very few males had actually
obtained the vaccine, so an examination was not completed of all three doses received.
Another limitation was the majority of respondents were non-Hispanic whites of high
socioeconomic status (Reiter et al., 2013). To improve this study, it would have been
25
beneficial to examine another follow-up in order to ensure that all three doses were
received.
Summary
In summary, it is important to assess the knowledge of HPV and the perceived
barriers for males and females. Prevalence rates continue to be a problem worldwide. By
having the knowledge and education on HPV and vaccines, many lives can be saved by
increase awareness and strengthening education communications can have the correct
knowledge about HPV and the recommended vaccines.
Chapter 3: Research Method
Research Design and Approach
This study used a quantitative design to examine the attitudes and beliefs about the
HPV vaccine of medical professionals in Lincoln, Nebraska. The researcher utilized
quantitative research to gain an understanding of these attitudes and beliefs by creating
and distributing a short, web-based survey. By using a quantitative approach, the
researcher was able to gain insight from medical professionals’ on what age the patients
are that physicians typically discuss sex-related topics with, how much importance they
place on educating their patients on HPV, and what the most common reasons females and
males give for choosing not to vaccinate.
The study also consisted of using variables such as age groups, gender, highest
educational degree, and medical specialty to examine descriptive data of the medical
professionals in Lincoln, Nebraska. This data will assist in exploring differences between
gender, race, age, and specialties in the health care field regarding their attitudes and
beliefs on the HPV vaccine for their patients. Participants within the study are anonymous
and there is no risk involved.
Setting and Sample
This study took place in Lincoln, Nebraska, which has a population size of
268,738 according to the most recent 2013 United States Census Bureau (U.S Census
Bureau, 2014). There are several hundreds of medical professionals who work in
hospitals, clinics, health departments, and private practices in Lincoln who may or may
not administer the HPV vaccine. The researcher completed a search of medical
27
professionals in Lincoln Nebraska through The Medical Association of Nebraska website
to locate the participants that represent the population selected. Twenty-three medical
offices in Lincoln Nebraska were contacted by telephone. The researcher followed the
phone script and asked the receptionist if a link could be sent to them via email and they
could forward it to any medical professionals in the office. Only two out of the twentythree offices provided the researcher with an email address. Within the email template, the
researcher asked if the participants could forward the link to other medical professionals
who they know and who might be willing to take the survey in order to increase the
response rate, thus using the snowball sampling method.
The researcher also posted the survey link on Facebook as well as forwarded to
personal contacts that work with several medical professionals to forward the link onto
them. It cannot be determined how many participants took the survey through Facebook.
However, it was confirmed that well over 100 medical professionals were emailed the link
inviting them to participate in the survey through the contacts the researcher spoke with
directly.
Data Collection and Analysis
A descriptive analysis will be conducted to determine the medical provider's
attitudes and beliefs on the HPV vaccination, as they are reported on the surveys, and
means and frequencies will be used to report the findings. The data collected may be used
in the development and implementation of health programs regarding education on the
HPV vaccine and cervical cancer.
The researcher confirmed face validity through peer review by a class of Master’s
in Public Health students at Concordia University Nebraska. Through an iterative process
of feedback and changes, the layout and questions within the survey were altered to ensure
the questions would measure what they were intended to in a consistent manner and were
easy to understand. Additionally, two university professors reviewed the survey and
analysis plan, one with postdoctoral work in advanced biostatistics.
Instrumentation and Materials
Materials used in this study are the CUNE Library Search Engines such as Ebscohost.
Searches were also expanded through Google for scholarly articles pertaining to HPV
virus, the vaccine, policies and regulations, and barriers of men and women obtaining the
vaccine. The researcher used Survey Monkey to create a web-based survey to email to the
medical professionals. The survey focuses on the relationship between patients and the
medical providers. It specifically asks the medical experts what age groups they typically
discuss sex-related topics with, what percentage of males and females receive each dose,
and to have them list the top two reasons why males and females choose to not vaccinate.
Data is scored through the use of Survey Monkey and an Excel workbook. Refer to the
appendix for a copy of the official survey.
Protection of Human Participants
The applied research project involved human participants but with very limited
risk. The data that was collected remained anonymous and confidential. Informed
consent was obtained prior to participants completing the survey. All information was
29
obtained through literary reviews regarding HPV and the recommended vaccine and the
results from the actual study.
Chapter 4: Results
Findings of the Web-based Survey
Cervical cancer is the second leading cause of death for women in the United
States. Many young males and females who have not received the HPV vaccine may be at
great risk for contracting high risk HPVs, which may cause HPV-related cancers, genital
warts, and lead to cervical cancer. The HPV vaccine tends to be controversial in today’s
society due to the vaccine being relatively new within the last 10 years. The vaccine has
dramatically reduced the number of cases of cervical cancer in the United States. Though
HPV is still on the rise, receiving the recommended vaccine is highly effective at reducing
the odds of getting cervical cancer. Medical providers are a primary point of contact for
education on HPV and the vaccine, but it is thought that providers do not discuss this
option with adolescent males and females often enough during routine office visits.
Though the response rate was relatively low, the responses from a few health care
providers were still able to be examined, which will likely be able to assist in developing a
future public health program regarding education topics and understanding of the HPV
vaccine.
A self-designed survey was used to collect data to answer the following research
questions:
a) Is age a relevant factor related to the willingness of physicians to discuss sexrelated topics?
b) Are girls and boys receiving the vaccine obtaining the full-recommended
dosage?
31
c) From a physician’s standpoint, when patients choose not to vaccinate, what is
their reasoning?
d) Do providers feel they have an adequate amount of time to discuss and educate
their patients on sex-related topics?
Results
Using descriptive statistical analysis, it was determined that of the 22 medical
professionals who completed the survey, 19 had the responsibility of administering the
HPV vaccine. Only surveys completed by respondents with this responsibility were
included in the data analysis. The respondents included in the analysis were primarily
female (89.47%), with a Master’s degree in Nursing, and an average age between 20 and
60 years or older. Predominately, 57.89% of these medical professionals have worked 1–5
years in their area of specialty (Figure 1).
12
10
8
6
4
2
0
1--5
6--10
11--20 21--30 31--40
41+
Figure 1. Number of years in specialty. This chart represents the number of physicians
that have experience in each range of years.
Half (n = 9) said it was extremely important to discuss the HPV vaccine with their
patients and just over half (n =10) said it was extremely important that their patients get
the vaccine. Surprisingly though, only slightly more than half (n = 10) reported having
materials on the HPV vaccine in their waiting room (Figure 2). Most (n =17) believe the
HPV vaccines on the market are safe and effective, leaving only a few (n = 2) undecided
on the safety and effectiveness of the vaccine itself.
47.4%
52.6%
Yes
No
Figure 2. Percent of providers with materials on HPV in the waiting room.
Only 18 participants answered the question regarding insurance coverage and cost
regarding the vaccine, four participants skipped this question. Seven of the medical
professionals reported charging patients without insurance between $0 and $250, four
professionals stated there is a sliding fee for payment, and seven of the 18 respondents
were unaware of the cost of the HPV vaccine for patients who do not have insurance. The
majority of the providers (68.42%) felt they have a sufficient amount of time to educate
their patients on sex-related topics and the HPV vaccine some of the time (Figure 3).
33
15
10
5
0
Yes
Sometimes
No
Figure 3. Providers that have sufficient time to educate on HPV. Number of providers and
the frequency they feel they have a sufficient amount of time to educate their patients on
the HPV vaccine.
Only 3 (15.79%) of the providers believed females ‘always’ received all three of
the required doses for the HPV vaccine. Most respondents (84.21%) felt that female
patients ‘sometimes’ receive all 3 shots of the 3-shot vaccine course, with an estimated
range of 51–75% of girls receiving the first HPV vaccine, 51–75% receiving the second
vaccine, and only 26–50% receiving the third shot (Figure 4).
12
10
8
0-25%
6
26-50%
51-75%
4
76-100%
2
0
1st vaccine
2nd vaccine
3rd vaccine
Figure 4. Estimate of the percent of girls that obtain each vaccine. When asked, the
providers reported an estimate of how many girls they believed received one, two, and
three shots.
The findings were worse for males, with only 1 (5.88%) reporting boys always
received the three doses and 15 (88.24%) stating males ‘sometimes’ receive all three
shots. When asked why the providers believed males and females did not get the
vaccinations, providers stated the top three reasons females did not receive the vaccination
were 1) parents do not believe their daughters need it, 2) fear of needles, and 3) a need for
more information. The most common reasons given for males not receiving the shots were
1) it’s a female vaccine, 2) they simply do not want it, and 3) parental refusal.
Hypothesis Testing. With a small sample size, it was not possible to run statistical
analyses to determine existing correlations proposed in the hypotheses in this study.
However, some useful results emerged nonetheless.
35
The first hypothesis was related to age and the willingness of providers to discuss
sex-related topics with their patients. It was presented as:
Hypothesis0. Age is not a relevant factor related to the willingness of physicians to
discuss sex-related topics.
Hypothesis1. Age is a relevant factor related to the willingness of physicians to
discuss sex-related topics.
For this question, participants had the option of selecting more than one age they
specifically speak with regarding sex-related topics. All of the providers reported
discussing sex-related topics with those aged 13–19 years old and just over half (52.63%)
stated they speak with 20–29 year olds also. Providers typically did not discuss sex or
related topics with patients above 30 years of age, but an additional 26.32% reported
discussing sex-related topics with 7–12 year olds.
With only 19 respondents to this answer, it was not possible to test for a
correlation, thus it is not possible to reject the null hypothesis. However, you can see from
this data that most providers seem to be talking to patients between the ages of 13–29
years, and almost none of them discuss sex-related topics with those over 30.
The second hypothesis was related to girls and boys obtaining the vaccine and
receiving the full-recommended dosage. It was presented as:
Hypothesis0. Girls and boys who obtain the vaccine are not receiving the fullrecommended dosage.
Hypothesis1. Girls and boys who obtain the vaccine are receiving the fullrecommended dosage.
Most of the providers (84.21%) reported a female patient “sometimes” receives all
three recommended doses. This number is quite high; there should be less “sometimes”
and more “always.” For males, the results were similar but slightly different. Only 17
participants answered this question while 19 answered the female’s question. However,
88.24% reported males “sometimes” receive all three doses and only 5.88% stated males
“always” receive all three doses. Much can be done about the lack of receipt of all three
doses. Convenience is key to ensure all three doses are obtained. By offering the HPV
vaccine at more school-based health facilities, health departments, and pharmacies, the
vaccination rate can be increased and obtaining them can become be more convenient for
young teens.
It was not possible to test for a correlation, thus, it is not possible to reject the null
hypothesis. However, you can see from this data that most providers more often see
female patients obtain all three series of doses compared, to males.
The third hypothesis was related to what patients respond with as to why they do
not obtain the HPV vaccine. It was presented as:
Hypothesis0. Patients see many barriers to obtaining the vaccine.
Hypothesis1. Patients do not see many barriers to obtaining the vaccine.
Providers stated the top 3 reasons females did not receive the vaccination were 1)
parents do not believe their daughters need it 2) a fear of needles and 3) a need for more
information. The most common reasons given for males not receiving the shots were 1)
it’s a female vaccine 2) they simply do not want it and 3) parental refusal. These
responses reflect a likelihood that parents and patients do not have adequate information
37
or knowledge on the virus and vaccine and this is exactly why HPV prevalence is
increasing.
It was not possible to test for a correlation, thus, it is not possible to reject the null
hypothesis. However, there are more than just one barrier to obtaining the vaccine for both
males and females.
The fourth hypothesis was related to providers having an adequate amount of time
to discuss and educate their patients about sex-related topics. It was presented as:
Hypothesis0. Providers feel they have an adequate amount of time to discuss and
educate their patients about sex-related topics.
Hypothesis1. Providers feel they do not have an adequate amount of time to discuss
and educate their patients about sex-related topics.
This question had an option to choose yes, sometimes, or no. There were 68.42%
that answered “sometimes,” 26.32% that answered “yes,” and 5.26% that answered “no.”
This causes some concern from a health care providers’ perspective. The more patients
they see each, the more money they make; however, from the patient’s side, they may not
be getting their money’s worth and their questions answered. Perhaps, in doctors’ offices,
there could be a health educator and/or health counselor to discuss sex-related topics with.
This would give patients more time and opportunity to get all of their questions answered,
and have someone truly listen.
It was also not possible to test for a correlation due to small sample size; thus, it is
not possible to reject the null hypothesis. However, you can see from this data, providers
believe they “sometimes” have enough time to properly educate and discuss sex-related
topics with their patients.
Summary
The results also showed providers stated one of the most common reasons patients
choose not to vaccine is due to lack of reliable information on the vaccine. This may be
due to the fact that the virus is relatively new, within the last decade. Perhaps medical
professionals are not up-to-date on the virus or vaccine, particularly if they are older.
However, there are plenty of reliable books and websites, such as the CDC and WebMD
that provide an abundance of information on HPV and the vaccine. Another reason may be
the time spent during the patient’s visit at a medical office. Some doctors may be
suggesting to parents that their children not receive the vaccine because they are low risk
and not sexually active or they simply don’t need it. Awareness and education on HPV
and the vaccine is in great demand; it is up to our teachers, parents, medical professionals,
and health educators to increase knowledge and awareness on HPV for our future.
39
Chapter 5: Discussion, Conclusions, and Recommendations
Introduction
Several years ago, cervical cancer was the most common cause of cancer death for
women in the United States. Fortunately, over the past few decades, cervical cancer deaths
have declined nearly 70% due to women receiving routine Pap tests (American Cancer
Society, 2014), however, the disease is still prevalent in many parts of the world such as
underdeveloped countries like Africa. Overall, cervical cancer kills around 270,000
women every year worldwide (WHO, 2012). This is all caused by HPV.
It is important to assess the knowledge of HPV by all parties’ involved, including
the patients receiving the vaccine and the medical providers administering it. By having
the knowledge and education on HPV and vaccines, many lives can be saved.
The purpose of this quantitative study was to examine this public health issue by
reaching out to medical providers to gain insight on their perspective regarding education
and the HPV vaccine of their patients, using a web-based survey to gather data. Despite
the fact that cervical cancer deaths have dramatically decreased over recent decades,
women contracting HPV is continuously increasing.
Discussion
A great deal about the virus remains to be studied; the vaccine has not even been
on the market for a decade. This makes it more difficult to educate and provide accurate
information to the population when researchers are still learning about the virus
themselves. Not only are researchers still learning, but the people of this country are, also.
According to the results of this study, one of the most common reasons why young adults
are not obtaining the vaccine is because parents need more information before vaccinating
their children; another was that many parents and healthcare providers did not see a need
to vaccinate boys. What people fail to remember is that men are a carrier of this virus and
can spread it rapidly, without even knowing they have it. This then gets spread to women
who can be severely affected by this virus. Thus, there is just as much need to vaccinate
boys as there is for girls.
Within this study, there were four main research questions the researcher wanted to
examine. Let’s look further into each question. “ Is age a relevant factor related to the
willingness of physicians to discuss sex-related topics?” Due to the small sample size, this
could not be concluded to a level of statistical significance; however, a clear trend
emerged simply using descriptive statistics. A right-sided bell curve pattern was seen. The
most common age group that providers discussed sex-related topics to were 13–19 years
old. Only five providers reported discussing sex-related topics with the age group of 7–
12. However, according to CDC (2014) the recommended age to obtain the vaccine is 11–
12 years old and even sometimes as low as nine. Providers should be talking to younger
patients as frequently as they are the 13–19 year old group. Vaccination rates would
heavily increase and more lives would be saved.
The second research question was, “Are girls and boys receiving the vaccine
obtaining the full-recommended dosage?” Most of the providers (84.21%) reported a
female patient “sometimes” receives all three recommended doses. This number is quite
high; there should be less “sometimes” and more “always.” For males, the results were
similar but slightly different. Only 17 participants answered this question while 19
41
answered the female’s question. However, 88.24% reported males “sometimes” receive
all three doses and only 5.88% stated males “always” receive all three doses. Much can
be done about the lack of receipt of all three doses. Convenience is key to ensure all three
doses are obtained. By offering the HPV vaccine at more school-based health facilities,
health departments, and pharmacies, the vaccination rate can be increased and obtaining
them can become more convenient for young teens.
The third question was, “When patients choose not to vaccinate, what is their
reasoning?” Providers stated the top 3 reasons females did not receive the vaccination
were 1) parents do not believe their daughters need it 2) a fear of needles and 3) a need for
more information. The most common reasons given for males not receiving the shots were
1) it’s a female vaccine 2) they simply do not want it and 3) parental refusal. These
responses reflect a likelihood that parents and patients do not have adequate information
or knowledge on the virus and vaccine and this is exactly why HPV prevalence is
increasing.
The question, “Do providers feel they have an adequate amount of time to discuss
and educate their patients about sex-related topics?” was presented with an option to
choose ‘yes,’ ‘sometimes,’ or ‘no’ to this question. There were 68.42% that answered
“sometimes,” 26.32% that answered “yes,” and 5.26% that answered “no.” This causes
some concern from a health care provider’s perspective. The more patients they each see,
the more money they make; however, from the patient’s side they may not be getting their
money’s worth and their questions answered. Perhaps, in a doctor’s office, there could be
a health educator and/or health counselor to discuss sex-related topics with. This would
give patients more time and opportunity to get all of their questions answered and has
someone truly listen.
Recommendations for Action
One of the articles previously described in this paper states there is movement
towards implementing policies and regulations regarding the HPV vaccine in the United
States. Due to religious and individual rights, it will more than likely be several years
before policy mandates the HPV vaccine for young boys and girls in the United States;
however, it is something to work towards in creating more public health policies.
Another recommendation for action is more social marketing. First, to provide
more educational materials in patient waiting rooms and have plenty of brochures and
pamphlets provided with credible resources. This will allow patients to take a free
brochure to read up on HPV and provide credible websites for further information and
education. Second, more schools should adopt the 12-year-old mandate, which requires
girls to get the vaccine before they enter schools. This shouldn’t only be limited to
females. The Gardasil vaccine was created not only for females, but for males also.
Limitations
Based on the results of this study, there are several recommendations on how to
minimize these limitations in future studies similar to this. Because of the difficulties in
getting physicians to participate in research studies, faxing a hard copy of the survey, or
delivering, paper copies, in addition to emailing a web-based survey, might increase the
response rate. The sample size was the largest limitation of the actual study. It would
43
have been beneficial to select a much larger city such as Omaha, or Nebraska as a whole
to increase response rate and enrich data.
Recommendations for Further Study
Suggestions for future research include expanding the population geographically to
survey a sample of physicians in a statewide region, rather than a single town. Another
recommendation is to select a different target population. A study surveying preteen and
teenaged male and female patients in the state of Nebraska on their knowledge and beliefs
about the HPV vaccine could yield some useful data on expanding the voluntary usage
rate in the teen and young adult population.
Conclusion
The research gathered from this study can guide physician practices by
encouraging them to talk to people of a larger age range, putting more materials in their
office, educate their patients about their reasons for not wanting to get the vaccines, and be
aware of and possibly adjust their fees for the vaccines for self-pay patient in the interest
of public health. These findings could also guide public health education efforts in
advocating for physician incentives, which could also lead to providers having time to talk
to people of different age ranges about the vaccine and provide more informational
materials for their offices, parents, and patients so they can overcome their reasons for not
receiving the vaccine. This study can also assist public health officials increase awareness
and education in schools to positively develop a new health curriculum.
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Longitudinal predictors of human papillomavirus vaccination among a national
sample of adolescent males. American Journal of Public Health, 103 (8), 14191427.
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.
The Nebraska Medical Center. (n.d). The facts of human papillomavirus (HPV).
Retrieved from http://www.nebraskamed.com/health-library/210244/the-facts-onhuman-papillomavirus-hpv
U.S. Census Bureau. (2014). State and county quick facts: Lincoln, Nebraska. Retrieved
from http://quickfacts.census.gov/qfd/states/31/3128000.html
WHO. (2014). Cervical cancer prevention and the Millennium Development Goals.
Bulletin of the World Health Organization. Retrieved from
http://www.who.int/bulletin/volumes/86/6/07-050450/en/
Zimmerman, R. (2006). Ethical analysis of HPV vaccine policy options. Vaccine 48(22).
4812-4820.
Appendix A: Informed Consent
DESCRIPTION: You are invited to participate in a research study on medical
professionals who administer the Human Papillomavirus (HPV). The purpose of this
47
study is to examine the barriers between medical professionals and patients regarding
education on and receipt of the HPV vaccine. You will be asked to complete a brief
questionnaire on your attitudes and beliefs on HPV and your patients and the time you
spend with them.
TIME INVOLVEMENT: Your participation will take approximately 3 minutes.
RISKS AND BENEFITS: There are no risks associated with this study. The benefits
which may reasonably be expected to result from this study are guidance on developing
more efficient, future health materials and programs for medical professionals and the
community for increasing awareness of HPV. We cannot and do not guarantee or
promise that you will receive any benefits from this study. Your decision whether
or not to participate in this study will not affect your medical practice or employment.
PAYMENTS: You will not receive any form of payment for your participation.
PARTICIPANT’S RIGHTS: If you have read this form and have decided to
participate in this project, please understand your participation is voluntary and you
have the right to withdraw your consent or discontinue participation at any
time without penalty or loss of benefits to which you are otherwise entitled.
The alternative is not to participate. You have the right to refuse to answer
particular questions. The results of this research study may be presented at scientific
or professional meetings or published in scientific journals.
CONTACT INFORMATION:
Questions: If you have any questions, concerns or complaints about this research, its
procedures, risks and benefits, contact the Protocol Director, Dr. Hollie Pavlica at (919)
259-0335.
Independent Contact: If you are not satisfied with how this study is being conducted,
or if you have any concerns, complaints, or general questions about the research or your
rights as a participant, please contact the Concordia Institutional Review Board (IRB)
Chair, Nancy Elwell, to speak to someone independent of the research team at 011 (402)
643-7337. You can also write to the Concordia University IRB at, Concordia University,
800 N Columbia Ave, Seward, NE 68434.
Appendix B: Survey Questions
Survey Questions for Medical Professionals in Lincoln, Nebraska
Please circle the answer that fits best.
Do you administer the HPV vaccine?
Yes
No
If no, please stop and submit the survey. Thank you!
If yes, please continue on completing the survey.
What ages are the patients you typically discuss sex-related topics with (Circle all that
apply)?
7-12
13-19
20-29
30-40
40+
How important is it to you to educate your patients on HPV?
Unimportant
Moderately Important
Important
Extremely important
How important is to you that the patient get the HPV vaccine when it is offered to them?
Unimportant
Moderately Important
Important
Extremely important
Do you have marketing materials on HPV/cervical cancer in your waiting room(s)?
Yes
No
The HPV vaccines currently on the market are safe and effective.
Disagree
Undecided
Agree
How much do you charge for the HPV vaccine for patients who do NOT have insurance?
Do you feel that you have a sufficient amount of time to truly educate your patients on
sex-related topics and vaccinations?
Yes
Sometimes
No
49
Do female patients who choose to vaccinate receive all three doses?
Always
Sometimes
Rarely
What percent of females get each vaccination?
1st: 0-25%, 26-50%,
2nd: 0-25%, 26-50%,
3rd: 0-25%, 26-50%,
51-75%,
51-75%,
51-75%,
76-100%
76-100%
76-100%
Do the male patients who choose to vaccinate receive all three doses?
Always
Sometimes
Rarely
What percent of females get each vaccination?
1st: 0-25%, 26-50%,
2nd: 0-25%, 26-50%,
3rd: 0-25%, 26-50%,
51-75%,
51-75%,
51-75%,
76-100%
76-100%
76-100%
Please list the top two most common reasons females choose NOT to vaccinate.
__________________________
_____________________________
Please list the top two most common reasons males tell you when they choose NOT to get
the vaccine.
__________________________
_____________________________
Highest Degree__________________ Medical Specialty____________________
How many years have you been working in your area of specialty?
1-5
6-10
41+
11-20
21-30
31-40
What is your gender?
What is your age group?
Male
20-29
Female
30-39
40-49
Other
50-59
Thank you for your time and effort into completing this survey.
60+