Disparities in parental human papillomavirus (HPV) vaccine awareness and uptake among adolescents

Trends in HPV vaccine awareness among parents of adolescent girls and boys (ages 13–17) and HPV vaccine uptake (≥1 dose) among girls (ages 13–17) were evaluated in Los Angeles County, California. Between 2007 and 2011, parental HPV vaccine awareness increased from 72% to 77% overall, with significant increases among mothers, Latinos, and respondents with daughters and Medi-Cal insured children. In 2011, parents who were male, older, less educated, Asian/Pacific Islander, and had sons remained significantly less likely to be aware. HPV vaccine initiation among daughters nearly doubled from 25% in 2007 to 48% in 2011, and girls who were older, uninsured, and had access-related barriers showed the largest improvements. In 2011, daughters who were younger and who had older and African American parents were at risk for low uptake. Thus, initiatives targeting male and younger adolescents, culturally-relevant information, and access to vaccination may help to reduce identified disparities.     

Quadrivalent HPV vaccine efficacy against disease related to vaccine and non-vaccine HPV types in males

A small number of HPV types are related to a majority of HPV-related neoplastic lesions in humans. High-risk types such as HPV 16 and 18 are most often implicated, although other oncogenic and non-oncogenic HPV types can cause disease in men. The efficacy of the quadrivalent HPV vaccine (qHPV) against external genital lesions and intra-anal disease related to HPV in men has been demonstrated. This report examines the vaccine's efficacy against disease due to 10 additional non-vaccine HPV types, as well as efficacy regardless of HPV detection. The data presented suggest that vaccinating males against HPV 6, 11, 16 and 18 protects them against most vaccine HPV-type related anogenital disease. However, significant efficacy against disease due to non-vaccine HPV types was not seen. In addition, the data do not provide any evidence that vaccination with qHPV vaccine will increase the likelihood of disease caused by non-vaccine types in the short term.     

男性HPV感染的流行病学研究进展

摘要:人乳头瘤病毒感染在人群中十分普遍,由于该病毒在宫颈癌中扮演的重要角色,其在女性中研究较多。随着分子生物学技术广泛地应用于人乳头瘤病毒的检测和流行病学调查,使人们对于男性人乳头瘤病毒的感染有进一步的认识。本文就男性HPV感染的检测取样方法、检测部位及不同部位的感染率、影响HPV感染率的危险因素进行综述。随着各种研究的出现,最近的观点认为临床医生取材的结果准确性优于患者本人。恰当的检测方法及检测手段对HPV感染检出率的提高至关重要,不同的标本均可从一定程度上反应该病毒的感染状态,医生可根据情况选择恰当的方案。未行包皮环切术及HIV感染等均为男性HPV感染的危险因素。     

HPV vaccine and adolescent males

In 2009, the United States approved quadrivalent HPV vaccine for males 9-26 years old, but data on vaccine uptake are lacking. We determined HPV vaccine uptake among adolescent males, as well as stage of adoption and vaccine acceptability to parents and their sons. A national sample of parents of adolescent males ages 11-17 years (n = 547) and their sons (n = 421) completed online surveys during August and September 2010. Analyses used multivariate linear regression. Few sons (2%) had received any doses of HPV vaccine, and most parents and sons were unaware the vaccine can be given to males. Parents with unvaccinated sons were moderately willing to get their sons free HPV vaccine (mean = 3.37, SD = 1.21, possible range 1-5). Parents were more willing to get their sons vaccinated if they perceived higher levels of HPV vaccine effectiveness (β = 0.20) or if they anticipated higher regret about their sons not getting vaccinated and later developing an HPV infection (β = 0.32). Vaccine acceptability was also modest among unvaccinated sons (mean = 2.98, SD = 1.13, possible range 1-5). Sons were more willing to get vaccinated if they perceived higher peer acceptance of HPV vaccine (β = 0.39) or anticipated higher regret about not getting vaccinated and later developing an HPV infection (β = 0.22). HPV vaccine uptake was nearly nonexistent a year after permissive national recommendations were first issued for males. Vaccine acceptability was moderate among both parents and sons. Efforts to increase vaccine uptake among adolescent males should consider the important role of peer acceptance and anticipated regret.     

Immunogenicity and safety of the 9-valent HPV vaccine in men

ObjectivesThis study was designed to evaluate the immunogenicity and tolerability of a prophylactic 9-valent HPV (types 6/11/16/18/31/33/45/52/58) VLP (9vHPV) vaccine in young men 16–26 years of age in comparison to young women 16–26 years of age (the population that was used to establish 9vHPV vaccine efficacy). Safety and immunogenicity data from this study will be used to bridge 9vHPV vaccine efficacy findings in 16–26 year old women to 16–26 year old men.MethodsThis study enrolled 1106 heterosexual men (HM) and 1101 women who had not yet received HPV vaccination. In addition, 313 men having sex with men (MSM) were enrolled and were evaluated separately for immunogenicity because previous results showed that antibody responses to quadrivalent HPV (types 6/11/16/18) VLP (qHPV) vaccine were lower in MSM than in HM. All subjects were administered a 3-dose regimen (Day 1, Month 2, Month 6) of 9vHPV vaccine. Serum samples were collected for anti-HPV assays. Safety information was collected for ∼12 months.ResultsThe geometric mean titers (GMTs) for HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58 for HM were non-inferior to those of women at Month 7. For all vaccine HPV types, Month 7 GMTs were numerically lower in MSM than in HM. Over 99.5% of subjects were seropositive at Month 7 for each vaccine HPV type. Administration of 9vHPV vaccine to both 16–26 year old men and women was generally well tolerated.ConclusionsThese results support bridging the efficacy findings with 9vHPV vaccine in young women 16–26 years of age to men 16–26 years of age.     

Knowledge and awareness of HPV and the HPV vaccine among young women in the first routinely vaccinated cohort in England

A national school-based human papillomavirus (HPV) vaccination programme has been available for 12–13 year old females in the UK since 2008, offering protection against HPV types 16 and 18, which are responsible for the majority of cervical cancer. Little is known about HPV knowledge in girls who have been offered the vaccine. Girls offered the school-based vaccine in the first routine cohort (n = 1033) were recruited from 13 schools in London three years post-vaccination. Participants completed a questionnaire about HPV awareness, knowledge about HPV and the vaccine, and demographic characteristics including vaccine status. About a fifth of the girls reported they were unaware of the HPV infection. Among those who reported being aware of HPV (n = 759) knowledge was relatively low. Approximately half of the participants knew that HPV infection causes cervical cancer, condoms can reduce the risk of transmission and that cervical screening is needed regardless of vaccination status. These results are helpful in benchmarking HPV-related knowledge in vaccinated girls and could be used in the development of appropriate educational messages to accompany the first cervical screening invitation in this cohort in the future.     

西安市妇科门诊患者HPV和HPV疫苗的认知调查

目的 了解西安市妇科门诊患者对人乳头瘤病毒(HPV)的认知情况及其接种HPV疫苗的态度,为推广HPV疫苗的接种提供依据. 方法 在西安市第四医院妇科门诊单纯随机抽取前来就诊的患者1 000人,采用自行设计的问卷,进行调查.问卷内容主要包括患者的基本资料(年龄、婚姻、学历、职业)、对HPV的认知、对HPV疫苗的认知及态度. 结果 32.5％患者知晓HPV,不同年龄、教育程度、职业的女性在HPV知晓率上差异均有统计学意义.30＜年龄≤40岁年龄段的女性对HPV的知晓率(49％)明显高于21≤年龄≤30岁(34.4％)和60＜年龄≤71岁(17.6％)年龄段的女性,大学及以上学历的女性对HPV的知晓率(44.3％)明显高于初高中组,未受过教育的女性对HPV的知晓率(29.7％)最低;干部/职员/技术人员对HPV的知晓率(41.7％)最高,而工人、农民、个体户/服务人员对HPV的知晓率普遍偏低.76.0％患者愿意接种HPV疫苗,担心会感染HPV(32.1％)或患宫颈癌(26.1％)的女性有较强的接种意愿.56.6％的患者能接受的疫苗价格在50 ～ 100元,有49.9％的患者更愿意接受政府提供的疫苗,40.8％的患者更愿意接受医疗机构提供的疫苗. 结论 西安市门诊患者对HPV及其疫苗的知晓率较低,应加强公众健康教育宣传力度,普及HPV疫苗相关知识.     

HPV vaccination among adolescent males: Results from the National Immunization Survey-Teen

US guidelines provided a permissive recommendation for HPV vaccine for males in 2009, with an updated recommendation for routine vaccination in 2011. Data on vaccine uptake among males, however, remain sparse. We analyzed 2010–2011 data (collected mostly prior to the recommendation for routine vaccination) from the National Immunization Survey-Teen for a nationally representative sample of adolescent males ages 13–17 (n = 22,365). We examined HPV vaccine initiation (receipt of at least one dose based on healthcare provider records) as the primary outcome. Analyses used weighted logistic regression. HPV vaccine initiation increased from 1.4% in 2010 to 8.3% in 2011. Parents who reported receiving a healthcare provider recommendation to get their sons HPV vaccine were much more likely to have vaccinated sons (OR = 19.02, 95% CI: 14.36–25.19). Initiation was also higher among sons who were Hispanic (OR = 1.83, 95% CI: 1.24–2.71) or who were eligible for the Vaccines for Children program (OR = 1.53, 95% CI: 1.01–2.31). Only 31.0% of parents with unvaccinated sons indicated their sons were “somewhat likely” or “very likely” to receive HPV vaccine in the next year. The most common main reasons for parents not intending to vaccinate were believing vaccination is not needed or not necessary (24.5%), not having received a provider recommendation (22.1%), and lack of knowledge (15.9%). HPV vaccination is low among adolescent males in the US, and provider recommendation for vaccination is likely key to improving vaccine uptake. Given the updated recommendation for routine vaccination and the changes in health insurance coverage that are likely to follow, continued efforts are needed to monitor HPV vaccination among males.     

Factors associated with Human Papilloma Virus (HPV) vaccine recommendation by physicians in Lebanon,a cross-sectional study

Persistent Human Papilloma Virus (HPV) infection is associated with the development of cervical cancer, a leading cause of female death worldwide. In Lebanon, cervical cancer is the 6th most common cancer amongst girls and women aged 14–44 years. Cervical cancer is preventable through HPV vaccination; however, Lebanon does not include HPV vaccination in its national routine vaccination schedule. Hence, physician recommendation is key for patient vaccine uptake. We conducted a cross-sectional study in Beirut, Lebanon to assess factors affecting physician recommendation regarding HPV vaccination. Physicians practicing in Obstetrics and Gynecology (OBGYN), Pediatrics, Family Medicine and Infectious Diseases were included in the study. In total, 228 physicians completed the survey (28.79% response rate). The survey consisted of a set of demographic and HPV knowledge questions along with clinical vignettes. The vignettes presented theoretical patients who differed in gender, age, sexual activity, social background and whether the patient presented with his mother or not. The results show that physicians tend to recommend the vaccine more commonly for vignettes presenting female patients, with an Adjusted Odds Ratio (AOR) of 6.8. Also, physicians were more likely to recommend the vaccine for vignettes with patients coming from a non-conservative background (AOR = 2.1), vignettes where patients claim to be sexually active (AOR = 2.7) and vignettes where patients presented with their mother (AOR = 1.4). Physicians tend to recommend the vaccine less in vignettes with married patients (AOR = 0.5). Physicians with higher knowledge scores recommended the vaccine more often (AOR = 3.4). Overall, OBGYN physicians recommended the vaccine less than pediatricians (AOR = 0.5). These results show that Lebanese physicians’ recommendations rely on factors external to international guidelines. The results also highlight the importance of knowledge in adequate patient consultation. Thus, improved physician awareness towards international guidelines and physician education regarding HPV vaccination is essential in order to improve patient care in Lebanon.     

Job satisfaction and trust in Health Insurance Review Agency among Korean physicians

OBJECTIVES: To measure Korean physicians' job satisfaction and to examine the relationship between trust in Health Insurance Review Agency (HIRA) and job satisfaction. METHODS: Stratified sampling was used. The sample was representative of Korean office-based physicians; 1593 office-based physicians in Korea were surveyed by mail over a 4-week period using a self-administered questionnaire. Multivariate analysis using logistic regression was performed to investigate predictors of physicians' job satisfaction and to examine whether trust in HIRA was related to job satisfaction. RESULTS: Overall, the job satisfaction of physicians was very low. The payment denial rate was not related to job satisfaction. Physicians who trusted HIRA were more likely to be satisfied with their job. CONCLUSIONS: Physicians who trusted in the HIRA were more likely to report satisfaction. These results emphasize that trust in the HIRA is key to physicians' job satisfaction.     

HPV vaccine acceptance among adolescent males and their parents in two suburban pediatric practices

PurposeTo measure HPV vaccine acceptance among unvaccinated adolescent males and parents and correlate acceptance with knowledge, awareness, and personal experience.MethodsAdolescent males ages 11–21 years old and their parents completed questionnaires measuring attitudes and knowledge about HPV vaccination and personal experience. Acceptance was defined as wanting the vaccine and conditional acceptance as wanting the vaccine if it would protect against genital warts or cervical cancer.ResultsAdolescent (n = 154) and parent (n = 121) vaccine acceptance was low (16% and 34%, respectively); however, conditional acceptance was higher. While adolescents had similar conditional acceptance for a vaccine against genital warts and cervical cancer, parents reported higher conditional acceptance for protection against genital warts. Independent predictors of acceptance included personal experience and demographic variables.ConclusionsHPV vaccine acceptance among adolescents and parents was low. Conditional acceptance levels highlight the importance of education about a few important benefits of HPV vaccination, which may increase vaccination rates.     

Completion of the human papillomavirus (HPV) vaccine series among males with private insurance between 2006 and 2009

Little is known about initiation and completion among males who received the HPV vaccine on an off-label basis before 2009. This study utilized administrative claims data from a private insurance company to examine completion of the 3 dose HPV series among 514 males who initiated the vaccine between 2006 and May of 2009. Frequencies of HPV vaccination were examined and multivariate logistic regression estimated the odds of completing the entire series within 365 days of initiation. We found that only 21% of male initiators completed all 3 vaccine doses within 12 months and completion decreased over time. Series completion did not vary significantly by provider type. These findings suggest that difficulties may be encountered in fully vaccinating enough males to achieve adequate herd immunity in the future.     

Cervical cancer and HPV: Awareness and vaccine acceptability among parents in Morocco

Cervical cancer is a major public health concern in Morocco where it represents the second most common and lethal cancer in women. Human papillomavirus (HPV) vaccines have been licensed in Morocco since 2008 but there are no available data on their acceptability. This study aimed to assess awareness of HPV and the vaccine, and to identify factors associated with acceptability of the vaccine among parents in Morocco.     

西安非医学专业女大学生对HPV和HPV疫苗的认知

目的 了解西安市高校非医学专业女大学生对人乳头瘤病毒(HPV)的认知情况及其对接种HPV疫苗的态度,为制定针对非医学专业大学生健康教育模式,推广HPV疫苗的接种提供依据.方法 采用整群随机抽样的方法,在西安市6所非医学类本科高校中抽取16个专业的大学二、三年级女大学生共2 131名,用自行设计的问卷进行调查,获有效问卷2 096份,有效回收率为98.4％.结果 仅11.3％被调查者知晓HPV,有性生活组大学生对HPV知晓率显著高于无性生活组(x2=20.182,P＜0.05),来自单亲或重组家庭的女大学生对HPV知晓率显著高于来自原生家庭组(x2=4.329,P＜0.05).不同年级间(x2=0.921),来自城市或农村(x2=0.891),是否独生子女(x2 =0.330)组间对HPV知晓率差异无统计学意义(P＞0.05).仅9.7％被调查者知晓HPV疫苗.79.9％的被调查者表示愿意接种HPV疫苗;担心会感染HPV (44.1％)或患宫颈癌(19.3％)的被调查者有较强的接种意愿;公众健康教育(42.2％)及医务人员推荐(34.7％)是女大学生们更愿意接受的疫苗推荐方式.超过半数被调查者(50.1％)能够接受的疫苗价格在50～ 100元.结论 西安非医学专业大学生对HPV及HPV疫苗的知晓率低,但接种意愿强.应加强科普健康教育,普及宫颈癌一级预防、HPV及HPV疫苗相关知识.     

Adolescents' awareness of HPV infections and attitudes towards HPV vaccination 3 years following the introduction of the HPV vaccine in Hungary

Hungary takes the fourth place regarding the incidence and the fifth regarding the mortality of cervical cancer among the member countries of the European Union, with 500 deaths due to this preventable illness and nearly 1200 new cases diagnosed every year. Although the vaccines have been available for 3 years, the estimated rate of the female population vaccinated against HPV is approximately 10% in the 12-26-year-age cohort. The aim of this study was to determine factors and motivations affecting the uptake of HPV vaccination among Hungarian adolescents. Examining the effects of some possible sociodemographic predictors (age and gender) and the exposure to health information on HPV vaccine acceptability were also focused on, as well as assessing the most trusted sources of information about sexually transmitted diseases (STDs).A nationwide anonymous questionnaire survey with a sample of 1769 students attending public primary or secondary schools was organised by the authors in 16 Hungarian cities and towns. Data were analysed using the Statistical Package for the Social Sciences (SPSS).Adolescents’ awareness of HPV was relatively low. Only 35% of the participants reported they had heard about HPV prior to the survey. Almost 70% of the potentially affected study population had not heard about the vaccine previously. Every fourth student did not believe that vaccination against HPV can prevent cervical cancer. If the vaccination was available free of charge, almost 80% of respondents would request it, but in case they had to pay for it, this number would significantly decrease. Significantly better knowledge and also more positive attitudes towards HPV vaccination was found in relation to the number of information sources. The majority of respondents (62-83%) were open for further information about STDs. The main trusted mediators were school-health services (61.3%), education on health at school (49.2%), health professionals (42.2%) and electronic media (24.6%).Since Hungarian adolescent students expect guidance about STDs principally from school health education, an urgent need for well-designed, HPV-focused educational programmes emerges. Launching such programmes would be especially important for the adolescent population to increase their awareness of the risks associated with HPV infection thus reducing the high incidence of cervical cancer in Hungary in the future.     

Bivalent AS04-adjuvanted HPV vaccine provides optimal cancer prevention for HPV types not included in the vaccine

All available HPV vaccines contain oncogenic types 16 and 18, most often found in HPV-related cancers and precursor lesions, but they differ in their valence and adjuvant potency. The quadri- and nonavalent HPV vaccines both contain additional types 6 and 11, related to anogenital warts, while the nonavalent vaccine contains another five types that are less frequently found in cancers. The bivalent vaccine is adjuvanted by AS04. Phase-III randomised controlled trials and population-based studies on bi- and quadrivalent vaccines suggest that the two vaccines when administered to HPV-naive persons, are optimally effective in preventing cervical intra-epithelial neoplasia grade 3 or greater, caused by types 16 or 18 (specific protection). In addition, the bivalent vaccine, but not the quadrivalent vaccine, cross-protects against HPV types not contained in the vaccine. The advantage of the quadrivalent vaccine to provide additional protection against anogenital warts, should not be traded for a lower overall efficacy in preventing pre-cancerous lesions and eventually cancer.     

Potential for HPV vaccination and primary HPV screening to reduce cervical cancer disparities: Example from New Zealand

BackgroundCervical cancer rates are over twice as high, and screening coverage is lower, in Māori women compared to other women in New Zealand, whereas uptake of HPV vaccine is higher in Maori females. We aimed to assess the impact of HPV vaccination and the proposed transition to 5-yearly primary HPV screening in Māori and other women in New Zealand, at current participation levels; and additionally to investigate which improvements to participation in Māori females (in vaccination, screening, or surveillance for screening-defined higher-risk women) would have the greatest impact on cervical cancer incidence/mortality.MethodsAn established model of HPV vaccination and cervical screening in New Zealand was adapted to fit observed ethnicity-specific data. Ethnicity-specific models were used to estimate the long-term impact of vaccination and screening (vaccination coverage 63% vs 47%; five-year screening coverage 68% vs 81% in Maori vs European/Other women, respectively).ResultsShifting from cytology to HPV-based screening is predicted to reduce cervical cancer incidence by 17% (14%) in Maori (European/Other) women, respectively. The corresponding reductions due to vaccination and HPV-based screening combined were 58% (44%), but at current participation levels long-term incidence would remain almost twice as high in Māori women (6.1/100,000 compared to 3.1/100,00 in European/Other women). Among strategies we examined, the greatest impact came from high vaccine coverage and achieving higher attendance by Māori women under surveillance for screen-detected abnormalities.ConclusionRelative reductions in cervical cancer due to vaccination and HPV-based screening are predicted to be greater in Maori than in European/Other women. While these interventions have the potential to substantially reduce between-group differences, cervical cancer incidence would remain higher in Maori women. These findings highlight the importance of multiple approaches and the potential influence of factors beyond HPV prevention.     

女大学生宫颈癌防治及HPV疫苗认知现况调查

目的了解女大学生对宫颈癌防治及人乳头瘤病毒(HPV)疫苗认知的情况,为我国高校开展大学生宫颈癌及HPV疫苗认知的健康教育和HPV疫苗的推广提供参考依据。方法 2019年9—10月,在新疆某医学院校采用分层整群随机抽样的方法抽取485名女大学生进行问卷调查,并对数据进行分析。结果女大学生宫颈癌防治认知总分为11.78±6.11,临床专业女大学生宫颈癌防治认知总得分(14.61±4.15)略高于非临床组(9.88±6.47),高年级女大学生宫颈癌防治认知总得分(13.36±5.26)略高于低年级组(9.80±6.51),差异均有统计学意义(均P<0.05)。485名女大学生中听说过HPV疫苗的有312名(64.3%),愿意定期做HPV筛查的有391名(80.6%),愿意接种HPV疫苗的有391名(80.6%)。结论女大学生对宫颈癌防治认知了解相对匮乏,但其HPV疫苗接种意愿较强,高校应开展相应活动及课程,提高学生对宫颈癌相关认知进而提高HPV疫苗接种水平,以达到预防宫颈癌的目的。     

Knowledge and intention to participate in cervical cancer screening after the human papillomavirus vaccine

Background

If women who receive the human papillomavirus (HPV) vaccine are unduly reassured about the cancer prevention benefits of vaccination, they may choose not to participate in screening, thereby increasing their risk for cervical cancer. This study assesses adult women's knowledge of the need to continue cervical cancer screening after HPV vaccination, describes Pap test intentions of vaccinated young adult women, and evaluates whether knowledge and intentions differ across groups at greatest risk for cervical cancer.

Methods

Data were from the 2008 Health Information National Trends Survey (HINTS) and the 2008 National Health Interview Survey (NHIS), which initiated data collection approximately 18 months after the first FDA approval of an HPV vaccine. We calculated associations between independent variables and the outcomes using chi-square tests.

Results

Of 1586 female HINTS respondents ages 18 through 74, 95.6% knew that HPV-vaccinated women should continue to receive Pap tests. This knowledge did not vary significantly by race/ethnicity, education, income, or healthcare access. Among 1101 female NHIS respondents ages 18-26 who had ever received a Pap test, the proportion (12.7%; n = 139) who reported receipt of the HPV vaccine were more likely than those not vaccinated to plan to receive a Pap test within three years (98.1% vs. 92.5%, p < 0.001).

Conclusions

US adult women possess high knowledge and intention to participate in Pap testing after HPV vaccination. The vast majority of young adult women who received the HPV vaccine within its first two years on the market intend to participate in cervical cancer screening in the near future. Future studies are needed to examine whether those vaccinated in adolescence will become aware of, and adhere to, screening guidelines as they become eligible.     

Prevalence and characteristics of HPV vaccine hesitancy among parents of adolescents across the US

BackgroundWhile many clinicians encounter parents or adolescents who refuse HPV vaccine, little is known about the prevalence of hesitancy for HPV vaccine nationally or its association with vaccination.MethodsIn April 2019, we surveyed families with adolescents 11–17 years using a national online panel (Knowledge Panel®) as the sampling frame. We assessed the prevalence of HPV vaccine hesitancy with the validated 9-item Vaccine Hesitancy Scale (VHS). We used multivariate analyses to assess demographic factors associated with HPV vaccine hesitancy. We also assessed practical barriers to receipt of HPV vaccine and the relationship between barriers and hesitancy. Finally, we evaluated the association between both HPV vaccine hesitancy and practical barriers on HPV vaccine receipt or refusal.Results2,177 parents out of 4,185 sampled (52%) completed the survey, 2,020 qualified (lived with adolescent). Using a VHS cut-off score > 3 out of 5 points, 23% of US parents were hesitant about HPV vaccine. Hesitancy was lower among those with Hispanic ethnicity. At least one out of five parents disagreed that the HPV vaccine is beneficial for their adolescent, that the vaccine is effective, protects against HPV-related cancers, or that they followed their adolescent’s health-care provider’s recommendation about the vaccine. Many were concerned about vaccine side effects and the novelty of the vaccine. Adolescents living with vaccine-hesitant parents were less than one-third as likely to have received the vaccine (RR = 0.29, 95% CI 0.24, 0.35) or completed the vaccine series (RR = 0.29, 95% CI 0.23, 0.36), and were 6-fold more likely to have refused the vaccine because of parental vaccine-related concerns (RR = 6.09, 95% CI = 5.26, 7.04). Most practical barriers were independently associated with vaccine receipt but not with vaccine refusal.ConclusionsHPV vaccine hesitancy is common nationally and strongly related to both under-vaccination and vaccine refusal.