HPV Vaccination in Communities with High Rates of Cervical Cancer: A Survey of Caregivers of Adolescent Girls in North Carolina Sami Gottlieb, MD, MSPH Centers for Disease Control and Prevention March 13, 2008

CHIME Project Collaborators UNC, Chapel Hill Noel Brewer, PI Karen Ziarnowski Jennifer Smith CDC Maya Sternberg Nicole Liddon Lauri Markowitz The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

HPV Vaccine in Communities with High Rates of Cervical Cancer HPV vaccine holds great promise for reducing burden of cervical cancer in the U.S. Recommended routine use in 11-12 year-old girls Especially important in communities with highest cervical cancer rates Large racial disparities in cervical cancer Often in underserved areas Little is known about HPV vaccine uptake in these communities Adolescents with greatest need may be least likely to receive it

Objective To assess HPV vaccine uptake and potential barriers to vaccination in an area with high cervical cancer rates

Study Population Survey of caregivers (parents/guardians) of 10- 18 year-old girls in 5 North Carolina counties County inclusion criteria Cervical cancer incidence >10 cases/100,000 Cervical cancer mortality >4 deaths/100,000 ≥ 20% African American residents Study counties Other eligible counties

Survey Methods Summer 2007: telephone interviews with a stratified random sample of county households Oversampling in African American, rural areas Questions on HPV vaccine uptake, main reasons for not vaccinating, and intentions to vaccinate Has your daughter had any shots of the HPV vaccine? How likely are you to get your daughter the HPV vaccine in the next year? Estimates weighted to incorporate study design and sampling methods

Results: Study Population 910 caregivers interviewed (response rate 63%) Selected characteristics, caregiver Mean age, years 41 Black/African American 38% Hispanic 5% Selected characteristics, daughter 14.4 Saw provider in last year 92% Had preventive care visit in last year 83%

Percentage of Daughters that Had Received ≥1 Dose of HPV Vaccine Characteristic N % vaccinated Odds ratio (95% CI) Overall 907 10.2 Age group, years 10-12 257 6.2 ref 13-15 299 7.9 1.3 (0.6- 2.8) 16-18 344 16.9 3.1 (1.4- 6.6) Race/ethnicity White 622 10.3 Black 205 12.5 1.2 (0.6-2.4) Hispanic/other 56 1.8 0.2 (0.03-0.8)

Percentage of Daughters that Had Received ≥1 Dose of HPV Vaccine Characteristic N % vaccinated Odds ratio (95% CI) Overall 907 10.2 Age group, years 10-12 257 6.2 ref 13-15 299 7.9 1.3 (0.6- 2.8) 16-18 344 16.9 3.1 (1.4- 6.6) Race/ethnicity White 622 10.3 Black 205 12.5 1.2 (0.6-2.4) Hispanic/other 56 1.8 0.2 (0.03-0.8) Need n??

Percentage of Daughters that Had Received ≥1 Dose of HPV Vaccine Characteristic N % vaccinated Odds ratio (95% CI) Overall 907 10.2 Age group, years 10-12 257 6.2 ref 13-15 299 7.9 1.3 (0.6- 2.8) 16-18 344 16.9 3.1 (1.4- 6.6) Race/ethnicity White 622 10.3 Black 205 12.5 1.2 (0.6-2.4) Hispanic/other 56 1.8 0.2 (0.03-0.8)

Percentage of Daughters that Had Received ≥1 Dose of HPV Vaccine Characteristic N % vaccinated Odds ratio (95% CI) Overall 907 10.2 Age group, years 10-12 257 6.2 ref 13-15 299 7.9 1.3 (0.6- 2.8) 16-18 344 16.9 3.1 (1.4- 6.6) Race/ethnicity White 622 10.3 Black 205 12.5 1.2 (0.6-2.4) Hispanic/other 56 1.8 0.2 (0.03-0.8)

Percentage of Daughters Vaccinated, by Daughters’ Health Insurance Status % vaccinated Odds ratio (95% CI) None 42 4.3 0.5 (0.1-1.7) Public only 108 16.1 1.9 (0.8-4.4) Private only 706 9.2 ref Public and private 28 8.3 0.9 (0.2-3.5)

Location and Costs of HPV Vaccination for Vaccinated Daughters (n=106) Where received vaccine Out-of-pocket costs <$100 35% OB/gyn 19% Pediatrics 40% Nothing 60% Family practice 23% ≥$100 4%

Main Reasons Reported for Not Having Vaccinated Daughters (n=780) Only 0.4% of caregivers cited concern about HPV vaccine making teenage girl more likely to have sex Few caregivers reported cost, insurance issues, or vaccine safety as main reasons Needing more information about vaccine 22% Haven’t been to MD, gotten around to it yet 17% Daughter is too young 16% Never heard of vaccine 14% Daughter is not having sex yet 12%

Intentions to Vaccinate: Caregivers with Unvaccinated Daughters (n=783) 62% reported that their daughters “probably” or “definitely” will get the vaccine in the next year Only 10% reported that their daughters “definitely won’t” get the HPV vaccine in the next year No significant differences in intentions to vaccinate by age group of daughters Intentions appeared slightly higher for blacks: 67% vs 58% for whites, but not significant 64% of Hispanics/others intended to vaccinate

Limitations Generalizability Self-reported vaccination status Response rate 63% Southeastern U.S. Self-reported vaccination status Survey done soon after vaccine available Still evolving, may not reflect current uptake

Summary 10.2% of caregivers reported 10-18 year-old daughters had received vaccine Higher uptake in older adolescents No racial disparities in vaccine uptake Main reasons for not having vaccinated: needing more information, feeling daughter too young Majority of caregivers with unvaccinated daughters intended for them to be vaccinated

Discussion and Implications Vaccine uptake, although low, was promising so soon after vaccine had become available Differential uptake by age may reflect: Desire to catch-up older teens Perception that vaccine not yet needed in younger girls Lack of early racial disparities encouraging: could help close racial gaps in cervical cancer Main barriers reported by caregivers can be overcome with information, education Additional efforts needed in communities with high cervical cancer rates

HPV Vaccine Awareness Overall, 78% of caregivers had heard of HPV vaccine prior to survey Awareness of vaccine varied significantly by race/ethnicity (p<0.001) 88% of whites 67% of blacks 69% of Hispanics/others Overall, 78% of the caregivers had heard of the HPV vaccine before the survey. However, HPV vaccine awareness varied significantly by race/ethnicity: 88% of whites had heard of the vaccine, compared with 67% of blacks, and 69% of Hispanics or others.