1. 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

2. 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.

3. 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 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

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

5. Study Population
Survey of caregivers (parents/guardians) of 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

6. 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

7. 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%

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 ( )
16-18
344
16.9
3.1 ( )
Race/ethnicity
White
622
10.3
Black
205
12.5
1.2 ( )
Hispanic/other 56
1.8
0.2 ( )

9. 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 ( )
16-18
344
16.9
3.1 ( )
Race/ethnicity
White
622
10.3
Black
205
12.5
1.2 ( )
Hispanic/other 56
1.8
0.2 ( )
Need n??

10. 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 ( )
16-18
344
16.9
3.1 ( )
Race/ethnicity
White
622
10.3
Black
205
12.5
1.2 ( )
Hispanic/other 56
1.8
0.2 ( )

11. 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 ( )
16-18
344
16.9
3.1 ( )
Race/ethnicity
White
622
10.3
Black
205
12.5
1.2 ( )
Hispanic/other 56
1.8
0.2 ( )

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

13. 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%

14. 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%

15. 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

16. 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

17. Summary
10.2% of caregivers reported 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

18. 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

20. 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.