Abstract
This quality improvement study aims to examine knowledge and attitudes about human papillomavirus (HPV) vaccination among women ages 18 through 26 in a Boston community health center to increase uptake of the HPV vaccine in the local community. This cross-sectional study was conducted from August 2007 to July 2008 at an urban community health center in Roxbury, Massachusetts. Women offered HPV vaccines were asked to complete a questionnaire. Eighty-four percent of participants had heard of the HPV vaccine. A higher percentage (69%) of minority women in this study as compared with those in other studies knew the vaccine protects against cervical cancer. Forty-two percent of women came to their appointment for the purpose of being vaccinated. The remaining 58% came for another reason and received vaccination upon health care provider recommendation. Only 38% of participants reported perceived risk for HPV infection as a motivation for vaccination. These findings suggest that generalizations of attitudes and knowledge about the HPV vaccine should not be made with regard to race and ethnicity alone, but rather need to be based on surveys of the specific local population served. In addition, education about HPV risk should be continued, especially about risk factors for HPV infection.
Keywords
Introduction
Since its approval in June 2006, the Gardasil human papillomavirus (HPV) vaccine has been offered to young women in the United States as a method to prevent infection with the types of HPV that cause most cases of cervical cancer and genital warts. The vaccine is recommended for 11- and 12-year-old girls, as well as girls and women ages 13 through 26 who have not been vaccinated or have not completed the vaccine series. This latter group is known as the “catch-up” group because the vaccine was not available when it might have been offered as part of preventive care. Many studies have been conducted on parents’ willingness to vaccinate their children against HPV.1-4 To a lesser extent, studies have examined knowledge and attitudes about HPV vaccination among young women in the catch-up group, predominantly women on college campuses.5-7
Differences in the United States regarding HPV knowledge, acceptability, and related issues have been documented in certain geographic areas and among certain ethnicities, including rural areas of low socioeconomic status and among African Americans and Hispanic immigrants—all groups at high risk for cervical cancer.8,9 However, the optimal way to recruit urban Boston women for vaccination is not clear, especially with respect to women in the catch-up group who might be at higher risk for cervical cancer, such as those in lower socioeconomic positions or minority groups. Studies suggest that unique educational strategies need to be developed based on the needs and perceptions of the targeted audience to achieve widespread acceptability and knowledge of this vaccine and its relationship to cervical cancer. 4
In 2007, we began a partnership with an urban community health center serving predominantly black and Hispanic communities in Boston, Massachusetts, to design and implement a successful model for community-based HPV vaccine outreach. The collaboration began with a survey designed to assess how and why urban Boston women in the catch-up group are choosing HPV vaccination. Through understanding the motivations for vaccination, this quality improvement project aimed to increase vaccine uptake within the catchment area. Data can guide future patient-, provider-, and community-targeted outreach and education for this and potentially other urban health centers with similar demographics.
Materials and Methods
This cross-sectional study was conducted from August 2007 through July 2008. Participants were recruited from the obstetrics and gynecology (OBGYN) clinic at The Dimock Center in Roxbury, Massachusetts. The study was developed in response to a need for widespread HPV vaccine distribution among women in this community health center’s catchment area. The study was initiated when the OBGYN clinic began to offer the HPV vaccine and was intended as a quality improvement project to guide outreach and education efforts.
All eligible English-speaking women aged 18 through 26, who visited the health center’s OBGYN department for any reason, were offered the HPV vaccine during their clinic visit. They were asked to complete a brief self-administered survey immediately following their appointment, regardless of whether they received or declined the vaccine. Women who had any contraindications (ie, pregnancy, febrile illness, or known hypersensitivity to any component of the vaccine) were not offered the vaccine and therefore excluded from the study. Two versions of the survey were distributed: one for women who agreed to vaccination and one for women who did not agree to vaccination. Women completed the survey in the privacy of their exam room and left the survey in a secure drop-box. Our institution’s Committee on Clinical Investigations approved the study.
The survey was designed to take 5 minutes to complete, and questions were written in either fixed-choice or open-ended format. The survey collected information about demographics, sources and depth of knowledge of the HPV vaccine, concerns about the vaccine, and motivations for vaccination. The version of the survey for women who were vaccinated also assessed whether patients requested vaccination or received vaccination upon provider recommendation. Vaccinated participants were asked if they knew regular Pap screening is needed even after completion of the HPV vaccination series, whether they were willing to pay for the vaccine, and, if so, how much they would pay. Finally, study participants were asked how to best educate and reach out to the community about the vaccine. No identifying information was collected from study participants. The authors developed the survey questions because there are no validated scales for this type of research.
All analyses were conducted using Statistical Analysis System (SAS 9.1.3; SAS Institute, Cary, North Carolina). Proportions were compared with the chi-square or Fisher’s exact test as appropriate. All P values <.05 were considered statistically significant.
Study Population
The community health center in this study is an urban multidisciplinary clinic that primarily serves residents of Roxbury, Dorchester, Jamaica Plain, Hyde Park, Mattapan, and Roslindale, Massachusetts. Residents of these neighborhoods are largely of lower socioeconomic position. Sixty-four percent of the health center clientele are black, and 22% are Hispanic. 10 In comparison, the population of Boston is 21% black, 17% Hispanic, and 50% white. 11 More than 25% of patients and clients at the health center are bilingual or report English as their second language. Census figures show 16% unemployment for the neighborhoods served by the health center, compared with 6% in Boston overall. 12 Incidence of sexually transmitted infections (STIs) is likewise comparatively high, with Chlamydia rates well above the city average in 2008. 13 Although information on the incidence of HPV infection in Boston is unavailable, it is reasonable to infer from the high rates of other STIs in the local community, as well as from the overall prevalence of HPV in the US population (33.8% among females aged 14-24 year), that HPV infection is widespread among the women in the health center’s catchment area.11,14
Results
Sixty-three women were eligible for the vaccine and offered the survey. Of the 60 women who completed the survey, 57 received the vaccine, and 3 declined the vaccine. Three women did not complete the survey, and all of them received the vaccine. Participants who refused vaccination were excluded from the analysis due to small sample size. Table 1 provides demographic data on participants.
Demographic Characteristics of Respondents
Of the 57 participants who were vaccinated, 42% came to their appointment for the purpose of being vaccinated. The remaining 58% came for another reason and received vaccination upon health care provider recommendation. Women who were at the clinic specifically to be vaccinated had higher levels of education than women who were at the clinic for all other reasons (P = .002).
Knowledge
Knowledge of the vaccine was high, with 84% of participants having heard of the HPV vaccine before their appointment. Forty-eight percent were aware of it from television, 40% from their health care office or provider, 19% from a friend or family member, 10% from a newspaper or magazine, and 2% from both Internet and community agency. Compared with other women, black participants were less likely to know about the vaccine from a newspaper or magazine (P = .004). Hispanic participants were less likely to have been informed about the vaccine from television (P = .021) than non-Hispanic women.
Most participants who had heard of the vaccine knew it protects against HPV infection (64%) and cervical cancer (69%). Fewer knew that the vaccine reduces the chance of an abnormal Pap smear (26%). Only 21% knew the vaccine protects against genital warts, and only 14% knew it protects against an STI. Compared with all other women, black participants were less likely to know that the vaccine protects against an STI (P = .024).
Motivations and Concerns
When asked to identify one main reason why they decided to be vaccinated, participants most often cited protection against HPV (43%), followed by protection against cervical cancer (27%). Only 5% cited protection against genital warts, and 4% were motivated by a reduced chance of an abnormal Pap smear. Only 2% reported a health care provider’s recommendation as the primary motivation. Table 2 summarizes participants’ motivations and concerns.
Motivations and Concerns of Study Participants Who Chose Vaccination
HPV, human papillomavirus; STI, sexually transmitted infection.
Only 38% of participants reported perceived risk for HPV infection as a motivation for vaccination. In fact, 32% felt they were not at risk for HPV infection. Compared with all other women, black women were less likely to be motivated by the fact that other women were being vaccinated (P = .005) and were less likely to feel they were at risk for HPV infection (P = .028). Similarly, black women were less likely than all other women to be concerned that they might already have had HPV (P = .030).
Outreach
Participants were asked for suggestions for successful outreach strategies. Several women suggested targeting young women through middle or high school advertising and information campaigns. Other suggestions included encouraging clinicians to speak with all patients about the vaccine and placing advertisements on television and public transit systems.
Discussion
This quality improvement study aimed to explore beliefs and attitudes about HPV vaccination among women using an urban community health center in Boston. This population is at high risk of acquiring HPV due to the large proportion of minority women and those in a lower socioeconomic position. In our high-risk urban sample, knowledge of the vaccine was high, with 84% of study participants having heard of the HPV vaccine before their clinic appointment, although only 42% of these women had come to the clinic specifically to receive the vaccine. The women attending the health center were surprisingly well informed about the link between HPV vaccine and cervical cancer protection, compared with minority women in less densely populated areas, suggesting that educational campaigns in the health center’s catchment area are working.8,9 Similar to broader studies of women with a range of socioeconomic statuses and ethnicities, women at this community health center cited protection against HPV and cervical cancer as primary motivations for vaccination.1,2,7,12 Like prior studies, decisions about HPV vaccination were not related to perceived risk of infection. In particular, black women from this health center were less likely than other groups to feel vulnerable to HPV infection. Also comparable to other studies, only 26% of participants knew the vaccine reduces the chance of an abnormal Pap smear, and only 21% knew the vaccine protects against genital warts.4-7,15 Fifty-eight percent of the women who received the vaccine came to the OBGYN clinic for a reason other than vaccination, suggesting that the simple strategy of offering HPV vaccination at the time of an appointment for any issue is an effective approach for increasing uptake.
The women from this Boston urban community health center differed from other minority populations in important ways. Unlike a 2009 study in Pittsburgh, Pennsylvania, and Hampton, Virginia, where only 18% of minority women knew that the vaccine protects against the types of HPV that cause most cases of cervical cancer, 69% of minority women surveyed at this Boston health center were aware of this fact, suggesting that local educational efforts have achieved some success. 15 It is possible that because time has passed since the 2009 study, the difference in HPV knowledge is due to additional time for education since the HPV vaccine became available, rather than the difference in geographic locations. In addition, in contrast to a rural southern study, black women from this Boston health center were less likely to be motivated by the fact that other women were being vaccinated. 8 These differences among subpopulations of the United States suggest that outreach campaigns need to be targeted to the specific population served, and different attitudes and beliefs among similar racial and socioeconomic groups from different areas may differ markedly. Thus, small focused surveys of the populations served are necessary to target appropriate messages and outreach methods for HPV prevention and vaccine distribution efforts.
High-risk populations such as those served by this urban community health center consistently underestimate their vulnerability to and risk for acquiring HPV.1,2,5 Future endeavors could focus on exploring the factors that influence perceived risk of acquiring HPV. Although it is estimated that 80% of women will acquire genital HPV in their lifetime, the women surveyed in this project believe their infection risk is low, with only 38% of participants reporting perceived risk for HPV infection as a motivation for vaccination. 16 This should be an area of focus for future educational campaigns.
A few limitations of the study bear mentioning. The largest is the lack of women who refused vaccination. Only 3 women refused vaccination, and this small sample size prevents the determination of factors that may influence women against HPV vaccination. The study also has a limited sample of women who were vaccinated. In addition, participants completed the questionnaire after they had been vaccinated, and responses may have been biased by provider education. Finally, the study was meant to be a quality improvement program for this urban Boston community health center, and results cannot be generalized, although they may be useful for other areas with similar demographics.
Footnotes
Acknowledgements
We thank Itza Villar and Tanee Willis at The Dimock Center for helping to administer the questionnaires and Fong Liu, MD, for her assistance in manuscript preparation.
The authors declared no potential conflicts of interest with respect to the authorship and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research and/or authorship of this article: Sasha Girouard and Gail Pokorney each received a $3000 stipend from Harvard Medical School’s Office of Enrichment Programs for their work on this project. We have no conflicts of interest and have upheld all standards of ethical adherence in carrying out this community-based participatory research project.