Why Parents Choose (or Refuse) HPV Vaccination

Larissa Hirsch, MD
Medical Editor for KidsHealth.orgCharles A. Pohl, MD—Series Editor: Dr Pohl is professor of pediatrics and associate dean of student affairs and career counseling at Jefferson Medical College in Philadelphia.

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New study identifies factors that influence initiation and completion of HPV vaccination.

vaccination HPVAlthough the human papillomavirus (HPV) vaccine has been available for 5 years and recommended for adolescent girls aged 11 and 12 years as well as for older unvaccinated teens, it is well known that vaccine coverage rates remain low. However, a recent study by Dorell and colleagues1 identified several factors associated with the likelihood of starting the HPV vaccine series, factors that clinicians have the ability to influence and that, if addressed, could increase vaccination rates.

Dorell and colleagues1 analyzed data from the 2008 and 2009 National Immunization Survey – Teen to identify (through telephone interviewing) and verify (through provider records) vaccination rates of more than 18,000 girls aged 13 to 17 years. The telephone interview included questions on parental knowledge of HPV and HPV vaccination and on whether a health care provider had recommended vaccination. Parents who responded that their daughter had not been vaccinated and that they were unlikely to vaccinate against HPV in the future were asked to explain their reasoning. The survey also collected socioeconomic data and insurance status.

Strongest motivator to vaccinate—doctor recommendation. Of the adolescent girls surveyed, only 40.5% had received one or more HPV vaccine doses, and only slightly more than half (53.3%) of those who started the series had completed all 3 required doses. The authors found that many factors were related to the likelihood of starting the HPV vaccination series. Girls who were more likely to have had at least one dose of the HPV vaccine were older, were from a high-income household, were seen for a preventive care visit at age 11 or 12 years, had a younger mother or a mother who never married, and had the vaccine recommended to them by their doctor. Of these factors, recommendation from a health care provider was most strongly related to initiation of the HPV vaccine series.

Girls who were Medicaid-eligible, covered under the State Children’s Health Insurance Program, or eligible for coverage under Vaccines For Children (VFC) and insured were more likely to start the HPV vaccination series than those with private insurance or those who were VFC-eligible and uninsured.

Primary obstacle to vaccine initiation—lack of knowledge. Of the girls who had not been vaccinated, about 40% of parents said they were unlikely to have their daughters vaccinated within the next 12 months. The most frequently reported reasons why parents decided not to vaccinate included a lack of knowledge about the vaccine, the opinion that the vaccine is unnecessary, belief that their daughter is not sexually active, and the provider did not recommend it.

Ways to increase HPV vaccination coverage. While some factors that affect the likelihood of vaccination are unchangeable (eg, maternal age), we can have an impact on other variables. By educating parents about the disease, the vaccine, and the need to administer the vaccine before a girl becomes sexually active, we may be able to increase vaccination coverage. Having a system in place to remind patients to return for their second and third vaccine doses can improve the rates of series completion. By recommending the vaccine series to the parents of young adolescent girls, we can also impact vaccination rates in the community.

The Dorell study is limited in that some data were collected through landline telephone calls, while some households no longer have landlines. However, the study shows us that there are things that we can do to improve the low vaccination rates against HPV. By improving vaccination rates in the early adolescent years, before teens have become sexually active, we can potentially reduce the incidence of cervical cancer and genital warts for our patients in the future. 


1. Dorell CG, Yankey D, Santibanez TA, Markowitz LE. Human papillomavirus vaccination series initiation and completion, 2008-2009. Pediatrics. 2011;128: