Adolescents’ receipt of the human papillomavirus (HPV) vaccine is primarily a decision of their parents. Health care providers’ recommendation increases parents’ likelihood of initiating the HPV vaccine for their child.1  Rates of HPV vaccine recommendations and the proportion of up-to-date adolescents have improved over time2 ; however, in 2017–2018, 7.3 million vaccine-eligible US adolescents were unvaccinated.1  Notably, despite a provider recommendation, parents of 60.6% of unvaccinated adolescents had no intention to initiate the HPV vaccine series.1  It is unclear whether the sentiment of HPV vaccine hesitancy is growing (because of the rise of the antivaccination movement), has dissipated (with a growing body of evidence pertaining to postlicensure efficacy and the safety of the HPV vaccine), or has remained unchanged over time. To understand the trajectory of acute HPV vaccine hesitancy, we evaluated trends in the proportion of parents lacking the intent to initiate HPV vaccination for their unvaccinated adolescent despite having received a provider recommendation.

We analyzed the 2012–2018 National Immunization Survey (NIS)–Teen, a national survey representative of the US adolescent population. Each year, the Centers for Disease Control and Prevention conducts a telephonic survey of US households with adolescents aged 13 to 17 years to examine coverage and vaccination behaviors. Adult caregivers most knowledgeable about their adolescent’s vaccination status answer questions regarding 7 adolescent vaccines (measles, hepatitis B, hepatitis A, varicella, tetanus, meningitis, and HPV). Each participant in the NIS is assigned a weight that allows estimates from the surveyed adolescents to be combined to obtain national estimates that reflect the true relative proportions of these groups in the nation as a whole. The survey includes questions on receipt of vaccine recommendation from a health care provider, number of vaccine doses received, and parental intent to vaccinate. A detailed description of the survey methodology and questionnaire are available on the NIS Web site.3  For this study, HPV-unvaccinated adolescents (ie, those who received 0 doses of the HPV vaccine) who reported receiving a vaccine recommendation from a health care provider were identified. Parental lack of intent in this subset was determined by using the question “How likely is it that your teen will receive HPV shots in the next 12 months?”; parents’ responses of “not likely at all” or “not too likely” were identified as lack of intent.

We used survey-weighted frequency procedures to derive nationally representative estimates of the proportion of adolescents who did not initiate the HPV vaccine series despite providers’ recommendations. Subsequently, the proportions of adolescents with parental lack of intent to vaccinate were estimated. Analyses were stratified by adolescents’ sex. Linear regression was used to test for trends. Multivariable logistic regression models compared the probability of parental lack of intent in 2018 vs 2012, adjusting for age, sex, race and ethnicity, poverty status, and the region of residence of the adolescent. Statistical significance was tested at P < .05. Analyses were performed per the NIS-Teen analytical guideline and adjusted for strata and weights by using survey procedures in SAS 9.4 (SAS Institute, Inc, Cary, NC).

The proportion of unvaccinated adolescents who were recommended the HPV vaccine by their provider increased from 27.0% in 2012 to 49.3% in 2018 (Ptrend < .0001). Among these adolescents, parental lack of intent to initiate the HPV vaccine series increased from 50.4% in 2012 to 64.0% in 2018 (Ptrend = .003) (Fig 1A). The lack of intent increased among parents of boys from 44.4% to 59.2% (Ptrend = .0097) (Fig 1B) and girls from 54.1% to 68.1% (Ptrend = .0061) (Fig 1C). Comparing 2018 to 2012, the difference in predicted probability (dPP) for parental lack of intent to vaccinate despite a provider recommendation was 13.6% (confidence interval [CI]: 13.2%–14.0%) (Table 1). Findings were consistent for boys (dPP = 13.9% [CI: 13.3%–14.5%]) and girls (dPP = 14.5% [CI: 14.0%–14.9%]).

FIGURE 1

Number of unvaccinated US adolescents who were recommended the HPV vaccine by a health care provider and the proportion with parental lack of intent to initiate the HPV vaccine. A, The overall number of US unvaccinated adolescents from 2012 to 2018 who were recommended the HPV vaccine by a health care provider and the overall proportion of these adolescents with no parental intent to initiate the HPV vaccine. B, The number of unvaccinated boys who were recommended the HPV vaccine by a health care provider and the proportion of boys with no parental intent to initiate the HPV vaccine. C, The number of unvaccinated girls who were recommended the HPV vaccine by a health care provider and the proportion of girls with no parental intent to initiate the HPV vaccine. The final analytical sample consisted of adolescents with nonmissing data on provider recommendation and parental intent (n = 42 859; weighted n = 12 991 729); adolescents with missing data were excluded.

FIGURE 1

Number of unvaccinated US adolescents who were recommended the HPV vaccine by a health care provider and the proportion with parental lack of intent to initiate the HPV vaccine. A, The overall number of US unvaccinated adolescents from 2012 to 2018 who were recommended the HPV vaccine by a health care provider and the overall proportion of these adolescents with no parental intent to initiate the HPV vaccine. B, The number of unvaccinated boys who were recommended the HPV vaccine by a health care provider and the proportion of boys with no parental intent to initiate the HPV vaccine. C, The number of unvaccinated girls who were recommended the HPV vaccine by a health care provider and the proportion of girls with no parental intent to initiate the HPV vaccine. The final analytical sample consisted of adolescents with nonmissing data on provider recommendation and parental intent (n = 42 859; weighted n = 12 991 729); adolescents with missing data were excluded.

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TABLE 1

Predicted Probability for Parental Lack of Intent to Initiate the HPV Vaccine Among Unvaccinated Adolescents Despite a Provider Recommendation, NIS-Teen 2012–2018

Predicted Probability, % (95% CI)adPP, % (95% CI)a
Overall   
 2012 50.3 (50.0–50.6) Reference 
 2018 64.0 (63.7–64.2) 13.6 (13.2–14.0) 
Boys   
 2012 50.1 (49.6–50.5) Reference 
 2018 63.9 (63.6–64.3) 13.9 (13.3–14.5) 
Girls   
 2012 49.2 (48.9–49.5) Reference 
 2018 63.7 (63.4–64.0) 14.5 (14.0–14.9) 
Predicted Probability, % (95% CI)adPP, % (95% CI)a
Overall   
 2012 50.3 (50.0–50.6) Reference 
 2018 64.0 (63.7–64.2) 13.6 (13.2–14.0) 
Boys   
 2012 50.1 (49.6–50.5) Reference 
 2018 63.9 (63.6–64.3) 13.9 (13.3–14.5) 
Girls   
 2012 49.2 (48.9–49.5) Reference 
 2018 63.7 (63.4–64.0) 14.5 (14.0–14.9) 
a

Predicted probabilities were adjusted for age, sex, race and ethnicity, poverty status, and region of residence of the adolescents.

The proportion of unvaccinated adolescents who reported receiving an HPV vaccine recommendation increased from 2012 to 2018; however, parental HPV vaccine hesitancy also increased simultaneously for these adolescents. The surge in HPV vaccine misinformation on social media (for instance, deaths [“Girl dies shortly after receiving HPV vaccine”], injury [“Thousands of UK Girls Injured by HPV”], and government conspiracy [“Tyrannical NY legislators looking to force toxic HPV vaccine on sixth graders”]), may have contributed to this upward trajectory in hesitancy among parents.4  With parents of only 50% of unvaccinated adolescents reportedly receiving HPV vaccine recommendation in 2018, there is an opportunity to further improve the recommendation rates. The data also suggest a need to improve the quality and effectiveness of vaccine recommendations to increase parental HPV vaccine acceptance.5  Information on the recommendation quality was unavailable in NIS-Teen; therefore, results of this study should be interpreted within the context of this caveat.

Our findings imply that recommendations alone will not lead to substantial improvements in vaccine uptake. Providers should proactively use tools such as motivational interviewing and presumptive announcements when they encounter hesitancy.6  Strategic national plans, such as the recently launched Vaccinate with Confidence program, will be crucial for empowering providers to tackle vaccine communication issues and to build public trust in vaccinations.7  Implementation of evidence-based strategies at both the clinic and community levels to address vaccine hesitancy will be important for accelerating the nation’s progress toward HPV vaccination goals.

Drs Sonawane and Deshmukh conceptualized and designed the study, supervised data analysis, drafted the initial manuscript, and reviewed and revised the manuscript; Ms Zhu and Ms Yueh-Yun Lin collected data, conducted the initial analyses, and reviewed and revised the manuscript; Drs Damgacioglu, Montealegre, and Lin coordinated data analysis and critically reviewed the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Supported by the National Cancer Institute of the National Institutes of Health under award number R01CA232888. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Funded by the National Institutes of Health (NIH).

     
  • CI

    confidence interval

  •  
  • dPP

    difference in predicted probability

  •  
  • HPV

    human papillomavirus

  •  
  • NIS

    National Immunization Survey

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: Dr Deshmukh received consulting fees from Merck on unrelated projects; the other authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.