https://orcid.org/0000-0002-5799-3459
ABSTRACT
Currently in the United States, Human Papillomavirus (HPV) vaccination coverage among eligible individuals is lower compared to coverage goals of 80% set by the HealthyPeople 2030 initiative. In this study, we used the National Health and Nutrition Examination Survey (NHANES) 2015–2016 and 2017–2018 datasets to determine the association between HPV vaccine initiation among individuals of ages 9 to 26 years and their patterns of healthcare access and utilization. In particular, we examined the following healthcare characteristics: 1) having a routine place of healthcare, 2) having health insurance coverage, 3) frequency of healthcare visits per year, and 4) type of routine place of healthcare (outpatient primary care vs. ED, etc.). We fit independent multivariable logistic regression models for each NHANES dataset and controlled for sociodemographic characteristics and interactions with healthcare access and utilization characteristics. Our findings suggest that HPV vaccine initiation is positively associated with having a routine place of healthcare (2015–2016: aOR 1.92, 95% CI 1.25–2.95; 2017–2018: aOR 1.99, 95% CI 1.07–3.68). Relatedly, HPV vaccine initiation is negatively associated with never having received healthcare in the past year (2015–2016: aOR 0.61, 95% CI 0.41–0.90; 2017–2018: aOR 0.45, 95% CI 0.27–0.75). The results of this study suggest that interventions to promote HPV vaccination should include strategies that promote access to and utilization of routine health care services. Our findings are particularly salient in light of the drop in HPV vaccine initiation and healthcare access and utilization among adolescents during the COVID-19 pandemic.
Introduction
In the United States (US), the most common sexually transmitted disease is human papillomavirus (HPV) infection.Citation1 HPV infection can lead to genital warts as well as cancer of the cervix, anus, genitals and oropharynx.Citation2 Vaccination against HPV is highly effective at preventing the transmission of non-carcinogenic (types 6 and 11) and carcinogenic (types 16 and 18) HPV strains that are most likely to result in symptoms.Citation3 The HPV vaccine has been approved in the US for females since 2006 and for males since 2011, and can be administered starting as early as age 9 and continuing through age 26 for both sexes.Citation1 Although vaccination has been effective in lowering the rate of HPV infections, HPV vaccination rates in the US remain lower than desired.Citation4 For instance, data from the 2019 US National Immunization Survey-Teen (NIS-Teen) reported up-to-date coverage of 56.8% in adolescent females and 51.8% in adolescent males, compared to the Office of Disease Prevention and Health Promotion’s (ODPHP) Healthy People 2030 goal of 80% for both males and females.Citation5,Citation6 Multiple reasons for this discrepancy have been investigated, including demographic differences such as race, income, and geographic location.Citation7–9 In addition to these factors, lower HPV vaccine initiation has also been linked to disparities in health care access among eligible individuals, including disparities in health insurance and routine access to primary care.
The impact that poor access to regular health care may have on the HPV vaccination rate in the US requires further exploration. Findings of the NIS-Teen survey estimated that in 2019, only 36% of uninsured adolescents were up to date on HPV vaccination compared to 50% of adolescents with private insurance and 66% with Medicaid insurance.Citation5 Additionally, one study using the 2013 National Health Interview Survey (NHIS) found that among individuals less than 26 years old in the US, a lack of usual place to receive medical care was associated with lower rates of HPV vaccination.Citation10 Other studies suggest that regular primary care visits can offer multiple advantages for patients (e.g., reduced long-term medical costs, continuity with providers, and improved education of adolescents and parents) and lead to better vaccination rates compared to infrequent primary care utilization or emergency department (ED) use.Citation11,Citation12 Results of a national survey of 1495 parents of 11–17 year old adolescents demonstrated that high-quality recommendations by primary care physicians can increase HPV vaccine initiation by 3-fold and completion by 9-fold, suggesting added benefits of routine healthcare visits on vaccination uptake.Citation13 As growing number of families in the US choose to utilize the ED for their main source of non-emergent care, there are concerns that preventive care, such as routine vaccinations, may be under-prioritized.Citation14–16
Although health care access has been described as an important barrier to receiving vaccination, a majority of ongoing efforts to promote HPV vaccination focus on adolescents, with limited data on the full spectrum of individuals (9–26 years) for whom HPV vaccination is recommended. Having a routine place of healthcare, the number of times healthcare is accessed within the past year, having health care insurance, and most frequently visited place for health care all may predict vaccination among adolescents and young adults that are vaccine-eligible. In this study, we used data from the two most recently published National Health and Nutrition Examination Survey (NHANES 2015–2016 and 2017–2018) to examine the relationship between healthcare access and utilization among adolescents and young adults in the US and HPV vaccine initiation. To our knowledge, this is the first study to examine the relationship between multiple health care access indicators and HPV vaccination among this age group (9–26 years old) using nationally-representative datasets.
Methods
The methods and results of this study are reported according to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist.Citation17
Setting and participants
The National Health and Nutrition Examination Survey (NHANES) is a national survey that is statistically representative of the United States population and is conducted biannually to study the general health, nutritional status, and habits of children and adults. Methodological details of the implementation of NHANES are published elsewhere.Citation18,Citation19 Of relevance to this study, participants in the survey were interviewed regarding their demographics, access to healthcare, and immunization status, among other questionnaire topics. Population weights included in the dataset were used to correct for any sampling biases and to ensure representativeness to the US population. The NHANES datasets are anonymized and publicly available for access, and no ethical review was required, per the Duke University Institutional Review Board.
Study sample
The analysis cohorts for this study were derived from the 2015–2016 NHANES dataset (number of respondents = 9971) and from the 2017–2018 NHANES dataset (number of respondents = 9254). We restricted our sample to individuals of ages 9 through 26 years old (the current recommend lower and upper limits for receiving the HPV vaccine) who have information regarding their HPV vaccine initiation status (n = 2342 and n = 2090 for the 2015–2016 and 2017–2018 cohorts, respectively).
Measures
The dependent variable for our analysis was HPV vaccine initiation, obtained from the response to the question: “Have you/Has SP [sample person] ever received one or more doses of the HPV vaccine?” Responses to this question were coded with three options in the original survey dataset (1 = Yes, 2 = No, 3 = Missing or incomplete). Respondents without a Yes or No response were removed from the analysis cohort for this study. Key independent variables included whether or not respondent has a “routine place for healthcare,” “times respondent received healthcare over past year,” “type of routine place most frequently visited,” and whether or not respondent was “covered by health insurance.” Demographic variables included age, sex, race, household reference person’s education level (reference person defined as the first household member 18 years of age or older listed on the household member roster, who owns or rents the residence where members of the household reside), and annual household income. Since NHANES reports annual household income categorically, we created a binary variable that we designated as “above mean income,” divided by whether or not a respondent’s household income was greater than $64,999 (the United States’ mean household income in 2018 was $64,324).Citation20
Statistical analysis
The same analysis was performed independently on each NHANES dataset to compare outcomes, as these two datasets were collected two years apart. We compared healthcare and demographic characteristics of “vaccinated” and “unvaccinated” groups using descriptive statistics. All variables analyzed were categorical, and comparisons were achieved via Rao-Scott chi-square tests. Survey weights were included with each dataset to generate nationally representative estimates and account for the survey design of NHANES. Statistical analysis was performed to identify associations between healthcare and demographic factors and HPV vaccine initiation. Lastly, to assess the independent association of each variable with vaccine initiation and control for potential confounding variables, we employed a multivariable regression model. Statistical tests were two-sided and statistical significance was indicated by p < .05. The statistical software program Stata 16 (StataCorp, College Station, TX) was used to implement survey data methods and perform all analyses.
Results
Descriptive statistics for demographic variables
Key demographic variables are shown in by the vaccination status of HPV age-eligible individuals for both the 2015–2016 and 2017–2018 cohorts. In the 2015–2016 cohort, 34.97% of the sample initiated the HPV vaccine compared to 36.17% of the sample in the 2017–2018 cohort. We found statistically significant differences in the age of the respondents at the time of the survey when comparing those that initiated the vaccine and those that did not for both cohorts. Also, those that initiated the HPV vaccine were more likely to be female than those who did not initiate vaccination for both 2015–2016 and 2017–2018 (p < .001 and p < .001, respectively). For the 2015–2016 cohort, we observed a difference in race/ethnicity composition between those that initiated vaccination and those not vaccinated (p = .0491), but this was not seen in the 2017–2018 cohort (p = .5620). For the 2017–2018 cohort, there was a significant difference in the household reference person’s education level between the two groups, with those who did not receive a vaccine having a greater proportion of household reference person’s education levels being “less than high school degree” (17.42% vs 11.77% of vaccinated adolescents and young adults; p = .0392).
Table 1. Demographic characteristics of vaccine-eligible individuals (ages 9–26 years) in the NHANES dataset
Descriptive statistics for variables of healthcare access and utilization
Key clinical variables are shown in , where we also observed multiple statistically significant differences between healthcare access and utilization variables associated with adolescents and young adults who initiated the HPV vaccine and those who did not. In both the 2015–2016 and 2017–2018 cohorts, more individuals who initiated vaccination had a routine place for healthcare compared with individuals who did not initiate vaccination (2015–2016: 86.58% vs 77.62%, p = .0003; 2017–2018: 84.37% vs 74.43%, p = .0075). Majority of respondents received health care in the past year; however, the number of times received healthcare was significantly different between vaccinated and non-vaccinated respondents in both cohorts (p = .0017 and p = .0008, respectively). In both cohorts, twice as many unvaccinated individuals reported never receiving care over the past year compared to vaccinated individuals (2015–2016: 21.24% vs 11.00%; 2017–2018: 20.29% vs 10.24%). In addition, a greater proportion of vaccinated individuals were covered by health insurance for both cohorts compared to unvaccinated respondents (90.91% vs. 85.71%, p = .0175; 90.65% vs. 85.05%, p = .0213). When comparing type of place a respondent goes to most often for healthcare, there was a statistically significant difference for both cohorts (p = .0121 and p = .0088, respectively). Notably, in both cohorts there was a higher proportion of “unknown” responses from unvaccinated respondents compared to vaccinated respondents (2015–2016: 21.73% vs. 12.85%; 2017–2018: 24.74% vs. 15.41%).
Table 2. Healthcare access and utilization among vaccine-eligible individuals (ages 9–26 years) in the NHANES dataset
Multivariable analysis
Results from the multivariable logistic regression are shown in for both cohorts, which controlled for socio-demographic variables that were statistically different in the univariable analysis (i.e., age, sex, race, family income, and household reference person’s educational level) between the vaccinated and unvaccinated groups. Type of place for healthcare was not included in the model as a significant portion (10–20%) of respondents in both cohorts did not choose a type of place. Associations between most of the healthcare variables and vaccination status seen in descriptive statistics remained significantly associated in the multivariable model for both cohorts. A strong positive association with HPV vaccine initiation and a routine place of healthcare was seen in both the 2015–2016 cohort (aOR = 1.919, CI, 1.250–2.948; p = .006) and the 2017–2018 cohort (aOR = 1.985, CI, 1.071–3.682; p = .032). In addition, never receiving healthcare over the past year was found to be negatively associated with HPV vaccination in both 2015–2016 (aOR = 0.609, CI, 0.411–0.901; p = .017) and 2017–2018 cohorts (aOR = 0.450, CI, 0.270–0.748; p = .004). In the 2015–2016 cohort, health insurance coverage was not significantly associated with vaccination status (aOR = 1.218, CI, 0.761–1.951; p = .385). This was in contrast to 2017–2018 cohort, where there was a strong positive association observed between having health insurance coverage and vaccination status (aOR = 1.679, CI, 1.124–2.506; p = .015). Of similar note, a family income of $65,000 or greater was not associated with vaccination status in 2015–2016 (aOR = 1.177, p = .266), but was positively associated with vaccination status in 2017–2018 (aOR = 1.330, p = .015).
Table 3. Multivariable logistic regression model examining healthcare and demographic characteristics associated with HPV vaccine initiation among vaccine-eligible individuals (ages 9–26 years) in the NHANES dataset
Discussion
The aim of this study was to use the US National Health and Nutrition Examination Survey (NHANES) data to examine the association between HPV vaccine initiation among individuals of ages 9 to 26 years old and their patterns of healthcare access and utilization. We analyzed data from the two most recent, nationally representative NHANES datasets, which include HPV vaccination data for the full spectrum of age-eligible individuals (ages 9–26 years). Our findings support the hypothesis that, for individuals ages 9–26 years old that are eligible for vaccination, those with a routine place of health care have significantly higher odds of HPV vaccine initiation compared to individuals without access to a routine place of healthcare. Having health insurance also improved the odds for vaccine initiation, and was correlated with family income. In addition, individuals without a visit to their routine provider within the past year had significantly lower odds of initiating the HPV vaccine. Thus, this study demonstrates that health care access is an important consideration when understanding the uptake of HPV vaccination among eligible individuals in the US.
The discrepancy observed in the correlation of health insurance and family income to HPV vaccine uptake between the 2015–2016 and 2017–2018 cohorts is unexpected. While we did not collect or analyze data to explain these differences, they may be related to confounding trends in HPV vaccination access correlated with socioeconomic factors. For instance, there are disparities in vaccination status among adolescents living in rural areas compared to urban and suburban areas. In 2017, it was found that adolescents living in metropolitan statistical areas (MSAs) were estimated to have 10.8% greater coverage of one or more doses of the HPV vaccine compared to adolescents living in non-MSAs.Citation21 Importantly, individuals living in non-MSAs may have decreased access to healthcare and lower family income.Citation22,Citation23 Moreover, there is evidence for increased vaccination uptake among those below the federal income level compared to those above the level due to government and private incentives.Citation24–26 In the 2019 NIS-Teen survey, it was found that of adolescents in non-MSAs, only 62.6% of those at or above the poverty level were reported to have received one or more doses of the HPV vaccine compared to 72.6% of those adolescents below the poverty level.Citation5 This difference ultimately may have been reflected in the multivariable model regarding the 2015–2016 cohort, but not the 2017–2018 cohort. It will be important that future investigations further explore these trends to help elucidate this association in insurance coverage, income, and HPV vaccine initiation.
Current interventions focus on reducing missed opportunities for HPV vaccinations during clinical encounters. Studies have so far demonstrated that having a regular clinician as the primary care provider serves to improve patient satisfaction, return rate, and patient outcomes among adolescents and young adults, which may lead to greater adherence to provider vaccine recommendations.Citation27,Citation28 In addition, the higher quality of the recommendations received from a regular clinician has consistently been shown to enhance comfort with the HPV vaccine and address more complex concerns, leading to increased coverage.Citation29–32 Previous research on this topic has already lead to multiple provider and healthcare systems-based interventions, including utilizing clinical decision support (CDS) aids, the addition of patient navigators, and supporting immunization information systems (IIS) to record all immunization doses given.Citation33–38 In addition to these clinic-based interventions, our findings suggest the need to understand and mitigate factors that limit access to a health provider in the first place.
To reach the target goal of 80% of eligible vaccine recipients receiving the recommended doses of the HPV vaccine as proposed by the ODPHP’s Healthy People 2030 goal, policies that promote access to and utilization of health care should be prioritized.Citation6 The Community Preventative Services Task Force (CPSTF) has found strong evidence to support interventions that enhance access to vaccination services, including reducing patient out-of-pocket costs, vaccination programs in schools and Women, Infants and Children (WIC) settings, and increasing home visits.Citation39 Programs like pharmacy vaccinations, community clinical linkages (CCLs), and school-based health center programs and vaccination requirements have also shown evidence of improving vaccine initiation for populations experiencing barriers to health care access.Citation40–42 In addition to Medicaid, federal and state funded programs like the Vaccines for Children (VFC) Program and the State Children’s Health Insurance Program (SCHIP) have also shown to be effective in improving access to vaccination.Citation24–26,Citation43 Considering that these programs are intimately tied to increased access to healthcare, they should be further researched regarding their ability to lower health disparities and increase vaccine uptake.
Strengths and limitations
This study has several strengths that allow for a robust contribution to this field. First, it uses nationally representative NHANES data, that provide a broad number of questionnaire topics including information not available in other nationally representative surveys, such as the healthcare data that served as the focus of this study. Moreover, while other studies may be limited to an adolescent age range (13–17 years old), this study included a boader age range (9–26 years old) that encompasses the complete range of eligible HPV vaccine recipients. In addition, the inclusion of two sequential datasets (2015–2016 and 2017–2018) allowed for an evaluation of any changes over time. Survey weights included with these dataset also provided nationally representative estimates and helped reduce sampling bias. Lastly, NHANES survey implementation allowed the provision of translators to all respondents if needed, increasing inclusivity in the survey sample.
The surveys and resulting datasets that serve as the foundation of this study are also limited in important ways. The NHANES survey utilizes proxy respondents for all individuals under the age of 16, which increases the chance that the reported data is inaccurate. In addition, vaccination data is self-reported, which may also contribute to inaccuracy. Moreover, while we infer that the household reference person of an individual is the parent or guardian of that individual, we were unable to verify this information. Finally, certain respondent characteristics such as rural/urban residence, cultural factors, and parent information were not accessible or available publicly, thus preventing a deeper dive into these factors.
Conclusion
Routine healthcare plays a major role in promoting eligible individuals to obtain the HPV vaccine in the US. Reducing barriers to routine healthcare access, hence, should be an important consideration for future policies and interventions aimed at increasing HPV vaccination coverage. In the future, a more extensive understanding of disparities in healthcare access and utilization may be crucial to developing new interventions to reach our goals of HPV vaccine uptake in adolescents and young adults, as well with other ACIP-recommended vaccinations such as the recently introduced COVID-19 vaccine.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
References
- Centers for Disease Control and Prevention. STD Facts - Human papillomavirus (HPV). Washington (DC): Office of the Associate Director for Communication, Digital Media Branch, Division of Public Affairs; 2021 Jan 19. [accessed 2021 Aug 29]. https://www.cdc.gov/std/hpv/stdfact-hpv.htm .
- National Cancer Institute. HPV and Cancer. Washington (DC): Office of Communications and Public Liason; 2021 Jan 22. [accessed 2021 August 26]. https://www.cancer.gov/about-cancer/causes-prevention/risk/infectious-agents/hpv-fact-sheet#q2 .
- Markowitz LE, Dunne EF, Saraiya M, Lawson HW, Chesson H, Unger ER. Quadrivalent human papillomavirus vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007;56:1–24.
- Rosenblum HG, Lewis RM, Gargano JW, Querec TD, Unger ER, Markowitz LE. Declines in prevalence of human papillomavirus vaccine-type infection among females after introduction of vaccine - United States, 2003-2018. MMWR Morb Mortal Wkly Rep. 2021;70(12):415–20. [accessed 2021 Mar 26]. doi:10.15585/mmwr.mm7012a2.
- Elam-Evans LD, Yankey D, Singleton JA, Sterrett N, Markowitz LE, Williams CL, Fredua B, McNamara L, Stokley S. National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years - United States, 2019. MMWR Morb Mortal Wkly Rep. 2020;69(33):1109–16. [accessed 2020 Aug 21]. doi:10.15585/mmwr.mm6933a1.
- Department of Health and Human Services. Increase the proportion of adolescents who get recommended doses of the HPV vaccine - IID-08. Rockville (MD): Office of Disease Prevention and Health Promotion; 2020 Jan 29. [accessed 2021 Aug 2]. https://health.gov/healthypeople/objectives-and-data/browse-objectives/vaccination/increase-proportion-adolescents-who-get-recommended-doses-hpv-vaccine-iid-08 .
- Brewer NT, Fazekas KI. Predictors of HPV vaccine acceptability: a theory-informed, systematic review. Prev Med. 2007;45(2–3):107–14. doi:10.1016/j.ypmed.2007.05.013.
- Tsui J, Gee GC, Rodriguez HP, Kominski GF, Glenn BA, Singhal R, Bastani R. Exploring the role of neighborhood socio-demographic factors on HPV vaccine initiation among low-income, ethnic minority girls. J Immigr Minor Health. 2013;15(4):732–40. doi:10.1007/s10903-012-9736-x.
- Henry KA, Stroup AM, Warner EL, Kepka D. Geographic factors and human papillomavirus (HPV) vaccination initiation among adolescent girls in the United States. Cancer Epidemiol Biomarkers Prev. 2016;25(2):309–17. doi:10.1158/1055-9965.EPI-15-0658.
- De P, Budhwani H. Human papillomavirus (HPV) vaccine initiation in minority Americans. Public Health. 2017;144:86–91. doi:10.1016/j.puhe.2016.11.005.
- Szilagyi PG, Rand CM, McLaurin J, Tan L, Britto M, Francis A, Dunne E, Rickert D. Delivering adolescent vaccinations in the medical home: a new era? Pediatrics. 2008;121(Suppl 1):S15–S24. doi:10.1542/peds.2007-1115C.
- Shi L. The impact of primary care: a focused review. Scientifica (Cairo). 2012;2012:432892. doi:10.6064/2012/432892.
- Gilkey MB, Calo WA, Moss JL, Shah PD, Marciniak MW, Brewer NT. Provider communication and HPV vaccination: the impact of recommendation quality. Vaccine. 2016;34(9):1187–92. doi:10.1016/j.vaccine.2016.01.023.
- Sempere-Selva T, Peiró S, Sendra-Pina P, Martínez-Espín C, López-Aguilera I. Inappropriate use of an accident and emergency department: magnitude, associated factors, and reasons–an approach with explicit criteria. Ann Emerg Med. 2001;37(6):568–79. doi:10.1067/mem.2001.113464.
- Coster JE, Turner JK, Bradbury D, Cantrell A. Why do people choose emergency and urgent care services? A rapid review utilizing a systematic literature search and narrative synthesis. Acad Emerg Med. 2017;24(9):1137–49. doi:10.1111/acem.13220.
- Rocovich C, Patel T. Emergency department visits: why adults choose the emergency room over a primary care physician visit during regular office hours? World J Emerg Med. 2012;3(2):91–97. doi:10.5847/wjem.j.1920-8642.2012.02.002.
- von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Int J Surg. 2014;12(12):1495–99. doi:10.1016/j.ijsu.2014.07.013.
- Chen TC, Clark J, Riddles MK, Mohadjer LK, Fakhouri THI. National health and nutrition examination survey, 2015-2018: sample design and estimation procedures. Vital Health Stat. 2020;2:1–35.
- Zipf G, Chiappa M, Porter KS, Ostchega Y, Lewis BG, Dostal J. National health and nutrition examination survey: plan and operations, 1999-2010. Vital Health Stat. 2013;1:1–37.
- Bureau USC. Income and poverty in the United States: 2019. Suitland (MD): The United States Census Bureau; 2020 Sept 15. [accessed 2021 Aug 23]. https://www.census.gov/library/publications/2020/demo/p60-270.html .
- Walker TY, Elam-Evans LD, Williams CL, Fredua B, Yankey D, Markowitz LE, Stokley S. Trends in human papillomavirus (HPV) vaccination initiation among adolescents aged 13-17 by metropolitan statistical area (MSA) status, National Immunization Survey - Teen, 2013-2017. Hum Vaccin Immunother. 2020;16(3):554–61. doi:10.1080/21645515.2019.1671765.
- Probst JC, Barker JC, Enders A, Gardiner P. Current state of child health in rural America: how context shapes children’s health. J Rural Health. 2018;34(Suppl 1):s3- s12. doi:10.1111/jrh.12222.
- Tsai Y, Lindley MC, Zhou F, Stokley S. Urban-rural disparities in vaccination service use among low-income adolescents. J Adolesc Health. 2021;69(1):114–20. doi:10.1016/j.jadohealth.2020.10.021.
- Markowitz LE, Dunne EF, Saraiya M, Chesson HW, Curtis CR, Gee J, Bocchini JA, Unger ER. Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2014;63(RR–05):1–30. PMID: 25167164.
- Walsh B, Doherty E, O’Neill C. Since the start of the vaccines for children program, uptake has increased, and most disparities have decreased. Health Aff (Millwood). 2016;35(2):356–64. doi:10.1377/hlthaff.2015.1019.
- Racine AD, Long TF, Helm ME, Hudak M, Shenkin BN, Snider IG, White PH, Droge M, Harbaugh N, Zimmerman EP. Children’s Health Insurance Program (CHIP): accomplishments, challenges, and policy recommendations. Pediatrics. 2014;133(3):e784–e793. doi:10.1542/peds.2013-4059.
- Green CA, Johnson KM, Yarborough BJ. Seeking, delaying, and avoiding routine health care services: patient perspectives. Am J Health Promot. 2014;28(5):286–93. doi:10.4278/ajhp.120702-QUAL-318.
- Blewett LA, Johnson PJ, Lee B, Scal PB. When a usual source of care and usual provider matter: adult prevention and screening services. J Gen Intern Med. 2008;23(9):1354–60. doi:10.1007/s11606-008-0659-0.
- Rahman M, Laz TH, McGrath CJ, Berenson AB. Provider recommendation mediates the relationship between parental human papillomavirus (HPV) vaccine awareness and HPV vaccine initiation and completion among 13- to 17-year-old U.S. adolescent children. Clin Pediatr (Phila). 2015;54(4):371–75. doi:10.1177/0009922814551135.
- Mohammed KA, Vivian E, Loux TM, Arnold LD. Factors associated with parents’ intent to vaccinate adolescents for human papillomavirus: findings from the 2014 national immunization survey-teen. Prev Chronic Dis. 2017:14:E45. [accessed 2017 Jun 8]. doi:10.5888/pcd14.160314.
- Ylitalo KR, Lee H, Mehta NK. Health care provider recommendation, human papillomavirus vaccination, and race/ethnicity in the US national immunization survey. Am J Public Health. 2013;103(1):164–69. doi:10.2105/AJPH.2011.300600.
- Caldwell AC, Madden CA, Thompson DM, Garbe MC, Roberts JR, Jacobson RM, Darden PM. The impact of provider recommendation on human papillomavirus vaccine and other adolescent vaccines. Hum Vaccin Immunother. 2021;17(4):1059–67. doi:10.1080/21645515.2020.1817713.
- Stockwell MS, Fiks AG. Utilizing health information technology to improve vaccine communication and coverage. Hum Vaccin Immunother. 2013;9(8):1802–11. doi:10.4161/hv.25031.
- Fiks AG, Grundmeier RW, Mayne S, Song L, Feemster K, Karavite D, Hughes CC, Massey J, Keren R, Bell LM, et al. Effectiveness of decision support for families, clinicians, or both on HPV vaccine receipt. Pediatrics. 2013;131(6):1114–24. doi:10.1542/peds.2012-3122.
- Szilagyi PG, Humiston SG, Gallivan S, Albertin C, Sandler M, Blumkin A. Effectiveness of a citywide patient immunization navigator program on improving adolescent immunizations and preventive care visit rates. Arch Pediatr Adolesc Med. 2011;165(6):547–53. doi:10.1001/archpediatrics.2011.73.
- Berenson AB, Hirth JM, Kuo YF, Starkey JM, Rupp RE. Use of patient navigators to increase HPV vaccination rates in a pediatric clinical population. Prev Med Rep. 2020;20:101194. [accessed 2020 Aug 28]. doi:10.1016/j.pmedr.2020.101194.
- National Vaccine Advisory Committee. Overcoming barriers to low HPV vaccine uptake in the United States: recommendations from the national vaccine advisory committee: approved by the national vaccine advisory committee on June 9, 2015. Public Health Rep. 2016;131(1):17–25. doi:10.1177/003335491613100106.
- Ruffin MT, Plegue MA, Rockwell PG, Young AP, Patel DA, Yeazel MW. Impact of an Electronic Health Record (EHR) Reminder on Human Papillomavirus (HPV) vaccine initiation and timely completion. J Am Board Fam Med. 2015;28(3):324–33. doi:10.3122/jabfm.2015.03.140082.
- CPSTF Findings for Increasing Vaccination. The guide to community preventive services (The Community Guide). [accessed September 30, 2020]. https://www.thecommunityguide.org/content/task-force-findings-increasing-vaccination .
- Brandt HM, Vanderpool RC, Curry SJ, Farris P, Daniel-Ulloa J, Seegmiller L, Stradtman LR, Vu T, Taylor V, Zubizarreta M. A multi-site case study of community-clinical linkages for promoting HPV vaccination. Hum Vaccin Immunother. 2019;15(7–8):1599–606. doi:10.1080/21645515.2019.1616501.
- Kaul S, Do TQN, Hsu E, Schmeler KM, Montealegre JR, Rodriguez AM. School-based human papillomavirus vaccination program for increasing vaccine uptake in an underserved area in Texas. Papillomavirus Res. 2019;8:100189. doi:10.1016/j.pvr.2019.100189.
- Bugenske E, Stokley S, Kennedy A, Dorell C. Middle school vaccination requirements and adolescent vaccination coverage. Pediatrics. 2012;129(6):1056–63. doi:10.1542/peds.2011-2641.
- Coffey A, Adams G, Hahn H. Young people and medical assistance: medicaid and the children’s health insurance program. Washington (DC): Urban Institute; 2021 Feb 10. [accessed 2021 Aug 23]. https://www.urban.org/research/publication/young-people-and-medical-assistance .