ARTICLE
Uptake of the Human
Papillomavirus Vaccine:
A Review of the Literature
and Report of a Quality
Assurance Project
Brenda Cassidy, MSN, RN, CPNP-PC, & Elizabeth A. Schlenk, PhD, RN
ABSTRACT
Purpose: The aims of this study were to review predictors of
knowledge about human papillomavirus (HPV), HPV vaccine,
and factors related to HPV vaccine uptake and report a quality
assurance project that evaluated HPV vaccine uptake and
three-dose completion rates.
Methods: The setting was a small private urban pediatric prac-
tice. Chart review was used to describe HPV vaccine uptake
and dose completion rates in 2007. The convenience sample
included 189 girls aged 12 to 21 years with HPV vaccine uptake.
Results: During 2007, 153 girls aged 12 to 17 years and 42 girls
aged 18 to 21 years were seen at well child care visits. HPV vac-
cine uptake was 72% (n = 110) for the younger group and 79%
(n = 33) for the older group. There was no significant differ-
ence in HPV vaccine uptake by group. One quarter (24%,
n = 46) received the HPV vaccine dose at an episodic visit.
The dose completion rate was 64% (n = 120).
Discussion: HPV vaccine uptake and dose completion rates
were higher than rates reported by the Centers for Disease
Brenda Cassidy, Instructor, University of Pittsburgh School of
Nursing, Pittsburgh, PA.
Elizabeth A. Schlenk, Assistant Professor, University of Pittsburgh
School of Nursing, Pittsburgh, PA.
Conflicts of interest: None to report.
Correspondence: Brenda Cassidy, MSN, RN, CPNP-PC,
University of Pittsburgh School of Nursing, 440 Victoria Bldg, 3500
Victoria St, Pittsburgh, PA 15261; e-mail: cassb@pitt.edu.
0891-5245/$36.00
Copyright 2010 by the National Association of Pediatric
Nurse Practitioners. Published by Elsevier Inc. All rights
reserved.
doi:10.1016/j.pedhc.2010.06.015
www.jpedhc.org
Control and Prevention. Effective strategies are needed to
promote HPV vaccine uptake and dose completion. J Pediatr
Health Care. (2010) -, ---.
KEY WORDS
Human papillomavirus, HPV vaccine, quality assurance,
parent/mother, knowledge/awareness, acceptance, inten-
tion/willingness
Cervical cancer is one of the most common types of
cancer in women worldwide (Barnholtz-Sloan et al.,
2009). Increased compliance with Papanicolaou (PAP)
cervical screening in the United States has affected the
early identification and treatment of cervical cancer,
thus reducing its morbidity and mortality rates. Despite
the positive effect that public health education has had
on compliance with PAP screening, disparities in
cervical cancer among non-White women persist
(American Cancer Society, 2010). Although invasive
cervical cancer rates have been reported to be on the
decline for many races, Hispanic and non-Hispanic
African American women have had a much higher inci-
dence than non-Hispanic White women (Barnholtz-
Sloan et al., 2009). These statistics signify the importance
of reducing cultural barriers to screening and preven-
tion of cervical cancer.
The majority of women have had abnormal results of
a PAP smear at some point in their lifetime. Many of these
abnormalities are related to human papillomavirus
(HPV), a sexually transmitted infection that has been
identified as a causative factor in cervical cancer. Multi-
ple oncogenic strains of HPV have been identified, and
two strains, HPV 16 and 18, cause 70% of cervical cancers
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(Keating et al., 2008). The presence of HPV infection also
has been associated with external condylomata, and
HPV strains 6 and 11 have been found to be a causative
factor in most of these lesions (Dunne et al., 2007).
Higher HPV prevalence rates have been reported
for non-Hispanic Black women compared with non-
Hispanic White and Mexican American women
(Dunne et al., 2007). Evidence-based educational
interventions that are culturally sensitive have the poten-
tial to reduce disparities in rates of HPV infection and
cervical cancer.
Both GlaxoSmithKline and Merck & Co have received
Food and Drug Administration approval to license vac-
cines to prevent HPV infection. The Advisory Committee
on Immunization Practices (ACIP) describes these
two available forms of the HPV vaccine: Cervarix by
GlaxoSmithKline, a bivalent vaccine that contains inac-
tive strains 16 and 18 of HPV, and Gardasil, a quadrivalent
vaccine by Merck & Co that contains inactive strains
16, 18, 6, and 11 of HPV (Middleman, 2007). Cervarix
has been used in the United Kingdom as part of their
national immunization program (Brabin et al., 2008)
and has been available in the United States since
fall 2009. Gardasil has been available in the United States
since spring 2006. Both vaccines are available in a three-
dose series for administration over a 6-month period to
girls and young women aged 9 to 26 years. Furthermore,
these vaccines have been reported to be safely adminis-
tered in conjunction with other vaccines. Parental
consent for administration of the HPV vaccine must be
obtained prior to the age of 18 years in both countries.
The Centers for Disease Control and Prevention (CDC)
(2009a), the American Academy of Pediatrics (AAP)
(AAP Committee on Infectious Diseases, 2007), and
the ACIP (Markowitz et al., 2007) recommend offering
the HPV vaccine routinely as part of the annual physical
examination in girls aged 11 to 12 years. In response to
these recommendations, a public health education
campaign was initiated to encourage HPV vaccine
uptake (Stanley, 2007).
Clinical trials have demonstrated that Gardasil has
100% efficacy to prevent HPV infection, if one is
exposed to the virus, when the three-dose series is
administered prior to coital debut (Markowitz et al.,
2007). According to Markowitz and colleagues (2007),
sustained immunity has been reported at 5 years and
seems similar to long-standing immunity reports of the
hepatitis B vaccine. Clinical trials also have shown that
antibody responses are highest in girls aged 9 to 15 years
(AAP Committee on Infectious Diseases, 2007). Re-
ported adverse effects of Gardasil have included pain
and redness at the injection site and dizziness with
some episodes of syncope (Markowitz et al., 2007).
Because the HPV vaccine is frequently given in conjunc-
tion with other vaccines, investigators have been unable
to determine if syncope is directly related to the HPV
vaccine.
2 Volume -  Number -
Adolescent sexual behaviors have been studied for
many years. Among adolescents aged 15 to 17 years,
nearly one third reported ever having had sex (Gavin
et al., 2009), and 39% reported having had sex during
or prior to the 9th grade (U.S. Department of Health
and Human Services, 2000). Additionally, adolescents
in grades 9 through 12 have been known to practice
risky sexual behaviors, including unprotected sex,
with rates as high as 15% (U.S. Department of Health
and Human Services, 2000). Increasing and alarming
risk factors exist for adolescents with early age initiation
of sexual activity as well. A high incidence of HPV infec-
tion exists in this age group, which can be attributed to
such risk factors as physiologic immaturity, early sexual
debut, multiple sex partners, and unsafe sex practices.
Middleman (2007) reported that several studies found
a high cumulative incidence of HPV infection in adoles-
cents aged 13 to 16 years shortly after their sexual debut.
Prevalence of HPV infection has been reported as being
25% in adolescents aged 14 to 19 years and 45% in young
adults aged 20 to 24 years (Dunne et al., 2007). These
statistics provide evidence of the likelihood of contract-
ing HPV infection without the benefit of receiving the
HPV vaccination as an adolescent or young adult.
In summary, the HPV vaccine is a primary preventive
strategy to reduce the incidence of HPV infection and
further reduce cervical cancer rates. Despite the benefit
to risk ratio of the HPV vaccine, parents have expressed
some hesitancy about having their daughters vacci-
nated. Understanding the factors that affect parental
intention for uptake of the HPV vaccine by their daugh-
ters may suggest strategies to improve the HPV vaccine
uptake rate. Utilizing culturally sensitive educational
methods to promote this cancer-preventing vaccine
can potentially reduce disparities in rates of HPV infec-
tion and cervical cancer.
The purposes of this article are to:
1. Review predictors of knowledge about HPV and the
HPV vaccine
2. Review predictors of parental intention for uptake of
the HPV vaccine by their daughters
3. Review provider factors related to uptake of the HPV
vaccine
4. Describe a quality assurance (QA) project in a private
practice to evaluate the HPV vaccine uptake rate ($1
dose) and HPV vaccine three-dose completion rate
and compare it with the HPV vaccine uptake rate and
three-dose completion rate reported in the literature.
LITERATURE REVIEW
Predictors of Knowledge About HPV and the
HPV Vaccine
Awareness of HPV and the HPV vaccine were studied in
women aged 18 to 49 years using data from the National
Immunization Survey (Jain et al., 2009). Eighty-four per-
cent of the women were aware of HPV, with the greatest
Journal of Pediatric Health Care
awareness in those 18 to 26 years of age. In this study,
both race and socioeconomic status were associated
with awareness of HPV and the HPV vaccine. Hispanics
and non-Hispanic African Americans were less aware of
both HPV and the HPV vaccine. Older non-Hispanic
African Americans were less aware of HPV and the
HPV vaccine, whereas college-educated non-Hispanic
African Americans had increased awareness (Jain et al.,
2009). Younger age (Fazekas, Brewer, & Smith, 2008;
Ogilvie et al., 2007) and older age (Di Giuseppe,
Abbate, Liquori, Albano, & Angelillo, 2008), White race
(Jain et al., 2009), and higher levels of education (Jain
et al., 2009) were associated with increased knowledge
of HPV. Similarly, African American race, non-White
Hispanic race, and manual workers were associated
with decreased knowledge of HPV (Walsh et al., 2008).
Di Giuseppe et al. (2008) reported that predictors for
having knowledge about HPV and the HPV vaccine
included greater perceived risk of HPV, personal
experience with cervical cancer, having a parent who
was a health care provider, and having a doctors
appointment in the past year in which the doctor pro-
vided information about the HPV vaccine.
Predictors of Parental Intention for Uptake
of the HPV Vaccine by Their Daughters
Multiple studies have investigated the relationship
between predictors of parental intention to vaccinate
daughters and uptake rates of the HPV vaccine. A sys-
tematic review of 28 studies by Brewer and Fazekas
(2007) reported predictors of intention for uptake of
the HPV vaccine as well as various barriers to getting
vaccinated. Brewer and Fazekas (2007) found a higher
intention for HPV vaccine uptake when parents
believed that HPV infection was more likely and the
HPV vaccine was effective and recommended by the
physician. Barriers related to intention for HPV vaccine
uptake included cost and, for a small percentage of
parents, the belief that the vaccine would promote
sexual behaviors in adolescents.
A pre-licensure study investigated a group of women
aged 18 to 30 years to identify attitudes and intention for
uptake of the HPV vaccine by themselves and their
daughters (Kahn, Rosenthal, Hamann, & Bernstein,
2003). Seventy percent of the women had accurate
knowledge about HPV, and the majority had positive
attitudes about the HPV vaccine for themselves and their
daughters. Most of the women thought that the HPV vac-
cine was safe and did not believe that there would be in-
creased risky sexual behaviors as a result of receiving the
vaccine. Factors associated with higher intention to vac-
cinate included greater knowledge about HPV, greater
personal and normative beliefs about the HPV vaccine,
and increased number of sexual partners. Significant
others support, primary care provider approval, and
history of sexually transmitted infection also were
associated with intention for uptake of the HPV vaccine.
www.jpedhc.org
Fazekas et al. (2008) reported on another pre-
licensure study of knowledge, beliefs, perceptions, bar-
riers, and cues to action related to intention for uptake of
the HPV vaccine in a predominantly African American
population in the rural southern United States with
high rates of cervical cancer. Eighty-four percent of
the mothers reported that they would vaccinate their
daughters if the vaccine was free. Other predictors that
significantly increased mothers intention to vaccinate
daughters included increased knowledge and beliefs
about HPV, HPV vaccine, and cervical cancer risk.
Beliefs about the severity of HPV and HPV-related
diseases, the likelihood of HPV causing cervical cancer,
limited negative consequences of the HPV vaccine, and
effectiveness of the HPV vaccine all increased mothers
willingness to vaccinate daughters if the vaccine was not
free.
Di Giuseppe et al. (2008) reported early post-
licensure results about knowledge, attitudes, and inten-
tion for uptake of the HPV vaccine in a randomized
sample of 1348 Italian female subjects aged 14 to 24
years. Fewer than one third knew that HPV was com-
mon and only half had heard of cervical cancer. Forty-
two percent knew of a preventive vaccine, and for
those who were positive about intention to vaccinate,
88% believed that the vaccine decreased the risk of
HPV infection and cervical cancer. Predictors for inten-
tion for uptake of the HPV vaccine included increased
number of sexual partners, greater perceived risk of
HPV, needing more information about the vaccine, per-
sonal experience with cervical cancer, having a parent
who was a health care provider, and having a doctors
appointment in the past year in which the doctor pro-
vided information about the vaccine.
Barriers to uptake of the HPV vaccine also have
been reported in the literature in multiple studies. Di
Giuseppe et al. (2008) reported barriers such as concern
about adverse reaction to the vaccine and decreased
perceived risk for HPV infection. Keating et al. (2008)
identified cost to patient and burden of insurance reim-
bursement as barriers. In a post-licensure study of
Chinese females aged 13 to 20 years who received edu-
cation via focus groups, a pre-test and post-test revealed
safety and effectiveness of the vaccine as predictors of
positive intention to accept the HPV vaccine, with the
majority declining the vaccine if cost was a barrier
(Kwan et al., 2008). Mothers who were more involved
with their daughters peer group and who had daughters
who did not resist having three injections also were more
likely to express positive intention to accept the HPV
vaccine (Rosenthal et al., 2008).
Sociodemographic factors such as race, education,
and age have been described in the literature as factors
related to intention for uptake of the HPV vaccine
(Brewer & Fazekas, 2007; Di Giuseppe et al., 2008;
Fazekas et al., 2008; Jain et al., 2009; Ogilvie et al.,
2007). Marlow, Waller, and Wardle (2008) reported on
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sociodemographic predictors of intention for HPV vac-
cine uptake in women aged 25 to 64 years. The majority
(74%) of the women reported intention for uptake of
the HPV vaccine for themselves and their daughters;
race and socioeconomic status were not related to
intention for uptake of the vaccine for their daughters.
Sociodemographic factors associated with decreased
intention for uptake of the HPV vaccine were reported
as non-White (Walsh et al., 2008) and African American
race (Fazekas et al., 2008). All of these sociodemo-
graphic factors should be considered when educating
parents of girls who are younger than 18 years of age
to obtain parental consent for this preventive vaccine.
Provider Factors Related to Uptake of the HPV
Vaccine
Health care providers can greatly affect uptake of the
HPV vaccine. Reports in the literature have identified
both predictors and barriers related to health care
providers recommen-
dations. Keating and
colleagues (2008) de-
Health care
scribed health care providers can
provider concerns in greatly affect
a southern rural area
of the United States. A
uptake of the HPV
telephone survey iden- vaccine.
tified only 59% of
health care providers who offered the HPV vaccine via
the Free Vaccines for Children supply; non-providers
believed that it was cheaper to refer patients because
of concern about low uptake and vaccine expiration.
A post-licensure study stated that 78% of pediatric
clinicians reported that they were extremely likely to
recommend the HPV vaccine (Feemster, Winters, Fiks,
Kinsman, & Kahn, 2008). Predictors of vaccine recom-
mendations included providers who were early
adopters of new technology and who anticipated paren-
tal concerns about safety and effectiveness of the HPV
vaccine. Responses on a 6-month post-licensure survey
of physicians, 52% of whom were women and half
of whom were in private practice, were compared
with responses from a 2004 Wall Street Journal online
survey about the HPV vaccine completed by the general
public (Ishibashi, Koopmans, Curlin, Alexander, & Ross,
2008). This randomized sample of physicians was more
likely than the public to give the vaccine without paren-
tal permission and less likely to agree with the statement
that PAP screening and abstinence programs were more
effective than the vaccine for HPV prevention.
Another study described poor uptake of the HPV vac-
cine despite the provision of much support and prepa-
ration to nine physicians in a faculty-based gynecology
practice in an urban setting (Jaspan, Dunton, & Cook,
2008). The office policy was to offer eligible women
the HPV vaccine immediately after licensure, but the
uptake rate was only 28.2%, and health care provider
4 Volume -  Number -
rates of recommendation varied. Five physicians had
less than a 20% recommendation rate, and four had
a recommendation rate higher than 20%.
Sussman et al. (2007) reported on a survey of primary
care clinicians about anticipatory guidance regarding
the HPV vaccine for adolescents. Facilitators of counsel-
ing about the HPV vaccine included building rapport
and believing that adolescents are at increased risk for
engaging in sexual behaviors. Barriers to counseling
this age group included the high level of complex coun-
seling that would be involved, a poor knowledge base,
and provider discomfort with this low level of knowl-
edge. Another barrier cited involved time constraints
for the usual office visit (Sussman et al., 2007). Most of-
fice visits are completed in less than 30 minutes and must
cover other complex topics for anticipatory guidance as
well. A strong influence on counseling the young
adolescent is the presence of the parent in the room
during anticipatory guidance. Sussman and colleagues
(2007) reported that the clinicians preferred to counsel
adolescents about such sensitive topics with parents
out of the room; however, the HPV vaccine typically is
discussed with this age group with parent(s) present.
Tissot et al. (2007) described strategies that were
identified by clinicians as crucial to effective counseling
about the HPV vaccine. Strategies focused on develop-
ing office policies related to easy access to and admin-
istration of the HPV vaccine. Useful methods for
vaccine delivery programs included office procedures
to enhance the identification of eligible patients and
procedures to promote dose completion, such as chart
reviews, computer queries, and mailed and telephone
reminders. Office procedures to initiate the first dose
at 11 years and to schedule, remind, and follow-up on
missed appointments for the second and third doses
will ensure completion of the three-dose series by age
12 years as recommended by the CDC (Jacobson
Vann & Szilagyi, 2009).
Strategies to promote vaccination such as screening
tools and reminder systems are recommended. For ex-
ample, Merck & Co. (2010) recommends key strategies
in the examination room, at the reception desk, and after
leaving the office to ensure completion of the three-
dose series of Gardasil. Reinforcing and reminding par-
ents in the examination room about the importance of
follow-up for the second and third doses, scheduling
appointments for the second and third doses at the
reception desk, and using telephone, mail, or electronic
reminders for scheduled appointments after leaving the
office is supported by Merck & Co. through their compli-
mentary provision of chart stickers, compliance sheets,
and appointment reminder cards.
Summary
In summary, sociodemographic factors, such as White
race and higher levels of education, as well as greater
perceived risk of HPV infection, personal experience
Journal of Pediatric Health Care
with cervical cancer, and receipt of information about
the HPV vaccine from a health care provider, were asso-
ciated with more knowledge about HPV and the HPV
vaccine. Predictors of parental intention for uptake of
the HPV vaccine by their daughters included knowl-
edge about HPV and the HPV vaccine as well as beliefs
about the likelihood of contracting HPV infection, the
likelihood of HPV causing cervical cancer, and the
severity of HPV and HPV-related diseases. Other factors
that predicted parental intention for uptake of the HPV
vaccine included support of significant others, physi-
cian recommendations, and perceptions of vaccine
safety and effectiveness. Factors relating to the reluc-
tance of parents to vaccinate their daughters were
cost, young age of the daughters, fear of promoting sex-
ual activity, concerns about adverse reactions to the
HPV vaccine, and concern about the long-term effec-
tiveness of the HPV vaccine. Factors related to recom-
mendations of the HPV vaccine by providers included
barriers to counseling of preteen girls, such as poor
knowledge base, time constraints, and presence of
parents in the room. Factors that enhanced counseling
by providers included having office policies and proce-
dures for vaccine delivery and reminder systems to pro-
mote completion of the three-dose series.
QUALITY ASSURANCE PROJECT
Health care providers working in a private pediatric
practice were preparing to submit an application
for certification with the National Committee for
Quality Assurance (National Committee for Quality
Assurance, 2010) to be recognized through the Physi-
cian Practice ConnectionsePatient-Centered Medical
Home. The application process involves an evaluation
of practice standards that demonstrates use of updated
information and systems to improve the quality of care
in the practice. The health care providers had to choose
several areas for evaluation, and given the recent
availability of the HPV vaccine and recommendation
for administration of the HPV vaccine to adolescent
girls, the decision was made to evaluate the percentage
of girls in the practice who had uptake of the vaccine
and completed the three-dose series in the first year
after its recommendation. The results of this evaluation
would be used to develop methods to ensure that the
HPV vaccine was offered to all eligible girls in the prac-
tice and to improve rates that were less than optimal.
METHODS
Description of the Practice
This quality assurance (QA) project used a descriptive
design. The project was undertaken in a small private
urban pediatric practice to examine the percentage of
eligible girls who had uptake of the HPV vaccine and
completed the three-dose series during the year of
2007. The practice includes one full-time board-certi-
fied pediatrician and two part-time board-certified
www.jpedhc.org
pediatric nurse practitioners and has an active patient
population of 2766. Ages of patients range from new-
born through age 21 years. Demographics of the study
population are shown in Table 1.
Participants
The practice policy was to offer the HPV vaccine during
all office visits for eligible girls, including both well child
care (WCC) and episodic visits (gynecologic and non-
gynecologic appointments). Eligibility for the HPV
vaccine was determined to be age 12 years or older.
Exclusion criteria included known pregnancy (the
CDC does not require pregnancy testing prior to the
administration of the vaccine), moderate or severe
illness, or hypersensitivity to yeast or any component
of the vaccine. The HPV vaccine can be given to female
clients who are lactating, are immuno-compromised,
have minor acute illness, have had genital warts or an
equivocal or abnormal PAP test, or have tested positive
for HPV via the Hybrid Capture II High Risk test (CDC,
2009a). The pediatrician and nurse practitioners uti-
lized typical office vaccination practices, including the
provision of brief verbal education during which cur-
rent recommendations for the HPV vaccine were pro-
vided followed by provision of a standardized CDC
Vaccine Information Sheet on the HPV vaccine to par-
ents (CDC, 2009a). If parents declined the HPV vaccine
for their daughters, a notation was made in the chart and
the HPV vaccine was to be offered again at the next
office visit. If parents agreed to uptake of the HPV vac-
cine, the first dose was given to their daughters and the
parents were encouraged to schedule an appointment
for administration of the next dose prior to leaving the
office. No reminders were used to follow up on the sec-
ond or third doses if they had not been scheduled, and
no follow-up telephone calls or postcards were sent for
second or third doses that were missed.
Data Collection
Methods of data collection included both computer
query and chart review. AWeb-based data management
system is used in the office for electronic scheduling
and billing. A query of this database identified the num-
ber of active patients who were eligible (N = 518) and
the number who received the vaccine within two age
cohorts: 12 to 17 years and 18 to 21 years. The unit of
analysis for this project was the patient, and all patients
were accounted for once they were in the data set as
described in the following section. Data were collected
on completion of the first, second, and third doses via
a chart review by the nurse practitioner.
Data Analysis
Descriptive statistics were used to summarize the HPV
vaccine uptake and dose completion rates. A v2 analysis
was used to examine the difference in proportions of
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 TABLE 1. Demographics of study population
Characteristic n %
Population drawn from practice neighborhood*,
African American race 72.5
Household income # $14,999 43.2
Education # high school 20.8
Population drawn from adjacent neighborhoods*,
African American race 4.4-22.6
Household income # $14,999 30.7-38.1
Education # high school 26.3-30.3
Sex of practice patients
Female 1020 36.9
Age of female practice patients
12-21 y 518 18.7
Insurance of practice patients
Private 2269 82.0
Public assistance 497 18.0

*Based on zip codes of the practice neighborhood and adjacent neighborhoods where more than one third of the patients in this practice
reside.
Vital statistics for these neighborhoods are from the 2000 census (Pittsburgh Department of City Planning, 2006).

HPV vaccine uptake between younger and older age
groups in the practice.
RESULTS
During 2007, 195 girls in the practice who were eligible
for the HPV vaccine and had scheduled WCC appoint-
ments were offered the HPV vaccine during their office
visit. The majority of the girls were aged 12 to 17 years
(n = 153), and 42 girls were aged 18 to 21 years. During
the review period, 73.3% (143/195) of the girls received
the HPV vaccine during their annual WCC office visit.
Uptake of the HPV vaccine in girls aged 12 to 17 years
was 71.9% (110/153), and uptake of the HPV vaccine
in girls aged 18 to 21 years was 78.6% (33/42). No signif-
icant difference in HPV vaccine uptake by age group
was found (v2 = .448, P = .503) (Table 2).
During the review period, a total of 189 girls who were
eligible for the HPV vaccine and scheduled either a WCC
or an episodic visit for acute or gynecological concerns
received the HPV vaccine. A total of 75.7% (143/189)
of the girls received the HPV vaccine at their WCC visit,
and 24.3% (46/189) of the girls received the HPV vaccine
at an episodic visit. Of the 46 girls with HPV vaccine up-
take at an episodic visit, almost two thirds (65.2%; 30/46)
were seen for non-gynecological concerns.
Dose completion rates also were examined during the
review period. Of the girls with HPV vaccine uptake
(n = 189), 63.5% (120/189) completed the three-dose se-
ries. Of the girls who completed the three-dose series,
only 66.7% (80/120) of them did so within 12 months
or less.
DISCUSSION
This QA project found an HPV vaccine uptake rate of
73.3% at WCC visits, which is higher than the rates re-
ported by the CDC, but still in need of improvement.
In 2007, the HPV vaccine uptake rate was 25.1% in
adolescent females aged 13 to 17 years (CDC, 2008).
In 2008, the HPV vaccine uptake rate in this population
increased to 37.2% (CDC, 2009b). Kahn et al. (2008)
reported a low HPV vaccine uptake rate of 5% in
females aged 13 to 26 years. Jain et al. (2009) reported
a low HPV vaccine uptake rate of 10% in women aged
18 to 26 years. In this older sample, factors associated
with receiving the vaccine included being single, hav-
ing adequate income, having insurance coverage, and
receiving the hepatitis B vaccine. It is interesting that
34% of this older sample had received health care pro-
vider recommendations for the HPV vaccine. Of the
66% of the women who did not receive such recom-
mendations, 90% of them reported that they intended
to receive the HPV vaccine. In contrast, Marlow and
colleagues (2008) reported that those who received
the HPV vaccine stated that health care provider recom-
mendations did not affect their decision making about
uptake of the HPV vaccine. The HPV vaccine uptake
rate in the QA project of 73.3% at WCC visits was some-
what similar to the rates of intention to receive the HPV
vaccine (Marlow et al., 2008; Ogilvie et al., 2007).
Compared with the CDC reports, a United Kingdom
study reported higher rates of HPV vaccine uptake;
however, the HPV vaccine was part of a national
TABLE 2. Uptake of HPV vaccine during well
child care visits by age groups
Uptake of HPV vaccine
Yes No
Age group (y) N n (%) n (%)
12-17 153 110 (71.9) 43 (28.1)
18-21 42 33 (78.6) 9 (21.4)
Total 195 143 (73.3) 52 (26.7)
HPV, human papillomavirus.

6 Volume -  Number - Journal of Pediatric Health Care

school-based immunization program (Brabin et al.,
2008). Brabin and colleagues (2008) reported data
from 36 schools with 2817 girls aged 12 to 13 years;
70.6% of the girls received the first dose of Cervarix,
and 68.5% received the second dose. Completion of
the series was negatively affected by the fact that 16%
and 27% of the girls missed the first and second doses,
respectively, resulting in rescheduling of appoint-
ments.
The QA finding of a three-dose completion rate of
66.7% within 12 months is only moderate but higher
than the rate reported by the CDC (2009b), in which
17.9% of female adolescents aged 13 to 17 years com-
pleted the three-dose series. The CDC reported that
among the adolescent girls with HPV vaccine uptake,
79.4% of them received the first dose in the previous
24 weeks; of these, 59.6% completed the three-dose
series. This finding implies that there is a recent trend
to complete the three-dose series now that the HPV vac-
cine is more established as a routine adolescent vacci-
nation. Table 3 provides a summary of the rates of
intention to receive the HPV vaccine and receipt of
the HPV vaccine in this QA project and in the literature.
Implications for Practice
Although reports in the literature indicate that a moder-
ately high percentage of mothers intend to receive the
HPV vaccine for themselves and/or for their daughters,
nationally reported HPV vaccine uptake rates have been
disappointing (Table 3).
It is imperative to de- Educational
velop and test strate-
gies to improve HPV strategies should
vaccine uptake and target evidence-
dose completion rates. based predictors,
Use of appropriate ed-
ucational strategies to such as
promote health care seriousness of HPV
provider ability to ad- infection and
dress patient and fam-
ily knowledge gaps cervical cancer,
about HPV and the susceptibility of
HPV vaccine in 5 min- adolescents to HPV
utes or less will help
health care providers infection, and risk
implement an effective of HPV infection.
office-based HPV vac-
cine delivery program. Educational strategies should
target evidence-based predictors, such as seriousness
of HPV infection and cervical cancer, susceptibility of
adolescents to HPV infection, and risk of HPV infection.
They also should address barriers to HPV vaccine
uptake and dose completion, such as parental concerns
about vaccine cost, safety, and effectiveness.
The need for culturally sensitive discussions with pa-
tients and parents and for educational resources is cru-
cial, given the racial disparities associated with HPV
www.jpedhc.org
infection and cervical cancer. Providers may benefit
from educational strategies that build knowledge and
skills to discuss adolescent sexuality in general and
HPV vaccination in particular with various racial, eth-
nic, or religious groups (Tissot et al., 2007). Culturally
sensitive materials that are easily accessible to health
care providers, office staff, patients, and families in
the office will further enhance knowledge about HPV
infection, cervical cancer, and the HPV vaccine.
Southall (2008) identified the importance of using all
windows of opportunity to vaccinate, including WCC
and episodic visits. The Society of Adolescent Medicine
published a position paper on adolescent immunization
and recommended that educational initiatives aimed at
improving adolescent immunization rates should in-
clude use of all opportunities to address the barrier of
a three-dose vaccine (Middleman et al., 2006). Maximiz-
ing HPV vaccine opportunities is consistent with the QA
finding in which nearly two thirds of the HPV vaccine
uptake that occurred during episodic visits took place
during non-gynecological appointments. This QA find-
ing is clinically significant and emphasizes the impor-
tance of offering the HPV vaccine at all visits.
Based on this literature review and the findings of the
QA project, our practice plans to embark on a follow-up
QA project. It is believed that if the health care providers
and office staff have support, educational resources,
and electronic reminders to address this sensitive topic
with adolescents and their parents, the practice HPV
vaccine uptake and dose completion rates can be im-
proved. A clinical protocol of educational information
sheets tailored to racial groups seen in the practice
along with a brief counseling script and electronic alert
system to prompt telephone reminders for return ap-
pointments will be developed, implemented, and eval-
uated. The use of evidence of predictors of parental
intention for uptake of the HPV vaccine and barriers
to implementing an effective HPV vaccine delivery pro-
gram as well as current technology for electronic re-
minders to prompt parents with telephone reminders
may improve HPV vaccine uptake and dose completion
rates at our practice. The U.S. Department of Health and
Human Services (2009) has proposed Healthy People
2020 objectives that include decreasing the proportion
of persons with HPV infection. Increasing the HPV
vaccine uptake and dose completion rate through a tar-
geted educational intervention that also utilizes tech-
nology to ensure dose completion will contribute to
meeting this important national goal. The Society of
Adolescent Medicine position paper on adolescent
immunization supports the use of effective strategies
to promote adolescent immunizations, including regis-
tries and reminder systems (Middleman et al., 2006).
Implications for Research
A fair amount of evidence exists on HPV vaccine uptake
rates and predictors of parental intention for uptake of
-/- 2010 7
 TABLE 3. Rates of intention to receive and receipt of HPV vaccine reported in the quality assurance
project and the literature
Rates of intention to receive and receipt of HPV vaccine
Intention to HPV vaccine
Intention to HPV vaccine receive subsequent uptake rate of
receive HPV uptake rate dose of HPV subsequent
Reference vaccine (%) of first dose (%) vaccine (%) doses (%)
QA Project, 2007 73.3 66.7 (series completion)
Brabin et al., 2008 70.6 68.5 (dose 2 completion)
(United Kingdom)
CDC, 2008 25.1
CDC, 2009b 37.2 17.9 (series completion)
CDC, 2009b (cohort from 79.4 59.6 (series completion)
previous 24 weeks)
Di Giuseppe et al., 2008 81.7
Fazekas et al., 2008 Self: 66.0
Daughter: 84.0 Daughter: 88.0
Jain et al., 2009 90.0 10.0
Jaspan et al., 2008 28.2
Kahn et al., 2003 Self: 85.0
Daughter: 83.0
Kahn et al., 2008 66.0 5.0 54.0 0.2 (series completion)
Marlow et al., 2008 74.0
Ogilvie et al., 2007 73.8
Rosenthal et al., 2008 22.0 26.0

CDC, Centers for Disease Control and Prevention; HPV, human papillomavirus; QA, quality assurance.

the HPV vaccine, but limited evidence is available about age-appropriate and parent-sensitive material can in-
appropriate vaccine delivery programs to improve HPV crease knowledge about HPV infection risk and pre-
vaccine uptake and series completion (e.g., Dempsey, vention (Vallely, Roberts, Kitchener, & Brabin, 2008).
Zimet, Davis, & Koutsky, 2006; Leader, Weiner, Kelly,
Hornik, & Cappella, 2009). Early data on HPV vaccine CONCLUSIONS
uptake rates of the first and second doses in the In conclusion, the office visit at 11 to 12 years of age is
United Kingdom were reported to be as high as 70% considered the primary immunization visit for adoles-
(Brabin et al., 2008), whereas U.S. reports are lower at cents, and a strong vaccine delivery program should
5% to 37% (CDC, 2008, 2009b; Jain et al., 2009; Jaspan be in place for this age
et al., 2008; Kahn et al., 2008; Rosenthal et al., 2008), group. Offices must .the office visit at
indicating a need for more studies of interventions to take advantage of in-
improve these rates in the United States. creased rates of adoles- 11 to 12 years of
Brewer and Fazekas (2007) found that education and cents presenting for age is considered
age were predictive of intention for HPV vaccine uptake. WCC and the likeli- the primary
Results were mixed for the effect of race on intention of hood of health care
HPV vaccine uptake (Brewer & Fazekas, 2007; provider screening for immunization visit
Di Giuseppe et al., 2008; Jain et al., 2009; Ogilvie et al., vaccines at this age. for adolescents,
2007). Further investigations of culturally sensitive There is an increased and a strong
intervention strategies to improve HPV vaccine uptake likelihood that parents
and series completion need to be conducted. Develop- will agree to uptake of vaccine delivery
ment and testing of educational material in lay the HPV vaccine after program should be
language about HPV and the HPV vaccine with receiving education in place for this age
emphasis on minority groups and lower levels of and support from the
education are essential. Interventions that consider soc- health care provider. group.
iodemographic factors have the potential to decrease Educational initiatives
disparities in rates of HPV infection and cervical cancer. should be in place to support health care providers
An ongoing need exists for reports of uptake of the and parents at this critical time, and all opportunities
second and third doses of the HPV vaccine, along must be utilized to break down barriers to completion
with appropriate educational strategies to increase of this three-dose vaccine.
HPV uptake and completion of the three-dose series. The National Vaccine Advisory Committee of the De-
Development of educational strategies geared toward partment of Health and Human Services has accepted

8 Volume -  Number - Journal of Pediatric Health Care

the recommendation of the Committees Adolescent
Immunization Working Group to promote successful
vaccination of adolescents in the United States
(Southall, 2008). Developing evidence-based vaccine
delivery programs based on what the Working Group
has identified as six crucial issues will promote achieve-
ment of the goal of successfully vaccinating the adoles-
cent population. These issues include sites for vaccine
implementation, consent for vaccinations, communica-
tion strategies, financial considerations, surveillance,
and possible school-based directives (Southall, 2008).
Primary care providers should implement and evaluate
evidence-based QA initiatives to improve HPV vaccine
uptake and dose completion rates, thus reducing rates
of HPV infection and cervical cancer.
We acknowledge the assistance of Dr. Carl Hilde-
brandt, physician owner of East Side Pediatrics, where
the Quality Assurance Project was conducted.
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