Implementation of Strategies to Improve Human Papillomavirus Vaccine Coverage: A Provider Survey


      Human papillomavirus (HPV) vaccine coverage in the U.S. is persistently suboptimal, despite research describing barriers to vaccination and strategies to increase vaccination coverage. The objective was to assess providers’ approach to the HPV vaccine and their implementation of strategies to increase HPV vaccination coverage. The hypothesis was that adoption of improvement measures to address underuse of the HPV vaccine has not occurred.


      Community pediatric providers from two Midwestern practice-based research networks completed self-administered electronic surveys. Data were collected over 6 months in 2015 and organized and analyzed in 2016.


      There were 100 providers that participated. Despite agreement with national recommendations, some providers delayed their recommendation until the adolescent was older and many reported missed vaccination opportunities. Many providers experienced parental concerns including safety of the HPV vaccine, belief their child was not at risk of HPV infection, and their child's resistance to receiving multiple shots. Providers identified the following as barriers to adherence to Advisory Committee on Immunization Practices guidelines: bad publicity of the HPV vaccine, information about the HPV vaccine on the web, and a lack of a follow-up system for those who delayed HPV vaccine initiation. Approximately half of the participants had implemented strategies to address these barriers beyond offering immunization-only appointments.


      Participants were aware of barriers to HPV vaccine use, but many had not adopted a systematic approach to increase vaccine coverage. A better understanding of the challenges facing providers to adopting improvement measures and a strategy to address barriers to implementation are needed to improve HPV coverage.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Jemal A
        • Simard EP
        • Dorell C
        • et al.
        Annual report to the nation on the status of cancer, 1975–2009, featuring the burden and trends in human papillomavirus (HPV)–associated cancers and HPV vaccination coverage levels.
        J Natl Cancer Inst. 2013; 105: 175-201
      1. Office of Disease Prevention and Health Promotion, HHS. Immunization and Infectious Diseases, Healthy People 2020. Accessed March 6, 2016.

        • Walker TY
        • Elam-Evans LD
        • Singleton JA
        • et al.
        National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years—United States, 2016.
        MMWR Morb Mortal Wkly Rep. 2017; 66: 874-882
        • Dillner J
        • Kjaer SK
        • Wheeler CM
        • et al.
        • FUTURE I/II Study Group
        Four year efficacy of prophylactic human papillomavirus quadrivalent vaccine against low grade cervical, vulvar, and vaginal intraepithelial neoplasia and anogenital warts: randomised controlled trial.
        BMJ. 2010; 2010;341: c3493
        • 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: 547-553
        • Szilagyi PG
        • Albertin C
        • Humiston SG
        • et al.
        A randomized trial of the effect of centralized reminder/recall on immunizations and preventive care visits for adolescents.
        Acad Pediatr. 2013; 13: 204-213
        • Matheson EC
        • Derouin A
        • Gagliano M
        • Thompson JA
        • Blood-Siegfried J
        Increasing HPV vaccination series completion rates via text message reminders.
        J Pediatr Health Care. 2014; 28: e35-e39
        • Perkins RB
        • Zisblatt L
        • Legler A
        • Trucks E
        • Hanchate A
        • Gorin SS
        Effectiveness of a provider-focused intervention to improve HPV vaccination rates in boys and girls.
        Vaccine. 2015; 33: 1223-1229
        • Gilkey MB
        • Dayton AM
        • Moss JL
        • et al.
        Increasing provision of adolescent vaccines in primary care: a randomized controlled trial.
        Pediatrics. 2014; 134: e346-e353
        • Fiks AG
        • Grundmeier RW
        • Mayne S
        • et al.
        Effectiveness of decision support for families, clinicians, or both on HPV vaccine receipt.
        Pediatrics. 2013; 131: 1114-1124
        • Centers for Disease Control and Prevention (CDC)
        Vaccines. AFIX: overview and effectiveness.
        (Accessed April 30.)
        • Chao C
        • Preciado M
        • Slezak J
        • Xu L
        A randomized intervention of reminder letter for human papillomavirus vaccine series completion.
        J Adolesc Health. 2015; 56: 85-90
        • Gilkey MB
        • McRee A-L
        Provider communication about HPV vaccination: a systematic review.
        Hum Vaccines Immunother. 2016; 12: 1454-1468
        • 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: 371-375
        • Darden PM
        • Jacobson RM
        Impact of a physician recommendation.
        Hum Vaccines Immunother. 2014; 10: 2632-2635
        • Finney Rutten LJ
        • St Sauver JL
        • Beebe TJ
        • et al.
        Association of both consistency and strength of self-reported clinician recommendation for HPV vaccination and HPV vaccine uptake among 11- to 12-year-old children.
        Vaccine. 2017; 35: 6122-6128
        • Harris PA
        • Taylor R
        • Thielke R
        • Payne J
        • Gonzalez N
        • Conde JG
        Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support.
        J Biomed Inform. 2009; 42: 377-381
        • Gilkey MB
        • Malo TL
        • Shah PD
        • Hall ME
        • Brewer NT
        Quality of physician communication about human papillomavirus vaccine: findings from a national survey.
        Cancer Epidemiol Biomark Prev. 2015; 24: 1673-1679
        • Bundy DG
        • Persing NM
        • Solomon BS
        • et al.
        Improving immunization delivery using an electronic health record: the ImmProve project.
        Acad Pediatr. 2013; 13: 458-465
        • Stockwell MS
        • Natarajan K
        • Ramakrishnan R
        • et al.
        Immunization data exchange with electronic health records.
        Pediatrics. 2016; 137e20154335.
        • American Association for Public Opinion Research
        Standard definitions: final dispositions of case codes and outcome rates for surveys.
        (Revised 2016. Accessed October 8,)
        • Perkins RB
        • Clark JA
        • Apte G
        • et al.
        Missed opportunities for HPV vaccination in adolescent girls: a qualitative study.
        Pediatrics. 2014; 134: e666-e674
        • Neubrand TPL
        • Breitkopf CR
        • Rupp R
        • Breitkopf D
        • Rosenthal SL
        Factors associated with completion of the human papillomavirus vaccine series.
        Clin Pediatr (Phila). 2009; 48: 966-969
        • Daley MF
        • Crane LA
        • Markowitz LE
        • et al.
        Human papillomavirus vaccination practices: a survey of U.S. physicians 18 months after licensure.
        Pediatrics. 2010; 126: 425-433
        • Vadaparampil ST
        • Kahn JA
        • Salmon D
        • et al.
        Missed clinical opportunities: provider recommendations for HPV vaccination for 11–12 year old girls are limited.
        Vaccine. 2011; 29: 8634-8641
        • Reiter PL
        • Stubbs B
        • Panozzo CA
        • Whitesell D
        • Brewer NT
        HPV and HPV vaccine education intervention: effects on parents, healthcare staff, and school staff.
        Cancer Epidemiol Biomark Prev. 2011; 20: 2354-2361
        • Fu LY
        • Bonhomme L-A
        • Cooper SC
        • Joseph JG
        • Zimet GD
        Educational interventions to increase HPV vaccination acceptance: a systematic review.
        Vaccine. 2014; 32: 1901-1920
        • O'Leary ST
        • Lockhart S
        • Barnard J
        • et al.
        Exploring facilitators and barriers to initiation and completion of the human papillomavirus (HPV) vaccine series among parents of girls in a safety net system.
        Int J Environ Res Public Health. 2018; 15: 185
        • Allison MA
        • Hurley LP
        • Markowitz L
        • et al.
        Primary care physicians’ perspectives about HPV vaccine.
        Pediatrics. 2016; 137: 1-9
        • Rutten LJF
        • St Sauver JL
        • Beebe TJ
        • et al.
        Clinician knowledge, clinician barriers, and perceived parental barriers regarding human papillomavirus vaccination: association with initiation and completion rates.
        Vaccine. 2017; 35: 164-169
        • Cabana MD
        • Ebel BE
        • Cooper-Patrick L
        • Powe NR
        • Rubin HR
        • Rand CS
        Barriers pediatricians face when using asthma practice guidelines.
        Arch Pediatr Adolesc Med. 2000; 154: 685-693
        • Opel DJ
        • Mangione-Smith R
        • Robinson JD
        • et al.
        The influence of provider communication behaviors on parental vaccine acceptance and visit experience.
        Am J Public Health. 2015; 105: 1998-2004
        • Malo TL
        • Gilkey MB
        • Hall ME
        • Shah PD
        • Brewer NT
        Messages to motivate human papillomavirus vaccination: national studies of parents and physicians.
        Cancer Epidemiol Biomark Prev. 2016; 25: 1383-1391
        • Brewer NT
        • Hall ME
        • Malo TL
        • Gilkey MB
        • Quinn B
        • Lathren C
        Announcements versus conversations to improve HPV vaccination coverage: a randomized trial.
        Pediatrics. 2017; 139e20161764.
        • Stockwell MS
        • Natarajan K
        • Ramakrishnan R
        • et al.
        Immunization data exchange with electronic health records.
        Pediatrics. 2016; 137e20154335.
        • Wolfson D
        • Bernabeo E
        • Leas B
        • Sofaer S
        • Pawlson G
        • Pillittere D
        Quality improvement in small office settings: an examination of successful practices.
        BMC Fam Pract. 2009; 10: 14
        • Smith PJ
        • Humiston SG
        • Marcuse EK
        • et al.
        Parental delay or refusal of vaccine doses, childhood vaccination coverage at 24 months of age, and the Health Belief Model.
        Public Health Rep. 2011; 126: 135-146
      2. Centers for Disease Control and Prevention (CDC). HPV, materials to keep parents informed. Published April 20, 2017. Accessed July 20, 2018.

        • Rand CM
        • Tyrrell H
        • Wallace-Brodeur R
        • et al.
        A learning collaborative model to improve human papillomavirus vaccination rates in primary care.
        Acad Pediatr. 2018; 18: S46-S52
        • Fiks AG
        • Luan X
        • Mayne SL
        Improving HPV vaccination rates using maintenance-of-certification requirements.
        Pediatrics. 2016; 137e20150675.