HPV Vaccine Hesitancy

Findings From a Statewide Survey of Health Care Providers

Annie-Laurie McRee, DrPH; Melissa B. Gilkey, PhD; Amanda F. Dempsey, MD, PhD, MPH


J Pediatr Health Care. 2014;28(6):541-549. 

In This Article

Abstract and Introduction


Introduction Health care provider recommendations are critical for human papillomavirus (HPV) vaccine uptake. We sought to describe providers' HPV vaccine recommendation practices and explore their perceptions of parental hesitancy.

Method A statewide sample (n = 575) of Minnesota health care providers (20% pediatricians, 47% family medicine physicians, and 33% nurse practitioners) completed our online survey in April 2013.

Results Only 76% of health care providers reported routinely recommending HPV vaccine for girls ages 11 to 12 years, and far fewer (46%) did so for boys (p < .001). A majority of providers reported asking questions about parents' concerns (74%), but many lacked time to probe reasons (47%) or believed that they could not change parents' minds (55%). Higher levels of self-efficacy and outcome expectations were associated with routine recommendations (p < .05).

Discussion Findings suggest that providers' perceptions of hesitancy may discourage them from routinely recommending the HPV vaccine. Improving providers' self-efficacy to address hesitancy may be important for improving vaccination rates.


The human papillomavirus (HPV) vaccine is a cost-effective way to confer protection against genital warts and several types of cancer, and yet it remains one of the most underused vaccines in the United States. National guidelines have recommended routine administration of HPV vaccine to 11- to 12-year-old girls since 2006 (Markowitz et al., 2007). In October 2011, this recommendation was extended to males (Dunne et al., 2011), strengthening the previous "permissive recommendation" that HPV vaccine received in 2009 (Centers for Disease Control and Prevention [CDC], 2010). Despite these recommendations, estimates from 2012 indicate that only 33% of adolescent girls and 7% of boys have completed the three-dose HPV vaccine series (Curtis et al., 2013). By contrast, two other vaccines introduced to adolescents' immunization schedule in the same time period have made steady progress toward the Healthy People 2020 goal of 80% coverage (U.S. Department of Health and Human Services, 2014). In light of the disappointing uptake, research to understand the unique challenges of HPV vaccination has gained prominence.

Of the many factors that influence HPV vaccination, the role of health care providers is perhaps the most important. Receiving a providers' recommendation is one of the strongest and most consistent predictors of HPV vaccination (Allen et al., 2010; Reiter, Brewer, Gottlieb, McRee, & Smith, 2009; Rosenthal et al., 2011; Ylitalo, Lee, & Mehta, 2013). Despite evidence suggesting that they are highly influential, health care providers often fail to recommend the vaccine according to guidelines (Vadaparampil et al., 2011). Parental reports suggest that only about half of female and 1 in 10 male adolescents have ever received a recommendation for HPV vaccine Darden et al., 2013; Reiter, Gilkey, & Brewer, 2013), and lack of provider recommendation is one of the most common reasons parents give for not getting the vaccine for their child (Dorell, Yankey, & Strasser, 2011; Reiter, Katz, & Paskett, 2013).

Health care providers face a number of barriers to recommending HPV vaccine, some of which are interpersonal in nature. For example, some providers express difficulty discussing sexual health issues that may attend HPV vaccination, particularly with younger adolescents in the target age range for vaccination (Daley et al., 2010; Vadaparampil et al., 2011). Others perceive parents as being opposed to the vaccine and are reluctant to strongly recommend the vaccine because of concerns about initiating time-consuming or confrontational debates (Daley et al., 2010; Hughes, Jones, Feemster, & Fiks, 2011). Indeed, prior research suggests that vaccine refusal and delay is common among parents of adolescents (Daley et al., 2010; Gilkey, McRee, & Brewer, 2013), although relatively little is known about how providers understand or address parental hesitancy specific to HPV vaccine. We sought to describe health care providers' HPV vaccine recommendation practices and to explore their perceptions of, and approaches to addressing, HPV vaccine hesitancy among parents of 11- to 12-year-old youth.