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Hum Vaccin Immunother
Hum Vaccin Immunother
Human Vaccines & Immunotherapeutics
2164-5515
2164-554X
Taylor & Francis

39268680
10.1080/21645515.2024.2390231
2390231
Version of Record
Research Article
HPV
Improving United States HPV vaccination rates: Factors predictive of parental attitudes towards middle school entry requirements
J. DESCH ET AL.
HUMAN VACCINES & IMMUNOTHERAPEUTICS
Desch Jill a
https://orcid.org/0000-0002-7115-0001
Thompson Erika b
Beckstead Jason a
Owens Heather c
https://orcid.org/0000-0003-1903-1512
Richardson Cayama Morgan a
Hernandez Paula a
Valencia Jacqueline d
Zimet Gregory e
https://orcid.org/0000-0003-0227-514X
Vamos Cheryl a
https://orcid.org/0000-0003-3020-295X
Daley Ellen a
a College of Public Health, University of South Florida , Tampa, FL, USA
b School of Public Health, University of Texas San Antonio , San Antonio, TX, USA
c Health Outcomes and Behavior, Moffitt Cancer Center and Research Institute , Tampa, USA
d Public Health Sector, Westat Management Services Company , Rockville, USA
e School of Medicine, Indiana University , Indianapolis, USA
CONTACT Paula Hernandez pahernandez@usf.edu College of Public Health, University of South Florida, 3111 E Fletcher Ave, Tampa, FL 33612, USA.
13 9 2024
2024
13 9 2024
20 1 2390231Integra13 9 2024
Integra13 9 2024
29 4 2024
30 7 2024
06 8 2024
© 2024 The Author(s). Published with license by Taylor & Francis Group, LLC.
2024
The Author(s)
https://creativecommons.org/licenses/by-nc/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (http://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. The terms on which this article has been published allow the posting of the Accepted Manuscript in a repository by the author(s) or with their consent.

ABSTRACT

Although the human papillomavirus (HPV) vaccine is effective at preventing infection and certain types of cancer, uptake is suboptimal. HPV vaccine requirements for school entry are an underutilized strategy to increase HPV vaccine uptake among adolescents. The purpose of this study was to understand the factors that are predictive of parents’ attitudes toward schools requiring the HPV vaccine for entry into middle school. Parents of adolescents ages 11–12 y were recruited to participate in an online survey via Qualtrics. Descriptive frequencies were obtained, and sequential regression analyses were conducted controlling for demographic characteristics. A total of 1,046 participants were included in the analysis. The mean age was 40.3 y (SD = 6.3) and the majority of participants were White (74.4%) and had some college education or higher (80.9%). Participant’s gender, political affiliation, urban/rural setting, and education level were significantly associated with attitudes toward school entry requirements. Adding psychosocial items related to perceptions of benefits, risks, and social norms significantly increased the amount of variance explained in the model [(ΔR2 = .312, F(5, 1036) = 132.621)]. Perceived social norms was the strongest predictor of attitudes [β = 0.321]. The results of this study can be used to inform policy changes around school-entry requirements in the United States. Further studies are needed to assess the influence of perceived social norms in vaccine hesitant groups.

KEYWORDS

Human papillomavirus (HPV)
HPV vaccine
vaccine hesitancy
vaccine strategies
school entry
National Cancer Institute 10.13039/100000054 Moffitt Cancer Center 10.13039/100009164 T32CA090314 Dr. Owens’ work was funded by the National Cancer Institute while she was a postdoctoral fellow at H. Lee Moffitt Cancer Center and Research Institute [T32CA090314; MPIs: S.T. Vadaparampil and V.N. Simmons].
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pmcIntroduction

The HPV vaccine was approved for use in the United States (U.S.) in 2006. As of 2016, the U.S. only administers the nine-valent HPV vaccine (Gardasil 9, 9vHPV) and it is available for the prevention of genital warts and six types of cancer.1 U.S. adolescents ages 11–12 are recommended to receive the HPV vaccine due to the improved protection of vaccinating at this age.1 If not yet vaccinated, adolescents and young adults can receive the HPV vaccine until age 26; between the ages of 27–45, patients can engage in shared clinical decision-making with a health-care provider.1 Adolescents and adults, if not vaccinated, are at an increased risk for multiple different cancer types (i.e., cervical, vagina, penis, anus, and oropharyngeal). Approximately 91% and 70% of cervical and oropharyngeal cancer cases are caused HPV infections, respectively.2 Each year around 4,000 women die due to cervical cancer caused by HPV, which is highly preventable with the vaccine.3 The Healthy People 2030 goal is to increase the percentage of those vaccinated to 80%.4 Unfortunately, only 62.6% of adolescents in the U.S. are up-to-date on the HPV vaccination series as of 2022, indicating considerable progress is needed for this long-available vaccine.5

Although the HPV vaccine is effective at preventing infection and certain types of cancer, uptake is suboptimal.6 Multiple strategies exist to increase vaccination rates, including school entry requirements.7 Currently, there are only five states or territories that have implemented HPV vaccine school entry requirements: Hawaii, Rhode Island, Virginia, Washington DC, and Puerto Rico.8 Among these states, grade requirements and difficulty of opt-out vary considerably.8,9 For example, some states allow parents to sign a declaration opting out of vaccination after reviewing educational materials on HPV and the vaccine, while others only allow religious or medical exemptions.9 Generally, school entry requirements are effective in increasing HPV vaccine uptake, as evident in the higher vaccination rate in states with requirements compared to those without.10,11 Internationally, over 117 countries include the HPV vaccine in routine national immunization schedules, although many of these offer vaccination through a mix of school- and community- or facility-based approaches.12 Australia, for example, has some of the highest HPV vaccine coverage rates, providing the vaccine at no cost through schools without a school-entry requirement.12

Despite the HPV vaccine being mandatory in some states, there continues to be barriers to the introduction of mandatory vaccination.13,14 Vaccine hesitancy among parents is commonly driven by the lack of knowledge and confidence in their own vaccine knowledge.15 A lack of knowledge and confidence is often due to negative reports of side effects and low perceived risk of their child being susceptible to HPV.15 Other factors attributable to vaccine hesitancy include trust and access to health-care providers, previous experiences with vaccines, and perceived safety and efficacy of the vaccine.16,17 HPV vaccine hesitancy has also been found to vary by demographic factors, including religion, age, and gender.18

The Health Belief Model (HBM) and Theory of Reasoned Action (TRA) are frequently used to guide public health studies and interventions.19 The HBM is comprised of six key constructs (perceived susceptibility, perceived severity, benefits, barriers, cues to action, and self-efficacy) aimed to identify and understand individual engagement in health behaviors.20–23 Prior research demonstrates that perceived benefits and barriers are among the strongest predictors of vaccination behaviors.20 Additionally, a commonly identified potential barrier to HPV vaccination is its connection with sexual activity. Parents may either believe their child is not susceptible to HPV because they are not sexually active or they may avoid discussing the vaccine because of HPV’s association with sexual activity.

The TRA assesses intention and attitudes through the use of components such as subjective norms.24 TRA seeks to understand and explain how human action is related to attitudes and behaviors, specifically the factors that motivate individuals in completing a behavior (e.g., subjective norms, attitudes, social circles).24,25 Additionally, social norms can help understand parental attitudes as a mediator between information sources and vaccine completion.26 Despite perceived social norms being a key predictor, further studies are needed to assess social norms in vaccine hesitant groups.

HPV vaccine requirements for school entry are an underutilized strategy to increase HPV vaccine uptake among adolescents, yet few studies have examined parents’ acceptance of such a requirement. Therefore, using constructs from both the HBM and TRA models, this study assessed demographic and psychosocial factors that are predictive of parents’ attitudes toward HPV vaccine school requirements.

Methods

Participants

Participants in the U.S. were recruited to participate in a cross-sectional study by completing an online survey administered through the Qualtrics Survey Panel. Qualtrics is a survey platform that uses market research panels to recruit study participants based on the study’s inclusion and exclusion criteria.27 On average, participants took 10 minutes to complete the survey. Data were collected September–October 2022 and participants received Qualtrics points or credits as compensation. This study was reviewed by the University of South Florida’s Institutional Review Board and determined exempt (STUDY004369).

A nationally representative (e.g., based on demographic characteristics) target sample of 1,000 participants was requested by the research team, and Qualtrics recruited a total of 1,047 to participate in this study. Participants from all 50 states were recruited by Qualtrics, with representation proportional to that of their respective state (e.g., the most commonly represented state was California and the least commonly represented states were Wyoming and Vermont). Study methodology is presented in Figure 1. Figure 1. Study methodology flowchart.

Inclusion Criteria

Participants were parents of HPV vaccine age-eligible adolescents in the United States. Specifically, inclusion criteria included: 1) ages 27–64 y; 2) parent of an adolescent 11–12 y; 3) able to read/speak English; and 4) be the primary health-care decision-maker for their family. Twenty-seven was selected as the minimum age because it is the earliest age at which someone having a child at age 18 would have a vaccine-eligible child. Parents younger than this would be outliers and would fall outside of the normal distribution and may interfere with data analyses. The upper limit for reproductive age is 45 y; due to this and the age eligibility for the vaccine, we anticipate that individuals over the age of 64 would likely not have children in the target age range. After a review of the literature, it was expected that 80% of women who have children are the primary health-care decision-maker for the family.28 Knowing this, we recruited males to be in equal proportion with women in this study, out of interest in further exploring their attitudes toward HPV vaccine and parental decision-making.

Exclusion Criteria

Participants were excluded from this study if they did not complete the survey in its entirety or if they took excessive time completing the survey (>4 hours).

Instruments and procedures for data collection

The survey measured parental attitudes and behaviors related to HPV vaccine school-entry requirements. The outcome was evaluated using three questions: 1) their own attitudes toward acceptance of a school entry requirement in their state; 2) how difficult they felt it should be to opt out of the requirement; and 3) the percentage of other parents they think would opt-out of the requirement. A 5-point Likert scale was used to assess acceptability (1 = not at all acceptable to 5 = completely acceptable) and difficulty of opting out (1 = not at all difficult to 5 = extremely difficult). A sliding scale ranging from None (0%) to All (100%) was used to capture the percentage of other parents participants think would opt-out of the requirement.

Participants were also asked a series of questions based on key components of the HBM and TRA (social norms, perceived severity, perceived susceptibility, general perceived benefit, and perceived benefit related to cancer prevention). Three of these questions (perceived social norms, general perceived benefit, and benefit of cancer prevention) utilized a 5-point Likert scale ranging from 1 (completely disagree) to 5 (completely agree); the remaining questions asked participants to identify how at risk their child was of an HPV infection (1 = low risk to 5 = high risk) and how serious an HPV infection would be ranging from 1 (not at all serious) to 5 (extremely serious). For all Likert scale questions, only the endpoints were labeled. Demographic characteristics asked of each participant included age, gender, race/ethnicity, political affiliation (1 = conservative to 5 = liberal), state of residence, and whether they lived in an urban, suburban, or rural area (referred to here as “urban/rural setting”).

Data analysis

Descriptive statistics were calculated for demographic and outcome variables. Regression analyses were conducted to determine which factors were predictive of parents’ attitudes toward HPV vaccine school entry requirements. Based on the literature, demographic variables that were previously found to be related to school entry requirement attitudes were controlled in the regression model; these included gender, political orientation, urban/rural setting, and education.29 This resulted in the use of two regression models – the first included only demographic variables and the second included psychosocial factors (one item from the TRA and four from the HBM), resulting in a total of nine predictor variables.

Results

Demographics and attitudes towards school-entry requirements

A total of 1,047 participants completed the online survey. One participant took over 4 hours to complete the survey and was thus excluded from the analysis because it was assumed that their responses may be biased. Therefore, the final sample size was 1,046 participants. The mean age was 40.3 y (standard deviation [SD] = 6.3), and the sample was composed of 47.9% males and 52.1% females. Most participants were white (74.4%), not of Hispanic, Latino, or Spanish origin (84.3%), had some college education or higher (80.9%), were married or in a civil union (76.4%), and had health insurance (96.7%) (Table 1). This sample’s mean political affiliation score was 3.3 (SD = 1.3). Given that the scale ranged from 1 (conservative) to 5 (liberal), this sample leaned slightly more liberal than conservative. Participants’ mean level of acceptance toward school-entry requirements was 3.7 (SD = 1.4), suggesting a more acceptable position toward school-entry requirements. The mean rating regarding the difficulty of opting-out was 3.2 (SD = 1.5), suggesting that they believe it should be more difficult for parents to opt out of vaccination requirements (Table 1).Table 1. Summary of demographic variables (N = 1,046).

 	N	%	
Mean age [SD]	40.3	[6.3]	
Gender	 	 	
 Male	501	47.9%	
 Female	545	52.1%	
Education	 	 	
 Less than high school graduate	26	2.5%	
 High school graduate or equivalent	174	16.6%	
 Some college or Associate’s degree	375	35.9%	
 Bachelor’s degree	335	32.0%	
 Advanced degree (Master’s, doctoral)	136	13.0%	
Race	 	 	
 White	778	74.4%	
 Black or African American	124	11.9%	
 Asian	36	3.4%	
 Native Hawaiian or Other Pacific Islander	20	1.9%	
 American Indian or Alaska Native	38	3.6%	
 Multiracial	31	3.0%	
 Other	19	1.8%	
Ethnicity	 	 	
 Hispanic, Latino, or of Spanish Origin	164	15.7%	
Health Insurance	 	 	
 Private insurance	422	40.3%	
 Medicaid	322	30.8%	
 Medicare	225	21.%	
 Tricare (Military insurance)	15	1.4%	
 No insurance	34	3.3%	
 Not Sure	13	1.2%	
 Other	15	1.4%	
Relationship Status	 	 	
 Married/civil union	799	76.4%	
 Single, never married	128	12.2%	
 Widowed	12	1.1%	
 Divorced	71	6.8%	
 Separated	21	2.0%	
 Living with partner	10	1.0%	
 Other	5	0.5%	
Home Setting	 	 	
 Urban	475	45.4%	
 Suburban	358	34.2%	
 Rural	213	20.4%	
Mean political leanings [SD]*	3.3	[1.3]	
Acceptance of school-entry requirement [SD]	3.7	[1.4]	
Difficulty opting-out of requirement [SD]	3.2	[1.5]	
Percentage that will opt-out of requirement [SD]	48.4%	[25.5%]	
*Measured using a five-point Likert scale with endpoints labeled 1 (conservative) to 5 (liberal).

Factors associated with attitudes towards school-entry requirements

In model 1, participant’s gender, political affiliation, urban/rural setting, and education were significantly associated with parental attitudes toward school entry (Table 2). These demographics explained a significant amount of variance in this model (R2 = .201, F(4, 1041) = 65.376). The second model inclusive of psychosocial items accounted for a significant amount of the variance (R2 = .513, F(9, 1036) = 132.621) (Table 2). The inclusion of these items increased the R2 significantly (ΔR2 = .312, F(5, 1036) = 132.621, p < .001). All psychosocial items were significantly associated with parental attitudes toward school entry. Urban/rural setting was no longer significant in the model due to its correlation with HBM items. Overall, the strongest predictor of attitudes toward school entry requirements was perceived social norms (β = 0.321).Table 2. Sequential regression analysis predicting parents’ acceptance of HPV vaccine for entry into middle school.

 	Model 1	Model 2	
b	SE b	β	b	SE b	β	
Intercept	1.936*	0.227	 	−0.580*	0.218	 	
Male	0.529*	0.085	0.186	0.234*	0.068	0.082	
Political Orientation**	0.310*	0.033	0.274	0.116*	0.027	0.102	
Urban/rural***	−0.132*	0.055	−0.071	−0.061*	0.043	−0.033	
Education	0.210*	0.042	0.146	0.092*	0.034	0.064	
Perceived Social Norms	 	 	 	0.326*	0.029	0.321	
Perceived Benefits (General)	 	 	 	0.212*	0.040	0.161	
Perceived Benefits (Cancer Prevention)	 	 	 	0.152*	0.041	0.112	
Perceived Risk	 	 	 	0.144*	0.030	0.133	
Perceived Severity	 	 	 	0.091*	0.034	0.068	
* p < .05; Model 1: R2 = .201, F(4, 1041) = 65.376; Model 2: R2 = .513, F(9, 1036) = 132.621.

ΔR2 = .312, F(5, 1036) = 132.621, p <.001.

**Higher score = more liberal, lower score = more conservative.

***Values of urban/rural range from 1 (urban) to 3 (rural).

Based on the literature, race and political affiliation were examined as potential effect modifiers.30–32 To evaluate race, the sample was limited to those identifying as White or African American/Black (n = 902). A race term was added to model 1, and model 3 included an interaction term between race, HBM, and TRA items in the model. Race was not significantly associated with attitude toward school entry requirements and there was no interaction between race and HBM or TRA. Interaction terms between political affiliation, HBM, and TRA were also added to the model and were non-significant. Lastly, the association between acceptance of school-entry requirements and residing in a state with an existing school-entry requirement was also evaluated and was found to be non-significant.

Opinions on the Difficulty of Opting Out of School-Entry Requirements

Participants’ opinions regarding the difficulty of opting out of an HPV vaccine requirement for school entry were also assessed. Overall, 46.2% of participants (n = 483) indicated that it should be difficult to opt-out of a school entry requirement, with an additional 22.3% (n = 233) remaining neutral (mid-point of the scale). Participants thought that roughly half (48.4%) of parents would opt-out of an HPV vaccine requirement for school-entry.

Discussion

This study examined the acceptability of an HPV vaccine requirement for school entry among US parents of adolescents ages 11–12 using psychosocial factors derived from the HBM and TRA. All HBM and TRA items were significantly associated with acceptability of school-entry requirements, with the strongest association tied to perceived social norms. There was also a relationship between attitudes toward school entry requirements and participant beliefs regarding how difficult it should be for parents to opt-out of these requirements.

When comparing other studies related to parental attitudes toward mandatory HPV vaccination for school entry, different factors have been identified. Parents of children and adolescents are more likely to be favorable to school entry when there is the possibility to opt-out and when they believe the HPV vaccine to be highly effective in protecting against cervical cancer.33 Another study conducted in the U.S. found that over half of parents were in favor of HPV vaccinations provided in schools and pointed to increased convenience and accessibility and positive peer pressure as reasons for their support.14 Generally, parents who were most supportive of school entry requirements were those who had not completed the series, compared to those who had not yet started the series and those who had completed it.14 However, studies have also highlighted that parental acceptance of school entry is lower in parents who have HPV vaccine safety concerns, believe the vaccine is being pushed by pharmaceutical companies, and that it may promote sexual activity in their children.14,33

In our study, social norms also emerged as a strong predictor of positive attitudes toward school entry requirements. Other studies have similarly found this to be a highly influential predictor of positive attitudes toward vaccination.34,35 In one study, researchers found that HPV vaccination intentions were strongly correlated with perceived social norms, specifically whether friends, parents, and doctor supported them in getting vaccinated against HPV.34 The influential role of social norms is also evident in the acceptance of other vaccines, such as coronavirus-19 (COVID-19), influenza, and diphtheria, tetanus, and acellular pertussis booster vaccine (TDAP).29,36,37 For example, pregnant women’s beliefs regarding whether they thought the majority of their friends and family would encourage them to get recommended vaccines was significantly associated with influenza and TDAP vaccine intention.38 In a study assessing the role of social influence on COVID-19 vaccine uptake, there was a significant correlation between having friends and family who discouraged vaccination and vaccine hesitancy.29 Similarly, a study assessing COVID-19 vaccine hesitancy among college students found greater vaccine hesitancy among those who were less likely to perceive that many people they knew were vaccinated and that the typical student at their university was less approving of the vaccine.37,39

Demographic factors associated with increased acceptability of school requirements for the HPV vaccine included being male, identifying as more politically liberal, and having a higher level of education. Gender differences are not unique to HPV vaccination, having also been identified in the context of COVID-19 vaccination. A recent systematic review and meta-analysis assessing gender differences in COVID-19 vaccine intention found that men were significantly more likely to get vaccinated compared to women, while another large United Kingdom-based study found that women respondents had significantly higher levels of COVID-19 vaccine uncertainty.40 Regarding political affiliation, other studies have similarly found an association between identifying as more politically liberal and greater support for HPV vaccination, including school-entry requirements.32,41 In one study, those who identified as Democrats were more likely to support middle school HPV vaccine requirements compared to those who identified as Republicans; there was also less support for school-entry requirements among those who believed that the HPV vaccine was often a part of political discourse and those who believed HPV to be “very controversial.”41 Research is conflicting, however, regarding the importance of educational attainment on HPV vaccine acceptance, with higher levels of education among caregivers having been shown elsewhere to reduce willingness to vaccinate adolescent children.42

Other factors have been identified in the literature as important for measuring and targeting vaccine readiness. The 7C’s model proposes 7 psychological antecedents, including confidence, complacency, constraints, calculation, collective responsibility, compliance, and conspiracy.43 Several of these factors align with constructs measured in the present study, including complacency (perceived severity and susceptibility to HPV infection) and calculation (perceived benefits of vaccination). Other components of this model likely impact HPV vaccination readiness among this population. For example, confidence in the vaccine, including concerns about safety and effectiveness, has been identified as barriers to HPV vaccination among parents.44,45 Conspiracy may be a growing concern and factor shaping parental acceptance toward school-entry requirements, as beliefs in medical conspiracy theories have been found to negatively impact uptake of vaccination and attitudes toward government regulations and have risen since the COVID-19 pandemic.43,46 Overall, the 7C’s model could be used to guide future research exploring factors associated with HPV vaccination readiness and attitudes among parents of adolescents.

There are also some ethical considerations that make vaccine mandates, including school-entry requirements, a controversial strategy for improving vaccine uptake. These include potential impacts on public trust and debates about personal autonomy. However, it has been argued that school-entry requirements for HPV vaccination are justifiable, given that HPV is the leading cause of cervical cancer and has a disproportionate impact on underserved communities who otherwise might lack access to the vaccine.47 Increased understanding of attitudes toward school-entry requirements and contributors to vaccine hesitancy are necessary for creating targeted educational campaigns aimed at improving parental acceptance. These campaigns must also address parental trust in the vaccine, increasing their awareness of the importance of HPV vaccination, vaccine safety, and efficacy.

Strengths of this study include the use of a large, nationally representative sample and the use of theory, namely the HBM and TRA, two theories commonly used to assess vaccine intentions and behaviors.22 An additional strength was the oversampling of men, as previous research assessing health-care decision-making has focused predominately on women and not included the perspectives of men, who may also participate in or lead health-care decision-making for children in their families.48–51 In the current study, we found that men had higher acceptance of HPV vaccine school-entry requirements compared to women and this difference would not have been detected if males and females were not equally sampled.

A limitation of the study is use of retrospective and prospective questions, depending upon the child’s HPV vaccination status. It is possible that questions asked of parents who had already vaccinated their child were biased due to their existing acceptance of the vaccine. However, all questions were asked as hypothetical situations, creating a common thread among questions that could help limit this bias. It is also possible that participants in this study differed from the general population in that they selected to be a part of a survey panel with Qualtrics, potentially reflecting volunteer or self-selection bias. Additionally, though race was explored as a potential effect modifier, this study was limited by low sample sizes among groups who did not identify as either white or Black/African American. Other research suggests that there are differences in HPV vaccination rates across racial and ethnic groups.52 Lastly, this study did not include an assessment of HPV knowledge; therefore, knowledge was not explored as a potential factor associated with attitudes toward school entry requirements.

Conclusion

Overall, when considering psychosocial factors (e.g., social norms, perceived severity, perceived susceptibility, perceived benefit), all factors were significantly associated with attitudes toward school entry requirements for HPV. However, perceived social norms (i.e., the expectation of friends and family to vaccinate their child against HPV) were most strongly associated with attitudes. The results of this study can be used to inform policy changes around school-entry requirements in the U. S. and create intervention strategies to support parental decision-making regarding the HPV vaccine. Perceived social norms were found to be the strongest predictor of acceptance of school-entry requirements; however, perceived risk of HPV and benefits of the vaccine also remain important predictors. Further studies are needed to assess the influence of perceived social norms in vaccine hesitant groups.

Jill K. Desch, MPH, is a Doctoral Candidate and Graduate Research Assistant at the University of South Florida College of Public Health.

Erika L. Thompson, PhD, MPH, is an Associate Professor in the School of Public Health at the University of Texas School of Public Health San Antonio.

Jason Beckstead, PhD, is a Professor at the University of South Florida College of Public Health.

Heather Owens, PhD, MPH, is a Applied Postdoctoral Fellow, Department of Health Outcomes and Behavior, Division of Population Science, H. Lee Moffitt Cancer Center and Research Institute, USA.

Morgan Richardson Cayama, MPH, is a Doctoral Student and Graduate Research Assistant at the University of South Florida, College of Public Health.

Paula A. Hernandez, BS, is a Master of Public Health Student and Graduate Research Assistant at the University of South Florida College of Public Health.

Jacqueline Valencia, MPH, is a Research Analyst II at Westat Management Services Company.

Gregory D. Zimet, PhD, MA, HSPP, is a Clinical Psychologist and Professor Emeritus of Pediatrics & Psychiatry, School of Medicine at Indiana University

Cheryl A. Vamos, PhD, MPH, is an Associate Professor in the University of South Florida College of Public Health.

Ellen M. Daley, PhD, MPH, is a Professor and the Senior Associate Dean for Research and Practice in the University of South Florida College of Public Health.

Disclosure statement

Dr. Ellen Daley previously served on the U.S. HPV Vaccine Advisory Board for Merck. Dr. Erika Thompson is a consultant for Merck Pharmaceuticals related to HPV vaccination. Dr. Erika Thompson and Dr. Ellen Daley were awarded Merck Investigators Studies Program funding. Dr. Zimet has served as an external advisory board member for Merck, Pfizer, and Moderna and as a consultant to Merck; has received investigator-initiated research funding from Merck administered through Indiana University and serves as an unpaid member of the Board of Directors for the Unity Consortium, a nonprofit organization that supports adolescent health through vaccination. None of the other authors have any conflicts of interest to disclose. All authors have read and approved this manuscript.

Author contributions statement

J. Desch: conception, analysis & interpretation, drafting, revising

E. Thompson: conception, interpretation, drafting & revising

J. Beckstead: conception: analysis & interpretation, revising

H. Owens: analysis & interpretation, drafting, and revising

M. Richardson Cayama: analysis & interpretation, drafting, and revising

P. Hernandez: drafting and revising

J. Valencia: drafting and revising

G. Zimet: interpretation, revising

C. Vamos, interpretation, revising

E. Daley: conception, interpretation, drafting, revising
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