This cross-sectional study evaluated HPV knowledge, screening, and vaccination practices as well as factors associated with vaccination among reproductive-age women living in Miami, Florida. It also evaluated barriers and motivations to HPV screening and vaccination. Findings suggest low vaccination uptake and screening practices amongst all the participants, and lower HPV knowledge was seen in the unvaccinated women compared to the vaccinated women. Our study also found that the cumulative HPV score, current contraceptive use, participant’s age, and healthcare-related motivators were significant predictors of HPV vaccination. Our results highlight the importance of increasing general HPV knowledge in women in a high-risk area particularly in those with little-to-no HPV knowledge, in order to increase vaccine uptake. To our knowledge, this is the first study in South Florida reporting on the use of a validated HPV score as a predictor of HPV vaccination, and to identify factors that can potentially be modified to increase HPV vaccine uptake.

Prior studies have shown that increased knowledge of HPV was correlated with vaccination status^12,23,24. Similarly, our study found that cumulative HPV score was highly correlated with vaccination status. The mean score of the overall 29-item questionnaire for the vaccinated group was more than double that of the unvaccinated group. An important finding to note is that the likelihood of vaccination increased for every 1-point increase in HPV score until reaching a plateau at a score of 16/29. Above 16, a 1-point increase in HPV score was not a significant predictor of HPV vaccination. This suggests that overall vaccination rates would increase by improving basic knowledge of HPV in those with little-to-no knowledge, as opposed to improving knowledge in those who already have a foundational knowledge of HPV. Educational interventions should target populations with minimal HPV knowledge to improve vaccination rates.

Prior studies have suggested using routine reproductive health visits, such as contraceptive counseling visits, are important opportunities for providers to educates patients about HPV vaccination^25,26. Our results are in alignment with this belief as there were more participants vaccinated among those who reported current contraception use. The strong correlation between contraceptive use and vaccination status could be related to multiple factors. Because contraception is provided by physicians, these participants presumably have frequent interaction with the healthcare system, increasing the likelihood that a provider will discuss HPV vaccination with them. Furthermore, these participants may have a higher degree of knowledge of sexual behaviors and risks, allowing them to see the benefit of the HPV vaccine. With regard to barrier contraception, a high number of participants who reported never using condoms during vaginal sex in the last month were unvaccinated. This serves as a reminder that there is still a subset of patients that can be counseled on HPV vaccines at their contraceptive health visits as well as HPV risk reduction through condom use.

The HPV vaccine became medically available in 2006, and in 2018 the FDA expanded the use of Gardasil 9, the current HPV vaccine, to include individuals ages 27 to 45. Prior to this date, the vaccine was only approved for ages 9 to 26.²⁷ The difference in age distribution among vaccinated and unvaccinated participants seen in our study is likely a result of the historic vaccination guidelines and is congruent with the current literature.^28,29 For the older participants in our study, HPV vaccination was less likely to have been recommended in their youth when they were more engaged with the health care system and followed routine immunization scheduling. In contrast, the younger participants were likely recommended HPV vaccination at pediatrician visits when they were adolescents. Currently the American College of Obstetrics and Gynecology and the Advisory Committee on Immunization Practices do not recommend catch-up vaccination for individuals age 27-45 but shared clinical decision making depending on the patient’s risk for new HPV infections.^30,31 Our results suggest that there could be a subset of older reproductive age women, that could still benefit from HPV risk factor screening and counseling.

Prior research found that barriers to HPV vaccination vary depending on the participant population studied^32-35. Of the barriers to HPV vaccination identified among unvaccinated women in our analysis, the majority were related to vaccine hesitancy and personal beliefs, and less due to low knowledge or healthcare access. These findings highlight the importance of promoting HPV vaccination, both within healthcare systems as well as throughout the community. Low-risk perception barriers were only reported by about 15% of unvaccinated women which could suggest a limited understanding of HPV risk factors.

Studies have also shown that provider recommendation is one of the strongest predictors of HPV vaccination¹⁹, and we see this in our study with 69.8% of vaccinated participants attesting to provider recommendation as a main reason for vaccination. Among the motivators for HPV vaccination, healthcare related motivators were found to increase odds of HPV vaccination by 300% when compared to individuals who did not identify these motivators. Based on this finding, increasing vaccination rates would be best accomplished through healthcare related routes, with a focus on provider recommendations.

A large limitation to this study is the sample size as it restricted the number of variables we could include in the multivariate analysis and thus models are subjected to uncontrolled confounders. Only 84/100 participants knew their vaccination status, limiting our sample but pointing to low HPV health literacy and health history knowledge in this population. Furthermore, this was a cross-sectional study which is limited by temporality. Ultimately, a cause-and-effect relationship cannot be determined with this study design. Our participant recruitment from prior study registries is another limitation to the generalizability of our results as it potentially introduces sampling bias. Providing surveys only in English presents another limitation in the ethnically diverse community of Miami.

Regardless of the limitations, this is an important study as it was conducted in a Southern US city with a high incidence of STIs and low HPV vaccination coverage. Despite an English-only survey, our participant population was racially and ethnically diverse. A strong component of this study is the use of validated questionnaires to assess HPV knowledge, screening, and vaccination practices as well as barriers and motivators. As the answers to these questions were found to be significantly different between the vaccinated and unvaccinated groups, it is important that the validity of these questions was confirmed. Moreover, the study design was strengthened by providing participants the option to complete the survey through a secure web-based system, likely reducing the risk of inaccurate responses that could occur if participants were concerned about privacy.

Overall, this study was successful in evaluating HPV knowledge, screening, and vaccination practices among women of reproductive age living in Miami. Future studies should recruit larger sample sizes and include surveys in Spanish, Haitian Creole and other languages in order to gain a better understanding of the racial and ethnic disparities related to HPV vaccination. The clear relationship between HPV knowledge and vaccination status further emphasizes the need to educate communities about HPV to reduce the spread of the disease and ultimately reduce the rates of HPV-related cancers.