Accepted Manuscript

Do Educational Seminars for the Human Papillomavirus Vaccine Improve Attitudes

Toward the Value of Vaccination?

Kay Roussos-Ross, M.D., Assistant Professor, L. Foster, M.D., Resident Physician,

H.V. Peterson, M.S., Medical Student, Julie Decesare, M.D., Associate Professor

PII: S1083-3188(16)30214-5
DOI: 10.1016/j.jpag.2016.12.003
Reference: PEDADO 2078

To appear in: Journal of Pediatric and Adolescent Gynecology

Received Date: 3 October 2016

Revised Date: 2 December 2016
Accepted Date: 28 December 2016

Please cite this article as: Roussos-Ross K, Foster L, Peterson HV, Decesare J, Do Educational
Seminars for the Human Papillomavirus Vaccine Improve Attitudes Toward the Value of Vaccination?,
Journal of Pediatric and Adolescent Gynecology (2017), doi: 10.1016/j.jpag.2016.12.003.

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Do Educational Seminars for the Human Papillomavirus Vaccine Improve Attitudes

Toward the Value of Vaccination?

Kay Roussos-Ross, M.D. Assistant Professor*

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L. Foster, M.D., Resident Physician*
H. V. Peterson, M.S., Medical Student*
Julie Decesare, M.D.; Associate Professor†

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*Department of Obstetrics and Gynecology, University of Florida College of Medicine,
Gainesville, Florida

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†
University of Florida, UF at Sacred Heart Health System, Pensacola, Florida

Financial support: None

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Corresponding author: Kay Roussos-Ross, M.D., Department of Obstetrics and Gynecology,
University of Florida, College of Medicine, Gainesville, FL, 32610-0254. Phone: (352) 273-
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7660; Fax (352) 294-5096; email: kroussos@ufl.edu.
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ABSTRACT

Study Objective: This study aimed to determine the effectiveness and impact of educational

seminars given at two sites in North-Central Florida on the knowledge of human papillomavirus

(HPV), perceived barriers to HPV vaccination, and willingness to vaccinate against HPV in

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eligible patients.

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Design, Setting, and Participants: This study was performed in conjunction with the

Committee for the Healthcare of Underserved Women, District XII, American College of

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Obstetrics and Gynecology (ACOG). One hundred participants, ages 18-65 years, were

included in the study.

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Interventions: Community outreach educational seminars, approximately 30 minutes in length,
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were given at two sites in Gainesville, Florida.

Main Outcomes Measures: Pre and post-seminar surveys were given to evaluate the impact of
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the seminars on knowledge of HPV, willingness to vaccinate against HPV, and barriers to
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vaccination.
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Results: There was a statistically significant improvement in the willingness to accept the HPV

vaccine and an improvement in knowledge of several HPV-related facts. There was a

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statistically significant decrease in several perceived barriers to HPV vaccination.

Conclusion: This study illustrates the utility of educational seminars in patients’ acceptance of
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healthcare options. Improving the educational opportunities of patients and families in relation
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to the HPV vaccine has the opportunity to make a significant outcome on vaccination rates.

Key Words: Human papillomavirus, HPV, vaccination, education, Florida

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INTRODUCTION

The human papillomavirus (HPV) is a small and non-enveloped, double-stranded DNA

virus.1 There are more than 150 strains of HPV that infect the stratified squamous epithelia of the

oral cavity, skin, and anogenital tract. HPV is the most prevalent sexually transmitted infection,

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and is contracted through skin-to-skin contact.

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HPV is known to be a highly causative agent of cervical cancer. HPV 16 and 18 are the

most carcinogenic strains, and are associated with approximately 70% of cervical cancer cases;

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and HPV 31, 33, 45, 52, and 58 are associated with another 20% of cervical cancers.2

Additionally, the low risk strains, HPV 6 and 11, are responsible for 90% of genital warts.3

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Approximately 80% of sexually active women will contract HPV in their lifetime, putting
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them at greater risk for cervical cancer.3 Annually, over 12,000 cases of invasive cervical cancer

occur in the United States and over 500,000 cases worldwide. Of these reported cases, there are
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more than 4,000 deaths a year in the U.S. and over 250,000 deaths worldwide.4 The number one
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risk factor for the development of cervical cancer is HPV. Other risks include smoking, number
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of sexual partners, early age of initiation of sexual activity, immunosuppression, and HIV

infection.2
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Several vaccines are available to help prevent HPV infection in young women and young

men, significantly decreasing the risk for development of HPV-associated cancers. The three
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approved HPV vaccines provide protection against different strains of the virus. Cervarix is a
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bivalent vaccine that protects against HPV 16 and 18, the strains most highly associated with

cervical cancer; Gardasil is a quadrivalent vaccine that protects against HPV 16, 18, 6, and 11,

protecting against the most carcinogenic strains and those that cause 90% of genital warts.5 The

newest recommended and approved vaccine by the Advisory Committee on Immunization

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Practices (ACIP) is Gardasil 9, which affords protection against HPV 6, 11, 16, 18, and the

additional strains 31, 33, 45, 52, and 58, the major causes of 90% of cervical cancer and genital

warts.5

Boys and girls ages 9-26 are eligible to receive any of the HPV vaccines.6 The vaccine is

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given in three doses: an initial dose at time zero, a second dose at two months, and a third dose at

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six months.6 Vaccination is most effective before initiation of sexual activity and, as such, early

vaccination is encouraged. Once initiated, the vaccine can be completed with any of the three

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vaccines, and, if a patient misses a subsequent dose, there is no need to re-initiate the vaccine

series.6 In October 2016, the CDC revised their recommendations to include that 11- to 12-year-

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old children receive two doses of the HPV vaccine at least six months apart, rather than the
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previously recommended three doses, to protect against cancers caused by HPV infections.

Teens and young adults who start the series later, at ages 13 through 26 years, will continue to
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need three doses of the HPV vaccine to protect against cancer-causing HPV infection.7
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In the U.S., as of 2014, there was only a 39.7% rate of vaccination series completion
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achieved in young females and only a 21.6% rate of vaccination series completion in young

males.8 In Florida, rates are even lower, at 28.5% of females and 17.5% of males.9 Even so,
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vaccination efforts have decreased the incidence of HPV in girls ages 14-19 in the US by 56%. 10
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MATERIALS AND METHODS

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Study Setting and Participants

Two community outreach educational seminars were conducted in North-Central Florida

within two venues: Women’s Advantage Meeting at the University of Florida (n=83) in August

2015 and Restoring Joy Church (n=17) in October 2015. Women’s Advantage is a free program

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offered by University of Florida (UF) Health in Gainesville, Florida that provides the community

with information on women’s health. Restoring Joy Church is a predominantly African

American church. Participants in this study were male and female, ages 18-65 years old, and

included both teenagers and young adults eligible for HPV vaccination and parents or guardians

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of children eligible for HPV vaccination.

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Design

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This study was performed in conjunction with the American College of Obstetrics and

Gynecology (ACOG) District XII Committee for the Healthcare of Underserved Women as an

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area of focus for the Committee. Upon presentation to the seminar venue, all attendees received
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an IRB-approved cover letter detailing the purpose of the study and offering participation in the

study. The participants were asked to complete a pre-seminar survey consisting of 17 questions.
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They then attended a 30-minute community outreach educational seminar entitled, “Preventive
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Care and Sexual Health Information for Tweens and Teens,” that was developed by the ACOG
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District XII Committee for the Healthcare of Underserved Women. The seminar included

general information on adolescent sexual health and behavior, background on sexually

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transmitted infections in Florida, information on the relationship of HPV to cervical cancer,

cervical cancer screening, HPV vaccine options and benefits to being vaccinated, vaccine safety,
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and current vaccination statistics. At the conclusion of the seminar, participants were asked to
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complete a post-seminar survey with the same 17 questions. Seven questions were related to

demographics and 10 questions assessed their knowledge of HPV, willingness to vaccinate, and

barriers to vaccination.

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Data Analysis

Data was entered into SBSS Statistics and GraphPad and analyzed using Fisher’s exact

test. A p-value of <0.05 was used to indicate statistical significance.

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Ethical Approval

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This study was approved by the University of Florida Institutional Review Board (IRB).

Each seminar participant was offered participation in study, but could elect to not participate and

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still attend the seminar. The surveys were conducted anonymously; there were no participant

identifiers.

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RESULTS

Demographic Information
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A total of 100 attendees were offered participation and enrolled in the study. A total of
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100 pre- and post-seminar surveys were collected and analyzed for this study (Table 1). The
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majority of participants were ages 56-65 (52%), followed by 36-55 years of age (16%), and 18-

35 years of age (6%); 26% of participants did not state their age. Sixty-four percent of
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participants were female. Participants varied in reported ethnicity: 38% Caucasian, 25% Black,

23% Hispanic, 12% Other, and 2% not stated. Seventy-three percent of participants had health
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insurance, and 64% of participants had attended college. Regarding religious affiliation, more
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than half of the participants identified themselves as Christian (57%), 11% as Other, and 24%

not reported.

Vaccine Knowledge

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Prior to the educational seminar, 70.3% of participants reported that their healthcare

provider had discussed the HPV vaccine with them. A statistically significant number of

participants reported a difference in knowledge before and after the seminar with regard to two

important facts about HPV: (1) HPV is the most common sexually transmitted infection (STI) in

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the United States (pre = 57.7%, post = 80%; p=0.0014); and (2) genital warts and cervical cancer

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are caused by HPV (74.2% pre, 87.2% post; p=0.0395).

The willingness of participants to receive the vaccine, or to allow their son/daughter to

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receive the vaccination, also increased significantly after the educational seminar; before the

seminar, 49.5% participants agreed they would be willing to receive the vaccination or allow

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their son/daughter to receive the vaccination, whereas 66.2% participants agreed after the
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seminar (p=0.0301) (Figure 1).
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Barriers to Vaccination
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There was a statistically significant increase in the number of participants who disagreed
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with perceived barriers to HPV vaccination after the educational seminar. Prior to the seminar,

only 57.7% of participants disagreed with the statement, “I am against vaccination at this time
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because of concern for the safety of the vaccine,” whereas 78.4% disagreed post-seminar

(p=0.0073). Pre-seminar, 62.5% of participants disagreed with the statement, “I am against

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vaccination at this time because of concerns of the side effects of the vaccine,” and 77.3%
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disagreed post-seminar (p=0.0431). With respect to cost of the vaccine, 60% of participants

disagreed with the statement, “I am against vaccination at this time because of concern for the

cost of the vaccine” pre-seminar, and 81.9% disagreed post-seminar (p=0.0033). Finally, 65.9%

of participants disagreed that they were “against the vaccination at this time because of concern

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that it may encourage risky sexual behavior” before the seminar, and 79.7% disagreed with this

perception post-seminar (p=0.0562) (Figure 2). In summary, our analyses noted a statistically

significant improvement in willingness to accept the HPV vaccine, improvement in knowledge

of several HPV-related facts, and a decrease in several perceived barriers to vaccination

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(p<0.05).

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DISCUSSION

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The educational seminar offered in this study proved to be effective in increasing the

knowledge of eligible patients and their caretakers, which, in turn, improved participants’

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willingness to accept the HPV vaccine and decreased concerns related to the vaccine. It is
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important to note that according to the National Immunization Survey of Teens, the reasons for

non-compliance with the HPV vaccine are different than with other vaccines.11 Noncompliance
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with the HPV vaccine is related not only to the safety concerns of parents, but also to their
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perception that their child is not sexually active and, thus, the vaccine is unwarranted. The top
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two reasons for non-compliance with other non-HPV-related teen vaccines are: not

recommended by provider and unnecessary. Furthermore, the overall intent to not vaccinate
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adolescents against HPV-related diseases has increased from 39.8% in 2008 to 43.9% in 2010,

albeit despite the fact that parents report that their physician are recommending the HPV
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vaccine.11 This demonstrates that provider-based education is an important element in

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vaccination acceptance, highlighting the importance of this study.10

The strengths of this study include a high response rate of participants, a heterogenous

study population, the availability of rapid data collection, and the toolkit availability from the

ACOG District XII Committee of Healthcare for Underserved Women. The toolkit used in this

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study is available on the ACOG District XII portal for utilization by the general public. This

enables healthcare providers to reproduce these seminars in their communities without having to

develop their own content. Limitations of the study include selection bias, as participants

voluntarily elected to attend the seminar and, thus, were likely interested in the topic.

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Additionally, since there were only two seminars conducted at the time of publication, the study

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sample was small. Although a large proportion of participants were in the older demographic of

56-65 years of age, they were in attendance as caretakers of eligible participants. Finally, as this

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was only an educational seminar, and the population surveyed was anonymous, there is no way

to determine what percentage of participants, or dependents of participants, received the

vaccination.
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Educational seminars distinctly show a clear benefit of increasing knowledge and

awareness regarding HPV and the HPV vaccine. Providing additional educational opportunities
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for eligible recipients and their guardians increases the willingness for vaccination. This study
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illustrates a cost-effective, patient-centered educational model that can make a valuable impact
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on the rates of HPV-related cancers in the future via vaccination.

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REFERENCES

1. Chelimo C, Wouldes TA, Cameron LD, et al. Risk factors for and prevention of human

papillomaviruses (HPV), genital warts and cervical cancer. J Infect 2013; 66:207.

2. Erickson BK, Alvarez RD, Huh WK. Human papillomavirus: what every provider should

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know. Am J Obstet Gynecol 2013; 208:169.

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3. Quadrivalent Human Papillomavirus Vaccine Recommendations of the Advisory Committee

on Immunization Practices (ACIP) [Internet]. [cited 2016 Aug 16]. Available from:

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http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5602a1.htm.

4. Committee on Practice Bulletins—Gynecology. ACOG Practice Bulletin Number 131:

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Screening for Cervical Cancer. Obstet Gynecol 2012;120:1222.
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5. Use of 9-Valent Human Papillomavirus (HPV) Vaccine: Updated HPV Vaccination

Recommendations of the Advisory Committee on Immunization Practices [Internet]. [cited

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2016 Aug 16]. Available from:

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http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6411a3.htm.
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6. Human Papillomavirus Vaccination: Recommendations of the Advisory Committee on

Immunization Practices (ACIP) [Internet]. [cited 2016 Aug 16]. Available from:
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http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6305a1.htm.
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7. CDC recommends only two HPV shots for younger adolescents [Internet]. [cited 2016 Oct
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19]. Available from: http://www.cdc.gov/media/releases/2016/p1020-hpv-shots.html.

8. Parents | Teen Vaccination Coverage | CDC [Internet]. [cited 2016 Aug 16]. Available from:

http://www.cdc.gov/vaccines/parents/vacc-coverage-teens.html.

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9. National, Regional, State, and Selected Local Area Vaccination Coverage Among

Adolescents Aged 13–17 Years — United States, 2014 [Internet]. [cited 2016 Aug 16].

Available from: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6429a3.htm. .

10. Markowitz L, Hariri S., Lin C., Dunne E, Steinau M, McQuillan G, Unger E. Reduction in

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Human Papillomavirus (HPV) Prevalence Among Young Women Following HPV Vaccine

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Introduction in the United States, National Health and Nutrition Examination Surveys, 2003–

2010. J Infect Dis June 2013.

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11. Darden PM, Thompson DM, Roberts JR, et al. Reasons for not vaccinating adolescents:

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National Immunization Survey of Teens, 2008-2010. Pediatrics 2013; 131:645-51. doi:
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10.1542/peds.2012-2384. Epub 2013 Mar.
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FIGURE LEGENDS

Figure 1 – “I am willing to receive the HPV vaccination or allow my son/daughter to receive the

vaccination.”

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Figure 2 - Percentage of respondents who disagree with perceived barriers to vaccination.

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Table 1. Participant Demographic Information

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66.2%
70.0%

60.0%

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49.5% 50.5%
50.0%

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33.8%

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40.0%

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30.0%

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20.0%

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10.0%

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Agree Disagree/Unsure
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Pre-test Post-test
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Agree Disagree/Unsure
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Pre-test 45 (49.5%) 46 (50.5%) 91

Post-test 51 (66.2%) 26 (33.8%) 77
P= 0.0301
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90.0%
82.0% 79.7%
80.0%
78.4% 77.3%

70.0% 65.9%
62.5%

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57.7% 60.0%
60.0%

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50.0%

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40.0%

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30.0%

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20.0%

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10.0%

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0.0%

Safety Side Effects Cost Sexual

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Behavior
Pre-Test Post-Test
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Pre-Test Post-Test
Safety 57.7% 78.4%
Side Effects 62.5% 77.3%
Cost 60.0% 82.0%
Sexual Behavior 65.9% 79.7%