Assessing the need for and acceptability of a free-of-charge postpartum HPV vaccination program




Objective


Human papillomavirus (HPV) vaccine uptake rate among young adult US women was only 23% in 2010. One way to improve this low rate is to administer the vaccine postpartum. We examined whether this population requires vaccination and whether they would be agreeable to receiving it free of charge after delivery.


Study Design


Women 26 years of age or younger seeking prenatal care in publicly funded clinics in southeast Texas were interviewed in 2012 regarding their HPV vaccination status, barriers to vaccination, and whether they would be willing to receive this vaccine postpartum if offered free of charge. Medical charts were reviewed to extract additional information.


Results


Overall, 13.0% (65 of 500) stated they had initiated and 7.6% (38 of 500) completed the 3-dose vaccine series. Ethnic differences were noted with 21.0% of non-Hispanic whites, 14.6% of blacks, and 9.3% of Hispanics ( P = .002) initiating the vaccine and 13.5%, 7.8%, and 5.2% ( P = .006) competing all 3 doses, respectively. Lowest initiation (4.2%) and completion (1.4%) rates were observed among recently immigrated Hispanic women. Those who had not graduated from high school and older women were less likely to have been vaccinated. Almost 83% of those who had not received any HPV doses or completed the series were willing to receive the injection free of charge in the hospital after their delivery.


Conclusion


HPV vaccine uptake rates are very low among women receiving prenatal care in southeast Texas. Offering this vaccine free of charge to postpartum women could be an effective strategy in this population because 5 of 6 women favored receiving it in this setting.


In 2006, a virus-like particle vaccine was approved for use in the United States, which protects against 4 human papillomavirus (HPV) strains (6, 11, 16, and 18) responsible for 70% of cervical cancer cases and 90% of genital warts. To prevent these diseases, the Advisory Committee on Immunization Practices (ACIP) recommends routine HPV vaccination of adolescents 11-12 years of age with catch-up vaccination of individuals 13-26 years of age not previously vaccinated. Recent national data, however, demonstrate that vaccination rates have been far less than needed with only 14% of US women 11-17 years of age and 13% of those 18-26 years of age completing the 3-dose vaccination regimen (0, 1-2 months, and 6 months). To protect the entire community (herd immunity), however, it is necessary to vaccinate 75-94% of the eligible population.


A committee opinion recently published by the American College of Obstetricians and Gynecologists recommended that obstetrician-gynecologists help improve this low uptake rate by “embracing immunizations as an integral part of their practice.” Although the HPV vaccine is contraindicated during pregnancy, the first dose could be given postpartum before the patient is discharged from the hospital. The subsequent doses would then be given as an outpatient.


Before this type of program can be recommended on a wide-scale basis, however, it is essential to determine the need of this population for HPV vaccination and whether they would be receptive to receiving it postpartum. To date, this has been assessed in only 1 study of 150 women who delivered in the Northeast. Thus, additional data are needed on women residing in other areas of the United States.


The objectives of this study were to estimate rates of prior HPV vaccination among patients receiving prenatal care and their willingness to receive the injection free of charge on the postpartum unit among women residing in south Texas.


Materials and Methods


Between January and April 2012, a total of 500 women 26 years of age or younger attending 1 of 5 publicly funded prenatal clinics located in southeast Texas were asked whether they were willing to participate in a brief interview, conducted in Spanish or English, on HPV vaccination. These facilities provide care to low-income women, of which nearly 80% have a family income less than $30,000/year. All eligible women who were approached agreed to participate in this interviewer-administered questionnaire survey.


Research coordinators asked patients about their prior HPV vaccinations, with the following question: “Have you taken the first HPV shot?” Responses included the following: yes, no, and “I have not taken any HPV shots.” Two additional questions were asked for second and third doses with similar wording and responses. Barriers to vaccination were explored using the question: “If you have not had an HPV shot yet, why not?” Responses included the following: “I have never heard of it”; “I don’t know enough about it”; “I don’t know where to get it”; “I can’t afford to get it”; “I am worried about side effects”; “I don’t think I need it”; “I do not get any vaccines”; and other.


Willingness to receive the HPV vaccine in the hospital after the delivery was assessed by asking, “Would you be willing to get an HPV shot in the hospital after your baby was born, if it were free of charge?” Responses included yes and no. A chart review of their medical record was then performed to obtain additional information on demographic characteristics, sexual history, and other clinical variables of interest.


Bivariate comparisons were performed using χ 2 tests or Fisher exact test as appropriate. Multivariable logistic regression was used to examine the correlates of HPV vaccine initiation and completion of the series. Variables were screened, and candidate variables with P ≤ .20 with any of the dependent variables (vaccine initiation and completion) were included in the initial multivariable models, whereas variables with P ≥ .20 were excluded from the final models. The Hosmer-Lemeshow test and area under the receiver-operating characteristics (ROC) curve were used to assess the fit and predictive ability of the final models. Analyses were performed using STATA 12 (StataCorp, College Station, TX). All procedures were approved by the institutional review board of the University of Texas Medical Branch.




Results


A total of 500 women completed the survey questionnaire. Of them, 53.8% (n = 269) were Hispanic, 23.8% (n = 119) white, 20.6% (n = 103) African American, and 1.8% (n = 9) from other racial/ethnic groups ( Table 1 ). Seventy-two women (14.4%) moved to the United States within the last 5 years. The mean age of the sample was 21.8 years (SD, 2.8, range, 14–26 years). Most of the women were high school graduates (58.9%; n = 294), worked in the home (61.0%; n = 305), and were multigravidas (61.4%; n = 307). The majority had sexual intercourse for the first time at 16 years of age or older (62.2; n = 311) and had obtained a Papanicolaou test in the past (73.2%; n = 366). Nearly half had 3 or more lifetime sexual partners, whereas 42 (8.4%) had a history of an abnormal Papanicolaou test.



Table 1

Summary statistics based on questionnaire survey (n = 500)































































































Survey question Response n (%) or mean (±SD)
What is your race? Non-Hispanic white 119 (23.8)
Non-Hispanic black 103 (20.6)
Hispanic or Latino 269 (53.8)
Others a 9 (1.8)
What is your current age? Age in years 21.8 (2.8)
Have you taken the first HPV shot? Yes 65 (13.0)
No 435 (87.0)
Did you take the second shot? Yes 43 (8.6)
No 22 (4.4)
I have not taken any HPV shot 435 (87.0)
Did you take the third shot? Yes 38 (7.6)
No 5 (1.0)
I have not taken any HPV shot 435 (87.0)
If you have not had an HPV shot yet, why not? b I have never heard of it 225 (51.7)
I don’t know enough about it 272 (62.5)
I don’t know where to go and get it 71 (16.3)
I can’t afford to get it 99 (22.8)
I am worried about side effects 47 (10.8)
I don’t think I need it 38 (8.7)
I do not get any vaccines 8 (1.8)
Are you pregnant? Yes 500 (100.0)
No 0 (0.0)
Where do you plan to deliver your baby? UTMB 392 (78.4)
Other clinics 108 (21.6)
Would you be willing to get an HPV shot in the hospital after your baby was born, if it were free of charge? c Yes 382 (82.7)
No 80 (17.3)

HPV , human papillomavirus; UTMB , University of Texas Medical Branch at Galveston, TX.

Berenson. Acceptability of a postpartum HPV vaccination program. Am J Obstet Gynecol 2014.

a Asian, American Indian/Alaskan native, Native Hawaiian, or other Pacific Islander


b Denominators are based on women who did not receive any dose of the HPV vaccine (n = 435)


c Denominator is based on women who had not received any HPV vaccine doses or completed the series (n = 462).



Overall awareness about the HPV vaccine was low because only 55.0% of women had ever heard about the vaccine. Awareness was lowest among Hispanics who had moved to the United States within the last 5 years (37.5%), followed by those Hispanics who were born in the United States or had moved to the United States more than 5 years ago (46.7%). Awareness was higher among white (72.3%) and black women (63.1%) than Hispanic women ( P < .001).


Overall, 13.0% of women interviewed (65 of 500) stated they had received at least 1 dose of the vaccine and 7.6% (38 of 500) had completed all 3 doses. Slightly more than half of those who had initiated the series received all 3 doses (38 of 65).


Ethnic differences were noted, with 21% of non-Hispanic whites, 14.6% of blacks, and 9.3% of Hispanics ( P = .002) having received the first dose, whereas 13.5%, 7.8%, and 5.2% ( P = .006) completed all 3 doses, respectively. Among Hispanics, those who had moved to the United States within the past 5 years (n = 72) had the lowest initiation (4.2%) and completion (1.4%) rates.


Vaccine series completion among the initiators did not differ by race/ethnicity. Bivariate analyses showed that being white, having at least a high school diploma, and having a gravidity less than 2 were associated with higher HPV vaccine initiation and completion of the series. Moreover, having 3 or more lifetime sexual partners was associated with higher HPV vaccine initiation ( Table 2 ).



Table 2

HPV initiation and completion rates by different characteristics among 14-26 year old women


























































































































































































































Variable Total a Received ≥1 doses Completed 3-dose vaccine series
n = 500 % (95% CI) P value % (95% CI) P value
Race/ethnicity .009 .033
White 119 21.0 (13.6–28.4) 13.5 (7.2–20.0)
Black 103 14.6 (7.6–21.5) 7.8 (2.5–13.0)
Hispanic (born in the US/moved >5 years ago) 197 11.2 (6.7–15.6) 6.6 (3.1–10.1)
Hispanic (moved to the US ≤5 years ago) 72 4.2 (0.5–8.9) 1.4 (less than 1.0 to 4.2)
Others b 9 0 0
Education, n (%) < .001 < .001
Did not graduate high school 205 6.3 (3.0–9.7) 3.9 (1.2–6.6)
High school graduate 294 17.4 (13.0–21.7) 10.2 (6.7–13.7)
Employment status, n (%) .075 .210
Homemaker 305 10.8 (7.3–14.3) 6.6 (3.8–9.6)
Part/full-time student 61 21.3 (10.7–31.9) 13.1 (4.4–21.8)
Part/full-time worker 134 14.2 (8.2–20.2) 7.5 (3.0–12.0)
Gravidity < .001 .001
<2 193 21.2 (15.4–27.1) 12.4 (7.7–17.1)
≥2 307 7.8 (4.8–10.8) 4.6 (2.2–6.9)
Age at first sexual intercourse, n (%) .061 .399
Younger than 16 years 169 16.6 (10.9–22.2) 8.9 (4.5–13.2)
16 years or older 311 10.6 (7.2–14.0) 6.8 (3.9–9.6)
Number of lifetime sexual partners .007 .146
<3 234 8.1 (4.6–11.6) 6.4 (3.2–9.6)
3-5 136 18.4 (11.8–25.0) 6.6 (2.4–10.8)
≥6 106 17.0 (9.7–24.2) 12.3 (5.9–18.6)
Had at least 1 Papanicolaou test .169 .146
No 134 16.4 (10.1–22.8) 10.4 (5.2–15.7)
Yes 366 11.8 (8.4–15.1) 6.6 (4.0–9.1)
Had abnormal Papanicolaou test result .471 .091
No c 455 12.7 (9.7–15.8) 7.0 (4.7–9.4)
Yes 42 16.7 (4.9–28.4) 14.3 (3.2–25.3)

CI , confidence interval; HPV , human papillomavirus; US , United States.

Berenson. Acceptability of a postpartum HPV vaccination program. Am J Obstet Gynecol 2014.

a Numbers do not add up because of missing values


b Asian, American Indian, or Alaskan


c Includes participants without a history of Papanicolaou testing.



Adjusted multivariable logistic regression models showed that younger women, high school graduates, and women with gravidity less than 2 were more likely to initiate and complete all 3 doses ( Table 3 ). Compared with white women, Hispanics who were born in the United States or moved to the United States more than 5 years ago ( P = .030) and Hispanics who moved to the United States during the last 5 years ( P = .026) were less likely to initiate the HPV vaccine.



Table 3

ORs of 14-26 year old women’s HPV initiation and completion by their characteristics




































































































Variable Received 1 dose OR (95% CI) P value Completed 3-dose series OR (95% CI) P value
Age, y 0.84 (0.75–0.95) .005 0.80 (0.68–0.93) .005
Race/ethnicity
White Referent Referent
Black 0.49 (0.23–1.05) .067 0.41 (0.16–1.06) .066
Hispanic (born in the US or moved >5 years ago) 0.48 (0.25–0.93) .030 0.46 (0.21–1.04) .063
Hispanic (moved to the US ≤5 years ago) 0.23 (0.07–0.84) .026 0.14 (0.02–1.09) .060
Education
Did not graduate high school Referent Referent
High school graduate 3.37 (1.68–6.77) .001 3.03 (1.26–7.30) .013
Gravidity
<2 Referent Referent
≥2 0.42 (0.23–0.78) .006 0.44 (0.19–0.99) .047
Had abnormal Papanicolaou test result
No a Referent
Yes 4.08 (1.40–11.95) .010

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May 11, 2017 | Posted by in GYNECOLOGY | Comments Off on Assessing the need for and acceptability of a free-of-charge postpartum HPV vaccination program
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