Saving Lives from Preventable Cancer: Solutions for Racial and Ethnic Disparities in HPV Vaccination

This post is the second of a three-part blog series exploring the disparities related to human papilloma virus (HPV) vaccination rates in the US. In this post, we explore the racial and ethnic disparities in HPV vaccination, with the goal of understanding the causes of these disparities to better inform recommendations for policy makers, patients, and providers. In the first post of this series, we examined the geographic disparities impacting HPV vaccination rates. In the final post, we will explore vaccination rate variation between Rhode Island and Mississippi, the best performing and worst performing state, respectively.

Given HPV is highly contagious and can lead to various types of cancers, why isn’t vaccination uptake higher? Are barriers related to vaccine access at play? Or perhaps the problems are safety concerns, mistrust in the medical community, or lack of perceived necessity. The best way to improve vaccination rates is to understand the root causes of low rates, and consider culture, language, and health literacy in engaging with patients.

HPV vaccination is a powerful and effective cancer-prevention strategy, but disparities in HPV vaccination persist.

Approximately 40 types of HPV have been identified as infecting the anogenital skin epithelium or mucous membranes. Of these, 12 are considered high-risk types that can cause cancer. Two types are responsible for the majority of HPV-related cancers, including cervical, anal, penile, and oropharyngeal cancers. All three HPV vaccines that are FDA approved (Gardasil, Gardasil 9, and Cervarix) protect against these high-risk HPV types (note: Gardasil 9 is the only HPV vaccine currently in use in the US). Since HPV vaccination was first recommended in 2006, infections with HPV types that cause most HPV cancers and genital warts have declined 88% among teen girls and 81% among young adult women.

Racial and ethnic disparities across the continuum of care associated with HPV, from screening and diagnosis to vaccine uptake and HPV-related cancer burden, have been well documented. Race-based differences in HPV vaccination initiation and completion were observed soon after the vaccine’s introduction. For example, among Florida Medicaid enrollees in 2008, Black adolescents (11-18 years of age) had both low HPV vaccination initiation and completion rates.

Recently, however, vaccine initiation across historically marginalized populations (namely, Black and Hispanic individuals) has increased, surpassing initiation rates among White individuals, though findings from the literature are not always in agreement. The observed difference could be due to whether rates were self-reported or provider-verified. In another interesting twist in the literature, research findings demonstrate lower HPV vaccination initiation rates among Hispanic, Black, and Asian adults, but higher rates among Black and Hispanic adolescents compared to their White counterparts.

Despite the lack of clarity in HPV vaccine initiation disparities, there is a stronger consensus about racial and ethnic disparities in HPV vaccine series completion. Literature through 2017 shows that Black and Hispanic individuals are generally less likely than White individuals to complete the full HPV vaccination series after initiation. However, more current literature from 2019 suggests that completion rates among White individuals is lower than all other subgroups (Black, Hispanic, Native American/Alaska Native, and Asian). It should be noted that HPV vaccination rates among Asian American individuals vary according to source. A systematic review published in 2020 posits that Asian American individuals have low initiation and completion rates overall, as well as when compared with White individuals. Given that Asian Americans comprise a small study population, results may be skewed, and should be interpreted with caution. When the literature is taken as a whole, there is lack of consensus about HPV vaccination rates among racial and ethnic subgroups, signaling an opportunity for further exploration and understanding of disparities.  

What drives the variable racial and ethnic disparities in HPV vaccination completion?

Factors associated with HPV vaccination initiation and completion include frequency of contact with providers/health system, insurance coverage, and provider recommendation (with provider recommendation generally established as the strongest driver of vaccination uptake). While the literature mainly focuses on individual-level factors that are associated with HPV vaccination uptake, such as race and education level, some researchers have identified key factors across multiple levels that influence HPV vaccination decisions.

In a systematic review, Rodriguez et al identified the following modifiable factors associated with HPV vaccination completion among adolescents in the US: health care provider recommendation, parental knowledge of the HPV vaccine, adolescent interaction with the health care system, maternal experiences with Pap tests, assessment of providers’ delivery of one or more vaccinations and feedback on their performance, reminder/recall systems, health clinic accessibility, and delivery model (eg, health facility, school based, mixed model). These factors span across the vaccine recipient, health care provider, and clinic levels, and can be used to inform effective interventions to improve HPV vaccination series completion.

A 2016 study that focused on Black and Latino teenagers identified vaccine mistrust, lack of vaccine information, and traveling back to the clinic as key barriers to HPV series completion. Results from a 2021 study of racial/ethnic minority communities also demonstrated evidence of mistrust leading to parental HPV vaccine hesitancy. A 2018 study revealed that the most common parental barriers to HPV vaccination perceived by providers were concerns about HPV vaccine safety. Providers may not sufficiently explain the HPV vaccination process, safety, and importance, causing some caregivers and adolescents to be unsure about the need for additional doses for series completion and potentially contributing to patient mistrust of the vaccine. Returning for additional vaccination doses may be hindered by access barriers, since timing for additional vaccination is not aligned with other standard provider visits. Concerns about safety or side effects can be mitigated by providing communities with information related to research, real-world evidence, and surveillance associated with the HPV vaccine’s safety and efficacy.

Insurance type must be considered when analyzing HPV vaccination rates among various racial/ethnic subsets of the population. Individuals with Medicaid have higher rates of HPV vaccine completion when compared with those who are privately insured, uninsured, or insured through other means. Given that White and Asian populations are among the lowest share of children with Medicaid, this might help explain the lower rates reported among these groups. Certain Medicaid plans speculate that their vaccination rates could be higher compared to commercial plans because some Medicaid populations, such as immigrant populations or those with lower socioeconomic status, may have first-hand experience with vaccine-preventable diseases. As a result, they may be more accepting of vaccines and less likely to refuse them.

Overall, there is a need for more research on community, environmental, and insurance factors that influence HPV initiation and completion specifically among racial and ethnic minority groups to inform effective interventions.

Successful efforts to address disparities can serve as best practices for future efforts.

Interventions that have successfully increased HPV vaccination initiation and completion include education-focused efforts, vaccination appointment invitations and reminders, and patient navigation support and referrals. These initiatives should be tailored to the individual, wherein health literacy is assessed, and language and cultural preferences are taken into account. For instance, New York has successfully increased HPV vaccination coverage across the state and among Black and Hispanic/Latino groups, supported by provider-parent communication strategies, the expansion of self-consent policies among teenagers, and school health centers as vaccination sites.

Culturally tailored multilevel strategies (eg, multimedia educational videos reflecting social and cultural contexts and interactive discussions with health educators) have demonstrated efficacy in improving vaccination rates, particularly among Asian American individuals whose parents are categorized as low-income and have limited English proficiency. However, the Asian American population represents an incredibly heterogenous group of individuals, with unique and diverse immigration histories, socioeconomic statuses, religious/cultural beliefs, social norms, and patterns of health services utilization.

When health care providers take action to remind patients of their upcoming HPV vaccination through methods such as phone calls, mail, or text messages, these reminders have had a beneficial effect on increasing the rate of HPV vaccination completion among Asian, Hispanic, and Black individuals. For example, in one intervention, reminder letters were shown to improve HPV vaccine series completion by 10% overall, with the strongest completion rate seen among Black and Hispanic young women. Another intervention that utilized SMS text messaging for vaccination reminders increased completion rates among Spanish-speaking individuals, indicating the importance of technology-based interventions.

As provider recommendation remains one of the strongest facilitators for vaccination coverage, efforts to address disparities should focus on increasing provider knowledge of the importance of the HPV vaccine and supporting their ability to communicate effectively with parents and youth. Provider recommendations can play a key role in addressing disparities; the increase in HPV vaccination initiation among Black and Hispanic groups has been linked in part to the increase in provider vaccination recommendations among these groups. While provider education is important, it is also essential that providers maintain cultural competency and humility, and evaluate health literacy when communicating with patients.  

Measurement can help drive change. As interventions to improve HPV vaccination are implemented, it's important to measure their effects. Interventions to improve racial and ethnic disparities in HPV vaccination must focus not only on series initiation following provider recommendations, but also on series completion. The National Committee for Quality Assurance Immunizations for Adolescents measure evaluates series completion among individuals 13 years of age who completed the HPV vaccine series. Beginning in measurement year 2023, this measure will include stratification by race and ethnicity, which is a key step in addressing disparities in HPV vaccination. Further, this measure will be required for all states to report as part of the Medicaid Child Core Set, beginning in 2024.   

Conclusion

The overall HPV vaccination rate among adolescents is 75%; however, there are significant disparities across races and ethnicities. Improvement efforts should focus on encouraging health care provider recommendations, addressing access barriers, providing culturally tailored interventions, and utilizing reminder systems to increase vaccination initiation and completion rates. Continued research, targeted interventions, and measurement are crucial for reducing disparities and ensuring effective HPV-related cancer prevention through HPV vaccination.

Disparities in HPV vaccination exist beyond the race- and ethnicity-based differences presented here, as demonstrated in the first blog post of this series. The next and final post of this three-part series will be a case study comparing HPV vaccination efforts between the best and worst performing states, with associated recommendations for policy makers, patients, and providers.

About the Quality Outlook Commentary Series

Breakthrough treatments in cancer care, including precision therapies tailored to specific patient factors, are driving rapid changes in the definitions of oncology quality and value. Efforts to implement value-based care models in oncology must meet the demands of evolving science, new best care practices, and shifting patient priorities. Quality measures must be up-to-date and relevant. Payment models must recognize the challenges and costs of managing complex patient populations with diverse needs. In this JCP blog series, Quality Outlook, Real Chemistry will explore key issues in oncology quality and value through posts focused on measurement, value-based payment, and quality improvement.

Anne DiSalvo

Anne DiSalvo, MPH, MBA, is a Director at Real Chemistry. She has a background in Medicaid policy and quality improvement, and currently applies her passion for public health and business within Real Chemistry’s Market Access Strategy division. Anne helps clients convey the value of their therapeutics by   leading the development of payer value propositions and crafting access strategies. She also oversees and conducts work related to state-level analysis of trends in access, policy, and health inequities. 

Kendall Logan

Kendall Logan, MPH, a Manager at Real Chemistry, brings a public health and health equity perspective to her work. In her role, she manages and supports client projects in the quality and value-based care space across a variety of therapeutic areas. Her recent work involved analyses of the oncology quality landscape and quality measurement, utilizing her experience in qualitative research and stakeholder engagement. With a commitment to client success, Kendall strives to provide comprehensive support and guidance to meet clients’ unique needs within the value-based marketplace.

Erik Muther

Erik Muther, a Senior Vice President at Real Chemistry, is a thought leader and subject matter expert in value-based care and healthcare performance measurement. Erik leads strategy and implementation projects related to primary care transformation, real-world evidence generation, provider engagement, quality measurement and multi-stakeholder collaboration with clients in the health and life sciences industry. 

Tom Valuck

Tom Valuck, MD, JD, is a Partner at Real Chemistry. He is a thought leader on health care system transformation and helps lead the firm’s focus on achieving better health and health care outcomes at a lower cost. Tom’s work at Real Chemistry includes facilitating the exploration of next-generation measurement and accountability models for health care delivery systems. He also helps clients develop strategies to achieve success within the value-based marketplace.