590115

research-article2015

CPJXXX10.1177/0009922815590115Clinical PediatricsApte et al

Article

Could Poor Parental Recall of HPV Vaccination Contribute to Low Vaccination Rates?

Clinical Pediatrics 2015, Vol. 54(10) 987­–991 © The Author(s) 2015 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/0009922815590115 cpj.sagepub.com

Gauri Apte, MBBS, MPH1, Natalie Pierre-Joseph, MD, MPH2, Jessica L. Vercruysse, MA1, and Rebecca B. Perkins, MD, MSc1

Abstract Introduction. Rates of initiation and completion of the human papillomavirus (HPV) vaccine series remain below national goals. Because parents are responsible for ensuring vaccination of their children, we examined the accuracy of parental recall of the number of shots their daughters received. Methods. Parents/guardians of girls aged 11 to 17 years were asked to recall the number of HPV doses received by their daughters. Dose number was confirmed using provider-verified medical records. Logistic regression assessed variables associated with correct recall. Results. A total of 79 (63%) parents/guardians correctly identified the number of shots their daughters received. Ninetyone (73%) were aware of whether their daughter started the series at all. The only factor significantly associated with accurate recall in logistic regression models was female gender of parent/guardian. Conclusion. Nearly 40% of parents/guardians inaccurately recalled the number of HPV shots their children received, which may contribute to low rates of vaccine initiation and completion. Keywords HPV vaccination, vaccine recall

Introduction

Methods

Vaccination against human papillomavirus (HPV) is currently recommended by the Centers for Disease Control and Prevention for adolescent males and females at the age of 11to 12 years, with catch up vaccination up to 26 years of age in females and 21 years in males. It is a 3-dose series given over 6 months. The World Health Organization recently modified its recommendation for the HPV vaccine from 3 to 2 doses1; however, recommendations in the United States at the time of this study and currently are that adolescents receive 3 doses. US national data indicate that only 57% of girls and 34% of boys initiated HPV vaccination in 2013, and among those who started the series, 70% of girls and 48% of boys completed it.2 Inaccurate recall of vaccination status could cause parents to incorrectly believe that their children have started or completed the series when they have not, and this in turn could contribute to low vaccine uptake. This study examined the accuracy of parent/guardian recall of daughters’ receipt of HPV vaccination and factors associated with correct recall.

We interviewed parents/guardians of girls aged 11 to 17 years who accompanied their daughters for preventive care or problem-related visits in 3 suburban private practice settings and 1 urban public safety net hospital between September 2012 and July 2013. Parents/guardians who spoke English, Spanish, or Haitian-Creole were eligible to participate. Trained research assistants reviewed clinical schedules to determine eligible patients, and then recruited parents in waiting rooms either before or after scheduled visits. We sought a diverse sample of parents who self-identified as white, black (including African American, Haitian, Afro-Caribbean, and African participants), Latino, or other. Interviews were performed in English, Spanish, and Haitian-Creole. Non-English 1

Boston University School of Public Health, Boston, MA, USA Boston University School of Medicine, Boston, MA, USA

2

Corresponding Author: Rebecca B. Perkins, Boston University School of Medicine, 85 East Concord Street, 6th Floor, Boston, MA 02118, USA. Email: [email protected]

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interviews were conducted by native speakers, translated to English, and then back-translated to ensure accuracy. The interviews were semistructured. Participants received $20 gift cards as compensation for participation. This study was approved by the institutional review boards at all participating institutions. Interviews were designed to elicit demographic information and vaccination status. Vaccination status was determined by first asking parents/guardians to recall whether or not their daughters had received any shots of the HPV vaccine, and then to recall the number of shots their daughters had received. To determine the concordance between parental recall of vaccination status and actual vaccination, provider verified electronic medical records were reviewed to confirm vaccination status in daughters. Documentation of HPV vaccination in the child’s immunization record, a nursing note describing vaccine injection, or a pharmaceutical order for HPV vaccine were considered evidence of vaccination. Data were analyzed used SAS 9.3. Univariate analyses were conducted, and logistic regression models used to determine the factors associated with parental recall of the HPV vaccine. Reverse selection was used to obtain a model with significantly associated variables.

Results Fifty-three (42%) participating parents/guardians selfidentified as white, 40 (32%) as black, 21(17%) as Latino, and 11(9%) as other races. Sixty-seven participants attended the urban safety net hospital and 58 attended the suburban private clinics (Table 1). Parents/ guardians ranged in age from 26 to 67 years. Sixteen were male and 109 were female. Seventy-five percent of patients at the public hospital received public insurance and 25% received private insurance, compared with 16% public and 84% private insurance at the private clinics. First we assessed whether parents/guardians were aware of whether their daughters had started the HPV series at all. Ninety-one (73%) participants correctly recalled whether their daughters had received any doses of HPV vaccine or none. Of those who lacked awareness of whether their daughters had started the series, 15 (12.8%) parents were unsure and 19 (15.2%) parents were confident but incorrect about whether their daughters had received any shots. Accuracy dropped when parents were asked to recall the number of doses received by their daughters. Among those with no shots, 79% of parents/guardians had accurate recall (42 of 53). Among those with 1 injection, 58% of parents/guardians had accurate recall (11 of 19). Among those with 2 injections, 60% of parents/guardians had accurate recall (9 of 15). Among those who had completed

Table 1.  Demographic Characteristics of Parents/ Guardians.a Variable Total Site  Public  Private   Age of parent/guardian, years, mean (range) Race  White  Black  Hispanic  Other Gender of parent/guardian  Male  Female Interviewee is  Mother  Father  Guardian Marital status  Married  Single  Divorced/widowed/separated   Nonmarriage partners Country of origin   United States  Other Religious affiliation  No  Yes Education   Less than high school   High school graduate   Some college   College graduate/postgraduate Household income, $  100 000 Insurance  Public  Private Accurately recalled shots   No shots   1 shot   2 shots   3 shots

n (%) 125 67 (54) 58 (46) 44.05 (26-67)

53 (42) 40 (32) 21 (17) 11 (9) 16 (13) 109 (87) 101 (80) 16 (13) 8 (7) 66 (54) 24 (19) 29 (23) 6 (4) 83 (67) 41 (33) 52 (42) 73 (58) 9 (7) 41 (33) 23 (18) 52 (42) 30 (24) 25 (20) 27 (22) 13 (11) 28 (23) 60 (49) 63 (51) 42 (33) 11 (9) 9 (7) 18 (14)

a Parents were asked of their religious affiliation during the interview. Race and sex of the parent were self-reported.

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Apte et al Table 2.  Factors Affecting Concordance. Concordance, n (%)   Site (n)   Public (67)   Private (58) Age range of parent, years   25-35 (21)   35-45 (51)   45-55 (42)   >55 (8) Race   White (53)   Black (40)   Hispanic (21)   Other (11) Gender parent/guardian (n)   Female (109)   Male (16) Interviewee is   Mother (101)   Father (16)   Guardian (8) Marital status   Married (66)   Single (24)  Divorced/widowed/separated(29)   Nonmarriage partnership (6) Country of origin (n)   United States (83)   Other (41) Religion (n)   Religious (73)   Not religious (52) Education (n)   Less than high school (9)   High school graduate (41)   Some college (23)   College graduate/ postgraduate (52) Household income, $ (n)   100 000 (28) Insurance (n)   Public (60)   Private (63)

P Value

Yes

No

34 (54) 45 (78)

33 (49) 13 (22)

9 (43) 32 (63) 32 (76) 4 (50)

12 (57) 19 (37) 10 (24) 4 (50)

39 (74) 21 (53) 14 (67) 5 (45)

14 (26) 19 (47) 7 (33) 6 (55)

75 (69) 4 (25)

34 (31) 11 (69)

.0007

69 (68) 4 (25) 6 (75)

32 (32) 11 (69) 2 (25)

.03

43 (64) 13 (54) 20 (69) 3 (50)

23 (35) 11 (46) 9 (31) 3 (50)

57 (69) 22 (54)

26 (31) 19 (46)

.10

48 (66) 31 (60)

25 (34) 21 (40)

.48

6 (67) 22 (54) 15 (65) 36 (69)

3 (33) 19 (46) 8 (35) 16 (31)

15 (50) 14 (56) 18 (67) 8 (62) 22 (79)

15 (50) 11 (44) 9 (33) 5 (38) 6 (21)

32 (53) 45 (71)

28 (47) 18 (29)

.002

.06

.11

.30

.47

.22

.038

P Value (Multivariate) .06     .48       .18     .001   —a       —a         .61   —a     —a         —a           —a    

a

Variable deleted via reverse selection for multivariate model.

all 3 shots, 49% of parents/guardians had accurate recall (18 of 37). Fourteen percent of parents overestimated the number of shots received by their daughters while 7% underestimated. Factors associated with correct recall in univariate analyses were female versus male gender (69% vs 25%,

P = .0007), mother (68%) versus father (25%) or guardian (75%) (P = .03), attendance at private practices versus the safety net hospital (78% vs 54%, P = .002), and private versus public insurance (71% vs 53%, P = .038) (Table 2). Race, age of parent, marital status, religion, income, and education were not significantly associated

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Clinical Pediatrics 54(10)

with accurate recall. The final logistic regression model included site, age of parent, race, gender, and country of origin. Because of colinearity of gender with interviewee (mother/father/guardian), and insurance type (public or private) with site (public or private), only the variables with the strongest association in univariate analyses were included. In the logistic regression model, gender was significantly associated with correct recall (P = .001), and private versus public clinic site showed a trend toward significance (P = .06).

Discussion Since licensure of the HPV vaccine in 2006, HPV vaccine coverage among US adolescents has increased but remains low compared with other recommended vaccines.3 While much attention has focused on the role of provider recommendation and parental attitudes toward vaccination,4-7 inaccurate parental recall may also play a role. We found that less than two-thirds of parents/ guardians correctly recalled the number of HPV vaccine injections their daughters received. Parents/guardians seen at the safety net hospital and those with public insurance were at greatest risk for inaccurate recall. Prior research has demonstrated lower HPV vaccine completion rates among low-income patients, those seen in public hospitals and with public insurance.8-10 Our study suggests that inaccurate recall may be one reason underlying persistently low completion rates in these groups of patients. Other studies have also demonstrated inaccurate vaccination recall among diverse groups of parents, with levels of inaccuracy ranging from 10% to 46%.11-13 Many widely cited national surveys estimate vaccination and utilization of screening procedures through instruments based on patient self-report14,15 and these surveys are often used to develop interventions targeted toward improving vaccine uptake and implementation of screening procedures.16,17 Misclassification of vaccination dosage can compromise the effectiveness of such interventions and hence it is important to assess the accuracy of estimates. Self-reported data can have limitations, including recall bias and social desirability bias.18 These inaccuracies are further magnified in lowincome urban populations,19 which limit the utility of such data for policy decisions, and as measure of the health status of a population. Although our study was limited by a small sample size and localized geographic region, similar results have been demonstrated in other areas of the United States, and for other preventive health measures, including cervical and breast cancer screening.11,19-21 Current data indicate that inaccurate recall of HPV vaccination

status may contribute to nonvaccination and noncompletion of vaccine series in nearly half of girls. These risks are magnified in vulnerable populations and may contribute to disparities in HPV vaccine completion rates. Increased use of vaccination recall systems, including utilization and expansion of existing immunization registries may improve vaccination rates by overcoming the limitations of parental recall. Acknowledgments The authors would like to thank Drs Betances, Cohen, and Lee, Ms Gaudette, Ms LaRosee, and Mr Silva for their help facilitating recruitment in their practices, and wish to thank Ms Belizaire, Ms Finlay, Ms Jansen, and Mr De La Cruz for their help recruiting patients and performing interviews.

Author Contributions GA performed data collection and data analysis, and led the writing of the manuscript. NPJ co-led the study design with RBP, and contributed to manuscript revision. JLV also performed data collection and contributed to manuscript revision. RBP led the study question design, and was the primary editor of the manuscript. RBP confirms full access to all aspects of the research and writing process, and takes final responsibility for the paper. All authors approved the final submitted version of the article. No authors have conflicts of interest to declare.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work is supported by American Cancer Society Mentored Research Scholar Grant (MRSG-09-151-01), and Centers for Disease Control and Prevention Cooperative Agreement (1UO1IP000636).

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Apte et al 4. Dorell C, Yankey D, Kennedy A, Stokley S. Factors that influence parental vaccination decisions for adolescents, 13 to 17 years old: National Immunization Survey–Teen, 2010. Clin Pediatr (Phila). 2013;52:162-170. 5. Dorell CG, Yankey D, Santibanez TA, Markowitz LE. Human papillomavirus vaccination series initiation and completion, 2008-2009. Pediatrics. 2011;128:830-839. 6. Lau M, Lin H, Flores G. Factors associated with human papillomavirus vaccine-series initiation and healthcare provider recommendation in US adolescent females: 2007 National Survey of Children’s Health. Vaccine. 2012;30:3112-3118. 7. Vadaparampil ST, Kahn JA, Salmon D, et al. Missed clinical opportunities: provider recommendations for HPV vaccination for 11-12 year old girls are limited. Vaccine. 2011;29:8634-8641. 8. Chou B, Krill LS, Horton BB, Barat CE, Trimble CL. Disparities in human papillomavirus vaccine completion among vaccine initiators. Obstet Gynecol. 2011;118:14-20. 9. Pourat N, Jones JM. Role of insurance, income, and affordability in human papillomavirus vaccination. Am J Manag Care. 2012;18:320-330. 10. Polonijo AN, Carpiano RM. Social inequalities in adolescent human papillomavirus (HPV) vaccination: a test of fundamental cause theory. Soc Sci Med. 2013;82: 115-125. 11. Ojha RP, Tota JE, Offutt-Powell TN, Klosky JL, Ashokkumar R, Gurney JG. The accuracy of human papillomavirus vaccination status based on adult proxy recall or household immunization records for adolescent females in the United States: results from the National Immunization Survey–Teen. Ann Epidemiol. 2013;23:281-285. 12. MacDonald R, Baken L, Nelson A, Nichol KL. Validation of self-report of influenza and pneumococcal vaccination status in elderly outpatients. Am J Prev Med. 1999;16: 173-177.

13. Mangtani P, Shah A, Roberts JA. Validation of influenza and pneumococcal vaccine status in adults based on selfreport. Epidemiol Infect. 2007;135:139-143. 14. NCI. HINTS Cycle 2 Methodology Report; 2013. http:// hints.cancer.gov/docs/HINTS_4_Cycle2_Methods_ Report.pdf. Accessed November 13, 2014. 15. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System: Survey Data & Documentation; 2013. http://www.cdc.gov/brfss/data_ documentation/index.htm. Accessed April 2, 2014. 16. Nsubuga P, White ME, Thacker SB, et al. Public health surveillance: a tool for targeting and monitoring interventions. In: Jamison DT, Breman JG, Measham AR, et al., eds. Disease Control Priorities in Developing Countries. 2nd ed. Washington, DC: World Bank; 2006:997-1015. 17. Thacker SB, Stroup DF. Future directions for comprehensive public health surveillance and health information systems in the United States. Am J Epidemiol. 1994;140:383-397. 18. Warnecke RB, Sudman S, Johnson TP, O’Rourke D, Davis AM, Jobe JB. Cognitive aspects of recalling and reporting health-related events: Papanicolaou smears, clinical breast examinations, and mammograms. Am J Epidemiol. 1997;146:982-992. 19. McGovern PG, Lurie N, Margolis KL, Slater JS. Accuracy of self-report of mammography and Pap smear in a lowincome urban population. Am J Prev Med. 1998;14:201208. 20. Howard M, Agarwal G, Lytwyn A. Accuracy of selfreports of Pap and mammography screening compared to medical record: a meta-analysis. Cancer Causes Control. 2009;20:1-13. 21. Stupiansky NW, Zimet GD, Cummings T, Fortenberry JD, Shew M. Accuracy of self-reported human papillomavirus vaccine receipt among adolescent girls and their mothers. J Adolesc Health. 2012;50:103-105.

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Could Poor Parental Recall of HPV Vaccination Contribute to Low Vaccination Rates?

Rates of initiation and completion of the human papillomavirus (HPV) vaccine series remain below national goals. Because parents are responsible for e...
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