Provider and Practice Factors Associated With On-Time HPV Vaccination in Primary Care

Published:December 30, 2022DOI:



      In 2018, only one third of girls and boys completed the 2-dose series of the human papillomavirus vaccine by their 13th birthday, the target for on-time vaccination. The study objective was to identify key patient, provider and practice-level factors associated with on-time vaccination in the primary care setting.


      We examined data from 20 primary care pediatric practices (89 providers) in St. Louis including: the percentage of eligible patients with on-time vaccination assessed from medical records; providers’ knowledge, attitudes and behaviors regarding on-time vaccination assessed with a survey; and practice-level strategies used to optimize vaccine delivery assessed with a 19-item vaccine delivery system score (VDSS). Factors that increased on-time vaccination were identified using logistic regression, controlling for clustering within providers.


      Completion of on-time vaccination occurred in 1347/3125 (43.10%) of patients (95% confidence interval [CI], 41.36%–44.86%) and varied among practices (7.39%–64.24%) and among providers (2.63%–82.50%). Independent predictors for higher completion of on-time vaccination included more frequent use by providers of the announcement style for vaccine recommendation (odds ratio [OR] 1.18, 95% CI, 1.04, 1.35), higher provider self-efficacy to deliver the vaccine according to guideline recommendations if parents were hesitant (OR 1.21, 95% CI, 1.05, 1.40), and higher VDSS (OR 1.20, 95% CI, 1.10, 1.31).


      Provider and practice-level factors were identified that may represent modifiable targets for improvement in on-time vaccine uptake. Future research is needed to test interventions built on these findings.


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      1. HPV and Cancer. CDC. Available at: Accessed February 7, 2022.

        • Pingali C
        • Yankey D
        • Elam-Evans LD
        • et al.
        National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years - United States, 2020.
        MMWR Morb Mortal Wkly Rep. 2021; 70: 1183-1190
        • Guo F
        • Cofie LE
        • Berenson AB.
        Cervical cancer incidence in young U.S. females after human papillomavirus vaccine introduction.
        Am J Prev Med. 2018; 55: 197-204
        • Markowitz LE
        • Gee J
        • Chesson H
        • et al.
        Ten years of human papillomavirus vaccination in the United States.
        Acad Pediatr. 2018; 18: S3-S10
        • Petrosky E
        • Bocchini Jr., JA
        • Hariri S
        • et al.
        Use of 9-valent human papillomavirus (HPV) vaccine: updated HPV vaccination recommendations of the Advisory Committee on Immunization Practices.
        MMWR Morb Mortal Wkly Rep. 2015; 64: 300-304
        • Finer LB
        • Philbin JM.
        Sexual initiation, contraceptive use, and pregnancy among young adolescents.
        Pediatrics. 2013; 131: 886-891
        • Winer RL
        • Feng Q
        • Hughes JP
        • et al.
        Risk of female human papillomavirus acquisition associated with first male sex partner.
        J Infect Dis. 2008; 197: 279-282
        • Chido-Amajuoyi OG
        • Talluri R
        • Wonodi C
        • et al.
        Trends in HPV vaccination initiation and completion within ages 9-12 years: 2008-2018.
        Pediatrics. 2021; 147e2020012765
        • Szilagyi PG
        • Albertin CS
        • Gurfinkel D
        • et al.
        Prevalence and characteristics of HPV vaccine hesitancy among parents of adolescents across the US.
        Vaccine. 2020; 38: 6027-6037
        • Lu PJ
        • Yankey D
        • Fredua B
        • et al.
        Human papillomavirus vaccination trends among adolescents: 2015 to 2020.
        Pediatrics. 2022; 150e2022056597
        • McRee AL
        • Gilkey MB
        • Dempsey AF.
        HPV vaccine hesitancy: findings from a statewide survey of health care providers.
        J Pediatr Health Care. 2014; 28: 541-549
        • Cunningham-Erves J
        • Koyama T
        • Huang Y
        • et al.
        Providers' perceptions of parental human papillomavirus vaccine hesitancy: cross-sectional study.
        JMIR Cancer. 2019; 5: e13832
        • Gilkey MB
        • McRee AL.
        Provider communication about HPV vaccination: a systematic review.
        Hum Vaccin Immunother. 2016; 12: 1454-1468
        • Rutten LJ
        • St Sauver JL
        • Beebe TJ
        • et al.
        Clinician knowledge, clinician barriers, and perceived parental barriers regarding human papillomavirus vaccination: Association with initiation and completion rates.
        Vaccine. 2017; 35: 164-169
        • Vu M
        • King AR
        • Jang HM
        • et al.
        Practice-, provider- and patient-level facilitators of and barriers to HPV vaccine promotion and uptake in Georgia: a qualitative study of healthcare providers' perspectives.
        Health Educ Res. 2020; 35: 512-523
        • Kong WY
        • Bustamante G
        • Pallotto IK
        • et al.
        Disparities in healthcare providers' recommendation of HPV vaccination for U.S. adolescents: a systematic review.
        Cancer Epidemiol Biomarkers Prev. 2021; 30: 1981-1992
        • Harris PA
        • Taylor R
        • Minor BL
        • et al.
        The REDCap consortium: building an international community of software platform partners.
        J Biomed Inform. 2019; 95103208
        • Harris PA
        • Taylor R
        • Thielke R
        • et al.
        Research electronic data capture (REDCap)–a metadata-driven methodology and workflow process for providing translational research informatics support.
        J Biomed Inform. 2009; 42: 377-381
        • Huijg JM
        • Gebhardt WA
        • Dusseldorp E
        • et al.
        Measuring determinants of implementation behavior: psychometric properties of a questionnaire based on the theoretical domains framework.
        Implement Sci. 2014; 9: 33
        • Cane J
        • O'Connor D
        • Michie S.
        Validation of the theoretical domains framework for use in behaviour change and implementation research.
        Implement Sci. 2012; 7: 37
        • Michie S.
        Designing and implementing behaviour change interventions to improve population health.
        J Health Serv Res Policy. 2008; 13: 64-69
        • Malo TL
        • Hall ME
        • Brewer NT
        • et al.
        Why is announcement training more effective than conversation training for introducing HPV vaccination? A theory-based investigation.
        Implement Sci. 2018; 13: 57
      2. Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Hall E., Wodi A.P., Hamborsky J., et al., eds. 14th ed. Washington, D.C. Public Health Foundation, 2021. Chapter 3.

        • Akaike H.
        A new look at the statistical model identification.
        IEEE Trans Autom Control. 1974; 19: 716-723
        • Brewer NT
        • Hall ME
        • Malo TL
        • et al.
        Announcements versus conversations to improve HPV vaccination coverage: a randomized trial.
        Pediatrics. 2017; 139e20161764
        • Dempsey AF
        • Pyrznawoski J
        • Lockhart S
        • et al.
        Effect of a health care professional communication training intervention on adolescent human papillomavirus vaccination: a cluster randomized clinical trial.
        JAMA Pediatr. 2018; 172e180016
      3. Office of Disease Prevention and Health Promotion. Available at: Accessed June 30, 2022.

        • Fiks AG
        • Grundmeier RW
        • Mayne S
        • et al.
        Effectiveness of decision support for families, clinicians, or both on HPV vaccine receipt.
        Pediatrics. 2013; 131: 1114-1124
        • Szilagyi PG
        • Humiston SG
        • Stephens-Shields AJ
        • et al.
        Effect of training pediatric clinicians in human papillomavirus communication strategies on human papillomavirus vaccination rates: a cluster randomized clinical trial.
        JAMA Pediatr. 2021; 175: 901-910
        • Limaye RJ
        • Opel DJ
        • Dempsey A
        • et al.
        Communicating with vaccine-hesitant parents: a narrative review.
        Acad Pediatr. 2021; 21: S24-S29
        • Abdullahi LH
        • Kagina BM
        • Ndze VN
        • et al.
        Improving vaccination uptake among adolescents.
        Cochrane Database Syst Rev. 2020; 1CD011895
        • Rand CM
        • Humiston SG.
        Provider focused interventions to improve child and adolescent vaccination rates.
        Acad Pediatr. 2021; 21: S34-S39
        • Smulian EA
        • Mitchell KR
        • Stokley S.
        Interventions to increase HPV vaccination coverage: a systematic review.
        Hum Vaccin Immunother. 2016; 12: 1566-1588
        • Lake PW
        • Kasting ML
        • Christy SM
        • et al.
        Provider perspectives on multilevel barriers to HPV vaccination.
        Hum Vaccin Immunother. 2019; 15: 1784-1793
      4. National Center for Health Statistics. Percentage of having a doctor visit for any reason in the past 12 months for children under age 18 years, United States, 2019—2021. National Health Interview Survey. 2022. Available at: Accessed December 10, 2022.