Research Article|Articles in Press

Associations of Maternal Age, Education, and Marital Status with HPV Vaccine Uptake and Hesitancy among United States Youth: A Cross-Sectional Analysis of the 2020 National Immunization Survey

  • C. Elenwo
    Address correspondence to: Covenant Elenwo, Oklahoma State University Center for Health Sciences, 1111 W 17th St. Tulsa, OK 74107; Phone (361) 701-9008
    Office of Medical Student Research, Oklahoma State University College of Osteopathic Medicine at Cherokee Nation, Tahlequah, Oklahoma
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  • K. Batioja
    Office of Medical Student Research, Oklahoma State University College of Osteopathic Medicine at Cherokee Nation, Tahlequah, Oklahoma
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  • T. Davis
    School of Community Medicine, University of Oklahoma - Schusterman Center, Tulsa, Oklahoma
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  • B.H. Greiner
    Department of Internal Medicine, University of Texas Medical Branch at Galveston, Galveston, Texas
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  • C. Markey
    School of Community Medicine, University of Oklahoma - Schusterman Center, Tulsa, Oklahoma

    Department of Obstetrics and Gynecology, University of Oklahoma School of Community Medicine, Tulsa, Oklahoma
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  • M. Hartwell
    Office of Medical Student Research, Oklahoma State University College of Osteopathic Medicine at Cherokee Nation, Tahlequah, Oklahoma

    Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, Oklahoma
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Published:February 07, 2023DOI:


      Study Objective

      Human papillomavirus (HPV) vaccination is proven to reduce the risk of HPV-associated cancers and lesions. Factors associated with HPV vaccine receipt or rejection have been studied, but specific maternal characteristics driving uptake among teens requires further investigation. The aim of this study was to examine maternal characteristics influencing teen vaccine uptake and intent to vaccinate.

      Study Design

      Cross-sectional analysis


      We analyzed data on 27,320 teens aged 13-17 using the 2020 National Immunization Survey-Teen. We constructed regression models to determine the associations, via relative risk, between child vaccination status and maternal characteristics.


      Compared with mothers with less education, those with a college degree were significantly more likely to have their children receive HPV vaccination (RR = 1.18; 95% CI, 1.11-1.26). Compared to mothers under 35 years, those aged 35-44 (RR 1.07; 95% CI 1.01-1.14) and over 45 (RR = 1.13; 95% CI, 1.07-1.21) were more likely to provide HPV vaccination to their child. Among children not previously vaccinated (n = 12,098; N = 5,752,355), educated mothers were significantly less likely to report intent to vaccinate their child in the next year. There was no significant difference in vaccination rates in mothers who were married compared with never married (RR = 0.99; 95% CI, 0.97-1.02).


      Maternal education was the strongest predictor of teens receiving the HPV vaccine. Among mothers with teens not previously vaccinated, intent to obtain the HPV vaccine for their child was higher among mothers with less education compared with college-level educated mothers. Understanding maternal characteristics driving HPV vaccine hesitancy can inform targeted approaches to improve vaccine uptake in children. Additionally, adequate and consistent health messaging on the safety, efficacy, and benefits of HPV vaccination from health providers and public health agencies could increase uptake among adolescents and teens of vaccine-hesitant mothers.

      Key Words

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        • Dunne EF
        • Park IU
        HPV and HPV-associated diseases.
        Infect Dis Clin North Am. 2013; 27: 765-778
        • Groves IJ
        • Coleman N
        Pathogenesis of human papillomavirus-associated mucosal disease.
        J Pathol. 2015; 235: 527-538
        • Crosbie EJ
        • Einstein MH
        • Franceschi S
        • Kitchener HC
        Human papillomavirus and cervical cancer.
        Lancet. 2013; 382: 889-899
        • Walsh CD
        • Gera A
        • Shah M
        • et al.
        Public knowledge and attitudes towards Human Papilloma Virus (HPV) vaccination.
        BMC Public Health. 2008; 8
        • Dilley S
        • Miller KM
        • Huh WK
        Human papillomavirus vaccination: Ongoing challenges and future directions.
        Gynecol Oncol. 2020; 156: 498-502
      1. Centers for Disease Control and Prevention: HPV-associated cancer diagnosis by age. Available: Accessed July 17, 2022

        • Sarier M
        • Ceyhan AM
        • Sepin N
        • et al.
        HPV infection in urology practice.
        Int Urol Nephrol. 2020; 52: 1-8
        • Wang R
        • Pan W
        • Jin L
        • et al.
        Human papillomavirus vaccine against cervical cancer: Opportunity and challenge.
        Cancer Lett. 2020; 471: 88-102
        • Chesson HW
        • Ekwueme DU
        • Saraiya M
        • et al.
        Estimates of the annual direct medical costs of the prevention and treatment of disease associated with human papillomavirus in the United States.
        Vaccine. 2012; 30: 6016-6019
        • Chesson HW
        • Meites E
        • Ekwueme DU
        • et al.
        Updated medical care cost estimates for HPV-associated cancers: implications for cost-effectiveness analyses of HPV vaccination in the United States.
        Hum Vaccines Immunother. 2019; 15: 1942-1948
        • Daley EM
        • Perrin KMK
        • McDermott RJ
        • et al.
        The psychosocial burden of HPV: a mixed-method study of knowledge, attitudes and behaviors among HPV+ women.
        J Health Psychol. 2010; 15: 279-290
        • Brotherton JML
        • Zuber PLF
        • Bloem PJN
        Primary prevention of HPV through vaccination: update on the current global status.
        Curr Obstet Gynecol Rep. 2016; 5: 210-224
      2. Centers for Disease Control and Prevention: HPV Vaccination Recommendations. Available: Accessed October 22, 2022

        • Arbyn M
        • Xu L
        Efficacy and safety of prophylactic HPV vaccines. A Cochrane review of randomized trials.
        Expert Rev Vaccines. 2018; 17: 1085-1091
        • Bednarczyk RA
        Addressing HPV vaccine myths: practical information for healthcare providers.
        Hum Vaccines Immunother. 2019; 15: 1628-1638
        • Dubé E
        • Laberge C
        • Guay M
        • et al.
        Vaccine hesitancy.
        Hum Vaccines Immunother. 2013; 9: 1763-1773
        • Berenson AB
        • Laz TH
        • Hirth JM
        • et al.
        Effect of the decision-making process in the family on HPV vaccination rates among adolescents 9–17 years of age.
        Hum Vaccines Immunother. 2014; 10: 1807-1811
        • Gross GJ
        • Howard M
        Mothers’ decision-making processes regarding health care for their children.
        Public Health Nurs. 2001; 18: 157-168
      3. Centers for Disease Control and Prevention: About the National Immunization Surveys. Available: Accessed May 16, 2022

        • Norton EC
        • Miller MM
        • Kleinman LC
        Computing adjusted risk ratios and risk differences in Stata.
        Stata J. 2013; 13: 492-509
        • Zhang J
        • Yu KF
        What's the relative risk? A method of correcting the odds ratio in cohort studies of common outcomes.
        JAMA. 1998; 280: 1690-1691
        • Lei J
        • Ploner A
        • Elfström KM
        • et al.
        HPV vaccination and the risk of invasive cervical cancer.
        N Engl J Med. 2020; 383: 1340-1348
        • Mohammed KA
        Factors associated with parents’ intent to vaccinate adolescents for human papillomavirus: findings from the 2014 National Immunization Survey–Teen.
        Prev Chronic Dis. 2017; 14
        • Smith PJ
        • Chu SY
        • Barker LE
        Children who have received no vaccines: who are they and where do they live?.
        Pediatrics. 2004; 114: 187-195
        • Williams CL
        • Walker TY
        • Elam-Evans LD
        • et al.
        Factors associated with not receiving HPV vaccine among adolescents by metropolitan statistical area status, United States, National Immunization Survey–Teen, 2016–2017.
        Hum Vaccines Immunother. 2020; 16: 562-572
        • Feiring B
        • Laake I
        • Molden T
        • et al.
        Do parental education and income matter? A nationwide register-based study on HPV vaccine uptake in the school-based immunisation programme in Norway.
        BMJ Open. 2015; 5e006422
        • DiAnna Kinder F
        Parental refusal of human papillomavirus vaccine: multisite study.
        J Pediatr Health Care. 2018; 32: 150-156
        • Selvin E
        • Brett KM
        Breast and cervical cancer screening: sociodemographic predictors among White, Black, and Hispanic women.
        Am J Public Health. 2003; 93: 618-623
      4. World Health Organization: One-dose Human Papillomavirus (HPV) vaccine offers solid protection against cervical cancer. Available: Accessed November 5, 2022

        • Wang VHC
        • Silver D
        • Pagán JA
        Generational differences in beliefs about COVID-19 vaccines.
        Prev Med. 2022; 157107005
      5. (Edited by)
        • Ajzen I
        The theory of planned behavior.
        in: Van Lange PAM Kruglanski AW Higgins ET Handbook of Theories of Social Psychology: Volume 1. Sage, 2012: 438-459 (Edited by)
        • Reiter PL
        • McRee AL
        • Kadis JA
        • Brewer NT
        HPV vaccine and adolescent males.
        Vaccine. 2011; 29: 5595-5602
        • Kasymova S
        Human papillomavirus (HPV) and HPV vaccine knowledge, the intention to vaccinate, and HPV vaccination uptake among male college students.
        J Am Coll Health. 2022; 70: 1079-1093
        • Daley EM
        • Vamos CA
        • Thompson EL
        • et al.
        The feminization of HPV: how science, politics, economics and gender norms shaped U.S. HPV vaccine implementation.
        Papillomavirus Res. 2017; 3: 142-148
        • Stanley M
        HPV vaccination in boys and men.
        Hum Vaccines Immunother. 2014; 10: 2109-2111
        • Gallant D
        • Tummers P
        • Weyers S
        • Merckx M
        Single-dose human papillomavirus vaccination in low- and middle-income countries-time for implementation?.
        J Pediatr Adolesc Gynecol. 2021; 34: 586-590