Ethnic and Gender Differences in HPV Knowledge, Awareness, and Vaccine Acceptability Among White and Hispanic Men and Women
The purpose of this study was to examine factors associated with human papillomavirus (HPV) knowledge and awareness, and HPV vaccination among White and Hispanic males and females. Differences in HPV knowledge, sources of information, vaccine awareness, vaccination status, and interest in vaccination were examined. A community sample was recruited from local health care clinics in a medium sized Midwestern city between May 2010 and December 2011. Participants (N = 507) were White (n = 243) and Hispanic, males (n = 202) and females between the ages of 15–30. Results indicate that White and female participants were significantly more likely to have heard of HPV, have higher levels of HPV knowledge, have been diagnosed with HPV, and be aware of the HPV vaccine for women. White and female participants were also more likely to have heard of HPV from their physician and were significantly more interested in receiving the HPV vaccine in the future. There was no effect of ethnicity on interest in the vaccine per a doctor’s recommendation, however. Findings suggest that Whites and females have greater levels of HPV awareness and knowledge and that, while Hispanic participants are less likely than White participants to be told about the HPV vaccine from their provider, they may be equally receptive to such a recommendation.
KeywordsHPV Health disparities Hispanic health HPV vaccination Gender differences Physician recommendation
Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States . It is estimated that at least 50 % of all sexually active individuals will contract HPV at some point in their lifetime . Prevalence estimates of HPV among US women aged 14–59 are approximately 27 % . A review by Dunne et al.  suggests that prevalence is comparable among men, with most studies reporting point prevalence greater than 20 %. There are over 100 subtypes of HPV, with types-6 and -11 known to cause genital warts in both men and women . Types-16 and -18 cause cervical, vulvar, and vaginal cancers in women, penile cancer among men, and anal, oral, and esophageal cancer in both men and women .
Disparities in HPV-Associated Diseases
In general, members of racial/ethnic minority groups, particularly Blacks and those of Hispanic ethnicity, are more likely to suffer from HPV-related morbidity and mortality than are Whites [4, 8, 9]. Of particular relevance to the current study are inequalities between Whites and Hispanics. For example, a disparity between White and Hispanic women exists in the incidence and prevalence of HPV-associated cervical cancers . Compared with White women, Hispanic women are diagnosed with cervical cancer at higher rates and are more likely to die from cervical cancer [2, 41]. Similarly, Hispanic men have a higher incidence of HPV-associated penile cancer than non-Hispanic men [8, 9], and men overall have more than twice the rates of HPV-associated oropharyngeal cancer than women do . In addition, rates of HPV-associated oropharyngeal cancer have increased so much that they are expected to surpass rates of HPV-associated cervical cancer by 2020.
A quadrivalent 3-dose HPV vaccine is available that protects against the most common high- (-16, and -18) and low-risk types of HPV (-6, and -11). Types-16 and -18 are considered “high risk” because of their oncogenic nature, whereas types-6 and -11 are known to cause genital warts. In 2006 the U.S. Food and Drug Administration (FDA) approved the vaccine for females aged 9–26 , and the Advisory Committee on Immunization Practices (ACIP) gave a routine recommendation . In 2009, the HPV vaccine was approved for males of the same ages . The ACIP, however, gave a permissive recommendation, indicating that the vaccine may be given. In 2011, the ACIP revised its recommendation for males to routine, indicating that the vaccine should be given as part of the routine standard of care . Because prophylactic HPV vaccination is safe, effective, and has the potential to substantially reduce morbidity and mortality, universal vaccination of males and females is now encouraged by public health professionals . Furthermore, it has been noted that universal vaccination has the potential to reduce disparities in HPV-associated cancer .
Studies suggest that overall, vaccine acceptability among both male and female patients is high; Brewer and colleagues found acceptability rates in the literature ranging from 55 to 100 % . Rates of vaccine uptake, however, are much lower; recent studies indicate that approximately 30 % of females , but only 2 % of males aged 11–17 received at least one of the three doses of vaccine in 2010 . In the years following approval and recommendation of the HPV vaccine, Hispanic women were less likely than White women to be vaccinated . More recent trends, however, indicate that Hispanic girls and boys now initiate and complete the vaccine series more frequently than White girls and boys .
Understanding sociocultural and behavioral factors associated with vaccine uptake for all individuals is a priority. Many factors have been linked to increased vaccination, including higher perceptions of risk [5, 21, 27, 47], perceived efficacy of the vaccine [14, 15, 22, 47], reduced cost [5, 21, 27, 47], high levels of mother–daughter communication [38, 42], and higher perceived vaccination norms .
HPV Vaccination Among Men
Previous research has tended to focus on HPV vaccination among White women; fewer studies have specifically examined attitudes regarding the HPV vaccine among men, especially those of Hispanic origin . Moreover, those that have included men have focused on immunocompromised men, those who have sex with other men , or samples of male college students rather than broader community samples [34, 44]. Studies including men suggest that men have lower HPV knowledge levels than women do [3, 36]. For example, Stock and colleagues found that significantly more male than female college students reported being very likely to receive the HPV vaccine (40 vs. 28 %, respectively). Ferris et al.  surveyed nearly 600 men aged 18–45 in order to examine factors associated with HPV vaccine acceptance. Results revealed that nearly 33 % of the men expressed a desire to be vaccinated against HPV, with only 27 % explicitly not wanting to receive the vaccine. Nearly 40 % of the sample remained uncertain. In this study, being more highly educated, being Hispanic, and being younger were associated with increased HPV vaccine acceptance. This study provides encouraging evidence that men, Hispanic men in particular, may be receptive to the HPV vaccine.
One additional study included 165 male college students to measure knowledge, attitudes, and willingness to receive the HPV vaccine . Overall, the young men reported relatively low levels of HPV knowledge and low perceived risk (in spite of the fact that most of them were sexually active). Approximately 70 % of participants, however, reported that they would be willing to discuss the HPV vaccine with their healthcare provider. While these results are also encouraging, the generalizability is limited by the predominantly White college student sample, and the fact that the HPV vaccine was not yet FDA approved at the time of data collection. In sum, much remains unknown about knowledge, attitudes, beliefs, and willingness to receive the HPV vaccine among an ethnically diverse sample of men and women.
Many studies have documented that health care providers, particularly physicians, play a key role in patients’ HPV vaccine uptake. Patients’ decisions to get the vaccine for their daughters [15, 26] or themselves  are significantly influenced by a physician’s recommendation. Moreover, physicians appear to have positive attitudes toward the HPV vaccine, particularly for older adolescent females . A nationally representative study, however, adult women found that only 24 % reported ever receiving a recommendation from a physician for the HPV vaccine . Research examining the influence of physician recommendation on males’ vaccine uptake, however, remains limited . Reiter and colleagues found in a national sample of predominately White parents of adolescent males, that only 2 % of participants’ sons had received the HPV vaccine; of the unvaccinated boys, only 3 % reported ever receiving a recommendation from their physician . Most notable, however, is that of the boys who had been vaccinated, 50 % had received physician recommendation to do so, suggesting that physician recommendation may be quite influential when received. Research that is specifically focused on physician recommendation among diverse samples, including Hispanics, and those of lower SES is lacking .
The Current Study
To date, there have been no studies the authors are aware of that have specifically focused on factors associated with knowledge of and interest in HPV vaccination among White and Hispanic men and women. The purpose of the current study was to examine gender and ethnic differences between White and Hispanic men and women in HPV knowledge and sources of information about HPV, awareness of the HPV vaccine, and interest in future vaccination among a community based sample of White and Hispanic men and women.
Participants and Procedures
A sample (N = 507) of 15–30 year-old White (48 %) and Hispanic participants (40 % male) was recruited to participate in this study. Participants were recruited from the waiting rooms of three health care clinics in a medium sized Midwestern city between May, 2010 and December, 2011. The clinics selected were all in a metropolitan area and served a diverse population of patients. Two of the three clinics were independent reduced fee/sliding scale clinics. The third clinic was a family practice clinic affiliated with a major hospital system. Inclusion criteria included being between the ages of 14–30, parental consent if under age 18, identifying as non-Hispanic White or of Hispanic/Latino ethnicity, and willingness to participate in a brief survey.
Potential participants who appeared to be within the specified age range were approached by bilingual research assistants in the waiting rooms of the health care clinics, and invited to participate in a survey about health behaviors, knowledge, and attitudes. Those who agreed to participate completed a self-administered questionnaire in the clinic waiting room or exam room. Participants were given the option of completing the questionnaire in either English or Spanish. Participants were compensated $10 for their time, fully debriefed on the purpose of the study, and provided with health education materials about HPV and the HPV vaccine, Gardasil®. These procedures were approved by the Des Moines University and Mercy Medical Center—Des Moines institutional review boards.
Participants were asked to report their gender, age, level of education, employment, marital status, and whether they currently had any form of insurance coverage. Participants also reported their income using a 12-point categorical scale from 1 (less than 10,000 per year) to 12 (more than 100,000 per year).
Participants were asked “Have you heard of HPV before this study?”. Response options were 0 (no/don’t know) and 1 (yes).
HPV knowledge was assessed with a series of ten questions, for example “HPV is the most common sexually transmitted infection,” “Men can have HPV,” “HPV can cause cervical cancer in women,” and “HPV can cause genital warts in men and women.” Response options ranged from 0 (strongly disagree), 2 (don’t know), to 4 (strongly agree). For the purposes of these analyses, responses of agree and strongly agree were coded as 1 = correct. All others were coded as 0 = incorrect. The knowledge index reflected a sum of the number of correct responses. The knowledge questionnaire was adapted from knowledge questionnaires used in other HPV studies [38, 42], and demonstrated strong internal reliability with α = .83.
Sources of Information on HPV
Participants who reported that they had heard of HPV prior to the study were then asked to indicate where they had heard of, or learned about, HPV. Options included: family, friends, significant others, health educators, physicians, television, internet, radio, magazines, pamphlets and newspapers. Responses for magazines, pamphlets, and newspapers were combined to reflect print media sources. Participants checked yes or no for each option, and were allowed make multiple selections.
Participants were asked “Have you ever been diagnosed with HPV?”. Response options were 0 (no/don’t know) and 1 (yes).
Participants were asked two separate questions to assess their awareness of the HPV vaccine: “There is an HPV vaccine available for women and girls” and “There is an HPV vaccine available for men and boys.” Response options ranged from 0 (strongly disagree), 2 (don’t know), to 4 (strongly agree).
Participants were asked if they had ever received the HPV vaccine. Response options were 0 (no/don’t know) and 1 (yes).
Interest in Future Vaccination
Participants who had not yet received the HPV vaccine were asked three questions regarding their interest in future vaccination: “Would you be interested in receiving the HPV vaccine for your own safety?”, “Would you be interested in receiving the HPV vaccine for your (current or future) partner’s safety?” and finally, “Would you be interested in receiving the HPV vaccine if your physician recommended it to you?” Responses options ranged from 0 (very uninterested) to 4 (very interested).
Participants who were not within the age range that would have been eligible to receive the HPV vaccine (i.e., age 26 or lower by 2009 for males, and age 26 or lower by 2006 for females) were not included in analyses (n = 35). Additionally, five women and five men did not provide their age, and were therefore excluded from all analyses. Therefore, the total remaining sample was n = 462. The sample size for individual measures may vary due to missing data. All analyses were conducted with IBM SPSS 19. A series of bivariate logistic regressions was conducted to examine differences in HPV awareness, HPV diagnosis, and HPV vaccination status. Hierarchical linear regressions were used to examine HPV knowledge and awareness of the HPV vaccine. All betas (β) reported are unstandardized. A series of one-way ANOVAs was then conducted on the vaccine interest measures, among participants who had not received the HPV vaccine and who had not previously been diagnosed with HPV. In all analyses, ethnicity, sex, and an ethnicity by sex product term were used as predictor variables. Because there was no consistent statistically significant effect of the other socio-demographic variables, they were not included as covariates in the final analyses.
Descriptives and correlations between all variables
Heard of HPV
Vax aware F
Vax aware M
Interest Dr. rec
Heard of HPV
Vax aware F
Vax aware M
Interest Dr. Rec
40 % male
48 % White
Awareness of HPV
We first examined whether gender, ethnicity, or both factors influenced the likelihood that participants had ever heard of HPV. Both ethnicity (OR .14, p < .001, Wald statistic = 35.48) and gender (OR .29, p < .01, Wald statistic = 10.76) were significant predictors. Specifically, being White and being female were significantly associated with having heard of HPV. The ethnicity by gender interaction term was not a significant predictor, p > .3.
A hierarchical linear regression analysis was conducted in which HPV knowledge was regressed on ethnicity, gender, an ethnicity by gender interaction term. Ethnicity (β = −.33, SE = .07, p < .001) and gender (β = −.19, SE = .09, p < .05) were significant predictors of HPV knowledge. Being Hispanic and male were both associated with lower levels of HPV knowledge relative to Whites and females, respectively. The interaction effect was only marginally statistically significant (β = .23, p < .10). There was an overall trend that White women had the highest HPV knowledge (M = 2.7, SD = .63), followed by White men (M = 2.5, SD = .57). Hispanic men and Hispanic women reported the lowest mean knowledge (M = 2.4, SD = .53; M = 2.4, SD = .64, respectively).
Sources of Information
Logistic regressions predicting source of HPV awareness (n = 362)
Upper 95 % CI
Lower 95 % CI
Diagnosed with HPV
We also examined whether gender and ethnicity were associated with ever having received an HPV diagnosis. Both ethnicity (OR .26, p < .01, Wald statistic = 7.76) and gender (OR .15, p < .05, Wald statistic = 6.50) were significant predictors. Specifically, being White and being female were significantly associated with having been diagnosed with HPV. There was not a significant ethnicity by gender interaction, p > .9.
Awareness of the HPV Vaccine
Overall awareness of the HPV vaccine for boys and men was approximately 18 %. Hierarchical linear regression analyses revealed that there was no significant effect of gender (p > .5), but a significant effect of ethnicity emerged (β = .32 SE = .17, p < .01). Surprisingly, these results reveal that Hispanic participants were more likely to be aware of the HPV vaccine for boys and men than were White participants. The gender by ethnicity product term was not significantly associated with vaccine awareness, p > .4.
No males in this sample had received the HPV vaccine; therefore, only ethnicity was included as a predictor of vaccination in the analysis. White women were significantly more likely than Hispanic women to have received the HPV vaccine (OR .28, p < .001, Wald statistic = 14.17).
Interest in Future Vaccination
To examine the effects of ethnicity and sex on interest in future vaccination among unvaccinated participants, a series of ANOVAs were conducted. Participants who reported ever having been diagnosed with HPV, and those who had already received the HPV vaccine were excluded from these analyses. Ethnicity, gender, and an ethnicity by gender interaction were included as predictor variables in each analysis. The first measure assessed whether participants would be interested in receiving the HPV vaccine for their own safety. A main effect of ethnicity, F (1, 339) = 16.83, p < .001, and a main effect of gender emerged, F (1, 339) = 8.37, p < .01, such that Hispanics and females were more interested than Whites and males, respectively. There was not a significant gender by ethnicity interaction, p > .6.
Next, participants were asked whether or not they would be interested in the HPV vaccine for their partner’s safety. Hispanic participants, F (1, 337) = 5.00, p < .05, and female participants, F (1, 337) = 4.07, p < .05, were significantly more interested than were White or male participants. The interaction term was not a significant predictor, p > .8.
Finally, participants were asked if they would be interested in receiving the HPV vaccine if their doctor recommended it. For this measure, only a significant effect of gender emerged, such that females, F (1, 339) = 5.71, p < .05, were significantly more interested in the HPV vaccine per a doctor’s recommendation than were male participants. The effect of ethnicity was marginally statistically significant, F (1, 339) = 2.93, p < .10. The product term was not significantly associated with interest in being vaccinated per a doctor’s recommendation, p > .6.
The purpose of this study was to determine differences between men and women and Whites and Hispanics on measures of HPV awareness, HPV knowledge, sources of HPV information, awareness of the HPV vaccine, vaccination status, and interest in future HPV vaccination. Our results demonstrate a consistent pattern of non-Hispanic Whites and women being more aware of HPV, more likely to have been diagnosed with HPV, being aware of the HPV vaccine, and having been vaccinated. Interestingly, our results also indicate that women and Hispanic participants express the greatest interest in receiving the vaccine in the future.
HPV Awareness, HPV Knowledge, and Sources of Information About HPV
We found that both Whites and women were more likely to have heard of HPV than were Hispanics or men. Our results further indicate that women and White participants in this sample had significantly higher levels of HPV knowledge than did men and Hispanic participants, respectively. This pattern of findings is consistent with previous studies that have compared HPV knowledge levels by gender and ethnicity. Recent research indicates that women tend to have moderate levels of HPV knowledge . Studies that have examined gender differences, however, have demonstrated that male participants lag behind their female counterparts in obtaining satisfactory levels of accurate HPV knowledge [3, 23]. The literature also suggests that minorities demonstrate lower HPV awareness, and lower levels of HPV knowledge, than do White participants [24, 29]. The findings in this study provide novel information, however, because they include White and Hispanic members of both genders from a community sample.
We were interested in exploring, among those participants who had heard of HPV, what sources of information they cited. The three most frequently cited sources of information among all of our participants were the TV, their physician, and various sources of print media. Gerend and Magloire  similarly found that their participants cited the media and health care providers as the two top sources of information on HPV. Female participants in this study were more likely than male participants to have heard of HPV from their physician, while male participants were more likely than female participants to have heard about HPV from a significant other. Given that the HPV vaccine has been approved and recommended for females longer than it has been for males, it is not surprising that females are more likely to have heard of HPV from their physician. White participants in this sample were more likely than Hispanics to have heard of HPV from friends, health education class, their physician, the internet, and the radio.
Previous studies have documented that Hispanics tend to be less knowledgeable about HPV than Whites are, and that despite public health efforts to increase HPV knowledge and increase vaccination these messages may not be sufficiently reaching ethnically diverse populations . What is surprising, however, is that our results suggest that physicians may not be informing their Hispanic patients about HPV as frequently as they are their Caucasian patients. While this study cannot rule out the possibility that these differences in learning about HPV are due to differences in lifetime access to educational opportunities or the healthcare system, our analyses did not find that factors such as health insurance or education could explain these effects. In addition, participants in this sample were all recruited from the same health care clinics, so at the time data collected, they were all similarly engaging with a primary care physician. Finally, the finding that men in this sample were significantly more likely than women to have heard of HPV from a significant other is consistent with other studies highlighting that women tend to be the caretakers of their male romantic partners’ health needs [30, 33].
White participants were significantly more likely to report ever having been diagnosed with HPV than were Hispanic participants. This is likely due to the fact that Hispanic women tend to report lower rates of pap tests (cervical cancer screening) and HPV tests throughout their lifespan than White women , and that men do not receive routine anal pap testing. Therefore, we speculate that this finding reflects trends in lifetime healthcare access rather than trends in epidemiology. In addition, it should be noted that HPV diagnosis was assessed by self-report and not by an examination of medical records. Therefore, we cannot rule out the possibility that the difference in HPV diagnosis found in this study reflects differences in willingness to disclose personal medical information rather than differences in actual diagnosis status.
Awareness of the HPV Vaccine
Hispanic and male participants in this study were significantly less likely than White and female participants to be aware of the HPV vaccine for girls and women. These main effects were qualified by a significant ethnicity by sex interaction. Examination of the pattern of results indicates that White females were the most aware of the availability of the HPV vaccine for women. There were no significant gender differences with respect to awareness of the availability of the HPV vaccine for boys and men. Surprisingly, however, our results indicated that Hispanic participants were significantly more likely than White participants to be aware of the HPV vaccine for men and boys.
The pattern of findings in this study regarding awareness of the availability of the HPV vaccine for women is consistent with previous studies that have included Hispanic participants . After the HPV vaccine was approved and recommended for girls and young women in 2006, the vaccine was heavily promoted by both pharmaceutical companies and by public health agencies. When the vaccine was approved for men in 2009, there was not a comparable media campaign. Our data suggest that while female participants were significantly more likely to be aware of the HPV vaccine for females, there were no significant gender effects with respect to the HPV vaccine for boys and men. We speculate that this pattern of findings is likely due to differences in publicity and message targeting of HPV vaccine messages. The finding that Hispanic participants were significantly more aware of the availability of the HPV vaccine for men is surprising. Because no other studies that the authors are aware of have reported similar findings, and given the overall low level of awareness of the HPV vaccine for males (less than 20 % of the sample), we believe this finding should be interpreted with caution. It is possible that an environmental confound not made aware to the researchers may explain this finding. More research examining patterns of potential disparities of awareness for the HPV vaccine for males is certainly warranted.
HPV Vaccine Uptake
Although recent research suggests that rates of HPV vaccination among men lags behind rates among women, it was surprising that not a single male in our sample had initiated the HPV vaccine series. Among the women, we found that Whites were significantly more likely than Hispanics to have received the HPV vaccine. Research documenting the patterns of vaccine uptake among Hispanics relative to Whites is limited, but appears mixed; Jain et al.  and Reimer et al.  both found non-significant differences, whereas a 2010 Morbidity and Mortality Weekly Report reported a significant difference in vaccine completion rates . The pattern of results in study, that Hispanics are less likely to be aware of the HPV vaccine and less likely to have been vaccinated is important, because universal HPV vaccination has the potential to reduce disparities in HPV-associated disease ; however, if this ethnic disparity trend continues, disparities in HPV-associated cancers may inadvertently be widened . The pattern of mixed results in the literature suggests additional research into ethnic differences in HPV vaccine uptake is needed.
Interest in Future HPV Vaccination
Women in this study were significantly more likely than men to be willing to get the HPV vaccine for their own safety, the safety of a partner, and if a doctor recommended it. Studies have found varied levels of support among males for the HPV vaccine. Stock and colleagues found that male participants reported significantly higher levels of willingness to receive the HPV vaccine than women . Our findings indicate that men from this lower SES, community-based sample were significantly less interested in receiving the HPV vaccine than were women. While this study cannot identify the specific reasons why these men reported less interest in the HPV vaccine, future studies should explore potential misconceptions among at-risk populations that may contribute to lowered vaccination interest.
Hispanic participants in this study were significantly more likely than White participants to be interested in getting the HPV vaccine for their own safety and the safety of a partner. These findings are encouraging, as they indicate that Hispanic patients may not only be equally likely, but perhaps even more willing, to receive prophylactic HPV vaccination as Whites are. Additionally, we found no differences by ethnicity in participants’ likelihood of getting the HPV vaccine per a doctor’s recommendation. We believe that in light of the finding that minority participants were significantly less likely to have heard about HPV from a doctor, these findings are quite important. These results may suggest that Hispanic participants are not being told about HPV from their health care providers at the same rate as White participants yet those same participants appear more willing to receive the HPV vaccine for their own and their partner’s safety, and equally receptive to physicians’ recommendations regarding HPV vaccine uptake.
The primary strength of this study is the relatively large and diverse community-based sample. To our knowledge, this is the first study to explicitly focus on differences between male and female White and Hispanic participants regarding awareness, knowledge, and willingness to receive the HPV vaccine. One limitation, however, is that all participants in this study were recruited from primary healthcare centers. It is possible that accessing participants in this manner may have led to the recruitment of more health-oriented, more conscientious, or perhaps even less healthy research. In addition, the methodology of this study was a cross-sectional survey study; therefore causal conclusions cannot be inferred. While the results from this study contribute novel and interesting information regarding both gender and ethnic differences in HPV knowledge, sources of information, and willingness to the vaccine, prospective studies are recommended to more fully examine these associations. Additionally, participants in this study who had received the HPV vaccine were asked how many of the three shots they had received however because vaccination rates overall were low, group comparisons in vaccine initiation versus vaccine completion rates were not examined in the current study.
This is the first study to specifically examine disparities between men and women, and between Whites and Hispanics, in important HPV-related constructs. The current findings reveal that overall, Hispanics and male participants are less aware of HPV, less aware of the HPV vaccine, less knowledgeable about HPV, and are not receiving information about HPV from their healthcare providers even though they may hold equivalent or higher levels of interest in the HPV vaccine compared to Whites and females.
We thank the Iowa Osteopathic Education and Research committee for funds to support this study. We also thank Melissa Deer, Kyle Kjome, and Lauren Christman for their efforts in collecting data for this article. This project was supported by the Iowa Osteopathic Education and Research Grant.
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