{"paper_id":"3f9599bf-ef79-4732-83b5-37041021b480","body_text":"1\nKnowledge, Attitudes, and Practices towards HPV Vaccination among Reproductive Age \nWomen in a HIV Hotspot in the US\nAasith Villavicencio1, Gray Kelsey2, Nicholas F Nogueira3, Julia Zukerberg2, Ana S Salazar3, \nLucila Hernandez3, Patricia Raccamarich3, Maria L Alcaide3*\n1 Division of Infectious Diseases, Hospital of the University of Pennsylvania, Philadelphia, \nPennsylvania, United States.\n2 University of Miami Miller School of Medicine, Miami, Florida, United States.\n3 Division of Infectious Diseases, Department of Medicine, University of Miami Miller School \nof Medicine, Miami, Florida, United States.\n*Corresponding Author:  \nEmail: malcaide@med.miami.edu (MA)\nKey Words: HPV Vaccine, HIV, HPV Knowledge\nAbbreviations: Multivariable logistic regressions (MLR), University of Miami (UM), Human \npapillomavirus (HPV)\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\n2\nABSTRACT\nBackground\nHuman papillomavirus (HPV) is the most common STI in the US, responsible for cervical cancer and \nincreased risk of HIV acquisition. Despite an effective HPV vaccine, women’s HPV vaccination \ncoverage and rates remain far below desired levels. This study aimed to evaluate HPV knowledge, \nattitudes, and vaccination practices as well as factors associated with HPV vaccination among women \nof reproductive age living in Miami, Florida, a Southern US city with a high incidence of STIs and low \nHPV vaccination coverage.\nMethods \nFrom April to June 2022, 100 HIV-negative, cisgender, sexually active women aged 18-45 years were \nwere recruited from the Miami community. Participants completed questionnaires using REDCap© \nelectronic surveys validated questionnaires assessing socio-demographics and sexual behaviors; HPV \nknowledge, screening, vaccination practices; barriers and motivators to HPV vaccination. A \ncumulative HPV knowledge score (HPV score) was generated. Factors associated with HPV \nvaccination were analyzed by Chi-square, Fisher’s exact test, studentized t-test, and multivariate \nlogistic regression (MLR).\nResults\nA total of 100 participants were enrolled, and 84 who knew their vaccination status were included in \nthe analysis. Of these, 43 reported receiving at least 1 HPV vaccine dose (vaccinated group) and 41 \nreported never being vaccinated (unvaccinated group). Mean age was 24.7 (SD 4.03) years for the \nvaccinated group and 31.4 (SD 8.33) for the unvaccinated group. Mean HPV score was 18.9/29 (SD \n6.05) for the vaccinated group and 9.1/29 (SD 8.82) for the unvaccinated group. Amongst vaccinated \nparticipants, 76.74% reported a history of HPV/Pap smear screening vs 87.80% in the unvaccinated \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n3\ngroup. Barriers to HPV vaccination included: 14.6% low-risk perception, 29.3% healthcare barriers, \nand 46.3% vaccine hesitancy and personal beliefs. Motivators t HPV vaccination included: risk \nperception and vaccine beliefs (71.42%), healthcare-related (60.71%) and social motivators (55.95%). \nIn the first MLR, one-point increases in HPV score were significantly associated with higher odds \nof HPV vaccination until an HPV score of 16, and a one-year increase in age was associated with \na 16% lower odds of HPV vaccination (aOR=0.84, 95% CI [0.72, 0.99]; p=0.035). Contraception \nuse was also associated with HPV vaccination (aOR 8.36 (95% CI [1.41, 49.62]; p=0.020). Race, \nethnicity, college education status, and number of sexual partners were not significant predictors \nof HPV vaccination. In the second MLR evaluating vaccination motivators as predictors of HPV \nvaccination, we found that individuals who were motivated by healthcare had 3.03 (95% CI [1.02, \n9.00]; p = 0.046) times the odds of HPV vaccination compared to individuals without healthcare-\nrelated motivators.\nConclusion\nFindings suggest suboptimal HPV knowledge and low vaccination rates among women of reproductive \nage. Public health efforts should focus on increasing basic HPV knowledge among women with \nlittle-to-no HPV knowledge to increase vaccine uptake.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n4\nINTRODUCTION\nIn the United States, human papillomavirus (HPV) is the most common sexually transmitted \ninfection (STI) among men and women. 1,2 It has been estimated that yearly, up to 14 million \nindividuals acquire a new HPV infection and 45,300 of those are diagnosed with HPV-associated \ncancers.3,4 While HPV vaccination has proven to be effective in decreasing the incidence of \ninfection and HPV-attributable cancers, in 2019 only 47.0% of adults aged 18–26 years had \nreceived at least one dose of the HPV vaccine.5 \nUneven HPV vaccination initiation and completion rates have been reported across states, by race \nand ethnicity, further widening disparities in HPV-related diseases. 6 While some studies have \nsuggested potential drivers for such disparities (e.g., health insurance, socioeconomic status, \nproviders recommendations), results seem to vary depending on the population demographics.7-11 \nHence, to reduce the gaps in HPV-related attitudes towards vaccination and to inform evidence-\nbased tools that mitigate these disparities, a better understanding of the predictors of HPV \nvaccination is needed. \nHPV knowledge has been used as a predictor of HPV vaccination acceptance and uptake.12 Thus, \nseveral states have committed funding to promote awareness of HPV and vaccination in the \ngeneral population. 13,14 Nonetheless, recent data suggest that HPV knowledge and general \nawareness have decreased overall in the U.S. since 2013.15,16 It is therefore important to assess the \npopulation-level awareness of HPV periodically to inform public health interventions aimed at \npromoting HPV awareness. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n5\nCompared to the national average, South Florida has a higher HPV-associated cancer incidence, \nlower HPV-vaccine completion rates, and a broad diversity in race/ethnicity. 2,17,18  Particularly in \nMiami, prior reports have shown lower rates of HPV vaccine uptake and national cancer screening \nguidelines compliance -including cervical cancer- primarily among racial minorities and those \nwith low socioeconomic status. 19 Thus, this study aims at understanding the current HPV-\nknowledge, screening and vaccination practices among multiethnic women of reproductive age in \nMiami. Findings will shed light on identifying potential modifiable factors that can increase HPV \nvaccination uptake and reduce the incidence of HPV associated cancers.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n6\nMATERIAL AND METHODS\nEthical Considerations\nThe study was approved by the University of Miami (UM) Miller School of Medicine the \nInstitutional Review Board (number: 20210504). Verbal consent was obtained from all \nparticipants before beginning the study assessment. A $15 dollar compensation was sent \nelectronically or by mail to all participants who completed the survey.\nStudy design and participants\nThis is a cross-sectional survey study conducted from April to June 2022. Participants were \ncisgender women, ages 18-45 years living in Miami, sexually active, HIV uninfected, and non \npregnant. Participants were selected in a convenience sampling method through printed flyers, \nword of mouth, and participant registries from prior studies conducted by the research team at the \nCenter for AIDS Research (CFAR) in Miami, Florida, including a study focused on understanding \nrecurrence bacterial vaginosis and HIV risk among reproductive age women. Exclusion criteria \nincluded self-reported positive HIV diagnosis, history of abnormal pap smear or history of HPV \ndiagnosis. Participants who were deemed eligible and provided consent were given the option to \ncomplete the study survey through a secure web-based system (self-administered via a unique web \nlink using the University of Miami REDCap©) or by telephone by trained interviewers and logged \ninto REDCap©. Time commitment for completion of the survey was 15 to 30 minutes. \nStudy Assessments\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n7\nStudy tools included questionnaires collecting basic participant information and validated \nsurveys. Sociodemographic variables were recorded including participant age, race, ethnicity, \nemployment status, living situation and monthly household income. Medical history was also \ncollected including obstetric and gynecological history, sexual and reproductive health, and \nhistory of genital infections or sexually transmitted infections. \nThe adapted Sexual Risk Behavior Assessment for adults, an established tool to assess HIV \nrisk behaviors, was used to evaluate number of sexual partners, condom use, frequency and \ndate of most recent intercourse, and alcohol and drug use. This survey has been previously \nused to assess risk behaviors. 20 \nA cumulative HPV score was calculated using the HPV knowledge, HPV testing and HPV \nvaccination survey, validated by Waller. 21 This is a 29-item measure survey with \npsychometric properties established by classical test theory and item response theory (16 \nitems - HPV knowledge score, 6 items – HPV testing (screening) score, 7 items – HPV \nvaccination score).   Cronbach’s alpha and test-retest reliability values were reported as 0.838 \n(n=648) and 0.79 (n=226) respectively. In addition, Barriers to the HPV vaccination among \nunvaccinated participants and motivators to vaccination were assessed using a survey by \nSteben et al.22 \nStatistical Analysis\nDescriptive statistics were calculated using frequencies and mean/median, and groups were \nstratified by HPV vaccination status. Group comparisons between women who received at least \none dose of HPV vaccination and no HPV vaccination were conducted using chi-square, Fisher’s \nexact test, studentized t-test, and Kruskal-Wallis test. Barriers and motivators to HPV vaccination \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n8\nwere collapsed into categories. Predictors of HPV vaccination were analyzed through two \nmultivariable logistic regressions (MLR). Inclusion of covariates in the model were based on \nprevious literature, and the number of independent variables was bounded by sample size \nrestrictions. Individuals with missing values for outcome and explanatory variables were not \nincluded in the final model. Linearity and multicollinearity assumptions were assessed using Box-\nTidwell test, condition indices (CNI) ≥ 30, and variance decomposition proportions (VDP) ≥ 0.8; \nand goodness-of-fit was examined using Hosmer-Lemeshow test. Violation of linearity \nassumption of HPV score and log odds was corrected with the inclusion of a higher order HPV \nscore term. Multicollinearity violations were corrected with recentering of age and HPV score \naround their medians. MLR results were presented as adjusted odds ratios (aOR) and 95% \nconfidence intervals (CI) in forest plots.  An α = 0.05 was used to determine statistical significance \nand analyses were conducted using SAS 9.4. \nRole of the Funding Source\nFunding was available through the University of Miami Miller School of Medicine MD/MPH \nPopulation Health Scholar Award. The study was supported by the Miami CFAR Clinical Cores \n(P30 AI073961) and the WHIMS study (R01 AI138718). The funder of the study had no role in \nthe study design, data collection, analysis, interpretation or writing of the manuscript. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n9\nRESULTS\nSociodemographic Characteristics and Sexual Behaviors of the Respondents \nA total of 487 women were identified as potential participants and contacted. Out of 157 women \nscreened, 141 deemed eligible with questionnaires distributed via email. One hundred \nquestionnaires were recovered (recovery rate of 70.9%). Among the 100 respondents, 43 (43.0%) \nwomen reported at least one HPV vaccine dose (i.e., vaccinated group), 41 (41.0%) reported not \nreceiving any dose (i.e., unvaccinated group), and 16 (16.0%) women did not know their \nvaccination status. The latter group was excluded from our analysis. Sociodemographic \ncharacteristics are presented in Table 1. \nTable 1. Sociodemographic Characteristics (N=84)\nVaccinated \nN=43 (51.2%)\nUnvaccinated\nN=41 (48.8%) P-value\nAge, years – mean (SD) 24.7 (4.03) 31.4 (8.33) < \n0.0001\nRace – n (%) 0.0144\nWhite 31 (72.1) 17 (41.5)\nBlack 5 (11.6) 13 (31.7)\nOther 7 (16.3) 11 (26.8)\nEthnicity – n (%) 0.9434\nHispanic 15 (34.9) 14 (34.2)\nNon-Hispanic 28 (65.1) 27 (65.9)\nMarital Status – n (%) 0.4821\nMarried 3 (7.3) 5 (12.5)\nSingle 38 (92.7) 35 (87.5)\nEmployment (Full/Part-time) – n (%) 29 (67.4) 23 (56.1) 0.2845\nEducational Attainment – n (%) 0.0077\nNo College Education 3 (7.0) 12 (29.3)\nSome or Completed College Education 40 (93.0) 29 (70.7)\nAverage household monthly income, USD – n (%) 0.0087\n$1000 or less 10 (23.3) 13 (31.7)\n$1001 to $3,000 11 (25.6) 20 (48.8)\n$3,001 or more 22 (51.2) 8 (19.5)\nSexual orientation – n (%) 0.6989\nHeterosexual 36 (83.7) 33 (80.5)\nLGBTQIA+ 7 (16.3) 8 (19.5)\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n10\nTable 2 reports the medical and gynecological history, sexual behaviors, HPV knowledge, \nscreening, and vaccination practices. The vaccinated group was younger (24.7 vs 31.4 years, p < \n0.0001), predominantly white (72.1% vs 31.5%, p = 0.0144), with some college education \n(93.0% vs 70.7%, p = 0.0077), higher average household income (51.2% vs 19.5%, p = 0.0087) \ncompared to the unvaccinated group. Furthermore, vaccinated women had a higher proportion of \ncurrent contraceptive use (69.8% vs 22.0%, p < 0.0001) and lifetime substance use (76.7% vs \n39.0%, p = 0.0005); and lower proportion of lifetime pregnancy (9.3% vs 51.2%, p < 0.0001).\nTable 2. Medical and Gynecological History, Sexual behaviors, HPV Education & Practices among \nstudy participants (N = 84)\nVaccinated \nN = 43 (51.2%)\nUnvaccinated\nN = 41 (48.8%) P-value\nMedical and Gynecological History\nHistory of previous HIV testing - n (%) 25 (58.1) 25 (61.0) 0.7912\nPrEP Aware - n (%) 27 (62.8) 25 (61.0) 0.8640\nPrEP Use - n (%) 0 (0.00) 0 (0.00) N/A\nCurrent Contraception Use - n (%) 30 (69.8) 9 (22.0) < \n0.0001\nHistory of Pregnancy - n (%) 4 (9.3) 21 (51.2) < \n0.0001\nHistory of STIa - n (%) 6 (14.0) 5 (12.2) 0.8113\nSexual Behaviors\nHistory of Sex for Money/Goods/Drugs - n (%) 2 (4.7) 5 (12.2) 0.2594\nAge at First Sexual Encounter, years – mean (SD) 17.2 (3.10) 16.8 (2.49) 0.5111\nNew Partners in the past month – n (%) 9 (22.0) 12 (33.3) 0.2632\nNumber of Male Sexual Partners in the past month \n– median (IQR) 1 (1 – 1) 1 (1 – 2) 0.0297\nNumber of Male Sexual Partners in the past 5 \nyears – median (IQR) 5 (2 – 11) 3 (3 – 7.5) 0.4759\nCondom use during vaginal sex in last month – n \n(%) 0.8330\nAlways 6 (17.1) 8 (22.9)\nSometimes 10 (28.6) 9 (25.7)\nNever 19 (54.3) 18 (51.4)\nHistory of substance useb – n (%) 33 (76.7) 16 (39.0) 0.0005\nHPV Knowledge, HPV testing and Vaccination \nPractices\nCumulative HPV Score, 29-item - mean (SD) 18.9 (6.05) 9.1 (8.82) < .0001\nHPV Knowledge Score, 16 item – mean (SD) 11.0 (3.97) 5.9 (5.46) < .0001\nHPV Testing Score, 6-item – mean (SD) 3.1 (1.81) 1.3 (1.78) < .0001\nHPV Vaccination Score, 7-item – mean (SD) 4.8 (1.44) 1.9 (2.64) < .0001\nHistory of Pap Smear – n (%) 33 (76.7) 36 (87.8) 0.1567\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n11\nAbbreviations. IQR, interquartile range; PrEP, pre-exposure prophylaxis; SD, standard deviation; STI, \nsexually transmitted infections\na Gonorrhea, chlamydia, syphilis, and Trichomonas\nb Medical or recreational marijuana, cocaine, crack, heroin, methamphetamine, hallucinogens, club drugs, \nor any other illicit or recreational drugs\nHPV Knowledge, Screening, and Vaccination Practices \nOn the cumulative HPV score, participants in the vaccinated group reported a mean score of 18.9 \n(SD = 6.05) compared to 9.1 (SD = 8.82) for unvaccinated individuals (p < 0.0001). Mean HPV \nsub-scores on the 16-item HPV knowledge (11.0 vs 5.9, p <0.0001), 6-item HPV testing (3.1 v \n1.3, p < 0.0001), and 7-item HPV vaccination (4.8 vs 1.9, p < 0.0001) scores remained \nsignificantly higher for the vaccinated individuals compared to non-vaccinated individuals. Out \nof the 84 individuals, only 66 (78.6%) women had ever heard of HPV and 58 (69.1%) had ever \nheard of HPV vaccination.  Among the group of 66 women who were aware of the virus, 60 \n(90.9%) knew that HPV infection could be sexually transmitted, 50 (89%) knew that having \nmany sexual partners increases the risk of getting HPV, and 54 (81.8%) knew that HPV causes \ncervical cancer. Within the group aware of HPV vaccination, 54 (93.1%) knew that it could \nprevent cervical cancer. Out of the 43 vaccinated women, 3 (7.0%) reported receiving one dose, \n5 (11.6%) two doses, and 31 (72.1%) three doses; 4 women (2.3%) did not know the exact \nnumber of doses received. The mean age at first HPV vaccine dose was 15 (SD = 5.14) years, \nand 49 (58.3%) women reported a history of HPV screening/Pap smear at least once.\nBarriers and Motivators to HPV vaccination \nAmong unvaccinated women, barriers to HPV vaccination included low-risk perception (14.6%), \nhealthcare barriers (29.3%), and vaccine hesitancy and personal beliefs (46.3%) with specific \nreasons shown in Table 3. The commonly reported motivators or reasons for willingness to \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n12\nreceive the HPV vaccine among both vaccinated and unvaccinated women included protecting \none’s health (67.8%), doctor recommendations (51.2%), and preventing the spread of HPV \n(51.2%) (Table 4). Significant group differences between vaccinated to unvaccinated women \nwere seen in protecting one’s health (83.7% vs 51.2%; p = 0.0014), information on the risks \nassociated with contracting HPV (44.2% vs 17.1%; p = 0.0072), doctor recommendations \n(69.8% vs 31.7%; p = 0.0005), preventing the spread of HPV (62.8% vs 39.0%; p = 0.0294), and \ndiscussion with parents or relatives (27.9% vs 0.0%; p = 0.0003). \nTable 3. Barriers to HPV vaccination in unvaccinated participants (N = \n41)\nLow-Risk Perception - n (%) 6 (14.6)\n“I am married/in a stable relationship”\n“I'm too old for the HPV vaccine”\n“Not sexually active”\n2 (2.4)\n4 (4.8)\n0 (0.0)\n“Already have HPV, sexually active, or at-risk” 0 (0.0)\nHealthcare Barriers - n (%) 12 (29.3)\n“My doctor has never discussed it with me” 11 (13.1)\n“Cost/no private insurance” 3 (3.6)\nVaccine Hesitancy and Personal Beliefs - n \n(%)\n19 (46.3)\n“I've never really thought about it” 10 (11.9)\n“I don't know enough about it” 6 (7.1)\n“I'm not sure it's safe” 4 (4.8)\n“Potential health risks” 2 (2.4)\n“Potential side effects” 3 (3.6)\n“Product(s) haven't been around long enough” 0 (0.0)\n“I am still undecided” 2 (2.4)\n“I don't like needles” 1 (1.2)\n“I don't agree with vaccination” 0 (0.0)\n“Not aligned with my religious/cultural beliefs” 0 (0.0)\n“The HPV vaccine doesn't work” 0 (0.0)\nTable 4. Motivators to HPV vaccination among \nvaccinate and unvaccinated participants (N = 84)\nVaccinated \nN = 43 \n(51.2%)\nUnvaccinated\nN = 41 (48.8%) P-value\nRisk Perception and Vaccine Beliefs - n (%) 37 (86.1) 23 (56.1) 0.0024\n“Protecting my health” 36 (83.7) 21 (51.2) 0.0014\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n13\n“Information on the risks associated with contracting \nHPV” 19 (44.2) 7 (17.1) 0.0072\n“Information on the efficacy of the vaccine” 11 (25.6) 6 (14.6) 0.2119\n“Information on the safety of the vaccine” 6 (14.0) 7 (17.1) 0.6927\n“I know someone who has HPV” 2 (4.7) 4 (9.8) 0.4274\n“I know someone who has had cervical cancer” 1 (2.3) 4 (9.8) 0.1965\nHealthcare-Related - n (%) 34 (79.1) 17 (41.5) 0.0004\n“A recommendation from my doctor” 30 (69.8) 13 (31.7) 0.0005\n“Discussions with my doctor” 16 (37.2) 9 (22.0) 0.1263\n “Vaccine was covered by health insurance” 14 (32.6) 7 (17.1) 0.1014\nSocial - n (%) 31 (72.1) 16 (39.0) 0.0023\n“Preventing the spread of HPV” 27 (62.8) 16 (39.0) 0.0294\n“Discussions with my parents or relatives” 12 (27.9) 0 (0.0) 0.0003\n“One of my friends got vaccinated” 2 (4.7) 4 (9.8) 0.4274\n“Mandatory at school” 3 (7.0) 3 (7.3) 1.0000\n“Offered at school” 1 (2.3) 3 (7.3) 0.3540\nFactors associated with HPV vaccination: Multivariate logistic regressions\nCovariates included in the first multivariate logistic regression analysis were the cumulative \nHPV score, age, race, ethnicity, college education status, current contraceptive use, and number \nof sexual partners (Fig 1 & 2). This model had no violations in multicollinearity (CNI = 10.8) \nand had good fit (X2 = 8.9, p = 0.349). A one-year increase in age was associated with a 16% \nlower odds of HPV vaccination (aOR = 0.84, 95% CI [0.72, 0.99]; p = 0.035) while controlling \nfor the other covariates in the model. Women who were using contraceptives had 8.36 (95% CI \n[1.41, 49.62]; p = 0.020) times the odds of HPV vaccination compared to women not on \ncontraceptives. Race, ethnicity, college education status, and number of sexual partners were not \nsignificant predictors of HPV vaccination (Fig 1). HPV score (estimate = 0.1732, p = 0.0086) \nand HPV score2 (estimate = -0.0148, p = 0.0344) were significant predictors of HPV vaccination. \nThe odds of HPV vaccination follow a quadratic relationship with diminishing odds of HPV \nvaccination after every one-point increase in HPV score. In fact, one-point increases in HPV \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n14\nscore were significantly associated with higher odds of HPV vaccination until an HPV score of \n16 (Fig 2). \nFig 1. Predictors of HPV Vaccination in Multivariate Logistic Regression (n = 84). \nPredictors of HPV vaccination in a multivariable logistic regression model containing age, race, \nethnicity, educational attainment, current contraceptive use, number of sexual partners, and \nHPV score. Adjusted Odd Ratios of adverse events were calculated and presented using a log \nbase 2 scale in a Forest Plot. Null line is indicated for no predictor effects and bolded lines \nrepresent adjusted odds ratio with 95% confidence intervals. Bolded lines above and below the \nnull line indicate increased or decreased odds of adverse events, respectively.\nFig 2.  HPV Score as a Predictor of HPV Vaccination in Multivariate Logistic Regression \n(n = 84). HPV Score as a predictor of HPV vaccination in a multivariable logistic regression \nmodel containing age, race, ethnicity, educational attainment, current contraceptive use, number \nof sexual partners, and HPV score. HPV Score (p = 0.009) and higher order quadratic term of \nHPV Score (p = 0.034) are significant predictors of HPV vaccination. Single score changes \nbeyond an HPV score of 16 are not associated with HPV vaccination. Adjusted Odd Ratios of \nadverse events were calculated and presented using a log base 2 scale in a Forest Plot. Null line \nis indicated for no predictor effects and bolded lines represent adjusted odds ratio with 95% \nconfidence intervals. Bolded lines above and below the null line indicate increased or decreased \nodds of adverse events, respectively.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n15\nThe second model selected evaluated vaccination motivators as predictors of HPV vaccination. \nCovariates fitted included collapsed categories of vaccination motivators: risk perception and \nvaccine beliefs, healthcare related, and social motivators (Table 4). The second model did not \nhave any multicollinearity violations (CNI = 5.04) and had good fit (X2 = 3.88, p = 0.422). \nIndividuals who were motivated by healthcare had 3.03 (95% CI [1.02, 9.00]; p = 0.046) times \nthe odds of HPV vaccination compared to individuals without healthcare-related motivators, \nwhile controlling for risk perception and vaccine beliefs, and social motivators (Fig 3). Risk \nperception and vaccine beliefs (aOR = 1.98, 95% CI [0.68, 5.76] ; p = 0.208) and social (aOR = \n2.47, 95% CI [0.75, 8.07]; p = 0.135) motivators did not significantly predict HPV vaccination. \nFig 3. Motivators of HPV Vaccination in Multivariate Logistic Regression (n = 84). \nMotivators of HPV vaccination in a multivariable logistic regression model containing risk \nperception & vaccine beliefs, healthcare related, and social motivators. Adjusted Odd Ratios of \nadverse events were calculated and presented using a log base 2 scale in a Forest Plot. Null line \nis indicated for no predictor effects and bolded lines represent adjusted odds ratio with 95% \nconfidence intervals. Bolded lines above and below the null line indicate increased or decreased \nodds of adverse events, respectively.\nDISCUSSION\nThis cross-sectional study evaluated HPV knowledge, screening, and vaccination practices as \nwell as factors associated with vaccination among reproductive-age women living in Miami, \nFlorida. It also evaluated barriers and motivations to HPV screening and vaccination. Findings \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n16\nsuggest low vaccination uptake and screening practices amongst all the participants, and lower \nHPV knowledge was seen in the unvaccinated women compared to the vaccinated women. Our \nstudy also found that the cumulative HPV score, current contraceptive use, participant’s age, and \nhealthcare-related motivators were significant predictors of HPV vaccination. Our results \nhighlight the importance of increasing general HPV knowledge in women in a high-risk area \nparticularly in those with little-to-no HPV knowledge, in order to increase vaccine uptake. To \nour knowledge, this is the first study in South Florida reporting on the use of a validated HPV \nscore as a predictor of HPV vaccination, and to identify factors that can potentially be modified \nto increase HPV vaccine uptake.\nPrior studies have shown that increased knowledge of HPV was correlated with vaccination \nstatus12,23,24. Similarly, our study found that cumulative HPV score was highly correlated with \nvaccination status. The mean score of the overall 29-item questionnaire for the vaccinated group \nwas more than double that of the unvaccinated group. An important finding to note is that the \nlikelihood of vaccination increased for every 1-point increase in HPV score until reaching a \nplateau at a score of 16/29. Above 16, a 1-point increase in HPV score was not a significant \npredictor of HPV vaccination. This suggests that overall vaccination rates would increase by \nimproving basic knowledge of HPV in those with little-to-no knowledge, as opposed to \nimproving knowledge in those who already have a foundational knowledge of HPV. Educational \ninterventions should target populations with minimal HPV knowledge to improve vaccination \nrates.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n17\nPrior studies have suggested using routine reproductive health visits, such as contraceptive \ncounseling visits, are important opportunities for providers to educates patients about HPV \nvaccination25,26.   Our results are in alignment with this belief as there were more participants \nvaccinated among those who reported current contraception use. The strong correlation between \ncontraceptive use and vaccination status could be related to multiple factors. Because \ncontraception is provided by physicians, these participants presumably have frequent interaction \nwith the healthcare system, increasing the likelihood that a provider will discuss HPV \nvaccination with them.  Furthermore, these participants may have a higher degree of knowledge \nof sexual behaviors and risks, allowing them to see the benefit of the HPV vaccine.  With regard \nto barrier contraception, a high number of participants who reported never using condoms during \nvaginal sex in the last month were unvaccinated. This serves as a reminder that there is still a \nsubset of patients that can be counseled on HPV vaccines at their contraceptive health visits as \nwell as HPV risk reduction through condom use.\nThe HPV vaccine became medically available in 2006, and in 2018 the FDA expanded the use of \nGardasil 9, the current HPV vaccine, to include individuals ages 27 to 45. Prior to this date, the \nvaccine was only approved for ages 9 to 26.27 The difference in age distribution among vaccinated \nand unvaccinated participants seen in our study is likely a result of the historic vaccination \nguidelines and is congruent with the current literature. 28,29 For the older participants in our study, \nHPV vaccination was less likely to have been recommended in their youth when they were more \nengaged with the health care system and followed routine immunization scheduling. In contrast, \nthe younger participants were likely recommended HPV vaccination at pediatrician visits when \nthey were adolescents. Currently the American College of Obstetrics and Gynecology and the \nAdvisory Committee on Immunization Practices do not recommend catch-up vaccination for \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n18\nindividuals age 27-45 but shared clinical decision making depending on the patient’s risk for new \nHPV infections.30,31   Our results suggest that there could be a subset of older reproductive age \nwomen, that could still benefit from HPV risk factor screening and counseling.\nPrior research found that barriers to HPV vaccination vary depending on the participant population \nstudied32-35. Of the barriers to HPV vaccination identified among unvaccinated women in our \nanalysis, the majority were related to vaccine hesitancy and personal beliefs, and less due to low \nknowledge or healthcare access. These findings highlight the importance of promoting HPV \nvaccination, both within healthcare systems as well as throughout the community. Low-risk \nperception barriers were only reported by about 15% of unvaccinated women which could suggest \na limited understanding of HPV risk factors.\nStudies have also shown that provider recommendation is one of the strongest predictors of HPV \nvaccination19, and we see this in our study with 69.8% of vaccinated participants attesting to \nprovider recommendation as a main reason for vaccination.  Among the motivators for HPV \nvaccination, healthcare related motivators were found to increase odds of HPV vaccination by \n300% when compared to individuals who did not identify these motivators. Based on this finding, \nincreasing vaccination rates would be best accomplished through healthcare related routes, with a \nfocus on provider recommendations. \nA large limitation to this study is the sample size as it restricted the number of variables we could \ninclude in the multivariate analysis and thus models are subjected to uncontrolled confounders. \nOnly 84/100 participants knew their vaccination status, limiting our sample but pointing to low \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n19\nHPV health literacy and health history knowledge in this population. Furthermore, this was a cross-\nsectional study which is limited by temporality. Ultimately, a cause-and-effect relationship cannot \nbe determined with this study design. Our participant recruitment from prior study registries is \nanother limitation to the generalizability of our results as it potentially introduces sampling bias.  \nProviding surveys only in English presents another limitation in the ethnically diverse community \nof Miami.\nRegardless of the limitations, this is an important study as it was conducted in a Southern US city \nwith a high incidence of STIs and low HPV vaccination coverage. Despite an English-only survey, \nour participant population was racially and ethnically diverse. A strong component of this study is \nthe use of validated questionnaires to assess HPV knowledge, screening, and vaccination \npractices as well as barriers and motivators. As the answers to these questions were found to be \nsignificantly different between the vaccinated and unvaccinated groups, it is important that the \nvalidity of these questions was confirmed. Moreover, the study design was strengthened by \nproviding participants the option to complete the survey through a secure web-based system, \nlikely reducing the risk of inaccurate responses that could occur if participants were concerned \nabout privacy.\nOverall, this study was successful in evaluating HPV knowledge, screening, and vaccination \npractices among women of reproductive age living in Miami. Future studies should recruit larger \nsample sizes and include surveys in Spanish, Haitian Creole and other languages in order to gain \na better understanding of the racial and ethnic disparities related to HPV vaccination. The clear \nrelationship between HPV knowledge and vaccination status further emphasizes the need to \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n20\neducate communities about HPV to reduce the spread of the disease and ultimately reduce the rates \nof HPV-related cancers.\nACKNOWLEDGEMENTS\nWe thank the members of the Miami CFAR (Center for AIDS research) for their support and \ncollaboration in the study. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n21\nREFERENCES\n1. zur Hausen H. 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May 2018;50(3):209-225. doi:10.1080/07853890.2018.1426875\n35. Halista CE, Kline RJ, Bepko J. Understanding Barriers to HPV Vaccination: Perspectives \nFrom Air Force Family Medicine Physicians and Active Duty Air Force Males. Mil Med. Jun 8 \n2020;185(5-6):e878-e886. doi:10.1093/milmed/usz403\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n26\nSUPPORTIVE INFORMATION\nNone\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint \n\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 13, 2022. ; https://doi.org/10.1101/2022.09.12.22279885doi: medRxiv preprint","source_license":"CC-BY-4.0","license_restricted":false}