Received: 2 September 2020 | Revised: 29 March 2021
DOI: 10.1002/nur.22135
RESEARCH ARTICLE
A systematic review of human papillomavirus vaccination
among US adolescents
Lisa N. Mansfield1,2 | Ashlee Vance3
1
Rosa M. Gonzalez‐Guarda
1
School of Nursing, Duke University, Durham,
North Carolina, USA
2
Division of General Internal Medicine and
Health Services Research, National Clinician
Scholars Program, University of California,
Los Angeles, Los Angeles, California, USA
3
Institute for Healthcare Policy and
Innovation, National Clinical Scholars
Program, University of Michigan, Ann Arbor,
Michigan, USA
Correspondence
Lisa N. Mansfield, Division of General Internal
Medicine and Health Services Research,
University of California, Los Angeles, 1100
Glendon Ave, Los Angeles, CA 90024, USA.
Email: lmansfield@mednet.ucla.edu
Funding information
National Institute of Nursing Research,
Grant/Award Number: F31NR018347
Res Nurs Health. 2021;44:473–489.
| Accepted: 2 April 2021
| Jacqueline A. Nikpour1 |
Abstract
The human papillomavirus (HPV) causes many anogenital and oral cancers affecting
young adults in the United States. Vaccination during adolescence can prevent HPV‐
associated cancers, but vaccine uptake among adolescents is low and influenced by
factors serving as barriers and facilitators to HPV vaccination. In this systematic
review, we synthesized research using the socioecological framework model to
examine individual‐level, relationship‐level, community‐level, and societal‐level
factors that influence HPV vaccine initiation and completion among US adoles-
cents. The Preferred Reporting Items for Systematic Reviews and Meta‐Analyses
guidelines were used to guide the methodology for this review. An electronic search
was conducted in January 2020 using PubMed, Cumulative Index of Nursing and
Allied Health Literature, ProQuest Central, Scopus, and American Psychological
Association PsycInfo databases. The Joanna Briggs Institute tools were used to
assess the quality for the 57 studies included in this review. The most consistent
influences of HPV vaccination included age at vaccination, awareness, and knowl-
edge about HPV vaccination, socioeconomic status, insurance status, race/ethnicity,
and preventative care behaviors at the individual level. Provider recommendation,
familial/peer support of vaccination, and parental health behaviors were influences
at the relationship level. Although fewer findings elucidated community‐level and
societal‐level influences, high‐poverty areas, high‐risk communities with large pro-
portions of racial/ethnic minority groups, healthcare facilities servicing children, and
combined health policies appear to serve as facilitators of HPV initiation and
completion. Findings from this review can inform culturally relevant and age‐specific
interventions and multi‐level policies aiming to improve HPV vaccination coverage
in the United States.
KEYWORDS
adolescence, care of minority groups/patients, decision making, health promotion/weIlness
behaviors, health seeking behaviors, immunization, parent–child relationships, social and
economic aspects of illness
wileyonlinelibrary.com/journal/nur © 2021 Wiley Periodicals LLC | 473
474 | MANSFIELD
1 | INTRODUCTION
The human papillomavirus (HPV) is the most common sexually trans-
mitted infection in the United States affecting individuals ages 15–24
(Centers for Disease Control and Prevention [CDC], 2020a; Markowitz
et al., 2014). HPV causes 91% of cervical and anal cancers, 63%–75% of
penile, vulvar, and vaginal cancers, and 70% of oral cancers
(CDC, 2020b). HPV‐associated cancers are preventable through vacci-
nation (CDC, 2020a). In the United States, Gardasil 9 is routinely ad-
ministered at ages 11–12 (Dunne et al., 2014; Petrosky et al., 2015) as a
two‐dose series (before age 15) and three‐dose series (after age 15)
(Meites et al., 2016) with parental consent (Ford et al., 2014) and is highly
effective in preventing HPV (Zhai & Tumban, 2016). Adolescent HPV
vaccination rates, however, are suboptimal of the nation's goal of 80%
coverage by age 15 (US Department of Health and Human Services
[DHHS], 2020); with initiation rates at 71.5% and completion rates at
54.2% (Elam‐Evans et al., 2020). A myriad of underlying barriers appears
to contribute to low HPV vaccine initiation and completion.
Previous literature reviews and meta‐analysis on HPV vaccination
have largely reported individual‐level and relationship‐level factors in-
fluencing vaccine initiation among adolescents (Bartlett
Peterson, 2011; Brewer & Fazekas, 2007; Gamble et al., 2010; Holman
et al., 2014; Lacombe‐Duncan et al., 2018; Newman et al., 2018;
Rambout et al., 2014; Rosen et al., 2018; Valentino & Poronsky, 2016).
The authors elucidated the importance of beliefs, attitudes, awareness,
and knowledge about HPV vaccination (Bartlett & Peterson, 2011;
Brewer & Fazekas, 2007; Lacombe‐Duncan et al., 2018) and of socio-
demographic characteristics on vaccine uptake (Galbraith et al., 2016;
Jeudin et al., 2014). Difficulty in parent‐provider and parent‐child com-
munication about the vaccine and sexual health (Gamble et al., 2010;
Rosen et al., 2018), and provider recommendation for vaccination
(Holman et al., 2014; Newman et al., 2018; Valentino & Poronsky, 2016)
also play a role.
Community‐level and societal‐level factors related to HPV vaccina-
tion have been less explored. In a recent meta‐ethnography, investigators
used a socioecological framework and identified parental duty to protect
and HPV vaccine messaging as community/societal‐level and systemic‐
level influences of HPV vaccination respectively (Lacombe‐Duncan
et al., 2018). Other factors, such as regional geographic location, urba-
nicity/rurality, and HPV vaccine policies, may influence vaccine uptake
among adolescents. Regional vaccination disparities exist in the United
States (Hirth, 2019; Ryan et al., 2018), but factors influencing these
disparities are not well‐understood (Hirth, 2019; Ryan et al., 2018) and
may be influenced by societal‐level factors, such as differences in state
policies for HPV vaccination. The influence of policies on HPV vaccina-
tion, however, has not been widely explored.
Using a socioecological approach, we sought to increase the
breadth of literature examining influences of HPV vaccination by
considering geographic characteristics and policy initiatives as
community‐level and societal‐level factors. Specifically, we aimed to
address the following research question: What are the barriers and
facilitators to HPV vaccine initiation and completion among US
adolescents across four socioecological levels?
ET AL.
1.1 | Theoretical framework
Health behavior theories, such as the Health Belief Model and
Theory of Planned Behavior, have largely informed the literature on
HPV vaccination (Askelson et al., 2010; Catalano et al., 2017;
Thomas et al., 2012) and are useful in explaining health‐seeking
behaviors and attitudes influencing health behavior (Poss, 2001).
Using a multilevel theoretical framework, such as the Centers for
Disease Control and Prevention social‐ecological model
(CDC, 2020c), may identify additional factors to HPV vaccination and
elicit a deeper understanding of how multi‐level factors influence
HPV vaccination among adolescents. Socioecological models are
used to understand how individual and environmental factors in-
teract to influence health behavior (Bronfenbrenner, 1986). The
creators of the CDC's model, developed from Bronfenbrenner's so-
cioecological model, posit that preventative health behaviors are
influenced by the interaction between individual, relationship, com-
munity, and societal factors (CDC, 2020c). This model was used in
this review to examine, organize, and synthesize findings related to
barriers and facilitators to HPV vaccination across four levels
& (Figure 1).
Individual‐level factors included studies focused on
parent–adolescent sociodemographic characteristics and their beliefs
about HPV vaccines that influence HPV vaccination. Relationship‐level
factors included studies focused on the role that social influences (e.g.,
family, peers, and healthcare providers) play on HPV vaccination.
Community‐level factors included studies focused on the influence of
community characteristics on HPV vaccination (e.g., socioeconomic sta-
tus, geographic characteristics, and accessibility to healthcare). Societal‐
level factors included studies focused on the influence of policy initiatives
on HPV vaccination among adolescents.
2 | ME THO D S
This review was guided by the Preferred Reporting Items for Sys-
tematic Reviews and Meta‐Analyses (PRISMA) guidelines (Moher
et al., 2009). We collaborated with a librarian to conduct an elec-
tronic literature search in January 2020 using PubMed, Cumulative
Index of Nursing and Allied Health Literature, ProQuest Central,
Scopus, and American Psychological Association PsycInfo databases
using the following keywords: “HPV vaccination,” “adolescents,”
“facilitators,” and “barriers.” Keywords were combined with relevant
Medical Subject Headings (MeSH) terms, medical, and subject
headings for each respective database. For example, the search
string used in PubMed included: “adolescent” [MeSH] OR teen OR
teenagers OR youth OR adolescence AND “vaccination” [MeSH] OR
vaccination OR vaccine OR vaccines OR Gardasil AND “Papilloma-
viridae” [MeSH] OR hpv OR “human papillomavirus virus” AND
“Health Knowledge, Attitudes, Practice” [MeSH] OR barrier OR ob-
stacles OR facilitators OR facilitate OR knowledge OR attitudes OR
perceptions. The search strings for each respective database are
provided in Table 1.
MANSFIELD ET AL. | 475

Barriers & Facilitators across Levels

Adolescents’
Accessibility to & parents’ beliefs
healthcare Healthcare provider
about human
influences
papillomavirus vaccination

Societal Community Relationship Individual

Parent & adolescent
Policies Community sociodemographic
supporting human socioeconomic Family/Peer influences characteristics
papillomavirus status
vaccination

Geographic
characteristics (e.g.
rural vs. urban)

F I G U R E 1 Center for Disease Control and Prevention (CDC) Social‐Ecological Model.1 Note: 1From “The Social‐Ecological Model: A
Framework for Prevention,” by National Center for Injury Prevention and Control, Division of Violence Prevention, 2020, (https://www.cdc.
gov/violenceprevention/publichealthissue/social-ecologicalmodel.html). Reference to this framework does not constitute its endorsement or
recommendation by the U.S. Government, Department of Health and Human Services, or Centers for Disease Control and Prevention. The
material is otherwise available on the agency website for no charge

2.1 | Eligibility criteria
Eligibility criteria included peer‐reviewed, English language studies pub-
lished between 2006 and 2019 in which investigators examined barriers
and facilitators to HPV vaccination among adolescents. We selected
published studies beginning in 2006 because the vaccine was approved
for administration on June 8, 2006 (US Food & Drug Administration
[FDA], 2009). Additional inclusion criteria included (a) quantitative stu-
dies of relationships between a factor and HPV vaccination, defined as
receiving at least one dose of an HPV vaccine (vaccine initiation) or three
doses (vaccine completion) based on the previous vaccine re-
commendations for all adolescent ages (FDA, 2009) and (b) studies in-
cluding parents of vaccine‐eligible adolescents (ages 9–18), and/or
adolescents ages 9–18. This age range was selected because HPV vac-
cines are approved for use in males and females beginning at age nine
(FDA, 2014). Exclusion criteria included: (a) intervention studies, (b) non‐
US studies, and (c) brief reports, short communications, editorials, dis-
sertations, conference abstracts, and literature reviews. Intervention
studies were excluded to avoid the influence of intervention strategies on
HPV vaccination. Studies conducted in other countries were excluded
due to differences in healthcare systems and practices for HPV vacci-
nation. Brief reports were excluded due to a lack of methodological
description to conduct the quality appraisal assessment.
sectional appraisal tool which assessed for the measurement of ex-
posure variables and key characteristics used for subject enrollment
(JBI, 2019). Sociodemographic characteristics were used as exposure
variables across most studies and are often measured without using
valid instruments. Therefore, demographic data were considered as
valid and reliable measures for the item criterion (JBI, 2019). The
CDC's age recommendation for HPV vaccination was used as the key
characteristic for subject enrollment (JBI, 2019).
Studies scoring 60% or greater on the JBI critical appraisal tools
were deemed eligible, determined by the sum of items marked “yes”
divided by the total number of items on the JBI tool. We ranked each
study's quality score as: Low (60%–74%), moderate (75%–89%), and high
(90%–100%). Reviewers may predetermine inclusion criteria (JBI, 2019).
A lower cut‐off score was selected because HPV vaccination was self‐
reported in most studies and demographic characteristics were used as
exposure variables. Three independent reviewers completed the quality
appraisal, with each study being reviewed by at least two reviewers.
There was substantial agreement among reviewers on scoring across
items (k = 0.967). Discrepancies for inclusion were discussed until a
consensus was reached.
2.3 | Data extraction

2.2 | Quality appraisal
The Joanna Briggs Institute (JBI) Critical Appraisal tools for cross‐
sectional and cohort studies (JBI, 2019) were used to assess the
quality and methodological rigor in each study (JBI, 2019). Responses
to each item were marked “yes,” “no,” “unclear,” or “not applicable.”
Modifications were made to items three and four on the cross‐
Data from each study were extracted and synthesized using Garrard's
matrix method (Garrard, 2014). Relevant data included authors, pub-
lication year, purpose, study setting and design, instruments, sample
characteristics, vaccine initiation and/or completion percentages, socio-
ecological level, and key findings. The socioecological level was de-
termined by using the study's purpose and key findings. Key findings
reflected barriers and facilitators to HPV vaccination reported in each
study.
476 | MANSFIELD ET AL.

TABLE 1 Electronic database search terms

Number of
Database Terms and Filters studies

PubMed (((((“adolescent” [MeSH Terms] OR adolescents[tiab] OR adolescent[tiab] OR teen[tiab] 1420

OR teens[tiab] OR teenagers[tiab] OR teenager[tiab] OR youth[tiab] OR
adolescence[tiab]))) AND (((“vaccination” [MeSH Terms] OR vaccination[tiab] OR
vaccinations[tiab] OR vaccine[tiab] OR vaccines[tiab] OR Gardasil[tiab]) AND
(“Papillomaviridae” [MeSH] OR hpv[tiab] OR “human papillomavirus virus” [tiab]))))
AND (((“Health Knowledge, Attitudes, Practice” [MeSH] OR barrier[tiab] OR barriers
[tiab] OR obstacles[tiab] OR obstacle[tiab] OR facilitator[tiab] OR facilitators[tiab]
OR facilitate[tiab] OR knowledge[tiab] OR attitude[tiab] OR attitudes[tiab] OR
perception[tiab] OR perceptions[tiab])))) NOT (Editorial[ptyp] OR Letter[ptyp] OR
Case Reports[ptyp] OR Comment[ptyp]) NOT (animals[mh] NOT humans[mh]) AND
((“2006/01/01” [PDAT]: “2019/12/31” [PDAT]) AND English[lang])

Cumulative Index of Nursing and
Allied Health Literature
(MH “Adolescence+” OR TI(adolescents OR adolescent OR teen OR teens OR teenagers 624
OR teenager OR youth OR adolescence) OR AB(adolescents OR adolescent OR teen
OR teens OR teenagers OR teenager OR youth OR adolescence)) AND (MH
“Papillomavirus Vaccine” OR (TI (vaccination OR vaccinations OR vaccine OR
vaccines OR Gardasil) OR AB (vaccination OR vaccinations OR vaccine OR vaccines
OR Gardasil)) AND ((TI (“Papillomaviridae” OR hpv OR “human papillomavirus
virus”) OR AB (“Papillomaviridae” OR hpv OR “human papillomavirus virus”)))) AND
((MH “Health Knowledge”) OR TI (barrier or barriers or obstacles or obstacle or
facilitator Or facilitators or facilitate OR knowledge OR attitude OR attitudes OR
perception OR perceptions) OR AB(barrier or barriers or obstacles or obstacle or
facilitator Or facilitators or facilitate OR knowledge OR attitude OR attitudes OR
perception OR perceptions))

American Psychology Association ((DE “Human Papillomavirus” OR “Papillomaviridae” OR hpv OR “human papillomavirus 655
PsycInfo virus”) AND (DE “Immunization” OR vaccination OR vaccinations OR vaccine OR
vaccines OR Gardasil)) AND (DE “Treatment Barriers” OR DE “Health Knowledge”
OR barrier or barriers or obstacles or obstacle or facilitator Or facilitators or
facilitate OR knowledge OR attitude OR attitudes OR perception OR perceptions)

ProQuest Central (HPV vaccination) AND barriers AND facilitators AND adolescents 359

Scopus ((TITLE‐ABS‐KEY (adolescents OR adolescent OR (teen OR teens OR teenagers OR 1055

teenager OR youth OR adolescence))) AND (TITLE‐ABS‐KEY (hpv OR “human
papillomavirus virus”)) AND (TITLE‐ABS‐KEY (vaccination OR vaccinations OR
vaccine OR vaccines OR gardasil))) AND (TITLE‐ABS‐KEY (barrier OR barriers OR
obstacles OR obstacle OR facilitator OR facilitators OR facilitate OR knowledge OR
attitude OR attitudes OR perception OR perceptions)) AND (LIMIT‐TO (PUBYEAR,
2019) OR LIMIT‐TO (PUBYEAR, 2018) OR LIMIT‐TO (PUBYEAR, 2017) OR LIMIT‐
TO (PUBYEAR, 2016) OR LIMIT‐TO (PUBYEAR, 2015) OR LIMIT‐TO (PUBYEAR,
2014) OR LIMIT‐TO (PUBYEAR, 2013) OR LIMIT‐TO (PUBYEAR, 2012) OR LIMIT‐
TO (PUBYEAR, 2011) OR LIMIT‐TO (PUBYEAR, 2010) OR LIMIT‐TO (PUBYEAR,
2009) OR LIMIT‐TO (PUBYEAR, 2008) OR LIMIT‐TO (PUBYEAR, 2007) OR LIMIT‐
TO (PUBYEAR, 2006)) AND (LIMIT‐TO (AFFILCOUNTRY, “United States”)) AND
(LIMIT‐TO (LANGUAGE, “English”))

Note: ProQuest Central did not contain specific database search terms.
Abbreviations: AB/ABS, abstract; AFFILCOUNTRY, affiliated country; DE, descriptors; Lang, language; MeSH, Medical Subject Headings; MH, MeSH
headings (PubMed) or Major/minor headings (Cumulative Index of Nursing and Allied Health Literature); PDAT, publication date; Ptyp, publication type;
PUBYEAR, publication year; Tiab, title and abstract; TI, title.

3 | RESULTS
The initial search resulted in 4113 studies (see Figure 2). After removing
duplicates, 2226 studies remained. Titles and abstracts were screened
using the eligibility criteria, removing 2106 studies. Full‐text studies
(n = 120) were further assessed for eligibility and quality appraisal. The
final systematic review included 57 studies. Three investigators were
involved in the process of identifying the final studies included in this
review.
Table 2 presents the quality appraisal results for each study.
Overall, most studies were moderate‐quality (n = 26), followed by high‐
quality (n = 16), and low‐quality (n = 15). The quality of the studies im-
proved over time, with most high‐quality studies published in 2015 or
later. The cross‐sectional studies were mostly moderate‐quality studies
and lacked discussion of confounding variables or use of valid and re-
liable measures to assess the primary outcome. Low‐quality studies
lacked a description of the study subjects and setting, clarity on the
characteristics used to determine subject enrollment, and discussion of
MANSFIELD ET AL.
F I G U R E 2 Preferred Reporting Items for
Identification
Systematic Reviews and Meta‐Analyses
(PRISMA) flow diagram of review search
Association PsycInfo, ProQuest Central, and Scopus
Screening
Eligibility
Included
addressing confounding factors. Among the longitudinal studies, stra-
tegies addressing incomplete follow‐up among participants were not
discussed, although reasons for loss to follow‐up were considered.
The studies included in this review enabled us to highlight key
findings identifying barriers and facilitators to HPV vaccination across
four socioecological levels. Most studies were cross‐sectional and used
survey designs and/or secondary data analyses of national data sets
(n = 52). Convenience, population‐based, and probability sampling meth-
ods were used across all studies. Other studies used longitudinal (n = 5)
designs. Participants were parents of adolescents (n = 32), but other
studies included adolescents and healthcare providers (n = 25). Adoles-
cents' ages ranged from 11 to 17 years, with study participants being
girls (n = 33) and boys (n = 24). Vaccine completion was measured using
the three‐dose series across all studies (n = 57). HPV vaccination was self‐
reported by parents or provided in vaccination records and state im-
munization registries by healthcare providers. Vaccination rates were
moderate across all studies, with initiation rates ranging from 3.7% to
64% and completion rates between 1.4% and 67.9%. Identified barriers
and facilitators are described and organized by each socioecological level
and summarized in Table 3.
| 477
Records identified through database searching: Additional records
PubMed, Cumulative Index of Nursing and Allied identified through other
Health Literature, American Psychological sources
(n = 0)
(n = 4,113)
Records remaining after duplicates removed
(n = 2,226)
Records excluded using titles and
Records screened based abstracts based on: (a) adolescent’s age
on titles and abstracts >18 years; (b) non-United States country;
(n = 2,226) (c) did not examine barriers and
facilitators to HPV vaccination; (d) brief
reports, short communications, editorials,
dissertations, conference abstracts, and
literature reviews; (e) qualitative studies
(n = 2,106)
Full-text articles excluded due to:
(1) sample ages not 9 to 18 (n = 4)
Full-text articles (2) did not examined barriers and facilitators
assessed for eligibility
to HPV vaccination (n = 6)
(n = 120) (3) did not measure vaccine initiation and/or
completion (n = 10)
(4) conducted outside of United States (n = 1)
(5) intervention studies (n = 4)
(6) qualitative/mixed-methods studies (n = 17)
(7) brief reports (n = 3)
Additional studies excluded:
Scored less than 60% on Joanna Briggs
Institute critical appraisal tool (n = 18)
Quantitative studies
included in synthesis
(n = 57)
3.1 | Individual
Studies focused on individual‐level factors included the influence of
parent–adolescent characteristics on HPV vaccine initiation and
completion (n = 33). Ten low‐quality, 15 moderate‐quality, and eight
high‐quality studies were included respectively.
3.1.1 | Adolescents' age at vaccination
The influence of adolescents' age at vaccination on HPV vacci-
nation was reported across four low‐quality, four moderate‐
quality, and two high‐quality studies. Parents with younger
adolescent girls were less likely to initiate HPV vaccines
(Gottlieb et al., 2009). By contrast, parents with older adolescent
girls and boys were more likely to initiate and complete the
vaccine series (Barboza & Dominguez, 2016; Bastani et al., 2011;
Dorell et al., 2011; Gerend et al., 2013; Gilkey et al., 2012;
Gottlieb et al., 2009; Lai et al., 2016; Rahman et al., 2015; Reiter
et al., 2010; Warner et al., 2017).
 478
|

TABLE 2 Critical appraisal of selected studies

Cross‐sectional studies quality appraisal items

Study Addresses
Eligibility condition Con‐founding confounding Outcome Statistical
Author criteria Subjects & setting Exposure measures criteria factors factors measure analysis Quality Level*
a
Allen et al. (2010) ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ High
a
Barboza and Dominguez (2016) ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ High
a
Bass et al. (2015) ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ High
a
Bastani et al. (2011) ✔ ✔ x ✔ x x ✔ ✔ Low

Bhatta and Phillips (2015)a ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ High

Bodson et al. (2017)a ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ High

Choi et al. (2016)a ✔ ✔ ✔ ✔ x x ✔ ✔ Moderate

a
Dela Cruz et al. (2018) ✔ ✔ x ✔ ✔ ✔ x ✔ Moderate
a
Donahue et al. (2015) ✔ ✔ ✔ ✔ x x ✔ ✔ Moderate
b
Dorell et al. (2011) ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ High
a
Farias et al. (2017) ✔ ✔ ✔ ✔ ✔ ✔ x ✔ Moderate
a
Gerend et al. (2013) ✔ ✔ ✔ ✔ x ✔ x ✔ Moderate
a
Gilkey et al. (2012) ✔ ✔ ✔ ✔ x x ✔ ✔ Moderate
a
Gilkey et al. (2016) ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ High
a
A. Glenn et al. (2015) ✔ ✔ ✔ ✔ x x ✔ ✔ Moderate
a
Gottlieb et al. (2009) ✔ ✔ ✔ ✔ x ✔ x ✔ Moderate

Gross et al. (2015)a ✔ ✔ ✔ ✔ ✔ ✔ x ✔ Moderate

Guerry et al. (2011)a ✔ ✔ ✔ ✔ x ✔ ✔ ✔ Moderate

Henry et al. (2017)a ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ High

a
Johnson et al. (2017) X ✔ ✔ ✔ x ✔ ✔ ✔ Moderate
a
Kester et al. (2013) ✔ ✔ ✔ x x ✔ x ✔ Low
a
Lai et al. (2016) ✔ ✔ ✔ ✔ x ✔ ✔ ✔ Moderate
MANSFIELD
ET AL.
 (Continued)
MANSFIELD

TABLE 2
ET AL.

Cross‐sectional studies quality appraisal items

Study Addresses
Eligibility condition Con‐founding confounding Outcome Statistical
Author criteria Subjects & setting Exposure measures criteria factors factors measure analysis Quality Level*
a
Landis et al. (2018) ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ High
a
Lau et al. (2012) ✔ ✔ ✔ ✔ ✔ ✔ x ✔ Moderate
a
Lee et al. (2016) ✔ ✔ ✔ ✔ ✔ ✔ x ✔ Moderate
a
Markovitz et al. (2014) ✔ x ✔ ✔ ✔ ✔ ✔ ✔ Moderate

Monnat and Wallington (2013)a ✔ ✔ x ✔ ✔ ✔ x ✔ Moderate

Monnat et al. (2016)a ✔ ✔ ✔ ✔ ✔ ✔ x ✔ Moderate

Moss et al. (2015)a X x ✔ ✔ x ✔ ✔ ✔ Low

a
Moss et al. (2016) ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ High
a
Munn et al. (2019) ✔ ✔ ✔ ✔ x x ✔ ✔ Moderate
a
O'Leary et al. (2018) ✔ ✔ ✔ ✔ x x x ✔ Low
a
Pierce et al. (2013) ✔ x x ✔ x ✔ ✔ ✔ Low
a
Pierre‐Victor et al. (2017) ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ High
a
Rahman et al. (2015) ✔ x ✔ ✔ x x ✔ ✔ Low
a
Rahman et al. (2017) ✔ x ✔ ✔ x x ✔ ✔ Low
a
Reiter et al. (2009) ✔ ✔ ✔ x x x ✔ ✔ Low
a
Reiter et al. (2010) ✔ ✔ ✔ x x x ✔ ✔ Low

Reiter, Gilkey, et al. (2013)a ✔ ✔ ✔ ✔ x x ✔ ✔ Moderate

Reiter, Gupta, et al. (2014)a ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ High

Reiter, Brewer, et al. (2014)a ✔ ✔ ✔ ✔ x x ✔ ✔ Moderate

a
Rutten et al. (2017) ✔ ✔ ✔ ✔ x x ✔ ✔ Moderate
a
Staras et al. (2014) ✔ ✔ ✔ ✔ ✔ x ✔ ✔ Moderate
a
J. L. Taylor et al. (2014) ✔ ✔ ✔ x x x ✔ ✔ Low

(Continues)
|
479
 480

TABLE 2 (Continued)
|

Cross‐sectional studies quality appraisal items

Study Addresses
Eligibility condition Con‐founding confounding Outcome Statistical
Author criteria Subjects & setting Exposure measures criteria factors factors measure analysis Quality Level*

V. M. Taylor et al. (2014)a ✔ ✔ ✔ x x x ✔ ✔ Low

a
Teplow‐Phipps et al. (2016) ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ High
a
Tsui, Gee, et al. (2013) ✔ ✔ ✔ ✔ ✔ x ✔ ✔ Moderate
a
Tsui, Singhal, et al. (2013) ✔ ✔ ✔ ✔ ✔ x ✔ ✔ Moderate
a
Vadaparampil et al. (2013) ✔ x ✔ ✔ x x ✔ ✔ Low
a,1
Walker et al. (2020) ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ High
a
Warner et al. (2017) ✔ x ✔ ✔ x x ✔ ✔ Low
a
Wong et al. (2011) ✔ ✔ ✔ ✔ ✔ x ✔ ✔ Moderate

Cohort studies quality appraisal items

Consistency of
exposure Addresses No previous Length of Addresses
Recruitment measures in Exposure Confounding confound- exposure to Outcome follow‐ Follow‐up incomplete Statistical
of groups groups measures factors ing factors outcome measures up time complete follow‐up analysis

Brewer et al. (2011)b ✔ ✔ ✔ x ✔ ✔ ✔ ✔ ✔ x ✔ Moderate

b
Fishman et al. (2016) ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ x ✔ High
b
Fishman et al. (2014) ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ x ✔ High
b
Gerend et al. (2019) ✔ ✔ ✔ x ✔ ✔ ✔ ✔ x x ✔ Low

Reiter, McRee, et al. X ✔ ✔ x x ✔ ✔ ✔ ✔ x ✔ Low

(2013)b
a
Joanna Briggs Institute Critical Appraisal tool for analytical cross‐sectional studies.
b
Joanna Briggs Institute Critical Appraisal tool for cohort studies. 1Published online October 2019, therefore included in this review based on the timeframe in which the search strategy was conducted.
Reference has since been assigned a journal issue cited in 2020.
*Quality level based on the following critical appraisal scores: Low: 60%–74%; Moderate: 75%–89%; High: 90%–100%
x = Criterion item not met.
✔= Criterion item met.
MANSFIELD
ET AL.
MANSFIELD ET AL. | 481

TABLE 3 Key findings across studies by socioecological model level

SEM level Barriers Facilitators

Individual Lack of HPV knowledge and awareness Older adolescent age

Perceiving high barriers Public insurance or insured through employer or union
Adolescent sexual inactivity Eligible for Vaccine for Children Program (boys only)
Fears of increased promiscuity (in earlier years) Engaging in HIV testing
Condom use Having multiple sex partners
Lack of knowledge about number of doses needed for vaccine Perceiving vaccine safe and effective
completion
Having vaccine safety concerns Wanting to protect child
Living in household with multiple children (completion only) Acculturated to the United States (Hispanics only)
Living in high‐income households and above federal poverty Proficiency in English (Hispanics and Cambodians only)
level
Living in high areas of poverty (based on family income)
Multiple healthcare or preventative visits
Receiving other adolescent vaccines (e.g. meningococcal,
flu, and TDap)

Contradictory evidencea Being uninsured

Having private insurance
Being of Black or Hispanic descent (vaccine completion only)

Relationship Lack of provider recommendation for vaccination(younger Provider recommendation

adolescents and boys only)
Patient‐provider discussion about vaccine (younger adolescents
and boys only)
Provider perceived barriers with parents following through with
vaccine regimen (vaccine completion)
Providers perceiving vaccine safety concerns
Provider perceived barriers with discussing sexual health with
parents
Quality of provider recommendation
Mother's gynecological preventative health behaviors
(girls only)
Positive vaccine opinions from family/peers
Receiving written HPV information from provider
(completion only)
Parent‐provider discussions about receiving other HPV
vaccine doses (completion only)
Family/peer support of parent's decision to vaccinate
Discussion about sexual health among parents and
adolescents
Older sibling already vaccinated
Parent receipt of flu vaccine

Community Living in areas with large Non‐Hispanic Black population Living in high poverty, low‐income, urban communities
(girls only)
Living in areas with high incidence and mortality of HPV‐related Living in high‐income, metropolitan areas (girls only)
cancers (girls only)
Receiving care from STD or teen clinic (vaccine completion only) Living among large populations of ‘Other' race/ethnicity or
minority groups
Living in states with high‐income households Receiving care from private, pediatrics, OB/GYN facilities
(vaccine initiation for girls only)
Living in states with lower proportions of Non‐Hispanic
White populations (boys only)
Clinics with vaccine providers
Clinics in high‐poverty areas (timely completion only)
a
Contradictory evidence Receiving vaccine doses from a school‐based clinic (vaccine
completion only)

Societal Single policy initiatives mandating HPV vaccination for school‐ Concurrent TDap booster requirements for school‐entry
entry and HPV vaccine administration

Abbreviations: HIV, human immunodeficiency virus; HPV, human papillomavirus; OB/GYN, obstetrics and gynecology; SEM, socioecological model; STD,
sexually transmitted disease; TDap, tetanus, diphtheria, pertussis.
a
Contradictory evidence reflects factors that were reported as both barriers and facilitators across selected studies.
482 | MANSFIELD
3.1.2 | HPV knowledge and awareness
The influence of HPV knowledge and awareness on HPV vaccination
were reported across two low‐quality, five moderate‐quality, and
three high‐quality studies. Parents aware of HPV vaccines were
more likely to initiate the vaccine compared with parents lacking
knowledge and awareness (Dela Cruz et al., 2018; Dorell et al., 2011;
Gottlieb et al., 2009; Guerry et al., 2011; Reiter, Brewer, et al., 2014;
Wong et al., 2011). Two high‐quality longitudinal cohort studies,
however, noted no effect between HPV knowledge, awareness, and
vaccination over 12‐months (Fishman et al., 2014, 2016). Incon-
sistencies could be explained by HPV knowledge and awareness
being assessed only at baseline in the longitudinal studies (Fishman
et al., 2014, 2016). Knowing the number of doses needed for vaccine
completion also influenced completion rates among adolescents
(Gerend et al., 2019; O'Leary et al., 2018).
3.1.3 | Attitudes about HPV vaccination
The influence of HPV vaccine attitudes on HPV vaccination was reported
across three low‐quality, four moderate‐quality, and three high‐quality
studies. Parents reporting barriers to vaccination and vaccine safety
concerns were less likely to initiate and complete the vaccine (Brewer
et al., 2011; Gerend et al., 2019; O'Leary et al., 2018; Reiter, Gupta,
et al., 2014). Shortly after the vaccine debuted, common barriers to
vaccine initiation among girls included parents' beliefs that HPV vacci-
nation was unnecessary due to sexual inactivity (Dorell et al., 2011;
Reiter, Gupta, et al., 2014; Wong et al., 2011) and fears of promiscuity
(Allen et al., 2010; B. A. Glenn et al., 2015; Reiter et al., 2009). Opinions
about HPV vaccination and adolescent sexual activity have changed over
time (Beavis et al., 2017). Positive vaccine attitudes (e.g., perceiving the
vaccine as effective, safe, and a health benefit) were associated with
1.54–9.03 times higher odds of HPV vaccination (Allen et al., 2010; Dela
Cruz et al., 2018).
3.1.4 | Socioeconomic status
The influence of socioeconomic status on HPV vaccination was reported
across three moderate‐quality and three high‐quality studies and incon-
sistencies in findings were noted. In two moderate‐quality studies, ado-
lescents living in high‐income households were 0.22–0.67 times less likely
to initiate HPV vaccines compared to adolescents living in low‐income
households (Choi et al., 2016; Gilkey et al., 2012). The likelihood of
vaccine initiation and completion in another moderate‐quality study,
however, was 79% higher among adolescents living in household incomes
less than 133% of the federal poverty level (Tsui, Gee, et al., 2013).
Higher vaccine initiation and completion rates among lower‐income
households may be explained by the eligibility for public insurance
(Dorell et al., 2011; Tsui, Gee, et al., 2013). The likelihood of vaccine
completion in two high‐quality studies, however, was 0.42–0.91 times
lower among adolescents living in households with four or more children
ET AL.
compared with adolescents living in households with fewer children
(Barboza & Dominguez, 2016; Reiter, Gupta, et al., 2014).
3.1.5 | Insurance status
The influence of healthcare insurance on HPV vaccination was reported
across two low‐quality, seven moderate‐quality, and three high‐quality
studies and resulted in mixed findings. Across three moderate‐quality
studies, having public insurance or private insurance served as a facil-
itator to vaccine initiation (Choi et al., 2016; Reiter, Brewer, et al., 2014;
Tsui, Gee, et al., 2013) and completion (Reiter, Brewer, et al., 2014). In a
high‐quality study, the odds of timely vaccine completion were 5% higher
among adolescent boys with public insurance compared to boys with
private insurance (Teplow‐Phipps et al., 2016). Private insurance and
being uninsured were reported as both a barrier and facilitator to vaccine
initiation (Lau et al., 2012; Pierce et al., 2013; J. L. Taylor et al., 2014;
Teplow‐Phipps et al., 2016; Wong et al., 2011). Being uninsured, how-
ever, decreased the odds for vaccine completion (Reiter, Gupta,
et al., 2014) and timely completion (Teplow‐Phipps et al., 2016). Vaccine
initiation was higher among adolescent boys eligible for the Vaccine for
Children program (Dorell et al., 2011; Johnson et al., 2017; Reiter, Gilkey,
et al., 2013).
3.1.6 | Race/ethnicity
The influence of race/ethnicity on HPV vaccination was reported across
four low‐quality, five moderate‐quality, and three high‐quality studies.
Although vaccine initiation was higher among Black and Hispanic ado-
lescents than Non‐Hispanic White adolescents (Barboza &
Dominguez, 2016; Choi et al., 2016; Gilkey et al., 2012; Kester
et al., 2013; Landis et al., 2018; Pierce et al., 2013), vaccine completion
was lower among these groups (Dorell et al., 2011; Monnat et al., 2016).
Vaccine series compliance, however, was higher among Hispanic ado-
lescent girls in a low quality‐study (Rahman et al., 2017). Differences in
findings may be attributed to the use of older national data sets pub-
lished when the vaccine debuted (Dorell et al., 2011; Monnat et al., 2016)
and a lack of description of adolescents' ages in the study sample
(Rahman et al., 2017). The likelihood of vaccine initiation was 86% higher
among Hispanic adolescent girls whose parents acculturated to the
United States (Gerend et al., 2013). Across two moderate‐quality studies,
the odds of vaccine initiation among Hispanic and Cambodian‐American
adolescent girls was 1.70–2.82 times higher if parents were proficient in
English compared with those with lower English proficiency (Gerend
et al., 2013; Lee et al., 2016).
3.1.7 | Preventative care behaviors
The influence of adolescent preventative care behaviors on HPV vacci-
nation was reported across five low‐quality, six moderate‐quality, and
four high‐quality studies. Vaccine initiation and completion were greater
MANSFIELD ET AL.
among adolescents with preventative visits within the past year (Barboza
& Dominguez, 2016; Dorell et al., 2011; Reiter et al., 2010; Reiter, Gilkey,
et al., 2013; Reiter, Gupta, et al., 2014; Reiter, Brewer, et al. 2014; Wong
et al., 2011). The odds of HPV vaccine initiation and completion was
1.46–7.89 times higher among adolescents receiving the meningococcal,
influenza, and TDap vaccines (Gerend et al., 2019; Gilkey et al., 2012; Lai
et al., 2016; Lau et al., 2012; Rahman et al., 2015; Reiter et al., 2010; V.
M. Taylor et al., 2014; Warner et al., 2017; Wong et al., 2011). The
likelihood of vaccine initiation was over two times higher among sexually
active adolescents who engaged in HIV testing and had multiple sexual
partners (Bass et al., 2015). The odds of vaccine initiation, however, were
60% lower among adolescents using condoms during intercourse (Bass
et al., 2015).
3.1.8 | Relationship
Studies focused on relationship‐level barriers and facilitators to HPV
vaccination largely included social influences from providers, family,
and peers (n = 14). Four low‐quality, eight moderate‐quality, and two
high‐quality studies were included respectively.
3.1.9 | Provider recommendation
Provider recommendation for HPV vaccination was the most statistically
significant facilitator to HPV vaccine initiation and completion among
adolescents and was reported across two low‐quality, eight moderate‐
quality, and four high‐quality studies (Dela Cruz et al., 2018; Donahue
et al., 2015; Dorell et al., 2011; Gerend et al., 2013; Gilkey et al., 2012;
Gottlieb et al., 2009; Guerry et al., 2011; Landis et al., 2018; Rahman
et al., 2017; Reiter, McRee, et al., 2013; Reiter, Gupta, et al., 2014; Reiter,
Brewer, et al., 2014b; Staras et al., 2014). The odds of vaccine initiation
among adolescents were five to nine times higher when providers ex-
pressed the importance and urgency for HPV vaccination (Donahue
et al., 2015; Gilkey et al., 2016; Staras et al., 2014). In a high‐quality study,
the odds of vaccine completion were nearly two times higher among
adolescents when providers framed vaccine messaging as cancer
prevention (Gilkey et al., 2016).
3.1.10 | Intrapersonal support for HPV vaccination
The influence of intrapersonal support for HPV vaccination on vaccine
uptake was reported across three low‐quality, six moderate‐quality, and
two high‐quality studies. In two moderate‐quality studies, receiving po-
sitive vaccine opinions from family and peers, supporting parents' deci-
sion for vaccination, and having older siblings who were vaccinated
increased vaccine initiation (Donahue et al., 2015; A. Glenn et al., 2015).
Parent–child discussions about sexually transmitted infections, HPV
vaccination, and safe‐sex practices resulted in higher odds of vaccine
initiation (Gilkey et al., 2016; Gross et al., 2015; V. M. Taylor et al., 2014).
Vaccine initiation was less likely, however, when parents lacked
| 483
discussions about HPV vaccination with their child's healthcare provider
(Donahue et al., 2015; Gross et al., 2015).
Patient‐provider discussion and recommendation for HPV vacci-
nation were less likely among younger adolescents and boys (Bhatta &
Phillips, 2015; Choi et al., 2016; Donahue et al., 2015; Gross
et al., 2015; Reiter, McRee, et al., 2013). Providers reported difficulty
in discussing sexual health with parents, perceiving the vaccine to
have limited safety data (Rutten et al., 2017), and ensuring adoles-
cents follow through with vaccine completion (Farias et al., 2017;
Rutten et al., 2017). In a longitudinal study, however, the odds of
vaccine completion were 2.26 times higher when providers discussed
the HPV vaccination schedule and nearly three times higher when
parents received written HPV information (Gerend et al., 2019).
Differences in findings may be explained by the length of time that
HPV vaccination was assessed (e.g., 12‐months) in the longitudinal
study (Gerend et al., 2019).
3.1.11 | Parental health behaviors
The influence of parents' engagement in preventive health on HPV
vaccination was reported across two low‐quality and three
moderate‐quality studies. Across two moderate‐quality and a low‐
quality study, adolescent girls were more likely to initiate and com-
plete the vaccine series if their mothers received Pap‐testing and
mammograms regularly, and reported previous abnormal Pap‐tests
and sexually transmitted infections (Markovitz et al., 2014; Monnat
& Wallington, 2013; V. M. Taylor et al., 2014). The odds of vaccine
initiation among adolescents was over two times higher (Gilkey
et al., 2012; Reiter et al., 2010) if parents received the flu vaccine.
3.2 | Community
Community‐level factors included studies focused on the influence of
neighborhood and clinic characteristics on HPV vaccination (n = 8).
One low‐quality, four moderate‐quality, and three high‐quality stu-
dies were included respectively.
3.2.1 | Poverty status
The influence of community poverty status on HPV vaccination was
reported across two moderate‐quality and three high‐quality studies.
Adolescents living in high‐poverty areas and urban communities were
more likely to achieve vaccine initiation and completion (Henry
et al., 2017; Monnat et al., 2016). Clinics in high‐poverty areas saw more
timely completion (Teplow‐Phipps et al., 2016). Differences by gender
and metropolitan status reported mixed results. In a high‐quality study,
adolescent boys living in high‐poverty, metropolitan areas were more
likely to complete the vaccine series (Henry et al., 2017), but findings in a
moderate‐quality study noted that living in high‐income metropolitan
areas contributed to parents' initiating vaccination for their daughters
484 | MANSFIELD
(Monnat et al., 2016). Differences in sample inclusion by gender across
both studies could contribute to this inconsistency. In a high‐quality
study, vaccine initiation was not influenced by poverty status in rural
areas, where initiation rates were lower (Walker et al., 2020). Among
low‐income girls in a moderate‐quality study, there was no effect be-
tween clinic proximity and vaccine initiation (Tsui, Singhal, et al., 2013).
3.2.2 | High‐risk communities
Communities at high risk for HPV‐associated cancers saw dif-
ferences in HPV vaccination by gender and were reported across
a low‐quality and a moderate‐quality study. Adolescent girls
living in states with higher household incomes and higher pro-
portions of Non‐Hispanic Black populations had lower propor-
tions of vaccine initiation (Moss et al., 2015). Vaccine initiation
was higher, however, among adolescent boys living in states with
lower proportions of Non‐Hispanic Whites and adolescents with
personal healthcare providers (Moss et al., 2015). Vaccine in-
itiation was higher for adolescent boys and girls living in states
with high proportions of ‘Other' race/ethnicity populations (Moss
et al., 2015). Similar findings were noted for low‐income girls
living among higher proportions of multiracial and ethnic min-
ority groups in a moderate‐quality study (Tsui, Gee, et al., 2013).
Vaccine initiation and completion rates were lower among ado-
lescent girls living in states with high incidence and mortality of
HPV‐related cancers (Moss et al., 2015).
3.2.3 | Healthcare facility type
The influence of healthcare facility type on HPV vaccination was
reported across three low‐quality, one moderate‐quality, and two
high‐quality studies. Private practices and healthcare facilities
with pediatricians, obstetricians/gynecologists, and vaccine pro-
viders saw higher vaccine initiation and completion rates among
adolescents (Bodson et al., 2017; Moss et al., 2015; Teplow‐
Phipps et al., 2016; Vadaparampil et al., 2013). In a low‐quality
study, adolescent girls receiving care from sexually transmitted
disease, teen, or school clinics were less likely to achieve vaccine
completion by age 12 (Rahman et al., 2017). Adolescents visiting
school health centers, however, saw higher vaccine completion
rates by age 13 in a moderate‐quality study (Munn et al., 2019).
These discrepancies may be attributed to the sample design used
in both studies (e.g. national data set vs. state immunization
registry).
3.3 | Societal
Only two studies explored societal‐level factors influencing HPV
vaccination among adolescents. Both studies were high‐quality
studies.
ET AL.
3.3.1 | Health policy initiatives
Mixed findings were reported regarding the effect of policies on HPV
vaccination. There was no effect among states mandating HPV vac-
cination for school entry and vaccine uptake (Moss et al., 2016;
Pierre‐Victor et al., 2017). An increase in HPV vaccination rates,
however, was noted with concurrent school requirements for the
TDap booster and coadministration of the meningococcal vaccine
(Moss et al., 2016).
4 | DISCUSS ION
We identified barriers and facilitators to HPV vaccine initiation and
completion among adolescents across four socioecological levels.
Overall, this review largely contained studies of adolescent girls. This
may be explained by policies' focus on improving HPV vaccination
among girls as a public health benefit, resulting in misperceptions in
the benefits of vaccinating boys (Newman et al., 2018). Vaccine in-
itiation and completion rates were moderate across all studies. Most
studies, however, were cross‐sectional and subsequent vaccine doses
may have been received post‐study period. All studies assessed
vaccine completion using the three‐dose series, although, as of 2016,
two doses are recommended for series completion for adolescents
before age 15 (Meites et al., 2016). Challenges to vaccine completion
discussed in this review may differ from those experienced for two‐
dose series completion. We identified similar individual‐level and
relationship‐level factors of HPV vaccination as other literature re-
views and meta‐analyses (Bartlett & Peterson, 2011; Brewer &
Fazekas, 2007; Gamble et al., 2010; Holman et al., 2014; Newman
et al., 2018; Rambout et al., 2014). Using a socioecological approach,
however, we identified additional community‐level and societal‐level
factors influencing HPV vaccination among adolescents.
Individual‐level barriers and facilitators were similar by gender
but differed by race/ethnicity. This finding is inconsistent with gen-
der differences in HPV vaccination noted in a meta‐analysis and may
be explained by the inclusion of non‐US studies (Newman
et al., 2018), where HPV vaccine recommendation for adolescent
boys may vary from that of the United States. Our findings were
consistent with other reviews in noting parental acculturation and
English‐proficiency as facilitators to vaccine initiation among His-
panic and Asian adolescents (Bartlett & Peterson, 2011; Lacombe‐
Duncan et al., 2018). In this review, however, higher vaccine com-
pletion and series compliance were noted among Hispanic adoles-
cent girls than previously reported (Galbraith et al., 2016; Jeudin
et al., 2014). Although this finding holds promise to improve racial
disparities in HPV vaccination, the incidence of HPV‐related cancers
continues to disproportionately affect US Black and Hispanic men
and women (CDC, 2020b). Future research should consider using
qualitative or mixed‐methods designs to explore how culturally re-
levant barriers influence racial disparities in HPV vaccination.
Insurance status resulted in mixed findings and differed by in-
surance type. Other reviews noted vaccine costs as a barrier to
MANSFIELD ET AL.
vaccination (Brewer & Fazekas, 2007; Garcini et al., 2012; Holman
et al., 2014), however, there was both a positive and negative as-
sociation between insurance coverage/costs and HPV vaccination in
a meta‐analysis (Newman et al., 2018). Being uninsured or privately
insured also resulted in mixed findings and may be explained by
differences in insurance plan services and government assistance for
uninsured individuals. Uninsured, underinsured, and Medicaid re-
cipients are eligible for free or low‐cost childhood vaccines through
the Vaccine for Children program (CDC, 2016). Additional costs as-
sociated with clinic visits, however, may present greater challenges
for uninsured families to receive subsequent vaccine doses. The Af-
fordable Care Act contains provisions for private insurance to cover
all childhood vaccines (DHHS, 2010), but co‐pays and service fees
may create differences in out‐of‐pocket costs. Future policies should
consider increasing accessibility of insurance coverage for uninsured
adolescents and improving insurance reimbursement to decrease
out‐of‐pocket costs for preventive services.
Among relationship‐level factors, provider recommendation was
the most influential facilitator to HPV vaccination among adoles-
cents in this review and others (Barlett & Peterson, 2011; Brewer &
Fazekas, 2007; Holman et al., 2014; Lacombe‐Duncan, 2018;
Newman et al., 2018; Valentino & Poronsky, 2016). Similar findings
were noted regarding disparities in recommendations and discus-
sions for HPV vaccination by age and gender (Liddon et al., 2010;
Rosen et al., 2018). The initial messaging for HPV vaccination and
parental perceptions of adolescent sexual activity may explain these
disparities. Initially, the vaccine was largely marketed as cervical
cancer prevention (Daley et al., 2017). The emphasis on a disease
affecting women may create a misconception of the benefits of
vaccinating boys. Furthermore, more than half of adolescents had
sex by age 18 (Abma & Martinez, 2017). Parents of younger ado-
lescents may delay vaccination until an older age when they perceive
their children to be sexually active. These disparities underscore the
importance of reframing HPV vaccine messaging and providing HPV
education to parents with younger adolescents and boys. Future
research should consider developing age‐specific and gender‐specific
messaging and communication strategies for HPV vaccination that
providers and parents can use for adolescents.
New community‐level factors of HPV vaccination were dis-
covered in this review. Both vaccine initiation and completion were
lower among girls living in high‐risk areas for HPV‐associated can-
cers. In a review focused on HPV vaccination in Appalachia, a high‐
risk region for HPV‐associated cancers, low vaccination rates were
attributed to low parental knowledge and risk perception of HPV
(Ryan et al., 2018). In this review, however, we identified higher
vaccine initiation and completion rates among high‐risk areas con-
centrated with healthcare facilities servicing adolescents (Bodson
et al., 2017; Moss et al., 2015; Munn et al., 2019). Although this
finding holds promise for improving HPV vaccination rates in high‐
risk communities, it underscores the importance of using alter-
native strategies to reach parents and adolescents who cannot
access care. Future studies should consider using schools to im-
plement HPV interventions and administer HPV vaccines. School‐
| 485
based programs have improved HPV vaccine coverage in other
countries (Walling et al., 2016) and may have implications in im-
proving US vaccination rates.
We reported mixed findings on the influence of poverty status
on HPV vaccination than findings previously reported in other re-
views. Racial/ethnic minority adolescents living below the poverty
level were more likely to initiate HPV vaccination but less likely to
complete the series (Jeudin et al., 2014). Although these findings are
consistent with those reported for race/ethnicity at the individual
level, findings from this review revealed higher vaccine completion
rates among adolescents living in high‐poverty areas (Henry
et al., 2017; Moss et al., 2015; Rahman et al., 2017). Although so-
cioeconomic status was measured differently at the individual level,
differences in findings shed light on how individual and environ-
mental factors interact to influence health behavior. Higher vacci-
nation rates among high‐poverty communities may be explained by
the composition of low‐income families living in these areas who are
eligible for public insurance and the Vaccine for Children program.
Parents' educational attainment and vaccine beliefs may explain
lower vaccination rates among high‐income families. Affluent families
tend to have higher levels of education and were more likely to
submit nonmedical exemptions for other childhood vaccines due to
vaccine safety concerns, medical distrust, misinformation about
vaccines, and beliefs in complementary alternative medicine (McNutt
et al., 2016; Morrison et al., 2020; Salmon et al., 2005). Similar
findings were noted for HPV vaccination as parents with college or
graduate‐level education were less likely to vaccinate their children
and reported more hesitation about HPV vaccines (Brewer &
Fazekas, 2007; Pruitt & Schootman, 2010; Warner et al., 2017).
Understanding how community characteristics influence adolescent
HPV vaccination is limited using quantitative designs. Future re-
search should consider using qualitative or mixed‐methods designs
to understand how neighborhood characteristics and resources in-
fluence HPV vaccination among adolescents living in low‐poverty
and high‐poverty areas.
To our knowledge, no other reviews have reported societal‐level
factors related to the effects of policies on HPV vaccination. Policies
combining requirements of other adolescent vaccines were more
effective at improving HPV vaccination than single policies man-
dating HPV vaccination for school‐entry (Moss et al., 2016; Pierre‐
Victor et al., 2017). Future policies should be considered that use
multi‐level approaches to develop initiatives addressing factors in-
fluencing HPV vaccination. Future research should also consider
developing multi‐level interventions that reduce barriers and pro-
mote facilitators of HPV vaccination to improve vaccination rates.
4.1 | Limitations
This review has several limitations. We only included quantitative stu-
dies, thus limiting the perspective on factors influencing HPV vaccination
to those predetermined by the investigators. Including qualitative studies
may identify other important variables and provide more comprehensive
486 | MANSFIELD
explanations for the influence that the factors examined play on HPV
vaccination. Studies excluded based on quality may have captured ad-
ditional factors influencing HPV vaccination among adolescents that
were not reported in this review. Lastly, we excluded non‐English and
non‐US studies and selected studies with participants mostly comprised
of adolescent girls. Thus, the generalizability of findings is limited among
parents with adolescents in other countries and limits our ability to make
direct comparisons by gender.
| C O N CL U S I O N
5
Barriers and facilitators of HPV vaccination are influenced by multi‐
level factors. Using a socioecological approach, we highlighted
individual‐level, relationship‐level, community‐level, and societal‐
level factors related to HPV vaccination among adolescents and
provided critical new insights into barriers reported in the current
literature. Deeper insight into multi‐level influences of HPV vacci-
nation may inform the development of interventions and policy in-
itiatives that may reduce barriers and improve vaccination rates
among adolescents.
A C K N O W L E D GM E N T S
The authors would like to acknowledge Amanda Woodward, MLIS
for her assistance with the search strategy for this review. Research
reported in this publication was supported by the National Institute
of Nursing Research of the National Institutes of Health under
Award Number F31NR018347. The content is solely the responsi-
bility of the authors and does not necessarily represent the official
views of the National Institutes of Health.
C O NF L IC T O F IN T E R ES T S
The authors declare that there are no conflict of interests or financial
disclosures that could be perceived as prejudicing the impartiality of
the research reported.
DATA AV AILA BILITY STATEMENT
The data that support the findings of this study are openly available
in Mendeley Data at (doi.)[doi to be inserted when the manuscript is
accepted for publication], reference number [insert reference num-
ber here when the manuscript is accepted for publication].
ORCID
Lisa N. Mansfield http://orcid.org/0000-0002-4617-2663
Ashlee Vance https://orcid.org/0000-0003-0284-3995
Jacqueline A. Nikpour https://orcid.org/0000-0001-9902-4368
Rosa M. Gonzalez‐Guarda https://orcid.org/0000-0002-0220-5208
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How to cite this article: Mansfield, L. N., Vance, A., Nikpour, J.
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