SOCW6362WK1Reading3.pdf

Parental Acceptance of a Mandatory Human
Papillomavirus (HPV) Vaccination Program
Daron Ferris, MD, Leslie Horn, BS, and Jennifer L. Waller, PhD

Objectives: The objective of this study was to determine factors that influence parent’s acceptance of a
mandatory school-based human papillomavirus (HPV) vaccination program.

Methods: A convenience sample of 325 parents, with children aged 9 to 17 years old, completed a
53-item survey. Survey questions targeted their opinions about HPV, the HPV vaccine, and a mandatory
HPV vaccination program. �2 tests were used to examine relationships between survey items.

Results: Characteristics of parents who believed the HPV vaccine should be mandated included lim-
ited financial resources (P � .03), history of HPV-related disease (P � .04), understanding their child’s
susceptibility (P � .03), interest in HPV vaccination for their child (P � .0001), and knowledge that the
vaccine reduces the risk of cervical cancer (P � .001). Parents of children aged 12 to 14 years old (P �
.02) or who knew the vaccine reduced their child’s risk of developing genital warts (P � .02) and cervi-
cal cancer (P � .001) would be more likely to comply with a mandatory HPV vaccine program.

Conclusions: Certain characteristics define parents who support a mandatory HPV vaccination pro-
gram. Greater education of parents and health care providers should improve vaccination uptake, which
ultimately reduces morbidity and mortality from HPV related diseases. ( J Am Board Fam Med 2010;23:
220 –229.)

Keywords: Human Papillomavirus, Health Care Surveys, Attitude, Vaccination

Although the quadrivalent human papillomavirus
(HPV) vaccine has demonstrated robust efficacy
and reasonable safety, suboptimal vaccination rates
raise concern and questions.1– 6 A survey conducted
in 2007 by the Centers for Disease Control and
Prevention found that approximately 25% of 13- to
17-year-old girls had received at least one dose of
the HPV vaccine.5 Moreover, far fewer 9- to 12-

year-old and 18- to 26-year-old girls and women
have initiated the vaccination series. The poor rate
of HPV vaccine coverage for 9- to 12-year-old girls
is particularly worrisome because this has been
deemed the ideal age to vaccinate.7 In comparison,
coverage for school-entry vaccines during the
2007–2008 school year estimated by the Centers
for Disease Control and Prevention varied between
94% (varicella) and 96% (hepatitis B).8 The differ-
ences in these vastly contrasting rates of vaccina-
tion are likely because of many factors, including
cost, safety, knowledge, provider issues, access, and
controversy.9 –11 However, one simple explanation
is that school-entry vaccines are mandated and the
HPV vaccine is not.

Although discussion of mandating vaccines gen-
erates conflicting opinions, this approach has
proven very beneficial from a public health per-
spective. School-mandated vaccination programs
have increased coverage for other vaccines.12–15

However, such an approach for the HPV vaccine
has met some resistance by the medical commu-
nity.16 Further, only a minority of parents ap-
prove mandating the quadrivalent HPV vac-
cine.17,18 Loss of parental autonomy, cost,
insufficient data from clinical trials, and too

This article was externally peer reviewed.
Submitted 22 April 2009; revised 8 July 2009; accepted 13

July 2009.
From the Gynecologic Cancer Prevention Center (DF);

the Departments of Family Medicine and Obstetrics and
Gynecology (DF) and the Department of Biostatistics
(JLW), Medical College of Georgia (LH), Augusta, Geor-
gia.

Funding: Residual grant funds.
Conflict of interest: Dr. Ferris is an investigator for Glaxo-

SmithKline vaccine studies. He is also a consultant, investi-
gator, and speaker for Merck and Co., Inc. Ms. Horn and
Dr. Waller have no potential conflicts.

Corresponding author: Dr. Daron G. Ferris, Department of
Family Medicine, Medical College of Georgia, 1423 Harper
Street, HH-105, Augusta, GA 30912 (E-mail: agerman@
mcg.edu).

See Related Commentary on
Page 149.

220 JABFM March–April 2010 Vol. 23 No. 2 http://www.jabfm.org

o
n
5

Ju
n
e

2
0
2

1
b

y g
u

e
st. P

ro
te

cte
d

b
y co

p
yrig

h
t.

h
ttp

://w
w

w
.ja

b
fm

.o
rg

/
J A

m
B

o
a

rd
F

a
m

M
e

d
: first p

u
b

lish
e

d
a

s 1
0

.3
1

2
2

/ja
b

fm
.2

0
1

0
.0

2
.0

9
0
0
9
1
o

n
5

M
a
rch

2
0
1
0
. D

o
w

n
lo

a
d
e
d
fro

m

http://www.jabfm.org/

many side effects are the main reasons for lack of
parental support.17,18 In addition, critical ap-
praisal of parental acceptance of a mandatory
HPV vaccination program would be beneficial
before promoting required HPV vaccination for
children. The purpose of this study was to deter-
mine factors that influence parental acceptance of
a mandatory HPV vaccination program.

Materials and Methods
We asked parents of 9- to 17-year-old children to
participate in this study. A convenience sample of
eligible parents was recruited from waiting rooms
in family medicine, obstetrics and gynecology, and
pediatric clinics at the Medical College of Georgia,
Augusta, and from Women’s Health Associates,
Atlanta, Georgia. Patients were also recruited from
community sites, including Riverview Park, North
Augusta, South Carolina; Suwanee Academy of the
Arts, Suwanee, Georgia; and hair and nail salons in
Augusta and Atlanta. We excluded parents who
were unable to read English. This study was ap-
proved by the Human Assurance Committee at the
Medical College of Georgia.

The questionnaire has been described previ-
ously, but it consisted of 53 questions that collected
demographic data, opinions about HPV and vac-
cines, attitudes about the HPV vaccine, and issues
involving a mandatory HPV vaccination pro-
gram.17 The main outcome questions determined
parental reactions to a mandated HPV vaccination
program. Specifically, these questions were (1) Do
you think the HPV vaccine should be added to the
list of school entry vaccine requirements? and (2) If
the vaccine was mandatory for a child to attend
school, which of the following statements most
agrees with your view? (answer options for question
2 were “I would sign a waiver to prevent my child
from receiving the vaccine”; “I would have my child
vaccinated”; or “I would do whatever my doctor
recommends.” Questions were structured as yes/no
and multiple choice. Some pertinent questions
from previously developed questionnaires were in-
cluded.19 –21

Parents were asked to participate in a study
about their opinions of the HPV vaccine and man-
datory vaccination programs. Eligible parents who
agreed to participate were given a 1-page cover
letter that described HPV and the HPV vaccine.
Subjects then completed the self-administered,

anonymous survey and returned it in an envelope to
the investigators.

Descriptive statistics, including means and
standard deviations, frequencies, and percent-
ages, were calculated for responses to each ques-
tion. �2 tests were used to examine the relation-
ship between various questionnaire items. All
statistical analyses were performed using SAS
software version 9.1.3 (SAS Institute, Inc., Cary,
NC) and statistical significance was assessed us-
ing an � level of 0.05.

Results
We asked 365 parents to participate in the study;
325 parents enrolled in the fall of 2008. The re-
sponse rate was 89%, with insufficient time and
length of the questionnaire being the main reasons
for parents’ refusal to participate. Complete demo-
graphic data based on the 325 parents have been
published previously.17 In summary, subjects
tended to be female, 30 to 39 years old, white,
protestant, have a family income between $20,000
and $50,000, have some college education, and
have private health insurance. Personal history of
HPV-related problems included 13% with a previ-
ous HPV infection, 5% with condyloma, and 37%
had a previous abnormal Papanicolaou test result.

Associations between demographic variables and
agreement with adding the HPV vaccine to school
entry requirements are seen in Table 1. Those with
incomes �$20,000, those with no health insurance,
Medicaid, or Tricare insurance, or those who have
ever had HPV were more likely to agree that the
HPV vaccine should be added to school entry re-
quirements. Sex, race, and age of children did not
predict support for an HPV vaccine mandate.

Associations between various other variables and
agreement with mandating the HPV vaccine were
also examined (Table 2). Subjects who were not
familiar or very familiar with HPV felt it very likely
that their child could contract HPV and thought it
was very important for their child to receive the
HPV vaccine; those who thought that the HPV
vaccine reduced the risk of cervical cancer more
frequently thought that the HPV vaccine should be
added to school entry requirements. Parents who
supported government-mandated vaccines thought
a mandatory HPV vaccine program would be very
helpful, and those who want the federal govern-
ment to help pay for the HPV vaccine more often
supported school entry requirements.

doi: 10.3122/jabfm.2010.02.090091 Parental Acceptance of a Mandatory HPV Vaccination Program 221

o
n
5

Ju
n
e

2
0
2

1
b

y g
u

e
st. P

ro
te

cte
d

b
y co

p
yrig

h
t.

h
ttp

://w
w

w
.ja

b
fm

.o
rg

/
J A

m
B

o
a

rd
F

a
m

M
e

d
: first p

u
b

lish
e

d
a

s 1
0

.3
1

2
2

/ja
b

fm
.2

0
1

0
.0

2
.0

9
0
0
9
1
o

n
5

M
a
rch

2
0
1
0
. D

o
w

n
lo

a
d
e
d
fro

m

http://www.jabfm.org/

Table 1. Association between Demographic Variables and Parent’s Agreement with Adding the Human Papilloma
Virus Vaccine to School Entry Requirements

Variable

Do you Think the HPV Vaccine should be
Added to the List of School Entry Vaccine

Requirements?

P*No (n �%�) Yes (n �%�)

Gender .47

Male 19 (51.4) 18 (48.7)

Female 163 (57.6) 120 (42.4)

Age (years) .19

18–29 30 (53.6) 26 (46.4)

30–39 81 (55.9) 64 (44.1)

40–49 49 (54.4) 41 (45.6)

50� 22 (75.9) 7 (24.1)

Race .50

White 103 (56.6) 79 (43.4)

African American 67 (54.9) 55 (45.1)

Asian 1 (50.0) 1 (50.0)

Hispanic 9 (75.0) 3 (25.0)

Other 2 (100.0) 0 (0.0)

Ages of Children, 9–11 .91

No 75 (57.3) 56 (42.8)

Yes 107 (56.6) 82 (43.4)

Ages of Children, 12–14 .05

No 126 (60.9) 81 (39.1)

Yes 56 (49.6) 57 (50.4)

Ages of Children, 15–17 .80

No 112 (57.4) 83 (42.6)

Yes 70 (56.0) 55 (44.0)

Income .03

�$20,000 17 (37.8) 28 (62.2)

$20,001-$50,000 77 (57.9) 56 (42.1)

$50,001-$100,000 54 (64.3) 30 (35.7)

�$100,000 34 (58.6) 24 (41.4)

Education .09

�High school 5 (38.5) 8 (61.5)

High school or GED 63 (51.6) 59 (48.4)

�College 114 (61.6) 71 (38.4)

Health insurance .01

None 9 (50.0) 9 (50.0)

Private 135 (61.6) 84 (38.4)

Medicaid 26 (40.6) 38 (59.4)

Medicare 2 (100.0) 0 (0.0)

Other 9 (75.0) 3 (25.0)

Tricare 1 (20.0) 4 (80.0)

Ever had HPV .04

Yes 18 (42.9) 24 (57.1)

No 155 (60.3) 102 (39.7)

Not sure 9 (42.9) 12 (57.1)

Ever had genital warts .78

Yes 8 (53.3) 7 (46.7)

No 174 (57.1) 131 (43.0)

Abnormal Papanicolaou test (women only) .55

Yes 67 (56.8) 51 (43.2)

No 98 (58.7) 69 (41.3)

Not sure 17 (48.6) 18 (51.4)

*�2 test.
HPV, human papillomavirus; GED, General Educational Development test.

222 JABFM March–April 2010 Vol. 23 No. 2 http://www.jabfm.org

o
n
5

Ju
n
e

2
0
2

1
b

y g
u

e
st. P

ro
te

cte
d

b
y co

p
yrig

h
t.

h
ttp

://w
w

w
.ja

b
fm

.o
rg

/
J A

m
B

o
a

rd
F

a
m

M
e

d
: first p

u
b

lish
e

d
a

s 1
0

.3
1

2
2

/ja
b

fm
.2

0
1

0
.0

2
.0

9
0
0
9
1
o

n
5

M
a
rch

2
0
1
0
. D

o
w

n
lo

a
d
e
d
fro

m

http://www.jabfm.org/

Table 2. Association of Parental Attitudes, Beliefs, and Agreement with Adding the Human Papillomavirus Vaccine
to School Entry Requirements

Variable

Do You Think the HPV Vaccine
Should be Added to the List of School

Entry Vaccine Requirement?

P*No (n �%�) Yes (n �%�)

Support government-mandated vaccine requirements �.0001
No 33 (97.1) 1 (2.9)
Yes 148 (51.9) 137 (48.1)

Familiar with HPV .02
Not familiar 20 (45.5) 24 (54.6)
Somewhat familiar 117 (63.6) 67 (36.4)
Very familiar 45 (48.9) 47 (51.1)

Likelihood of child to contract HPV .03
Not at all likely 85 (57.8) 62 (42.2)
Somewhat likely 93 (59.6) 63 (40.4)
Very likely 4 (25.0) 12 (75.0)

Important for child to receive HPV vaccine �.0001
Not at all important 42 (84.0) 8 (16.0)
Somewhat important 96 (72.7) 36 (27.3)
Very important 43 (31.6) 93 (68.4)

Concerned about side effects of HPV vaccine .56
Not at all concerned 20 (60.6) 13 (39.4)
Somewhat concerned 75 (53.6) 65 (46.4)
Very concerned 86 (59.3) 59 (40.7)

HPV vaccine reduces risk of cervical cancer .001
No 30 (83.3) 6 (16.7)
Yes 117 (51.5) 110 (48.5)
No girls 32 (60.4) 21 (39.6)

HPV vaccine reduces risk of genital warts .06
No 74 (63.8) 42 (36.2)
Yes 104 (52.8) 93 (47.2)

Want child to receive HPV vaccine �.0001
No 55 (90.2) 6 (9.8)
Yes 123 (48.2) 132 (51.8)

Child has received HPV vaccine .008
No 166 (59.7) 112 (40.3)
Yes 16 (38.1) 26 (61.9)

Physician supports HPV vaccine .07
No 4 (50.0) 4 (50.0)
Yes 43 (47.3) 48 (52.8)
Not Discussed 135 (61.1) 86 (38.9)

Most influences decision to get HPV vaccine .006
Doctor 97 (51.1) 93 (49.0)
Spouse 14 (82.4) 3 (17.7)
Child 13 (48.2) 14 (51.9)
Parent 2 (28.6) 5 (71.4)
Mandatory school requirement 14 (70.0) 6 (30.0)
None 41 (70.7) 17 (29.3)

Comfortable with mandated HPV vaccine �.0001
Not comfortable 87 (97.8) 2 (2.3)
Somewhat comfortable 87 (53.4) 76 (46.7)
Very comfortable 7 (10.5) 60 (89.6)

doi: 10.3122/jabfm.2010.02.090091 Parental Acceptance of a Mandatory HPV Vaccination Program 223

o
n
5

Ju
n
e

2
0
2

1
b

y g
u

e
st. P

ro
te

cte
d

b
y co

p
yrig

h
t.

h
ttp

://w
w

w
.ja

b
fm

.o
rg

/
J A

m
B

o
a

rd
F

a
m

M
e

d
: first p

u
b

lish
e

d
a

s 1
0

.3
1

2
2

/ja
b

fm
.2

0
1

0
.0

2
.0

9
0
0
9
1
o

n
5

M
a
rch

2
0
1
0
. D

o
w

n
lo

a
d
e
d
fro

m

http://www.jabfm.org/

We then examined parents’ possible reactions to
a mandatory HPV vaccine program: signing a
waiver to prevent their child from receiving the
HPV vaccine, having their child vaccinated, or do-
ing what their doctor recommends (Table 3). Par-
ents with a child aged 12 to 14 years who were not
familiar or very familiar with HPV thought it was
very likely their child could contract HPV and
thought the HPV vaccine reduced the risk of cer-
vical cancer and genital warts. Those whose physi-
cian supported the HPV vaccine more frequently
agreed with the statement that they would have
their child vaccinated with the HPV vaccine. Sub-
jects who were very comfortable with a mandatory
HPV vaccine program thought the federal govern-
ment should pay for a mandatory HPV vaccine
program and were very interested in the HPV vac-
cine for their child; these parents were more likely
to have their child vaccinated.

Several associations with government interven-
tion in HPV vaccination were also examined. Par-
ents who wanted their child to receive the HPV
vaccine (45.5%) were more likely than those who
did not want their child to receive the vaccine
(8.2%) to want their government representative to
make a law requiring the HPV vaccine (P � .0001).
Subjects who thought the HPV vaccine should be
added to the list of school-entry vaccine require-

ments (84.1%) were more likely to want their gov-
ernment representative to make a law requiring the
HPV vaccine than those who do not think it should
be added to the school-entry vaccine requirements
(28%; P � .0001). Individuals with incomes
�$20,000 were more likely to want the state of
Georgia (P � .004) and the federal government
(P � .003) to pay for the HPV vaccine for school
children than parents at all other income levels
(84.4% and 86.7%, respectively).

Conclusions
Our study identified numerous factors that increase
the likelihood of parents accepting a mandatory
HPV vaccination program. Parents with a personal
history of HPV-related disease (HPV infection or
genital warts) were more likely to support such a
mandated program. Parents who had greater famil-
iarity with the adverse consequences of HPV infec-
tion were also more apt to approve a school-based
mandate. Interestingly, mothers with a history of a
previous abnormal Papanicolaou test were not
more inclined to support a mandatory program.
Many women were unaware of the viral cause for
abnormal cervical cytology. A greater number of
parents with the lowest income would also comply
with a mandatory vaccination program; because

Table 2. (Continued)

Variable

Do You Think the HPV Vaccine
Should be Added to the List of School

Entry Vaccine Requirement?

P*No (n �%�) Yes (n �%�)

Mandatory HPV vaccine program helpful �.0001
Not helpful 45 (97.8) 1 (2.2)
Somewhat helpful 125 (64.1) 70 (35.9)
Very helpful 12 (15.2) 67 (84.8)

Mandatory HPV vaccine program important �.0001
Not important 47 (94.0) 3 (6.0)
Somewhat important 123 (67.2) 60 (32.8)
Very important 12 (13.8) 75 (86.2)

Federal government to pay for HPV vaccine �.0001
No 90 (82.6) 19 (17.4)
Yes 91 (43.3) 119 (56.7)

Interested in HPV vaccination for child �.0001
Not interested 52 (91.2) 5 (8.8)
Somewhat interested 100 (66.2) 51 (33.8)
Very interested 30 (26.8) 82 (73.2)

*�2 test.
HPV, human papillomavirus.

224 JABFM March–April 2010 Vol. 23 No. 2 http://www.jabfm.org

o
n
5

Ju
n
e

2
0
2

1
b

y g
u

e
st. P

ro
te

cte
d

b
y co

p
yrig

h
t.

h
ttp

://w
w

w
.ja

b
fm

.o
rg

/
J A

m
B

o
a

rd
F

a
m

M
e

d
: first p

u
b

lish
e

d
a

s 1
0

.3
1

2
2

/ja
b

fm
.2

0
1

0
.0

2
.0

9
0
0
9
1
o

n
5

M
a
rch

2
0
1
0
. D

o
w

n
lo

a
d
e
d
fro

m

http://www.jabfm.org/

Table 3. Association of Parental Attitudes, Beliefs, and Possible Responses to a Mandatory Human Papillomavirus
Vaccine

Variable

If the HPV Vaccine was Mandatory to Attend School, Which of the
Following Statements Most Agrees with Your View?

P*

Would Sign a Waiver to
Prevent my Child from
Receiving the Vaccine

(n �%�)
Would have My Child

Vaccinated (n �%�)

Would do Whatever
My Doctor

Recommends
(n �%�)

Gender .95
Male 6 (16.2) 25 (67.6) 6 (16.2)
Female 52 (18.4) 186 (65.7) 45 (15.9)

Age (years) .84
18–29 11 (19.6) 36 (64.3) 9 (16.1)
30–39 23 (15.9) 95 (65.5) 27 (18.6)
40–49 17 (18.9) 61 (67.8) 12 (13.3)
50� 7 (24.1) 19 (65.5) 3 (10.3)

Race .40
White 40 (22.0) 114 (62.6) 28 (15.4)
African American 18 (14.8) 84 (68.9) 20 (16.4)
Asian 0 (0.0) 1 (50.0) 1 (50.0)
Hispanic 0 (0.0) 10 (83.3) 2 (16.7)
Other 0 (0.0) 2 (100.0) 0 (0.0)

Ages of children, 9–11 .91
No 25 (19.1) 86 (65.7) 20 (15.3)
Yes 33 (17.5) 125 (66.1) 31 (16.4)

Ages of children, 12–14 .02
No 39 (18.8) 127 (61.4) 41 (19.8)
Yes 19 (16.8) 84 (74.3) 10 (8.9)

Ages of children, 15–17 .23
No 41 (21.0) 123 (63.1) 31 (15.9)
Yes 17 (13.6) 88 (70.4) 20 (16.0)

Income .54
�$20,000 6 (13.3) 33 (73.3) 6 (13.3)

$20,001-$50,000 22 (16.5) 88 (66.2) 23 (17.3)
$50,001-$100,000 21 (25.0) 49 (58.3) 14 (16.7)
�$100,000 9 (15.5) 41 (70.7) 8 (13.8)

Education .84
�High school 2 (15.4) 9 (69.2) 2 (15.4)

High school or GED 20 (16.4) 85 (69.7) 17 (13.9)
�College or more 36 (19.5) 117 (63.2) 32 (17.3)

Health insurance .06
None 2 (11.1) 10 (55.6) 6 (33.3)
Private 47 (21.5) 139 (63.5) 33 (15.1)
Medicaid 5 (7.8) 51 (79.7) 8 (12.5)
Medicare 0 (0.0) 2 (100.0) 0 (0.0)
Other 3 (25.0) 5 (41.7) 4 (33.3)
Tricare 1 (20.0) 4 (80.0) 0 (0.0)

Ever had HPV .19
Yes 10 (23.8) 30 (71.4) 2 (4.8)
No 46 (17.9) 165 (64.2) 46 (17.9)
Not sure 2 (9.5) 16 (76.2) 3 (14.3)

Ever had genital warts .22
Yes 3 (20.0) 12 (80.0) 0 (0.0)
No 55 (18.0) 199 (65.3) 51 (16.7)

doi: 10.3122/jabfm.2010.02.090091 Parental Acceptance of a Mandatory HPV Vaccination Program 225

o
n
5

Ju
n
e

2
0
2

1
b

y g
u

e
st. P

ro
te

cte
d

b
y co

p
yrig

h
t.

h
ttp

://w
w

w
.ja

b
fm

.o
rg

/
J A

m
B

o
a

rd
F

a
m

M
e

d
: first p

u
b

lish
e

d
a

s 1
0

.3
1

2
2

/ja
b

fm
.2

0
1

0
.0

2
.0

9
0
0
9
1
o

n
5

M
a
rch

2
0
1
0
. D

o
w

n
lo

a
d
e
d
fro

m

http://www.jabfm.org/

Table 3. (Continued)

Variable

If the HPV Vaccine was Mandatory to Attend School, Which of the
Following Statements Most Agrees with Your View?

P*

Would Sign a Waiver to
Prevent my Child from
Receiving the Vaccine

(n �%�)
Would have My Child

Vaccinated (n �%�)

Would do Whatever
My Doctor

Recommends
(n �%�)

Abnormal Papanicolaou test (women
only)

.62

Yes 23 (19.5) 80 (67.8) 15 (12.7)
No 31 (18.6) 106 (63.5) 30 (18.0)
Not sure 4 (11.4) 25 (71.4) 6 (17.1)

Support government mandated vaccines
requirements

�.0001

No 17 (50.0) 10 (29.4) 7 (20.6)
Yes 40 (14.0) 201 (70.5) 44 (15.4)

Familiar with HPV .02
Not familiar 7 (15.9) 30 (68.2) 7 (15.9)
Somewhat familiar 30 (16.3) 115 (62.5) 39 (21.2)
Very familiar 21 (22.8) 66 (71.7) 5 (5.4)

Likelihood of child to contract HPV �.0001
Not at all likely 36 (24.5) 76 (51.7) 35 (23.8)
Somewhat likely 20 (12.8) 120 (76.9) 16 (10.3)
Very likely 2 (12.5) 14 (87.5) 0 (0.0)

Important for child to receive HPV
vaccine

�.0001

Not at all important 29 (58.0) 10 (20.0) 11 (22.0)
Somewhat important 23 (17.4) 81 (61.4) 28 (21.2)
Very important 5 (3.7) 119 (87.5) 12 (8.8)

Concerned about side effects of HPV
vaccine

.08

Not at all concerned 8 (24.2) 20 (60.6) 5 (15.2)
Somewhat concerned 16 (11.4) 102 (72.9) 22 (15.7)
Very concerned 34 (23.5) 87 (60.0) 24 (16.6)

HPV vaccine reduces risk of cervical
cancer

�.0001

No 20 (55.6) 10 (27.8) 6 (16.7)
Yes 25 (11.0) 169 (74.5) 33 (14.5)
No girls 11 (20.8) 30 (56.6) 12 (22.6)

HPV vaccine reduces risk of genital
warts

.02

No 30 (25.9) 70 (60.3) 16 (13.8)
Yes 26 (13.2) 136 (69.0) 35 (17.8)

Want child to receive HPV vaccine �.0001
No 35 (57.4) 10 (16.4) 16 (26.2)
Yes 21 (8.24) 199 (78.0) 35 (13.7)

Child has received HPV vaccine .001
No 57 (20.50) 173 (62.2) 48 (17.28)
Yes 1 (2.4) 38 (90.5) 3 (7.1)

Physician supports HPV vaccine .0004
No 3 (37.5) 2 (25.0) 3 (37.5)
Yes 7 (7.7) 75 (82.4) 9 (9.9)
Not discussed 48 (21.7) 134 (60.6) 39 (17.7)

226 JABFM March–April 2010 Vol. 23 No. 2 http://www.jabfm.org

o
n
5

Ju
n
e

2
0
2

1
b

y g
u

e
st. P

ro
te

cte
d

b
y co

p
yrig

h
t.

h
ttp

://w
w

w
.ja

b
fm

.o
rg

/
J A

m
B

o
a

rd
F

a
m

M
e

d
: first p

u
b

lish
e

d
a

s 1
0

.3
1

2
2

/ja
b

fm
.2

0
1

0
.0

2
.0

9
0
0
9
1
o

n
5

M
a
rch

2
0
1
0
. D

o
w

n
lo

a
d
e
d
fro

m

http://www.jabfm.org/

this vaccine is fairly expensive, one could assume
that mandating vaccination might have equaled free
availability in their minds. In fact, the Vaccines for
Children Program provides free HPV vaccines to
indigent children 18 years old or younger. This is a
voluntary federal vaccination program that is prob-
ably underutilized. The sex, age, race, education,
and type of health insurance parents had did not
influence their opinion about the importance of a
mandated vaccine program. In fact, fewer college-

educated parents thought a mandatory HPV vac-
cine program should be implemented.

Parents who understood the true vulnerability of
their child and the possibility of their contracting
HPV supported a mandatory HPV vaccine pro-
gram. Tragically, most parents do not know the
ubiquitous nature of HPV21 and awareness of this
principle is an important cornerstone for vaccine
acceptance. Moreover, no one can advise parents
about how their child’s immune system might re-

Table 3. (Continued)

Variable

If the HPV Vaccine was Mandatory to Attend School, Which of the
Following Statements Most Agrees with Your View?

P*

Would Sign a Waiver to
Prevent my Child from
Receiving the Vaccine

(n �%�)
Would have My Child

Vaccinated (n �%�)

Would do Whatever
My Doctor

Recommends
(n �%�)

Most influences decision to get HPV
vaccine

�.0001

Doctor 20 (10.5) 137 (72.1) 33 (17.4)
Spouse 5 (29.4) 8 (47.1) 4 (23.5)
Child 2 (7.4) 21 (77.8) 4 (14.8)
Parent 0 (0.0) 5 (71.4) 2 (28.6)
Mandatory school requirement 4 (20.0) 15 (75.0) 1 (5.0)
None 27 (46.6) 24 (41.4) 7 (12.1)
Somewhat comfortable 8 (4.91) 128 (78.5) 27 (16.6)
Very comfortable 0 (0.00) 64 (95.5) 3 (4.5)

Mandatory HPV vaccine program
helpful

�.0001

Not helpful 31 (67.4) 9 (19.6) 6 (13.0)
Somewhat helpful 27 (13.9) 127 (65.1) 41 (21.0)
Very helpful 0 (0.0) 75 (94.9) 4 (5.1)

Mandatory HPV vaccine program
important

�.0001

Not important 32 (64.0) 12 (24.0) 6 (12.0)
Somewhat important 25 (13.7) 118 (64.5) 40 (21.9)
Very important 1 (1.2) 81 (93.1) 5 (5.8)

Federal government to pay for HPV
vaccine

�.0001

No 42 (38.5) 48 (44.0) 19 (17.4)
Yes 16 (7.6) 162 (77.1) 32 (15.2)

Interested in HPV vaccination for child �.0001
Not interested 41 (71.9) 7 (12.3) 9 (15.8)
Somewhat interested 16 (10.6) 102 (67.6) 33 (21.9)
Very interested 1 (0.9) 102 (91.1) 9 (8.0)

HPV vaccine should be added to the
list of school entry vaccine
requirements

�.0001

No 57 (31.3) 86 (47.3) 39 (21.4)
Yes 1 (0.7) 125 (90.6) 12 (8.7)

*�2 test.
HPV, human papillomavirus; GED, General Educational Development test.

doi: 10.3122/jabfm.2010.02.090091 Parental Acceptance of a Mandatory HPV Vaccination Program 227

o
n
5

Ju
n
e

2
0
2

1
b

y g
u

e
st. P

ro
te

cte
d

b
y co

p
yrig

h
t.

h
ttp

://w
w

w
.ja

b
fm

.o
rg

/
J A

m
B

o
a

rd
F

a
m

M
e

d
: first p

u
b

lish
e

d
a

s 1
0

.3
1

2
2

/ja
b

fm
.2

0
1

0
.0

2
.0

9
0
0
9
1
o

n
5

M
a
rch

2
0
1
0
. D

o
w

n
lo

a
d
e
d
fro

m

http://www.jabfm.org/

spond to HPV infection, eg, spontaneous clearance
or persistence that may increase the risk for devel-
oping a malignancy. Parents who knew that the
HPV vaccine reduced the risk of their child devel-
oping cervical cancer were more inclined to con-
done a mandatory program. Further education
about HPV and its potential consequences are
needed to improve HPV vaccine uptake. Such ed-
ucation could influence response to a mandated
program.

Parents whose health care providers supported
the HPV vaccine were not more likely to support a
mandatory vaccination program. Yet other studies
have demonstrated the value of medical advice with
respect to HPV vaccine acceptance.19,21,22 The
opinion of a trusted health care provider is partic-
ularly important with respect to preventive medical
care. The dialogue between parent and health care
provider probably has centered around action (get-
ting the vaccine) and not the particular process
(voluntary vs mandatory).

Many other variables indicated that parents
thought the HPV vaccine should be added to the
list of school-entry vaccine requirements. Parents
with no insurance or federally financed insurance
more often agreed that the HPV vaccine should be
required. Reliance on government-funded heath
insurance may have an affect on parental auton-
omy. These parents may be more willing to abdi-
cate these health decisions to the medical legislative
process. However, others caution that such a man-
datory program for the HPV vaccine would place a
financial burden on existing government health
programs, thereby potentially reducing coverage
rates for other vaccines.23

To parents we posed a realistic scenario: that the
HPV vaccine was required for school. They could
choose to sign a waiver to prevent their child from
receiving the HPV vaccine, have their child vacci-
nated, or follow the recommendation of their
health care provider. Most parents (66%) would
simply select to allow their child to receive the
vaccination. Those parents who supported manda-
tory vaccination programs knew the potential
harms from HPV, realized their child was very
susceptible to HPV infection, and wanted their
child to receive the vaccine readily accepted com-
pliance with an HPV vaccination mandate. Once
again, knowledge about the problem seemed con-
ducive to parents accepting mandatory health pro-

grams designed to prevent unnecessary morbidity
and mortality.

The remaining parents were fairly divided be-
tween the other 2 options. A certain number of
parents want to retain the autonomy of making
health decisions for their children. In our country
and the state in which our study was conducted,
opting out of vaccination for religious, medical, or
philosophical reasons is allowed. However, some
argue that society should protect innocent children
who may be hurt by the choices of their parents.24

The issue has been conceptualized as conflict be-
tween autonomy and utilitarianism.25 Other par-
ents place the decision in the hands of their health
care provider. Education of these influential people
is critically necessary to assure proper guidance is
given.

Our study was limited by regional sampling,
greater participation by mothers, and limited Asian
and Hispanic involvement. A national sample in-
cluding more fathers and minorities may have al-
tered our findings. Our study was also conducted
immediately after unjust negative publicity from
the national media. The HPV vaccine controversy
is clouded by too many unproven assumptions and
unknown factors.26 Although acceptance of a man-
datory policy for the HPV vaccine may improve in
the future, additional research may be beneficial to
assess changing and evolving attitudes.

References
1. Villa LL, Costa RLR, Petta CA, et al. Prophylactic

quadrivalent human papillomavirus (types 6, 11, 16
and 18) L1 virus-like …