We found that the HPV vaccine is being offered to patients in the approved age range, 9 to 26 years, in a 5-county region of Appalachian Pennsylvania. Most practices that did not currently offer the vaccine intended to offer it in the future. In addition, most practices were willing to provide the vaccine to patients of other practices and participate in educational programs. Barriers to vaccination included the cost of the vaccine, especially for women aged 18 to 26 years, an age group that is not covered by the Vaccines for Children program. The belief among some providers that the recommended age is too low and that the vaccine promotes sexual activity among young women may also restrict access to the vaccine. One family health practice that did not offer the vaccine at the time of the initial survey ("We are doing our own research and looking to order vaccine soon.") reported on second survey that they were offering the vaccine but not to young girls ("[The vaccine] is not given to the extremely young. We are waiting for the vaccine to prove effective and safe. I don't want patients to feel falsely safe and free to sleep around.").
These findings can guide future community-based initiatives to increase vaccination. Barriers to vaccination, including cost and health insurance coverage, should be addressed in future initiatives. Other barriers have previously been reported, including lack of knowledge about HPV transmission and associated risks for cervical cancer and other genital diseases, parental concerns about the vaccine and vaccinating minors against sexually transmitted infections, lack of knowledge about financial assistance programs, challenges related to health care–seeking behavior of young women, and barriers specific to HPV infection (eg, protection against only certain types of HPV) (13
Few evidence-based interventions to increase vaccination have been reported. A randomized study conducted before the HPV vaccine was licensed found that parents who received an HPV information sheet had higher mean scores on HPV knowledge than did parents who did not receive the information (13
). However, the groups did not differ in terms of vaccine acceptability (13
). Among women aged 18 to 30, knowledge, personal beliefs about vaccination, belief that others would approve of vaccination, and a higher number of sexual partners were significantly associated with intention to vaccinate (3
). A study of women aged 18 to 25 found that those who had had vaginal sex in the past 12 months were 4 times as likely to report acceptance of vaccination (14
). In addition, those who had ever had a sexually transmitted infection or an abnormal Papanicolaou test were also more likely to indicate acceptance.
Limitations to this study must be acknowledged. The sample was drawn from a specific geographic area, thus limiting the generalizabilty of the results. Several factors may have limited the validity of the results. First, the study collected data that were self-reported and not verified by direct observation or medical record review. The study also used 2 instruments that had not been validated previously. Instruments that had been validated in previous studies would have been preferable, but none was known to the investigators as the study was being planned. Two surveys of health care providers have since been reported (15
The study also has numerous strengths. First, the response rate was high, which may be partially because the survey was brief, was conducted by a local organization, and focused on a timely topic. Second, the survey was conducted in Appalachia, a region that has cervical cancer health disparities. Third, the study was participatory and initiated communication between ACTION Health and local primary care practices. Future partnerships may develop from this initial communication, which could expand ACTION Health's network of health care affiliates for cancer prevention and control. Finally, the study design was community-based, and results can be used to facilitate future interventions in the specific area of ACTION Health.
We conclude that most practices in this area of Appalachian Pennsylvania recommend the HPV vaccine or provide it if patients request it. Future community education interventions should target women and girls in the appropriate age range to increase their knowledge of cervical cancer and the risks and benefits of HPV vaccination.