Background: Low adolescent HPV vaccination initiation due to parents declining vaccination remains a challenge for providers. In 2018, 65% of adolescent girls and 56% of adolescent boys in Texas initiated HPV vaccination. Gaps between HPV vaccination rates and those for Tdap (83%) and meningococcal vaccines (87%) among 13-17 year olds highlights missed opportunities to prevent HPV-related cancers. While leading medical organizations endorse a presumptive, bundled recommendation, in which the provider presents HPV vaccination the same way as other vaccines, bundled between Tdap and meningococcal at 11- or 12-year-old visits, provider recommendations vary.

Methods: In 2015, we surveyed pediatricians in a large Texas pediatric clinic network to assess physician knowledge, beliefs, attitudes and behaviors regarding adolescent HPV vaccination. To ascertain HPV vaccination outcomes, survey data were merged with patient electronic health records. We examined the association of pediatrician HPV vaccination recommendation and vaccination using multivariable multilevel generalized linear models clustered by physicians. Adjusted odds ratios were calculated.

Results: Among 226 physicians, 59.8% completed the emailed survey. Controlling for patient and physician demographics, odds of HPV vaccination initiation were significantly increased if physicians used a bundled approach to recommend the HPV vaccine: “Your child is due for three vaccines: Tdap, HPV, and meningococcal vaccine” versus “Your child is due for two vaccines, Tdap and meningococcal. There is also the HPV vaccine, which is optional” (OR: 1.59, 95% CI 1.30-1.96).

Conclusion: This study links physician HPV vaccine recommendation wording and outcomes, showing the significant effect of bundling HPV vaccination for adolescent patients.

Author Biography

Dr. Lara Savas has extensive research expertise developing, adapting and evaluating health intervention and implementation projects in clinic and community settings. She has over twenty years of experience collaborating in community-academic partnerships on multiple funded behavioral interventions, including recent projects focused on cancer screening, smoking cessation, COVID-19 testing, and lay communication among underserved populations. Dr. Savas has been Co-PI on three CPRIT-funded multi-component intervention projects to increase HPV vaccination rates in clinics throughout Texas.


Albert J. Farias was a postdoctoral research fellow supported by a University of Texas Health Science Center at Houston School of Public Health's Cancer Education and Career Development Program grant from the National Cancer Institute (R25-CA57712). The study was supported by two grants from the Cancer Prevention and Research Institute of Texas (CPRIT) (RP150014 and PP140183).