The primary goal of this study was to examine socioeconomic differences in the likelihood of a discussion on HPV vaccine occurring between a woman and her HCP using a model that accounts for potential sample selection bias. Our analysis suggested that African American women were more likely to have had discussions about the HPV vaccine with their HCPs than White women. Overall, we did not find evidence that socioeconomic disadvantages were associated with a lower chance of having a discussion on HPV vaccine with HCPs. A similar finding was reported by Hughes et al. (2009), who did not find evident socioeconomic disparities in the odds of reporting HCPs as previous sources of HPV vaccine information
These results are encouraging although not intuitively predictable. Many studies demonstrate that the socioeconomically disadvantaged tend to have less access to health care
[26–28], which leads to the assumption that such individuals may have fewer opportunities to discuss the HPV vaccine with their HCPs, supposing they have one. However, our results contradict this assumption; the influence of a patient’s race and socioeconomic status on the screening practices of HCPs could primarily explain this contradiction. Studies have shown that HCPs are more likely to provide counseling services on the prevention of sexually transmitted infections (STIs) to a patient from a minority ethnic group and a lower socioeconomic status than one from a non-minority ethnic group
 and a higher socioeconomic status
, respectively. HCPs generally prioritize their screening practices based on actual epidemiological data, showing the association of race and socioeconomic status with STIs
. Since HPV infection is a STI, a similar reasoning can be used to explain the lack of socioeconomic disparities observed in this study. A HCP who is aware that the prevalence of HPV infections is higher among African American women and women with low levels of education and income will be more likely to discuss the HPV vaccine with these groups.
Secondly, both the psychosocial factors that affect a woman’s behavior on seeking health information and the predictors of a HCP recommending the HPV vaccine influence whether a woman discusses the HPV vaccine with her HCP. Individual psychosocial factors such as having a higher internal locus of control
[32, 33] and a preference for involvement in health-related decision making
 were found to contribute positively to information seeking behavior. Trust in HCPs was also correlated with more information seeking from HCPs
. Among HCPs, an early adopter of a new intervention generally has a higher intention of recommending the HPV vaccine
[36, 37]. Physicians’ practices
[38, 39] and their beliefs and attitudes towards the HPV vaccine
[37, 40] were also found to affect their propensity to recommend the HPV vaccines to their patients. Albeit beyond the scope of this study, the presence of numerous HCP- and patient-related factors, including their intricate interaction with one another, possibly mitigated the socioeconomic disparities in having discussions on HPV vaccine with HCPs.
However, similar to other studies
[9, 25, 26, 41, 42], our statistical analysis has revealed a troubling disparity in HPV vaccine awareness across multiple dimensions of socioeconomic status. Belonging to a minority race/ethnicity, and having a lower household income and education level were independently associated with a lower probability of being aware of the HPV vaccine. The disparities in HPV vaccine awareness were all statistically significant and showed a fairly consistent gradient for both income and education.
The results of this study have a number of important implications for research, practice and policy. In terms of research, our statistical approach provides a fuller picture of socioeconomic disparities in HPV vaccine by simultaneously examining two related indicators. However, the eventual uptake of the vaccine depends on a complex interplay of factors in a woman’s psychosocial milieu as well as other demographic and socioeconomic factors. Thus, future research that assesses the impact of socioeconomic status on the integrated continuum of HPV vaccine awareness, acquisition of information, and vaccine uptake will greatly inform policy makers and health care providers in guiding education and practice.
Regarding the implications for clinical practice, HCPs may be the preferred source of health care information for the socioeconomically disadvantaged because of the lack of other reliable options; this preference results in a higher likelihood of having discussions on HPV vaccine. Thus, HCPs can play a pivotal role in dispensing accurate, objective information about the vaccine, and help dispel any myths or negative attitudes about HPV vaccination, thereby allowing socioeconomically disadvantaged women to make informed decisions for themselves and for their daughters.
Lastly, our findings that lower socioeconomic status is associated with lower awareness but not with lower opportunities for discussions on HPV vaccine with HCPs has important public health and policy implications. Primarily, social disparities in HPV vaccine uptake will be greatly reduced if discussions between patients and their HCPs become more prevalent. Targeted outreach programs should also be promoted in order to raise awareness about the vaccine among socioeconomically disadvantaged women and should be tailored to address attitudes and perceptions that are specific to each ethnic group. In addition, given the potential for HCPs to ameliorate social disparities in HPV vaccine uptake and its importance, public health efforts can be directed toward giving full support to HCPs for HPV vaccination promotion. This support can come in the form of informative pamphlets in various vernaculars to enhance communication and provide easily accessible, timely, and up-to-date information on HPV vaccine research.
Notwithstanding these implications, the findings presented herein should be considered in the context of a few limitations. A key limitation of this study was the short interval between the FDA approval of the quadrivalent HPV vaccine in 2006 and the launch of the HINTS in early 2008. Thus, the small number of respondents who reported having HPV vaccine discussions with their HCPs may not be reflective of the corresponding number today. Future research involving HCPs who are more familiar with the vaccines may offer a more accurate picture of the prevalence of vaccine discussions between women and their HCPs. A second limitation, which is related to the first, is that four years have elapsed since the launch of HINTS in early 2008; thus, the results may not reflect the current situation today. However, while average awareness of the vaccine may have increased over the years, the increment of increase is unknown and its rate differs among populations. Hence, this study is still pertinent in underserved populations whose awareness of the HPV vaccine and accessibility to HCPs remains low, and in which identifying ways to best target patient education remains crucial. Additionally, the self-reported status of having discussions on HPV vaccine with a HCP is subject to recall bias. Moreover, the content and extent of the discussion was unknown, and a standard definition for what qualifies as a “discussion on HPV vaccine” was not described in the survey. This could have resulted in an underestimation or overestimation of the number of respondents who reported having discussions on HPV vaccine with their providers. Lastly, the HINTS was not developed to include constructs that aim to capture HCP factors and individual psychosocial factors that could have influenced the likelihood of women having discussions on HPV vaccine with their HCPs. Future research surveys designed to capture all of these factors could give a more comprehensive analysis of socioeconomic disparities in HPV vaccine discussions.