A total of 304 patients presenting for an Ob/Gyn clinic visit completed surveys. Of the respondents, 124 (41%) self-identified as Hispanic White (HW), 16 (5%) as NHW, 58 (19%) as Non-Hispanic Black (NHB), 6 (2%) as Hispanic Black (HB), 29 (9.5%) as Haitian, 44 (14%) as Hispanic Other (HO), 7 (2%) as Non-Hispanic Other (NHO) and 20 (6.6%) as No Response (NR) ( Table 1 ). With respect to insurance status, 112 (34%) patients had Medicaid, 45 (14%) patients were uninsured, 38 (12%) had hospital safety net funding, 39 (12%) had Medicare and 29 (9%) had private insurance. The median age of respondents was 32 (range 18-80).

Only 45% (n=138) of patients knew that HPV causes cancer ( Table 2 ). While 213 (70%) patients identified at least one correct route of transmission including vaginal, anal, or oral sex and associated skin-to-skin contact, 78 (26%) patients reported that they did not know the route of HPV transmission. Over half (n=183, 60%) of patients identified at least one health consequence of HPV infection, while 106 (35%) patients reported that they did not know the health consequences of HPV infection.

Only 22 (7%) patients knew that HPV vaccination eligibility had been extended up to the age of 45. The majority (83%) of patients did not know how many doses of HPV vaccination are required. Few patients (n=113 37%) were aware that men were eligible for HPV vaccination.

Many patients had never discussed HPV (n=113, 37%) or the HPV vaccine (n=189, 62%) with a healthcare provider ( Table 3 ). Additionally, more than half (n=211, 69%) of patients reported that a healthcare provider had never recommended HPV vaccination to them.

More than half (n=173, 57%) of all patients reported that they did not believe that the HPV vaccine was available to be given the same day in the clinic, including both those who had and who had not been offered the vaccine. A majority (n=241, 79%) of patients were unvaccinated. Among patients who were not vaccinated reasons cited included not being offered vaccination (n=86, 28%), not being aware that they were eligible for vaccination (n=86, 28%), concerns about toxic ingredients in the vaccine (n=48, 16%), not believing in vaccinations (n=21, 7%), not being able to afford vaccination (n=43, 14%), and perceived inconvenience of receiving the vaccine (n=24, 8%).

HPV vaccination was not available to patients with commercial insurance in our safety net clinic prior to September 2021. From September 2021-September 2022, the number of patients receiving HPV vaccination increased compared to the 1 year prior to expansion of eligibility.

HPV knowledge is fundamental to increasing vaccine uptake (29–33). However, HPV and HPV vaccine knowledge in the U.S. remains low, with studies showing that only 68% of adults report having heard of HPV and the vaccine (34, 35). There are significant disparities in knowledge of and access to the vaccine (10). Associations have been noted between HPV knowledge and factors such as race, ethnicity, national origin, and primary language (11). There are multiple barriers to patient knowledge that have been identified in the literature, including language, cost, lack of information, and fear or mistrust of the healthcare system (36–38). While informational interventions can have a positive impact on vaccine uptake (29, 39, 40), educational interventions alone are likely insufficient to significantly improve vaccination rates (29, 41).

Consistent with prior literature, our study at a diverse safety net clinic found that most patients did not know basic information about the HPV vaccine, had not received HPV vaccination and that vaccination had never been discussed with them. High levels of health literacy have been linked to cervical cancer screening behaviors (42). Studies have also shown that health literacy is a stronger predictor of knowledge of risk factors for cervical dysplasia than race and ethnicity (43). Furthermore, increased information has a positive impact on vaccine uptake (39, 40, 44). Understanding the risk of HPV infection and benefits of vaccination has been associated with intention to vaccinate (45, 46).

Most patients in our study did not know that HPV infection could lead to cervical cancer, with a lower percentage of NHO, NHB, HW and Haitian patients, but a higher percentage of NHW, HB and HO patients reporting this knowledge. While this reflects findings of other studies that have demonstrated that NHB patients were less likely to report knowledge of the association between HPV and cervical cancer, it differs from findings among Hispanic patients (47). In contrast to other studies, we found proportionally higher reported knowledge of the association between HPV and cervical cancer among patients identifying as Hispanic other than HW patients (47). This discrepancy possibly reflects the unique demographic composition of Miami Dade County, which is majority Hispanic. Most patients in our study did not know basic information about the HPV vaccine such as ages of eligibility, number of doses, and whether men could receive the vaccine. Given the association between HPV and vaccine knowledge and uptake, it is imperative for healthcare providers to continue to strengthen targeted education efforts for patients and their communities.

Most patients in our study had not received the HPV vaccine. NHO, HB and Haitian patients had the highest level of vaccine uptake. These results were not consistent with prior studies that have shown that misconceptions regarding HPV and vaccination are extremely common among immigrants from Haiti in the U.S (48). This discrepancy could reflect a higher level of Haitian and Haitian Creole-speaking providers in our population, but conclusions are limited by small sample size. It is important to increase education and outreach efforts, as studies have demonstrated that knowledge is a positive predictor of HPV vaccination (35).

While many patients had discussed HPV with a healthcare provider, most had not discussed HPV vaccination or had the HPV vaccine recommended to them. This result was consistent across racial groups, with the greatest number of Hispanic patients reporting having discussed HPV and HPV vaccination. Other studies have found that many Hispanic and Haitian patients have not received vaccination recommendations from providers, and that patients with limited English proficiency were most affected (49, 50). The discrepancy in our data from these national studies likely reflects the unique patient and provider population of Miami Dade County, where the majority of the population is Hispanic. This is consistent with previous studies that have found significantly better outcomes among Hispanic patients with cervical cancer in Miami Dade County compared to nationally (51). Patient understanding and satisfaction increase in environments with culturally and linguistically concordant care (52, 53). Our data support creating clinical environments where providers and support staff have the linguistic ability and cultural competency to properly counsel patients.

Multiple studies have shown that a strong recommendation from a healthcare provider has a positive impact on vaccine uptake (50, 54–56). Furthermore, patients who report receiving HPV information from a physician have been found to have higher knowledge scores (35). In our study among those patients who were not vaccinated, lack of strong recommendation from a healthcare provider and lack of awareness of eligibility were cited as significant barriers. Additionally, previous work has shown major deficits in knowledge of the HPV vaccine among students in the health professions and healthcare providers (57). Even among patients in gynecologic oncology clinics, providers are less likely to offer vaccination to patients without HPV-related dysplasia (58). It is critical to ensure that healthcare providers are knowledgeable about HPV vaccination, up to date on current practice guidelines, and trained in counselling patients given the recent increase in vaccine hesitancy (59).

The quality improvement initiative performed in connection with our study noted an increase in HPV vaccine administration following expansion of eligibility to patients with insurance. Although many of our patients reported that they did not believe that the HPV vaccine was available for same-day clinic administration, uptake increased with expanded eligibility. The convenience of administration is a known barrier to vaccine acceptance, administration, and series completion (60, 61). Interventions such as designated provider champions, clinical screening, financial assistance and elimination of barriers such a pregnancy testing have been shown to improve vaccine uptake (62). A limited number of patients completed the recommended 3-dose vaccine series, which is consistent with national trends (63–65). The percentage of women age 18 to 26 who received the recommended number of doses has been increasing, from 25.7% in 2013 to 35.3% in 2018, although completion rates still remain below target (9). Research has demonstrated protective benefits with even one dose of the vaccine, although the benefit increases with series completion (66). It is imperative that healthcare providers and clinic staff continue to educate patients regarding vaccination schedules and work to identify and minimize barriers to adherence with recommended follow-up. Additionally, to ensure that all patients who are eligible for vaccination have the opportunity to opt in, asking about HPV vaccine status should be included as a standard element of a gynecologic history.

The strength of this study is the diverse patient population across a spectrum of age, race, ethnicity, and nativity. Additionally, the inclusion of Haitian identity allows for the ascertainment of unique disparities in this population. Limitations include survey administration at a single hospital site, limiting generalizability of findings to the national population. Notably, the majority of patients were Hispanic, and a comparatively low number of respondents identified as Haitian. Our surveys were anonymous, and we therefore were unable to link responses with vaccination data, series completion data or cervical cancer screening data in our clinic.