Preventive Medicine 99 (2017) 299–304

Contents lists available at ScienceDirect

Preventive Medicine

journal homepage: www.elsevier.com/locate/ypmed

Not just a woman's business! Understanding men and women's

knowledge of HPV, the HPV vaccine, and HPV-associated cancers
Nosayaba Osazuwa-Peters a,b,c,1, Eric Adjei Boakye d,⁎,1, Kahee A. Mohammed d, Betelihem B. Tobo a,
Christian J. Geneus e, Mario Schootman a
a
Department of Epidemiology, College for Public Health and Social Justice, Saint Louis University, St. Louis, MO, USA
b
Saint Louis University Cancer Center, St. Louis, MO 63110, USA
c
Saint Louis University, School of Medicine, Department of Otolaryngology - Head and Neck Surgery, St. Louis, MO, USA
d
Saint Louis University Center for Outcomes Research (SLUCOR), Saint Louis University, St. Louis, MO, USA
e
Department of Biostatistics and Bioinformatics, Tulane School of Public Health and Tropical Medicine, Tulane University, New Orleans, LA, USA

a r t i c l e i n f o a b s t r a c t

Article history: Few studies have included men when assessing differences in knowledge about HPV, and HPV-associated can-
Received 7 September 2016 cers. We examined gender differences in knowledge about HPV, HPV vaccine, and HPV-associated cancers. Mul-
Received in revised form 15 February 2017 tivariable logistic regression models were used to analyze data of 3,677 survey respondents aged 18 years and
Accepted 20 March 2017
older from the 2014 Health Information National Trends Survey. Covariates included age, race/ethnicity, marital
Available online 22 March 2017
status, education, income level, regular provider, general health, internet use, and family structure aged 9 to 27
Keywords:
years. Analyses were conducted in 2015. Sixty-four percent of respondents had heard of HPV and the HPV vac-
HPV knowledge cine. Seventy-eight percent of respondents knew HPV causes cervical cancer, but only 29% knew it causes penile
HPV vaccine cancer, 26% knew it causes anal cancer, and 30% knew it causes oral cancer. In multivariable analyses, males were
HPV-associated cancers less likely to have heard of HPV (aOR: 0.33; 95% CI: 0.25–0.45), and less likely to have heard of the HPV vaccine
Gender (aOR: 0.24; 95% CI: 0.18–0.32) compared to females. No differences existed between males and females regard-
ing knowledge about HPV-associated cancers. In conclusion, knowledge of HPV, the vaccine, and HPV-associated
cancers in both males and females in the United States remains very low, especially among men.
© 2017 Elsevier Inc. All rights reserved.

1. Introduction 50 years ago when 50,000 women died of cervical cancer annually
(Akers et al., 2007).
The human papillomavirus (HPV) is the most common sexually Meanwhile, oropharyngeal cancer, a subset of head and neck cancer,
transmitted infection (STI) among both men and women in the United is one of the few cancers that has continued to increase in incidence. Its
States (US), with 14 million new infections each year (Satterwhite et al., incidence has increased N 225% in the last 30 years (Chaturvedi et al.,
2013). Oncogenic strains of the HPV are associated with at least six dif- 2011), and between 70% and 90% of all oropharyngeal cancer cases are
ferent cancers including oropharyngeal, anal, cervical, vaginal, vulvar, thought to be HPV-associated (Young et al., 2015). With approximately
and penile cancers (Dunne et al., 2014). While cervical, vaginal, and vul- 75% of HPV-associated oropharyngeal cancer patients being male
var cancers occur only in women, both oropharyngeal and anal cancers (Saraiya et al., 2015), oropharyngeal cancer is the leading HPV-associat-
occur in both sexes, and penile cancer only in men. The burden of HPV- ed cancer among men, and it is projected that it will surpass cervical
associated cancers has been changing over the past fifty years, shifting cancer as the most common HPV-associated cancer in the United States
from a predominantly female cancer to one where males now account in 2020 (Chaturvedi et al., 2011). Even though incidence of anal cancer
for 35% of annual new cancers (Dunne et al., 2014; Saraiya et al., 2015; is higher in women than men, its increasing incidence has become larg-
Palefsky, 2010a). Similarly, there are fewer than 5000 deaths from cer- er among men than women; (Johnson et al., 2004) heightened particu-
vical cancer annually following the development of the Pap test, unlike larly among men who have sex with men, and men diagnosed with HIV
(Shiels et al., 2015).
In 2011, the recommendation for routine HPV vaccination was ex-
panded to include young males, five years after it was first approved
⁎ Corresponding author at: Saint Louis University Center for Outcomes Research
(SLUCOR), Salus Center – 3545 Lafayette Avenue, 4th Floor, Saint Louis, MO 63104, USA.
for young females in the US (Markowitz et al., 2014). The quadrivalent
E-mail address: [email protected] (E. Adjei Boakye). vaccine prevents approximately 70% of cervical cancer and the 9-valent
1
These authors contributed equally to this work. vaccine prevents approximately 81% of cervical cancer, 66% of

http://dx.doi.org/10.1016/j.ypmed.2017.03.014
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300 N. Osazuwa-Peters et al. / Preventive Medicine 99 (2017) 299–304

oropharyngeal cancer, 88% of anal cancer, and 57% of penile cancer available and is called the cervical cancer vaccine or HPV shot. Before
(Saraiya et al., 2015; Palefsky, 2010b; Petrosky et al., 2015; Viens, today, have you ever heard of the cervical cancer vaccine or HPV
2016). While HPV vaccines have been available since 2006 for women shot?” Response options for these variables included “yes” or “no.”
and since 2011 for men, vaccine uptake remains suboptimal. This is par- Secondary analyses were performed to examine factors associated
ticularly true for completion of the three previously required doses with knowing that HPV is an STI and causes certain types of cancers.
(Stokley et al., 2014). The Healthy People 2020 goal of vaccinating 80% These questions were asked of only those who had heard of HPV. The
of eligible males and females (U.S. Department of Health and Human following questions were asked to assess participant knowledge: “Do
Services, 2013) will likely not be met if current trends in HPV vaccine you think HPV can cause cervical cancer?” “Do you think HPV can
uptake continue (Jemal et al., 2013). cause penile cancer?” “Do you think HPV can cause anal cancer?” and
There have been several studies examining the association between “Do you think HPV can cause oral cancer?” Response options included
knowledge and HPV vaccination, including systematic reviews (Radisic “yes,” “no,” or “not sure.” Options “no” and “not sure” were combined
et al., 2017; Coles et al., 2015; Holman et al., 2014; Hendry et al., 2013; and all outcome variables were recoded into “yes” and “no.”
Newman et al., 2013; Trim et al., 2011). Increasing knowledge about
HPV, HPV vaccine, and HPV-associated cancers has been recognized in 2.3. Predictor variables
the literature as a potential means of making informed decisions related
to vaccine uptake (Reiter et al., 2011; Marlow et al., 2013; Mills et al., Factors potentially associated with knowing about HPV were select-
2013; Klug et al., 2008; Brewer & Fazekas, 2007). Of the theories in ed based on previous studies (Blake et al., 2015) and included
the literature that relates to HPV vaccine uptake, the Integrated Behav- sociodemographic characteristics (age, race/ethnicity, marital status,
ioral Model (IBM) particularly associates knowledge and behavioral in- education, and household income), access to a health care provider,
tentions and change (Montano & Kasprzyk, 2015). This theory has been self-perceived health, use of the internet, and family composition. Hav-
applied in the past to HPV vaccine and HPV-associated cancer related ing a regular health care provider was assessed by asking, “Not includ-
studies (Mills et al., 2013; Head & Cohen, 2012). Although studies ing psychiatrists and other mental health professionals, is there a
have found an association between increased HPV knowledge and in- particular doctor, nurse, or other health professional that you see most
creased HPV vaccination; (Brewer et al., 2011; Grandahl et al., 2014) often? [yes/no]” Respondents' general health status was recoded as “Ex-
the general acceptability of this association is not uncontested as several cellent/Very Good,” “Good,” and “Fair/Poor.” Internet use was assessed
studies have also found no association between HPV knowledge and using a question that asked “Do you ever go on-line to access the Inter-
HPV vaccination (Krawczyk et al., 2015a; Gerend et al., 2009; Jacobson net or World Wide Web, or to send and receive e-mail? [yes/no]” Re-
et al., 2016; Walling et al., 2016). Although there is growing literature spondents were asked if they have at least one or more immediate
on increasing HPV vaccine uptake, most studies have focused on family members between the ages of 9 and 27 years old, dichotomized
women. Since there is a 5-year lag between both recommendations as 0 or ≥1.
(adding boys to the recommendation to receive HPV vaccination), and
many men typically consider HPV as a female-only issue (Daley et al., 2.4. Statistical analysis
2016), it is pertinent to increase knowledge about HPV, HPV vaccines,
and HPV-associated cancers as the morbidity and mortality related to Descriptive statistics were used to analyze participants' characteris-
HPV-associated cancers in the United States continue to grow among tics. We compared sociodemographic characteristics and covariates by
men compared to women. gender using chi-square tests. Multivariable logistic regression models
In this study, we compared knowledge of HPV, HPV vaccine, and and listwise deletion for missing data were used to assess the associa-
HPV-associated cancers in men vs. women, an important step in tion between gender and the primary and secondary outcomes. All var-
highlighting the knowledge gap that will become the focus of future iables were included in the multivariable models regardless of their
vaccine uptake studies. We aimed to examine gender differences in: association with the outcome variable. For outcomes with a significant
(Satterwhite et al., 2013) knowledge about HPV, HPV vaccine, and difference between men and women, we used a logistic regression to
HPV-associated cancers, and (Dunne et al., 2014) factors associated estimate the effects of sociodemographic and covariates on the out-
with knowledge about HPV, HPV vaccine, and HPV-associated cancers. comes stratified by gender. We performed a sensitivity analysis where
we limited the data to only participants who were b50 years with the
2. Methods assumption that individuals younger than 50 years are more likely,
compared to older (50 years or older) to have children between 9 and
2.1. Data source 26 years, who are eligible to receive the vaccination. Statistical signifi-
cance was set at p b 0.05 and all tests were two tailed. All analyses
Data from the Health Information National Trends Survey (HINTS) were performed using SAS version 9.4 (SAS Institute, Cary, NC). Sur-
4 cycle 4 (November 2014), administered by the National Cancer Insti- vey-specific procedures were used to account for the complex sampling
tute, were analyzed for 3,608 survey participants aged 18 years and design. Weights were used to represent the U.S. population.
older. HINTS is a nationally representative probability survey of adults
aged 18 or older in the civilian non-institutionalized population of the 3. Results
United States, which assesses usage of and trends in health information
access. Details about the HINTS data source and methodology have been Table 1 shows the characteristics of the study population. Overall,
described elsewhere (National Cancer Institute, 2014; Nelson et al., most respondents were Non-Hispanic White (66.6%), married or living
2004; Finney Rutten et al., 2012). The dataset is publicly available and with a partner (58.3%), had a college degree (46.6%), had a regular pro-
excludes identifying information on individual respondents, thereby vider (63.3%), and reported excellent or good overall health (52.4%).
negating the need for Institutional Review Board approval.
3.1. Knowledge of HPV, the vaccine and HPV-associated cancers
2.2. Outcome variables
Compared to women (Table 2), men reported a statistically lower
The two primary outcomes of interest which have been previously prevalence of knowing about HPV (56.2% vs. 72.0%) and HPV vaccine
used (Blake et al., 2015) were measured using the following questions: (52.7% vs. 74.4%). In the multivariate analysis, men were significantly
“Have you ever heard of HPV? HPV stands for Human Papillomavirus. It less likely to have heard of HPV (aOR = 0.33; 95% CI, 0.25–0.45) and
is not HIV, HSV, or herpes” and “A vaccine to prevent HPV infection is the HPV vaccine (aOR = 0.24; 95% CI, 0.18–0.32) compared to

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Table 1 Table 2
Descriptive statistics of sociodemographic and other variables stratified by gender, HINTS Prevalence and predictors of knowledge and awareness of HPV, HPV vaccine, and HPV-as-
2014. sociated cancers by gender.

Total Genderb p-Valuec Outcome variables Weighted prevalence (%) Adjusted OR (95% CI)a
(3677)
Men Women Men Women
n (wt%)a
(1424) (2184)
Heard of HPV 56.2 72.0 0.33 (0.25–0.45)
wt%a wt%a
Heard of HPV vaccine 52.7 74.4 0.24 (0.18–0.32)
Age 0.3981 HPV causes cervical cancer 76.1 79.3 0.74 (0.50–1.10)
18–34 704 (30.8) 32.0 29.6 HPV causes oral cancer 31.5 28.7 1.19 (0.83–1.70)
35–49 611 (26.7) 27.1 26.3 HPV causes anal cancer 27.1 25.0 1.13 (0.77–1.67)
50–64 575 (25.1) 25.1 25.1 HPV causes penile cancer 29.9 28.9 1.04 (0.72–1.51)
65+ 400 (17.4) 15.8 19.0 HPV causes STD 73.3 67.4 1.22 (0.85–1.73)
Race 0.1928
Note: OR = odds ratio; CI = confidence interval, HPV = human papillomavirus; HINTS =
Non-Hispanic White 1444 (66.6) 67.5 65.9
Health Information National Trends Survey; STD = sexually transmitted disease.
Non-Hispanic Black 245 (11.3) 9.4 13.0 a
Adjusted for age, race/ethnicity, marital status, education, income level, regular pro-
Hispanic 328 (15.1) 15.2 15.0
vider, general health, internet use, has family between 9 and 27 years.
Other 150 (6.9) 7.9 6.1
Marital status b0.0001
Married/living with a partner 1293 (56.4) 58.3 54.6
Divorced/widowed/separated 339 (14.8) 9.7 19.5 who reported their race as “other” were significantly less likely to be
Never been married 659 (28.8) 32.0 25.9 aware of HPV (aOR = 0.23, 95% CI = 0.10–0.54). Likewise, compared
Education 0.0002
College graduate 924 (40.1) 46.6 34.5
to Non-Hispanic White women, Non-Hispanic Blacks (aOR = 0.46,
Some college 691 (30.0) 27.1 32.3 95% CI = 0.24–0.88) and women who reported their race as “other”
High school graduate 419 (18.2) 16.5 19.9 (aOR = 0.36, 95% CI = 0.17–0.78) were less likely to know about
Less than high school 268 (11.6) 9.7 13.4 HPV. Women with less than a high school diploma (aOR = 0.29, 95%
Household income b0.0001
CI = 0.14–0.60), and who obtained a high school diploma (aOR =
$100,000 or more 468 (21.9) 27.8 16.6
$75,000 to $99,999 299 (14.0) 15.5 12.7 0.34, 95% CI = 0.19–0.61) were less likely to be aware of HPV compared
$50,000 to $74,999 369 (17.2) 16.6 17.9 to college graduates, but men's education was not statistically associat-
$35,000 to $49,999 316 (14.8) 15.6 13.9 ed with HPV awareness. Furthermore, among both men and women,
$20,000 to $34,999 272 (12.7) 9.4 15.9 non-internet users were less likely to be aware of HPV (men: aOR =
$0 to $19,999 414 (19.4) 15.1 23.0
Regular provider 0.7064
0.54, 95% CI 0.29–0.98 and women: aOR = 0.57, 95% CI = 0.35–0.93).
Yes 1502 (64.0) 63.3 64.4
No 847 (36.0) 36.7 35.6 3.3. Gender-specific correlates of HPV vaccine awareness
General health 0.0049
Excellent/very good 1115 (48.1) 52.4 44.2
Table 3 shows that men over 65 years were less likely to have heard
Good 902 (38.8) 36.7 40.9
Fair/poor 303 (13.1) 10.9 14.9 of the HPV vaccine (aOR = 0.29, 95% CI = 014–0.59), compared to their
Use internet 0.0530 younger counterparts (18–34 years). Similar findings were also noted
Yes 1969 (83.4) 85.5 82.2 among women; however, the association was not statistically signifi-
No 392 (16.6) 14.5 17.8 cant. Hispanic men (aOR = 0.49, 95% CI = 0.27–0.88) and men who re-
Has family between 9 and 27 years 0.7925
Yes 1168 (49.9) 49.5 50.2
ported their race as “other” (aOR = 0.51, 95% CI = 0.26–0.98) were
No 1175 (50.1) 50.5 49.8 significantly less likely to be aware of HPV vaccine, compared to Non-
Hispanic White men. Similarly, non-Hispanic Black women (aOR =
wt% = weighted percentages.
HINTS = Health Information National Trends Survey. 0.36, 95% CI = 0.19–0.67), Hispanic women (aOR = 0.49, 95% CI =
a
Percentages may not total 100% due to rounding error. 0.27–0.88), and women who reported their race as “other” (aOR =
b
Male and female do not add up to total due to missing data. 0.51, 95% CI = 0.26–0.98) were significantly less likely to know about
c
Based on chi-square tests. HPV vaccine compared to their Non-Hispanic White counterparts.
Men's education was not statistically associated with HPV vaccine
awareness, however women with a high school diploma (aOR = 0.39,
95% CI 0.21–0.71) were less likely to have heard about the HPV vaccine
women. Only participants who had heard of HPV were asked the ques- compared to college graduates. Furthermore, non-Internet users were
tions relating to knowledge of HPV-associated cancers. The prevalence less likely to have heard about HPV compared to those who regularly
of knowing that HPV causes oral, anal, and penile cancers was similar use the Internet; (aOR = 0.54, 95% CI = 0.29–0.98) for men, and (aOR
among men and women. There was no statistically significant difference = 0.57, 95% CI = 0.35–0.93) for women.
between men and women regarding knowledge about HPV-associated
cancers. After limiting the data to only respondents who were below 4. Discussion
50 years old in our sensitivity analysis (Supplemental Table 1), the find-
ings did not change – both genders had low knowledge about HPV-as- Our study examined gender differences in knowledge of HPV, HPV
sociated cancers and men had low knowledge of HPV and the vaccine vaccine, and HPV-associated cancers among a nationally representative
compared to women. sample of adults in the United States. We found that men were less like-
ly than women to have heard of HPV and the HPV vaccine. This result is
3.2. Gender-specific correlates of HPV awareness consistent with previous finding which reported that compared to
women, men were 73% and 75% less likely to have heard of HPV and
Table 3 indicates that male respondents aged 65 or older were less the vaccine, respectively (Blake et al., 2015). It continues to be
likely to have heard about HPV (aOR = 0.25, 95% CI = 0.13–0.50) com- concerning that only a little more than half of males in this national
pared to 18–34 year old men. Similarly, women aged 65 or older were sample had heard about HPV and the HPV vaccine, even though the vac-
less likely to have heard of HPV (aOR = 0.41, 95% CI = 0.21–0.81) com- cine has been licensed for routine use in young boys for the past five
pared to 18–34 year old women. Racial disparities were observed years. Several reasons could explain this. First, campaigns promoting
among both genders. Compared to Non-Hispanic White men, men the vaccine as a cancer-preventing vaccine have mostly targeted

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Table 3
Adjusted logistic regression predicting knowledge about HPV and the HPV vaccine stratified by gender, HINTS 2014.

Heard of HPV (n = 2780) Heard of HPV vaccine (n = 2766)

Men Women Men Women

Age
18–34 Ref Ref Ref Ref
35–49 0.66 (0.35–1.22) 1.47 (0.77–2.80) 0.71 (0.38–1.33) 1.12 (0.58–2.15)
50–64 0.52 (0.28–0.96) 0.84 (0.46–1.54) 0.41 (0.22–0.78) 0.78 (0.42–1.45)
65+ 0.25 (0.13–0.50) 0.41 (0.21–0.81) 0.29 (0.14–0.59) 0.51 (0.26–1.01)
Race
Non-Hispanic White Ref Ref Ref Ref
Non-Hispanic Black 0.66 (0.35–1.26) 0.46 (0.24–0.88) 0.56 (0.28–1.14) 0.36 (0.19–0.67)
Hispanic 0.61 (0.32–1.14) 1.36 (0.77–2.40) 0.31 (0.16–0.62) 0.49 (0.27–0.88)
Other 0.23 (0.10–0.54) 0.36 (0.17–0.78) 0.22 (0.09–0.53) 0.51 (0.26–0.98)
Marital status
Married/living as married Ref Ref Ref Ref
Divorced/widowed/separated 1.61 (1.00–2.60) 1.59 (1.03–2.43) 1.26 (0.77–2.04) 0.99 (0.63–1.54)
Never married 1.35 (0.76–2.41) 1.94 (1.00–3.77) 1.51 (0.85–2.68) 2.09 (1.08–4.07)
Education
College graduate Ref Ref Ref Ref
Some college 0.93 (0.57–1.49) 0.73 (0.41–1.31) 0.97 (0.60–1.58) 0.89 (0.52–1.54)
High school graduate 0.74 (0.41–1.32) 0.34 (0.19–0.61) 0.84 (0.46–1.55) 0.39 (0.21–0.71)
Less than high school 0.76 (0.28–2.08) 0.29 (0.14–0.60) 1.07 (0.43–2.69) 0.69 (0.34–1.43)
Income level
$100,000 or more Ref Ref Ref Ref
$75,000 to $99,999 0.50 (0.26–0.96) 1.31 (0.56–3.05) 0.70 (0.37–1.32) 1.09 (0.48–2.48)
$50,000 to $74,999 0.74 (0.41–1.34) 0.92 (0.46–1.83) 0.71 (0.41–1.24) 1.31 (0.64–2.71)
$35,000 to $49,999 0.61 (0.31–1.21) 0.89 (0.41–1.94) 0.39 (0.21–0.75) 0.68 (0.31–1.46)
$20,000 to $34,999 0.69 (0.32–1.50) 0.58 (0.26–1.29) 0.34 (0.16–0.72) 0.56 (0.24–1.32)
$0 to $19,999 0.40 (0.18–0.91) 0.73 (0.30–1.82) 0.23 (0.09–0.61) 0.62 (0.26–1.46)
Regular provider
Yes Ref Ref Ref Ref
No 0.80 (0.50–1.26) 0.89 (0.56–1.41) 0.57 (0.35–0.93) 0.65 (0.41–1.03)
General health
Excellent/very good Ref Ref Ref Ref
Good 0.77 (0.50–1.17) 0.59 (0.35–0.98) 0.92 (0.60–1.42) 0.67 (0.43–1.03)
Fair/poor 0.53 (0.26–1.10) 0.52 (0.29–0.93) 0.76 (0.33–1.73) 0.67 (0.40–1.12)
Use internet
Yes Ref Ref Ref Ref
No 0.54 (0.29–0.98) 0.57 (0.35–0.93) 0.57 (0.28–1.15) 0.54 (0.32–0.89)
Has family between 9 and 27 years
Yes Ref Ref Ref Ref
No 0.68 (0.45–1.05) 0.71 (0.45–1.11) 0.58 (0.38–0.89) 0.47 (0.31–0.71)

HPV = human papillomavirus; HINTS = Health Information National Trends Survey.

females, and so conversations around HPV and HPV vaccines have been One theory that has been used in framing the association between
largely female-centered (Patel & Berenson, 2013; Pisciotta, 2012). In ad- increasing knowledge and change of behavior is the IBM. Relating this
dition, women often make decisions as to whether their child(ren) get model to our study, we found that men have lower knowledge of the
the HPV vaccine (Berenson et al., 2014) and as a result men may not HPV vaccine. However, our study did not measure actual rates of vac-
feel like they need to know more about HPV vaccine since their wives/ cine uptake due to knowledge, so while we found lower knowledge,
significant others will take care of it. we cannot draw a conclusion that increasing HPV knowledge will defi-
A more concerted effort should be placed on increasing awareness nitely lead to an increase in HPV vaccine uptake. There are several stud-
about the HPV vaccines' effectiveness in preventing cancers found in ies that have found a correlation between increasing knowledge and
both genders rather than the largely female-centric HPV conversations HPV vaccine uptake (Brewer et al., 2011; Grandahl et al., 2014); howev-
taking place currently. Even though women tend to be more involved er, there are also studies that have shown no association, or an inverse
with a decision to vaccinate their children against HPV, a recent study association between increasing knowledge and receiving the HPV vac-
found that 22% of women involved their husbands/partners in HPV vac- cine (Krawczyk et al., 2015a; Gerend et al., 2009; Jacobson et al., 2016;
cination decision (Berenson et al., 2014). Therefore, it may be beneficial Walling et al., 2016). Whatever the case, knowledge of HPV vaccine
to include more men in the HPV vaccine conversation than what it is and HPV-associated cancers was low in both males and females in our
currently done. A recent study from our group (Mohammed et al., study, and a previous study indicates that most parents (men and
2016) showed that women with less education were less likely to re- women) are receptive to the idea of increasing their general knowledge
ceive a recommendation from providers, therefore increasing men's about HPV in order to make more informed decision about HPV vaccine
knowledge and involvement might lead to increase vaccine uptake. In uptake (Krawczyk et al., 2015b). It is therefore important that interven-
addition, there is an increasing incidence of HPV-associated cancers in tions are designed to facilitate providing adequate and reliable informa-
the male population of the United States. Of the 30,700 new cases of tion to parents, especially information provided by a healthcare
HPV-associated cancers in the United States annually, almost 40% are practitioner (Perez et al., 2016).
found in men (Viens, 2016). Several health theories postulate that indi- This study explored knowledge of the association between HPV and
viduals are more likely to have a behavioral change when they perceive four major HPV-associated cancers in the US: cervical, penile, anal, and
susceptibility, or when an issue more salient to them (Montano & oral cancers. Our results showed that knowledge of HPV's association
Kasprzyk, 2015). Thus, men may become more interested in increasing with cervical cancer was highest, and most comparable, across genders,
their awareness of HPV vaccine and HPV-associated cancers the more compared to the other HPV-associated cancers in this study. With the
they understand that HPV is not just a woman's issue. decrease in incidence of cervical cancer, it becomes important to raise

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the level of awareness of other HPV-associated cancers, which we show status and therefore this may limit generalizability of findings to the
to be very low for both genders. Only 30% of respondents knew HPV was population at-large. Lastly, there could be bias introduce through factors
causally associated with oral and penile cancers and only 27% knew relating to the HINTS data such as survey question wording, and sam-
about the association between HPV and anal cancer. The lack of statisti- pling technique that could affect our findings. Despite these limitations,
cally significant differences in knowledge of anal cancer between males our study is one of the few to examine gender differences in HPV-asso-
and females and its association with HPV underscores the need to in- ciated cancer knowledge in a national sample.
crease awareness especially among men who have sex with men, in
whom anal cancer is a significant concern. 5. Conclusion
Less than one-third of male respondent knew of the association be-
tween oral cancer and HPV, and this was similar among females in our More than half of our study population had knowledge of the HPV
study. The 225% increase in HPV-associated oropharyngeal cancer in and the HPV vaccine, but men had lower knowledge compared to
the last 30 years (Chaturvedi et al., 2011) has been largely attributed women. Knowledge about HPV-associated cancers was very low
to salient sexual behaviors particularly related to oral sex (D'Souza et among both genders. Among women, racial minorities and respondents
al., 2009). More adolescents are experimenting with oral sex; and with lower education reported lower knowledge about HPV and the
males engage in oral sex more than females, initiate oral sex earlier, HPV vaccine.
have more oral sexual partners, and develop HPV-associated oropha- Supplementary data to this article can be found online at http://dx.
ryngeal cancer more often than females (Gillison, 2008). The fact that doi.org/10.1016/j.ypmed.2017.03.014.
there was no gender difference in knowledge of HPV's association
with oral cancer suggests the need for further education of men about
Funding sources
this association. Some national agencies and scientific organizations
aim to increase oral cancer knowledge through mass oral cancer screen-
This research did not receive any specific grant from funding agen-
ings in the community (AAOM Clinical Practice Statement, 2016; The
cies in the public, commercial, or not-for-profit sectors.
American Head and Neck Society, 2014).
We found that African American women were less likely to have
heard of HPV and the vaccine compare to white women. This corrobo- Conflict of interest
rates findings from a study that used data collected within two years
of the HPV vaccine recommendation in 2006 (Gelman et al., 2011). It There are no conflicts of interest for all authors.
is concerning that almost a decade since the vaccine was first recom-
mended, African American women are still less likely to have heard of Transparency document
HPV and the HPV vaccine. Paradoxically, African Americans have higher
vaccine initiation than Whites (Viens, 2016). One explanation for this is The Transparency document associated with this article can be
that while both African American and White women are more likely to found, in online version.
initiate HPV vaccination following a physician recommendation, the
odds of uptake is much higher among African Americans than Whites References
(Ylitalo et al., 2013). Additionally, African American women are now
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