A national cross-sectional study of dentists’ vaccine hesitancy and intention to provide HPV vaccines following emergency COVID-19 vaccination authorization - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Official websites use .gov A .gov website belongs to an official government organization in the United States. Secure .gov websites use HTTPS A lock ( Lock Locked padlock icon ) or https:// means you've safely connected to the .gov website. Share sensitive information only on official, secure websites. Search Log in Dashboard Publications Account settings Log out Search… Search NCBI Primary site navigation Search Logged in as: Dashboard Publications Account settings Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide PERMALINK Copy As a library, NLM provides access to scientific literature. 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Published in final edited form as: Vaccine. 2025 Apr 4;53:127035. doi: 10.1016/j.vaccine.2025.127035 Search in PMC Search in PubMed View in NLM Catalog Add to search A national cross-sectional study of dentists’ vaccine hesitancy and intention to provide HPV vaccines following emergency COVID-19 vaccination authorization Priscilla M Flynn Priscilla M Flynn a Department of Public and Primary Oral Health, School of Dentistry, University of Minnesota, 9-372 Moos Tower, 515 Delaware St. SE, Minneapolis, MN 55455 Find articles by Priscilla M Flynn a , Cynthia Stull Cynthia Stull a Department of Public and Primary Oral Health, School of Dentistry, University of Minnesota, 9-372 Moos Tower, 515 Delaware St. SE, Minneapolis, MN 55455 Find articles by Cynthia Stull a , Vedushi M Jain Vedushi M Jain b Research Assistant, RELab, School of Nursing, University of Minnesota, 308 Harvard Street SE, Minneapolis, MN 55455 Find articles by Vedushi M Jain b , Michael D Evans Michael D Evans c Clinical and Translational Science Institute, University of Minnesota, 2221 University Ave SE Suite 200, Minneapolis MN 55414 Find articles by Michael D Evans c Author information Article notes Copyright and License information a Department of Public and Primary Oral Health, School of Dentistry, University of Minnesota, 9-372 Moos Tower, 515 Delaware St. SE, Minneapolis, MN 55455 b Research Assistant, RELab, School of Nursing, University of Minnesota, 308 Harvard Street SE, Minneapolis, MN 55455 c Clinical and Translational Science Institute, University of Minnesota, 2221 University Ave SE Suite 200, Minneapolis MN 55414 ✉ Corresponding author: Priscilla M. Flynn, [email protected] Issue date 2025 Apr 19. PMC Copyright notice PMCID: PMC12110664 NIHMSID: NIHMS2072110 PMID: 40186992 The publisher's version of this article is available at Vaccine Abstract Background Oropharyngeal cancers are the most common human papillomavirus (HPV)-related cancers in the United States, yet are largely preventable with timely administration of the HPV vaccine. While the two-dose vaccine is currently underutilized, one strategy to meet the Healthy People 2030 HPV vaccination goal is to expand dentists’ scope of practice to include vaccination. This study was conducted to report dentists’ willingness to administer the HPV vaccine to their patients if allowed by state legislation, and to what extent vaccine hesitancy affected their decision. Methods A representative sample of currently licensed dentists (n=902) completed an electronic survey measuring their willingness to administer the HPV vaccine, vaccine hesitancy using the 5C model, and current HPV vaccination knowledge, attitudes, beliefs and behaviors. The Transtheoretical Model was used to dichotomize dentists’ willingness to provide the HPV vaccine as either ‘pre-action’ or ‘action +’, facilitating logistic regression analysis. Results/Conclusion This study found that over half (56.2%) of the 902 dentists surveyed reported willingness to administer the HPV vaccine in their practice. Modifiable factors associated with willingness to vaccinate include currently recommending the HPV vaccine to patients, comfort in administering vaccinations, previous training to provide COVID-19 vaccinations, and appropriate practice infrastructures to administer HPV vaccinations. Only the 5C vaccine hesitancy model construct of “Constraints” was predictive of the willingness to administer the HPV vaccine. These findings indicate a need for dentistry to prioritize knowledge and skills-based training in HPV vaccine communication and administration to prepare dentists to provide vaccines in their practices as state legislation allows. Keywords: Human Papillomavirus Vaccines, Vaccine Hesitancy, Oropharyngeal Neoplasms, Dentists, Transtheoretical Model INTRODUCTION Oropharyngeal cancers (OPCs) have overtaken cervical cancer as the most common human papillomavirus (HPV)-related cancers in the United States.( 1 ) The FDA-approved 9-valent HPV vaccine provides protection against the predominant high-risk strains that are closely linked to several types of cancers, including those impacting the oropharynx that occur mainly at the base of the tongue and tonsils.( 2 ) Administered in two doses at a six-month interval before age 15, it effectively stimulates a strong immune response and provides enduring protection against HPV-related diseases.( 3 ) Despite clear benefits and recommendations, HPV vaccination rates are suboptimal and are far from the Healthy People 2030 goals of 80% up-to-date vaccination.( 4 , 5 ) Over 31.1 million U.S. residents sought care from a dentist, but not from their physician in 2017.( 6 ) This suggests that dentists could play a pivotal role in increasing the uptake of HPV vaccination, particularly since the two-dose vaccine could be administered at consecutive preventive appointments six months apart. Recent national legislation granted dentists the authority to administer vaccines in emergency scenarios, including during the COVID-19 pandemic.( 7 ) Although emergency authorization in most states has expired, several states either retain or have enacted legislation for the administration of selected vaccines. Dentists in Indiana, Kentucky, Louisiana, Massachusetts, Mississippi, New Jersey, and Oregon were authorized to administer the HPV vaccination at the time of this study.( 8 ) Further, the American Dental Association approved new Current Dental Terminology (CDT) codes used for HPV vaccine administration in 2023, a step toward removing financial barriers to HPV administration by dental providers.( 9 ) While enabling legislation is critical to further expansion of HPV vaccination by dentists, other factors are barriers to vaccine administration including personal vaccine hesitancy.( 10 , 11 ) Vaccine hesitancy, according to the World Health Organization (WHO), is the delay in acceptance or refusal of vaccines despite the availability of vaccine services.( 12 ) While dentists possess a favorable position to influence their patients on vaccination decisions, dentists are also susceptible to their own personal priorities, beliefs, and attitudes about vaccines.( 10 , 11 ) Studies have shown that healthcare providers (HCPs) who received vaccinations themselves or planned to be vaccinated were more likely to recommend vaccines to their patients.( 10 , 13 ) On the other hand, some non-vaccinated HCPs made a distinction between their personal choices and the recommendations they gave to patients.( 10 , 13 ) One of the major concerns among HCPs is vaccine safety and possible adverse effects following vaccination. Dentists, in particular, face challenges such as subject literacy, the presence of stigma surrounding the topic, reimbursement issues, and parental hesitation, which contribute to their reluctance in discussing the HPV vaccination with patients and caregivers.( 14 ) While the COVID-19 pandemic may have influenced healthcare practices and attitudes toward vaccination, including among dentists, there is currently insufficient evidence to determine if dentists are more or less willing to administer vaccines in general, and the HPV vaccine in particular.( 15 ) The aims of this study were to identify the willingness of dentists to administer the HPV vaccine in their dental practice, and to identify the predictive nature of vaccine hesitancy and related factors toward HPV vaccine administration. Results may assist dental professionals and policy makers in the decision to expand scope-of-practice to include HPV vaccination. MATERIAL AND METHODS Sampling. The American Dental Association’s Legislation Action Center listed the total number of licensed dentists as 196,467 at the time of this study.( 16 ) The number of dentists in each state were grouped into the six regions established by the National Dental Practice-Based Research Network (DPBRN) as illustrated in Figure 1 .( 17 ) A sample size of 900 completed surveys was established as an adequate sample size to estimate the “true” rate of willingness of dentists to administer the HPV vaccine with a precision (half-width of 95% confidence interval) of ±3.3%. The precision is based on an expected proportion of 56.0% of dentists willing to administer HPV vaccines from a recent national survey.( 18 ) The number of completed surveys required from each district was calculated based on the proportion of licensed dentists in each region as shown in Table 1 .( 17 ) Figure 1. Open in a new tab Dental Practice-Based Research Network Regions. Graphic design courtesy of Xavier Moen. Table 1. Survey sampling strategy grouping dentists into DPBRN regions by state licensure proportions * . Licensed dentists ** % Target n per region WESTERN REGION 48,958 24.90% 224 MIDWEST 34,114 17.40% 157 SOUTHWEST 22,797 11.60% 104 SOUTH CENTRAL 16,400 8.30% 75 SOUTH ATLANTIC 28,520 14.50% 130 NORTHEAST 45,678 23.30% 210 TOTAL 196,467 100.00% 900 Open in a new tab * Regions defined by the National Dental Practice-Based Research Network. ** Licensed dentists in each state determined by the American Dental Association Legislative Action Network. Data source: ada.org/advocacy/legislative-action-center . Accessed 5/27/2023 Survey instrument. The Transtheoretical Model (TTM) was developed by James Prochaska, merging leading theories of psychotherapy and behavioral change.( 19 ) Originally used for tobacco cessation, TTM has been applied to numerous health behavior change processes and used as a tool to facilitate educational interventions. ( 18 ) The TTM assigns individuals to one of five temporal behavioral change processes identified as the Stages of Change (SOC) described as precontemplation, contemplation, preparation, action, and maintenance.( 19 ) Stronger commitment to future behavioral change occurs as individuals take steps to adopt the target behavior. Once an individual is in action stage, or has been practicing the targeted behavior for about six months, they are placed in maintenance stage.( 19 , 20 ) The TTM posits that behavior is fluid and may progress and regress over time.( 19 ) This study uses (TTM) to assess the gap between willingness to provide the HPV vaccine, or action stage, and current participation in HPV vaccination, maintenance stage, and dentists’ current behavior regarding HPV vaccination. Vaccine administration is a relatively new scope of practice in dentistry, and only three states (Oregon, Illinois and Minnesota) enacted vaccination-enabling legislation prior to the emergency COVID-19 vaccination order for all states during the pandemic.( 21 ) As dentists in states with vaccination enabling legislation continue to deliver vaccines routinely, and as other states enact laws to enable dentists as vaccinators, TTM allows for movement between the SOC as attitudes, social norms and environmental factors may affect this behavior over time. The dependent variable, dentists’ readiness to provide the HPV vaccine, was measured using a single item based on the Transtheoretical Model (TTM) adapted from a previous study by Aldrossi et al. (2021).( 20 ) Phrased as, “Which of the following statements BEST describes your thoughts about administering the HPV vaccine if allowed by your State?”, answer choices and associated TTM Stage of Change (SOC) were, I would not participate and I haven’t thought about it (precontemplation), I would consider it (contemplation), I would participate in HPV vaccination (preparation), and I currently participate in HPV vaccination (action/maintenance). Replicating Aldrossi et al.’s study (2021), these SOC were collapsed into two categories to facilitate logistic regression analysis.( 20 ) Precontemplation, contemplation, and preparation were collapsed into the “Pre-action” category, and action/maintenance was relabeled as “Action+”.( 20 ) While Aldrossi, et al.’s (2021) was not validated, the item was replicated as it was the only published survey assessing HPV vaccination practices of dentists.( 20 ) The “5C” vaccine hesitancy scale, designed and validated by Betsch et al. (2018) was selected to measure vaccine hesitancy.( 21 ) The valid and reliable instrument integrated concepts and definitions from WHO’s Strategic Group of Experts on Immunization (SAGE) 3C model( 10 ), the 4C model( 22 ), and the 5A model.( 23 ) The 15-item scale consists of three items representing each of five constructs hypothesized to comprise vaccine hesitancy. The 5Cs consist of Confidence (attitude), Complacency (perceived personal health status and invulnerability), Constraints (self-control), Collective Responsibility (communal orientation), and Calculation (preference for deliberation).( 21 ) While the 5C model was developed for general audiences, the instrument used in this study was adapted and validated for use among health care providers by Kwok et al. (2021).( 24 ) A representative item was, “Vaccine-preventable diseases are not so severe that I should be vaccinated” with response choices ranging from 1=strongly disagree to 5=strongly agree on a Likert-type scale. Negatively worded items were reverse coded prior to analysis.( 25 , 26 ) All fifteen 5C questions are provided in Supplemental Table 1 . Prior to the COVID-19 pandemic, a positive linear relationship between HPV-related knowledge and attitudes about HPV vaccination was well-documented.( 10 , 20 , 27 ) As most childhood immunizations including the HPV vaccination stalled during the pandemic, it was unknown if this relationship may have changed in association with the scrutiny of the COVID-19 vaccine. Therefore, we reviewed the literature and selected ten representative questions covering the key areas of HPV infection, oropharyngeal cancers, and HPV vaccination.( 10 , 11 , 14 , 18 , 20 , 25 , 28 – 31 ) Additional items to measure attitudes and beliefs( 32 ), comfort level of vaccine administration( 18 ), current HPV vaccination recommendation( 20 ), barriers( 18 , 25 , 27 – 29 , 32 ), infrastructure/environment( 28 ), and perceived role in HPV vaccination( 18 ) were replicated from other recent studies. The item to determine the level of COVID-19 vaccination training and participation was designed specifically for this study. An “attention check question” was added midway through the survey to eliminate respondents who may harm data quality by speeding through the survey and providing inattentive answers.( 33 ) The survey was piloted among eight dentists currently practicing in Minnesota and Wisconsin. Comments on survey question clarity, response selections, and recommendations for additional questions were solicited, and respondents were given the option to comment via email or telephone. Two respondents commented via telephone and offered no revisions, and no comments were received via email. The survey was then administered by a third-party professional survey company (Qualtrics, Provo, UT). The survey was “soft launched” on August 1, 2023 and completed by 49 respondents. The data were reviewed with no coding errors identified. The survey was then sent to 99,780 potential respondents in the study population. Respondents completing the survey received an undisclosed amount of financial remuneration. Statistical Analysis. Respondent characteristics were reported using means and standard deviations (SD) for continuous variables, and frequencies and proportions (%) for categorical variables. Potential predictors of the intention to provide HPV vaccinations were examined using univariable and multivariable logistic regression analysis. Two multivariable models were considered, one including the full list of predictors, and one including predictors chosen by stepwise variable selection using Akaike’s Information Criterion (AIC). The non-modifiable predictors of practice type, practice setting, region, race, and ethnicity were included in both models. The results of all models are reported using odds ratios with 95% confidence intervals. Analyses were conducted using R version 4.2.2 (R Foundation for Statistical Computing).( 34 ) Cronbach’s α was used as an indicator of reliability for the 5C vaccine hesitancy scale, and principal component analysis was used to examine the factorial validity of the 5C model scale. RESULTS The proportion established to meet sampling requirements was met for each state and DPBRN district as depicted in the participant flow diagram below. The average survey completion time was 6.5 minutes. As displayed in Table 2 , the majority of participants identified as female, White or White and another race, and non-Hispanic. Nearly two-thirds reported practicing dentistry for 10 years or less, the majority practiced in an urban area, and in private, specialty, hospital-based or Dental Service Organization (DSO) practices. Table 2. Characteristics of the study sample (n=902). Gender Male 402 (44.6) Female 480 (53.2) Non-binary 8 (0.9) Prefer not to answer * 12 (1.3) Years in Practice 0 to 5 301 (33.4) 6 to 10 256 (28.4) 11 to 15 176 (19.5) 16 to 20 79 (8.8) 21 or more 90 (10.0) Race Black or Black and another race 98 (10.9) HA/PI or HA/PI and another race 15 (1.7) AI/AN or AI/AN and another race 22 (2.4) Asian or Asian and another race 85 (9.4) White or White and another race 661 (73.3) Prefer not to answer * 41 (4.5) Ethnicity Hispanic 150 (16.6) Not Hispanic 710 (78.7) Prefer not to answer * 42 (4.7) Practice Region Midwest 158 (17.5) Northeast 211 (23.4) South Atlantic 131 (14.5) South Central 74 (8.2) Southwest 105 (11.6) Western 223 (24.7) Practice Setting Urban - over 100,000 inhabitants 459 (50.9) Town/Suburb - more than 5,000, but fewer than 100,000 inhabitants 383 (42.5) Rural – 5,000 or fewer inhabitants 69 (6.7) Practice Type Private practice/ general dentistry 337 (37.4) Specialty practice 101 (11.2) Hospital-based clinic 159 (17.6) Dental Service Organization (e.g., Aspen/Kool Smiles, etc.) 112 (12.4) Academic Institution 53 (5.9) Local Health Department 33 (3.7) Federally Qualified Health Center (FQHC) 35 (3.9) Mobile Dentistry Practice 9 (1.0) Non-profit/Free Clinic (not an FQHC) 10 (1.1) Other * 53 (5.9) Open in a new tab * Categories omitted in further analyses. To answer the study’s first aim, to identify the willingness of dentists to administer the HPV vaccine in their dental practice, over half (56.2%) of dentists were willing to provide the HPV vaccine in their practice and were categorized in TTM “Action +” stage (see Table 3 ). Table 3. Frequencies of “willingness to administer the HPV vaccine” predictive of Transtheoretical Model Stage of Change (n=902) Frequency (%) TTM Stage Frequency (%) 0 = I would not participate. 75 (8.3) PRE-ACTION 395 (43.8) 1 = I haven’t thought about it. 137 (15.2) 2 = I would consider it. 183(20.3) 3 = I would participate in HPV vaccination. 335 (37.1) ACTION + 507 (56.2) 4 = I currently participate in HPV vaccination. 172 (19.1) Open in a new tab As reported in Table 4 , more than half of dentists correctly answered questions about having HPV infection without knowing it, the HPV vaccine’s protection against OPCs, who should receive the vaccine, common OPC anatomical sites, and vaccine insurance coverage. Fewer than half answered questions correctly about sexual activity and HPV infection, HPV vaccine dosage, and cases of HPV-related OPCs compared to cervical cancer. The mean score (SD) out of a possible 10 points was 5.83 (2.16). Table 4. Items measuring knowledge about HPV, HPV vaccinations and oropharyngeal cancers. Frequency (%) Item Correct Answer Participants answering correctly Participants answering incorrectly Participants answering “Not sure” You can have HPV without knowing it. TRUE 728 (80.7) 120 (13.3) 54 (6.0) Most sexually active people will get HPV. TRUE 415 (46.0) 335 (37.1) 152 (16.9) HPV vaccines can protect men and women against HPV related oropharyngeal cancer. TRUE 688 (76.3) 112 (12.4) 102 (11.3) Patients with a history of HPV should not receive the vaccine. FALSE 514 (57.0) 170 (18.8) 218 (24.2) The HPV vaccine does not cause serious side effects. TRUE 452 (50.1) 231 (25.6) 219 (24.3) The full age range approved by the FDA for HPV vaccination is from 9–45 years. TRUE 543 (60.2) 144 (16.0) 215 (23.8) The HPV vaccine is administered in one dose. FALSE 409 (45.3) 241 (26.7) 252 (27.9) Anatomical sites for oropharyngeal cancer include the tonsils, posterior pharyngeal wall, soft palate and base of the tongue. TRUE 629 (69.7) 110 (12.2) 163 (18.1) There are more cases of HPV-related oropharyngeal cancers than cervical cancer. TRUE 383 (42.5) 184 (20.4) 335 (37.1) HPV vaccines are not covered by most insurance providers. FALSE 495 (54.9) 165 (18.3) 242 (26.8) Open in a new tab Table 5 reports the results of vaccine hesitancy construct subscores, attitudes, behaviors, beliefs, the knowledge of HPV total scores, and practice characteristics, thus addressing the study’s second aim: to identify the predictive nature of vaccine hesitancy and related factors toward HPV vaccine administration. Table 5. Logistic regression of factors predictive of TTM ‘action+’ SOC. Unadjusted Univariable Model Model 1 Model 2 Variable OR (95% CI) Vaccine Hesitancy subscores Confidence 1.1 (1.05, 1.16) * 1.04 (0.64, 1.67) Complacency 1.06 (1.01, 1.12) * 0.93 (0.58, 1.49) Constraints 1.07 (1.03, 1.11) * 1.57 (1.01, 2.47) * 1.43 (1.03, 2.00) * Calculation 1.01 (0.96, 1.05) 0.69 (0.48, 0.99) * 0.71 (0.50, 1.01) Collective Responsibility 1.06 (1.01, 1.12) * 1.12 (0.60, 2.13) HPV Knowledge Total Score 1.12 (1.06, 1.20) * 0.88 (0.52, 1.47) Recommend HPV vaccine (Yes vs No) 4.27 (3.01, 6.13) * 3.85 (2.32, 6.47) * 4.16 (2.5, 6.77) * Recommend HPV vaccine (Not Sure vs No) 0.51 (0.26, 0.94) * 0.65 (0.28, 1.47) 0.71 (0.31, 1.55) Comfort with general vaccination administration (1=comfortable/very comfortable, 0=otherwise) ** 7.50 (5.40, 10.53) * 6.79 (4.26, 11.04) * 7.33 (4.68, 11.7) * Trained to give vaccine 4.45 (3.18, 6.34) * 1.85 (1.08, 3.20) * 2.00 (1.23, 3.29) * Gave vaccines 3.2 (2.31, 4.49) * 1.15 (0.65, 2.02) Trained prior to pandemic 2.45 (1.75, 3.48) * 1.15 (0.67, 1.99) Not aware 0.5 (0.35, 0.71) * 0.64 (0.33, 1.23) 0.63 (0.38, 1.05) State didn’t allow 0.75 (0.51, 1.09) 0.70 (0.36, 1.37) 0.68 (0.39, 1.16) Not interested 0.30 (0.22, 0.43) * 0.88 (0.44, 1.77) Factors affecting vaccine administration behaviors (1=agree/strongly agree, 0 otherwise) Not comfortable discussing HPV 0.76 (0.69, 0.84) * 0.79 (0.47, 1.30) Concerned about vaccine record access 1.02 (0.92, 1.13) 1.16 (0.75, 1.81) Staff buy-in will affect acceptance 1.2 (1.08, 1.34) * 1.23 (0.80, 1.89) Practice infrastructure appropriate 1.73 (1.54, 1.95) * 2.11 (1.36, 3.27) * 2.37 (1.58, 3.58) * No discussion space 0.79 (0.71, 0.87) * 0.60 (0.37, 0.96) * 0.62 (0.40, 0.97) * Leave HPV vaccination to MDs 1.06 (0.95, 1.18) 1.38 (0.90, 2.12) 1.47 (0.98, 2.21) Concerns about reimbursement 1.32 (1.18, 1.47) * 1.15 (0.67, 1.96) Knew more about vaccine preservation 1.29 (1.16, 1.44) * 1.09 (0.62, 1.88) Confident that billing code available 1.23 (1.1, 1.37) * 0.57 (0.32, 0.99) * 0.66 (0.43, 1.02) Delegate to dental hygienist 1.32 (1.19, 1.47) * 1.07 (0.68, 1.69) Open in a new tab Model 1 includes all variables. Model 2 includes variables chosen via stepwise variable selection using the AIC. * Denotes statistical significance at the p<0.05 level ** More than 1 answer allowed. Analysis excluded respondents who answered YES to both “I provided COVID-19 vaccines” and either “I was not interested in providing the COVID-19 vaccine” or “I was not aware that I could provide COVID-19 vaccinations”. Vaccine hesitancy construct subscores can range from 3 to 15 with a higher score equated to Increased vaccine hesitancy. The mean (SD) for each construct were Confidence =11.82 (2.92), Complacency=7.91 (2.78), Constraints=5.98 (3.33), Calculation = 11.35 (2.85), and Collective Responsibility= 12.47 (2.50). Four of the five vaccine hesitancy constructs were predictive of dentists’ willingness to administer the HPV vaccine in the unadjusted analysis, but only Constraints was retained in a stepwise selection model and remained statistically significant in Model 2. Factors were grouped into “modifiable” and “difficult/unable to modify” to identify potential targets for future interventions. Beliefs, attitudes and behaviors (modifiable factors) predictive of ‘Action+’ stage in Model 2 were found among dentists who currently recommend the HPV vaccine, were comfortable administering vaccinations trained to provide COVID-19 vaccinations, and had appropriate practice infrastructures to administer HPV vaccinations. Dentists without an appropriate location to discuss HPV as a sexually transmitted disease were more likely to be in ‘Pre-action’ stage. Figure 2 illustrates the “modifiable” factors predictive of ‘Action+’ stage. Figure 2. Open in a new tab Adjusted multivariable logistic regression of dentists’ modifiable beliefs, attitudes and behaviors predictive of TTM ‘action+’ SOC. Factors that were deemed either difficult or unable to modify predictive of intention to provide the HPV vaccine are shown in Table 6 . Hospital-based dental practices, Dental Service Organizations (DSO), and mobile dental clinic locations were found to be predictive of ‘Action +’ stage in Model 2, with private practice as the reference group. Dentists practicing over 21 years were less likely to be in ‘Action+’ stage compared to dentists just entering practice (0–5 years). Table 6. Logistic regression of factors difficult or unable to modify predictive of TTM ‘action+’ SOC. Unadjusted Univariable Model Model 1 Model 2 Variable Reference Response OR (95% CI) OR (95% CI) Practice type Private Specialty 1.51 (0.97, 2.38) 1.70 (0.88, 3.33) 1.73 (0.90, 3.38) Hospital-based 3.74 (2.48, 5.75) * 2.55 (1.38, 4.83) * 2.59 (1.43, 4.79) * DSO 2.11 (1.36, 3.29) * 1.93 (1.03, 3.68) * 1.90 (1.02, 3.57) * Academic setting 1.47 (0.82, 2.65) 2.12 (0.93, 4.85) 2.20 (1.00, 4.88) * Local health department 2.43 (1.17, 5.36) * 2.57 (0.85, 8.40) 2.60 (0.85, 8.47) Federally- Qualified Health Clinic (FQHC) 2.06 (1.02, 4.33) * 1.53 (0.58, 4.15) 1.71 (0.64, 4.65) Mobile dental clinic 9.74 (1.76, 181.64) * 13.00 (1.57, 302.55) * 12.71 (1.56, 296.39) * Non-profit/Free clinic 0.81 (0.20, 2.89) 1.22 (0.19, 6.49) 1.18 (0.18, 6.42) Practice Setting Urban Suburban 0.67 (0.37, 1.16) 1.43 (0.59, 3.37) 1.46 (0.61, 3.38) Rural 0.78 (0.44, 1.36) 1.35 (0.56, 3.17) 1.41(0.59, 3.27) DPBRN Region Midwest Northeast 0.6 (0.39, 0.91) * 0.63 (0.34, 1.15) 0.63 (0.35, 1.14) South Atlantic 0.69 (0.43, 1.11) 0.84 (0.42, 1.68) 0.82 (0.41, 1.62) South Central 0.72 (0.41, 1.27) 0.81 (0.37, 1.78) 0.81 (0.37, 1.76) Southwest 0.56 (0.34, 0.92) * 0.70 (0.34, 1.44) 0.66 (.32, 1.33) Western 0.73 (0.48, 1.1) 0.71 (0.38, 1.32) 0.71 (0.39, 1.29) Years in Practice 0–5 6–10 1.21 (0.96, 1.7) 0.74 (0.43, 1.25) 0.71 (0.42, 1.19) 11–15 0.9 (0.62, 1.31) 0.58 (0.33, 1.02) 0.56 (0.32, 0.98) 16–20 0.8 (0.48, 1.31) 0.58 (0.28, 1.21) 0.57 (0.27, 1.19) 21+ 0.3 (0.18, 0.49) * 0.31 (0.14, 0.66) * 0.28 (0.13, 0.59) * Ethnicity Hispanic Non-Hispanic 0.71 (0.49, 1.02) 0.49 (0.27, 0.86) * 0.51 (0.29, 0.89) * Race ** Black vs non-Black 1.26 (0.82, 1.95) 3.76 (1.19, 12.56) * 3.72 (1.18, 12.33) * HI/PI vs non-HI/PI 5.17 (1.42, 33.2) * 8.97 (1.51, 80.66) * 8.79 (1.48, 79, 44) * AI/AN vs non-AI/AN 1.37 (0.58, 3.47) 1.43 (0.31, 6.95) 1.53 (0.33, 7.44) Asian vs non-Asian 0.67 (0.42, 1.04) 4.25 (1.35, 14.67) * 4.30 (1.38, 14.67) * White vs non-White 1.42 (1.06, 1.92) * 5.40 (1.87, 16.70) * 5.41 (1.87, 16.67) * Open in a new tab Model 1 includes all variables. Model 2 includes variables chosen via stepwise variable selection using the AIC * Denotes statistical significance at the p<0.05 level ** Race analysis used “not present” as the reference group for each comparison. Racial identification allowed for multiple categories and results were analyzed with each racial group represented as either “present” vs. “absent”. Results found that all racial groups except American Indian/Native Alaskans were predictive of ‘Action+’ stage although sample sizes in some groups were small yielding wide confidence intervals. Those indicating Hispanic ethnicity were more likely than non-Hispanics to be in ‘Action+’ stage. Reliability of the 5C vaccine hesitancy scale yielded a Cronbach’s alpha of 0.70. Principal component analysis yielded all factor loadings between 0.605 and 0.766 except one item within the “Complacency” subscale regarding compromised immune systems yielding 0.323. DISCUSSION The current suboptimal HPV vaccination rates in the U.S. have drawn attention to the importance of adolescents receiving vaccines in alternative settings, including dental offices. The willingness of U.S. dentists to administer the HPV vaccine in their dental practice aligns with other researchers who found 58% of Indiana dentists (Shukla et al., 2022) and 51% of Michigan dentists (Guadiana et al., 2021) willing to provide vaccinations, if allowed by state statute.( 27 , 32 ) Although Indiana dentists were willing, only 19.1% of dentists reported currently administering HPV vaccines.( 32 ) Plausibly, this may be due to legislative constraints, as in most states. However, several other factors were found to be significantly associated with dentists’ level of willingness to provide the HPV vaccine. Dentists who perceived their existing office infrastructure would support vaccine administration were nearly 2.5 times more willing to administer the vaccine. Supportive office infrastructures generally include resources such as adequate staffing, legal review, time, and space to accommodate the introduction of new procedures. Conversely, dentists who reported a lack of space to discuss vaccination privately were 62% less likely to report willingness to vaccinate. In the unadjusted model, dentists who practice in hospital-based, DSO, local health department, FQHC, and mobile clinic settings were more likely to report willingness to administer the vaccine. However, controlling for variables in the adjusted model, willingness to vaccinate was limited to dentists who practice in mobile, hospital-based, academic, or DSO settings. This may be due to amenable infrastructure and resources for some (DSO) and the perceptions of others who work in public health-focused settings (mobile, academic, hospital). While a previous DPBRN qualitative study of dentists (n=25) and dental hygienists (n=6) perceived that vaccine hesitancy among staff would be a barrier to vaccination,( 28 ) staff buy-in in this study did not reach statistical significance although it was positively associated with willingness to vaccinate. Factors related to willingness to administer the vaccine are logical. Dentists who reported comfort in administering the COVID-19 vaccine were seven times more willing to provide the HPV vaccine than those who reported discomfort. Those who were trained to administer COVID-19 vaccines were two times more willing to provide the HPV vaccine than those who did not receive training. Interestingly, only slightly over one-quarter of dentists in this study (n=243; 27%) reported discomfort in discussing HPV with their patients. Further, 67.5% (n=609) of dentists reported recommending the HPV vaccine to eligible patients. In contrast, past research found that most dentists were uncomfortable discussing a sexually transmitted disease.( 35 – 37 ) This may be reflective of the recent attention toward the role of dental providers in HPV prevention and the American Dental Association’s recent policy supporting HPV vaccine use and administration.( 38 ) Those who currently recommended the HPV vaccine to their eligible patients were four times more willing to administer the vaccine than those who did not. Training dental providers in HPV communication techniques such as framing the discussion as cancer prevention using the motivational interviewing approach has been suggested to improve comfort and confidence for HPV prevention in practice and may be the first step toward comfort in HPV vaccine administration.( 36 , 37 , 39 ) Knowledge of HPV and vaccination was low among participants. The mean overall score (SD) was 5.82 (2.16) out of ten possible points. Similarly, Stull and Lunos (2019) found a mean knowledge score of 61% among Minnesota dentists and dental hygienists.( 36 ) Lack of knowledge of the subject has been shown to be a barrier to dental providers’ willingness to recommend and administer the HPV vaccine.( 27 ) Conversely, higher knowledge has been shown to be associated with willingness to recommend HPV immunization to their patients.( 20 ) Collectively, these findings highlight the importance of skills-based training for HPV communication and vaccine administration in dental curricula and in continuing education for licensed providers. For example, one of the authors has provided webinar and in-person continuing education on brief motivational interviewing for HPV vaccine communication to dentists and dental hygienists at national professional association meetings and institutional continuing dental education programs. Only the 5C vaccine hesitancy construct of “Constraints” was predictive of dentists’ willingness to vaccinate their patients against HPV in this study, while Kwok et al. found that all five constructs were predictive of nurses’ intention to receive the COVID-19 vaccine. ( 24 ) A previous study using the 5C instrument found that parents of vaccine-eligible children found that only “Confidence” was predictive of their intention to allow HPV vaccination. ( 21 ) These results may be due to the differences in knowledge, risks and benefits attributed to each vaccination, the different audiences surveyed, and the uncertain reliability of the 5C scale. The internal consistency of the 5C model measured by Cronbach’s alpha was similar in the current and Betsch et al. (2018) study (0.70 vs. 0.71)( 21 ), and both studies found the lowest factor loadings among the “Complacency” construct items.( 21 ) Clearly, more studies are required using the 5C instrument to further explore both the validity and reliability. Specific to the predictive ability of the vaccine hesitancy scale in this study, Betsch et al. (2018) defines constraints as, “physical availability, affordability and willingness-to-pay, geographical accessibility, ability to understand (language and health literacy) and appeal of immunization service uptake” (p. 3).( 21 ) Items on the scale included, “Everyday stress prevents me from being vaccinated”; “For me, it is inconvenient to be vaccinated”; and “Visiting the doctor makes me feel uncomfortable, this keeps me from being vaccinated”.( 21 ) Dentists too busy to receive their own immunizations may not perceive the importance of providing immunization services for their patients, particularly because acting as a vaccinator has not historically been a role of dentists. ( 27 ) Since dentists do not typically vaccinate, they may perceive insurmountable barriers such as staff buy-in, liability, reimbursement, and integration of medical and dental records. ( 29 ) It is also possible that dentists in this study did not perceive the importance of the HPV vaccine for themselves or their children. A survey of 173 dentists (n=38) and dental hygienists (n=135) in Texas found that over 25% of dentists and dental hygienists reported they would not accept the HPV vaccine for themselves or their children.( 40 ) Future research should investigate the impact of a training program focused on the barriers reported in this study on the willingness of dentists to offer immunizations to their patients. A qualitative study of dentists stratified by years in practice may provide insight to the finding that dentists just entering practice (0–5 years) were more willing to vaccinate than those with several decades of practice experience. Strengths of this study included the sampling strategy used that successfully recruited aproportional sample from each state and DPBRN region across the U.S. Further, this was the first study to our knowledge that explored the association between willingness to provide vaccines and personal vaccine hesitancy. The TTM theoretical model recognizes that attitudes and behaviors changes over time. Therefore, the use of this theoretical model will allow future researchers to compare these initial results to findings in future years. Limitations of this cross-sectional survey research include issues related to self-report where participants may respond to survey items perceived to be more favorable or socially desirable even though the survey was anonymous. Self-selection may also lead to response biases as dentists more engaged with or passionate about HPV vaccinations, either pro or con, may influence survey answers.( 41 ) Although a third party conducted the survey, only recruited dentists who received remuneration were invited to participate in the survey. Dentists have a very low rate of survey completion; therefore, this limitation to the study’s methodology was accepted as necessary in order to gather enough completed surveys to answer the study’s research questions. Readers need to take the study results into consideration when considering the bias inherent in the study’s participants. The authors caution interpretation of the low number of correct responses to two knowledge items, which may have lacked clarity in wording. The item, “most sexually active people will get HPV” may have been interpreted by participants as including people who have received the HPV vaccine. The other item, “the HPV vaccine is administered in one dose”, could have been interpreted as a correct statement by participants knowing that some low-resource countries outside of the U.S. have recommended one dose for certain individuals. CONCLUSIONS This study found that over half (56.2%) of the 902 dentists surveyed reported willingness to administer the HPV vaccine in their practice. Modifiable factors associated with willingness to vaccinate include currently recommending the HPV vaccine to patients, comfort in administering vaccinations, previous training to provide COVID-19 vaccinations, and appropriate practice infrastructures to administer HPV vaccinations. Only the 5C vaccine hesitancy model construct of “Constraints” was predictive of the willingness to administer the HPV vaccine. These findings indicate a need for dentistry to prioritize knowledge and skills-based training in HPV vaccine communication and administration to prepare dentists to provide vaccines in their practices as state legislation allows. Supplementary Material Supplemental Table 1 NIHMS2072110-supplement-Supplemental_Table_1.docx (15.1KB, docx) Highlights. The HPV vaccine is under-utilized and far from meeting Healthy People 2030 goals. Dentists are positioned to provide HPV-vaccinations to their patients with 6-month preventive appointments and two-dose vaccine time periods coinciding. All U.S. dentists were given emergency authorization to provide COVID-19 vaccinations during the pandemic. Sampling for the cross-sectional survey provided an accurate proportion of each state’s licensed dentists. Results indicate that more than half of participants would provide HPV vaccinations to their patients if allowed by state legislation. Results can inform dental educators and policy makers regarding the movement toward dentists to provide HPV vaccinations. Funding Acknowledgement This work was supported be funding from Merck Sharp & Dohme Corp [grant number 61183], and the National Institutes of Health’s National Center for Advancing Translational Sciences, [grant number UM1TR004405]. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health’s National Center for Advancing Translational Sciences. The sponsors played no role in the study design, data collection, analysis or interpretation of the data, in the writing of the manuscript or decision to submit the article for publication. All authors attest that they meet the ICMJE criteria for authorship. Declaration of interests Michael Evans reports financial support was provided by NIH National Center for Advancing Translational Sciences. Priscilla Flynn reports financial support was provided by Merck Sharp & Dohme Corp. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Footnotes Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. CRediT Authorship Statement Priscilla Flynn : Conceptualization, Methodology, Writing – original draft, Writing – review and editing, Visualization, Supervision, Project administration, Funding acquisition. Cynthia Stull : Conceptualization, Methodology, Writing – original draft, Writing - review and editing, Visualization, Funding acquisition. Vedushi Jain : Writing – original draft, Writing - review and editing. Michael Evans : Formal analysis, Data curation, Visualization, Writing – original draft, Writing – review and editing. BIBLIOGRAPHY 1. Lechner M, Liu J, Masterson L, Fenton TR. HPV-associated oropharyngeal cancer: epidemiology, molecular biology and clinical management. Nat Rev Clin Oncol. 2022;19:306–27. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] 2. U.S. Food and Drug Administration. Gardasil 9 2023. [updated 4/28/2023. Available from: https://www.fda.gov/vaccines-blood-biologics/vaccines/gardasil-9 . 3. Lu B, Kumar A, Castellsagué X, Giuliano A. Efficacy and safety of prophylactic vaccines against cervical HPV infection and diseases among women: a systematic review & meta-analysis. BMC Infect Dis. 2011;Jan 12(11). 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