Differences in Human Papillomavirus Vaccination Among Adolescent Girls in Metropolitan Versus Non-metropolitan Areas: Considering the Moderating Roles of Maternal Socioeconomic Status and Health Care Access

Boot Camp Translation using Community-Engaged messaging for adolescent Vaccination: A Cluster-Randomized trial

BACKGROUND

Routine vaccination coverage for adolescents living in the rural US is lower than adolescents living in urban areas. We sought to measure the effect of Boot Camp Translation (BCT), a community-based participatory intervention, on rural adolescent vaccination coverage.

METHODS

A cluster randomized controlled trial was performed September 2018-November 2021 involving 16 rural Colorado counties. Intervention county community members engaged in BCT to develop interventions to improve adolescent vaccination locally. Adolescent vaccination coverage was measured using the Colorado Immunization Information System.

RESULTS

For 11-12-year-olds, HPV initiation, HPV up-to-date, MenACWY, and Tdap vaccination coverage was lower post- versus pre-intervention in the control and intervention groups. For 11-12-year-olds in the intervention group, there was no significant difference post- versus pre-intervention in the odds of HPV vaccine initiation (adjusted ratio of odds ratios [aROR] = 0.93, 95 %: 0.85-1.02, p = 0.10) or up-to-date HPV vaccination (aROR: 1.10, 95 % CI: 0.98-1.23, p = 0.11) compared with the control group. Among 11-12-year-olds, the decrease in the proportion vaccinated with MenACWY and Tdap in the intervention group was significantly greater than the control group. Among 13-17-year-olds, there were significant increases in HPV initiation, HPV up-to-date, MenACWY, and Tdap vaccination coverage from pre- to post-intervention for both groups, with no significant differences between groups.

CONCLUSION

11-12-year-old vaccination coverage decreased slightly from pre- to post-intervention while 13-17-year-old vaccination coverage increased. We saw no effect from the BCT intervention. Our findings about the effectiveness of BCT for improving vaccine uptake may not be generalizable because the study coincided with the COVID-19 pandemic.

CLINICAL TRIAL REGISTRY

This study was registered with ClinicalTrials.gov, NCT03955757.

Surveillance Mammography Behaviors in Black and White Breast Cancer Survivors: Behavioral Risk Factors and Surveillance System, 2016

BACKGROUND

Surveillance mammography is recommended annually for early detection of disease relapse among breast cancer survivors; yet Black women have poorer national rates of surveillance mammography compared to White women. Factors that influence racial disparities in surveillance mammography rates are poorly understood. The purpose of this study is to evaluate the contribution of health care access, socioeconomic status, and perceived health status on adherence to surveillance mammography among breast cancer survivors.

METHODS

This is a secondary analysis of a cross-sectional survey among Black and White women ≥ 18 years, who reported a breast cancer diagnosis and completed breast surgery and adjuvant treatment from the 2016 Behavioral Risk Factor Surveillance System National Survey (BRFSS). Bivariate associations (chi-squared, t-test) for independent variables (e.g., health insurance, marital status) were analyzed with adherence to nationally recommended surveillance guidelines defined as two levels: adherent (received a mammogram in the last 12 months), vs. non- adherent ("received a mammogram in the last 2-5 years, 5 or more years or unsure). Multivariable logistic regression models were used to evaluate the relationship between study variables with adherence, while adjusting for potential confounders.

RESULTS

Of 963 breast cancer survivors, 91.7% were White women with an average age of 65. 71.7% reported a surveillance mammogram in the last 12 months, while 28.2% did not. Diagnosed > 5 years (p < 0.001); not having a routine checkup visit within 12 months (p = 0.045); and not seeing a doctor when needed due to cost (p = 0.026), were significantly related to survivor's non-adherence to surveillance mammography guidelines. A significant interaction was found between race and residential area (p < 0.001). Compared to White women, Black women living in metropolitan/suburban residential areas were more likely to receive surveillance guidelines (OR:3.77;95% CI: 1.32-10.81); however Black women living in non-metropolitan areas were less likely to receive a surveillance mammogram compared to White women living in non-metropolitan areas (OR: 0.04; 95% CI: 0.00-0.50).

CONCLUSION

Findings from our study further explain the impact of socioeconomic disparities on racial differences in the use of surveillance mammography among breast cancer survivors. Black women living in non-metropolitan counties are an important subgroup for future research and screening and navigation interventions.

Key stakeholder perspectives on challenges and opportunities for rural HPV vaccination in North and South Carolina

The objective of this study was to identify factors at the individual, provider, and systems levels that serve as challenges or opportunities for increasing adolescent vaccination-including Human Papillomavirus (HPV) vaccination-in rural communities in the southern United States (US). As part of a broader study to increase HPV vaccine uptake in the southern US, we conducted in-depth interviews with vaccination stakeholders representing public health and education agencies in North Carolina (NC) and South Carolina (SC). Fourteen key stakeholders were recruited using purposive sampling to obtain insights into challenges and solutions to rural-urban disparities in HPV vaccination coverage. Stakeholders were also queried about their experiences and attitudes toward school-based vaccination promotion programs and campaigns. We used a rapid qualitative approach to analyze the data. Stakeholders identified factors at the individual, provider, and systems levels that serve as challenges to vaccination in rural communities. Similar to previous studies, stakeholders mentioned challenges with healthcare access and vaccine-related misconceptions that pose barriers to HPV vaccination for rural residents. Systems-level challenges identified included limited access to high-speed internet in rural areas that may impact providers' ability to interface with state-level digital systems such as the vaccination registry. Stakeholders identified a number of opportunities to increase HPV vaccination coverage, including through school-based health promotion programs. Stakeholders strongly supported school-based programs and approaches to strengthen confidence and demand for HPV vaccination and to help address persistent social determinants and system level factors that pose challenges to HPV vaccination coverage in many rural areas.

Factors Associated With Human Papillomavirus Vaccine Series Completion Among Adolescents

INTRODUCTION

Most cancers associated with the human papillomavirus are preventable through vaccination. However, adolescent series completion rates are at 75.8%. Two vaccine doses are recommended for adolescents, but factors influencing 2-dose series completion are not well explored. The purpose of this study is to examine individual-level and community-level factors associated with timely human papillomavirus vaccine series completion among adolescents in the Southeastern U.S.

METHODS

Series completion was assessed from January 2018 to February 2019 among a cohort of adolescents initiating vaccination in 2017. Factors influencing overall series completion and timely series completion were assessed using multivariable logistic regression.

RESULTS

Among the sample, 64.4% completed the vaccine series and 53.8% completed it timely (e.g., 14 months). Higher odds of series completion were among adolescents who were younger at vaccine initiation (AOR=1.94, 95% CI=1.50, 2.50), who traveled moderate distances to the clinic (AOR=1.62, 95% CI=1.03, 2.56), and who lived in low-deprivation neighborhoods (AOR=1.85, 95% CI=1.31, 2.60), and lower among Hispanic (AOR=0.62, 95% CI=0.45, 0.87) and non-Hispanic Black (AOR=0.66, 95% CI=0.54, 0.81) adolescents and among those without private insurance (AOR=0.68, 95% CI=0.56, 0.83). Timely series completion resulted in similar findings; however, lower odds were among Hispanic (AOR=0.63, 95% CI=0.43, 0.95) and non-Hispanic Black (AOR=0.68, 95% CI=0.50, 0.92) adolescents than among non-Hispanic other adolescents.

CONCLUSIONS

Individual-level and community-level factors continue to influence adolescent series completion, despite a reduction in doses. Future research is needed to understand racial/ethnic and regional disparities in human papillomavirus vaccine series completion and to develop interventions to promote series completion.

Factors Associated With Human Papillomavirus Vaccine Series Completion Among Adolescents

INTRODUCTION

Most cancers associated with the human papillomavirus are preventable through vaccination. However, adolescent series completion rates are at 75.8%. Two vaccine doses are recommended for adolescents, but factors influencing 2-dose series completion are not well explored. The purpose of this study is to examine individual-level and community-level factors associated with timely human papillomavirus vaccine series completion among adolescents in the Southeastern U.S.

METHODS

Series completion was assessed from January 2018 to February 2019 among a cohort of adolescents initiating vaccination in 2017. Factors influencing overall series completion and timely series completion were assessed using multivariable logistic regression.

RESULTS

Among the sample, 64.4% completed the vaccine series and 53.8% completed it timely (e.g., 14 months). Higher odds of series completion were among adolescents who were younger at vaccine initiation (AOR=1.94, 95% CI=1.50, 2.50), who traveled moderate distances to the clinic (AOR=1.62, 95% CI=1.03, 2.56), and who lived in low-deprivation neighborhoods (AOR=1.85, 95% CI=1.31, 2.60), and lower among Hispanic (AOR=0.62, 95% CI=0.45, 0.87) and non-Hispanic Black (AOR=0.66, 95% CI=0.54, 0.81) adolescents and among those without private insurance (AOR=0.68, 95% CI=0.56, 0.83). Timely series completion resulted in similar findings; however, lower odds were among Hispanic (AOR=0.63, 95% CI=0.43, 0.95) and non-Hispanic Black (AOR=0.68, 95% CI=0.50, 0.92) adolescents than among non-Hispanic other adolescents.

CONCLUSIONS

Individual-level and community-level factors continue to influence adolescent series completion, despite a reduction in doses. Future research is needed to understand racial/ethnic and regional disparities in human papillomavirus vaccine series completion and to develop interventions to promote series completion.

Human Papillomavirus Vaccination Trends and Disparities in the United States: Who Is Getting Left Behind?

BACKGROUND

United States guidelines recommend human papillomavirus (HPV) vaccination for males and females up to 26, with more recent extended coverage for those 27 to 45 years based on discussion with patients' clinician. This study seeks to assess trends and disparities of vaccination in the United States based on demographic characteristics.

METHODS

Data were obtained from the National Health and Nutrition Examination Survey between 2007 and 2016. χ2 Analyses were used for statistical methods.

RESULTS

Of 12,844 participants (median age, 22 years; range, 9-36 years), 2711 (21.3%) initiated HPV vaccination, of which 1358 (56.3%) completed the 3-dose vaccination series. Vaccination rates were higher in females compared with males (24.6% vs 13.0%; P < 0.001) and in Whites compared to Mexican Americans (22.6% vs 19.4%; P = 0.02). The uninsured had lower vaccination rates than private insurance and Medicaid (12.5% vs 22.4% vs 28.5%; P < 0.001). We divided the 10 year study into five separate periods (2007-2008, 2009-2010, 2011-2012, 2013-2014, and 2015-2016) to analyze trends. Vaccine initiation increased from 19.6% to 49.6% for 14-19-year olds (P < 0.001), 10.4% to 35.5% for females (P < 0.001), and 8.5% to 32.9% for Blacks (P < 0.001). Although on trend analyses, the vaccination rates with the highest proportional increase were found in those: older than 25 to 29 years (4.56-fold), Mexican Americans (4.56 fold), below high school education (2.32 fold), and low income group (2.90 fold) over time.

CONCLUSIONS

The HPV vaccination rates in Mexican Americans increased nearly 5-fold over the last 10 years. However, their vaccination rates continue to lag behind Whites and Blacks.

Disparities in Healthcare Providers' Recommendation of HPV Vaccination for U.S. Adolescents: A Systematic Review

Infrequent provider recommendations continue to be a key barrier to human papillomavirus (HPV) vaccination, including among adolescents at higher risk for future HPV cancers. To inform future interventions, we sought to characterize disparities in health care providers' HPV vaccine recommendation for U.S. adolescents. We systematically reviewed studies published in 2012-2019 that assessed provider HPV vaccine recommendations for adolescents aged 9-17. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we identified 52 eligible studies and used a standardized abstraction form to assess recommendation prevalence by adolescent demographic characteristics. Studies consistently found that fewer parents of boys than girls reported receiving HPV vaccine recommendations (14 studies, range of difference: -11 to -35 percentage points). Studies also found fewer recommendations for adolescents who were younger (2 studies, -3% to -12% points), non-White (3 studies, -5% to -7% points, females only), lower income (3 studies, -1% to -8% points), or uninsured (1 study, -21% points, males only). Studies identified geographic disparities in southern and rural areas. In conclusion, findings from this systematic review identify disparities in HPV vaccine recommendation that may contribute to suboptimal vaccine uptake. Efforts to improve providers' HPV vaccine communication should focus on increasing recommendation consistency, especially for lower-income, non-White, and rural adolescents.

The Impact of the Human Papillomavirus Vaccine on High-Grade Cervical Lesions in Urban and Rural Areas: An Age-Period-Cohort Analysis

Simple Summary

Human papillomavirus (HPV) vaccination disparities between urban and rural regions may moderate the vaccine’s impact on reducing cervical precancer (CIN2+) and cancer incidence. We assessed population-level trends in CIN2+ incidence (2008–2018) in urban and rural areas among Medicaid-enrolled women aged 18–39 years in Tennessee, United States. A sub-group analysis among women screened for cervical cancer was conducted to control for changing screening trends. CIN2+ incidence among young women aged 18–20 and 21–24 years, who most likely benefited from the HPV vaccine, declined similarly between urban and rural areas, although significant declines began earlier in urban versus rural areas. Our results suggest evidence of HPV vaccine impact regardless of urbanicity but demonstrate lagged impact in rural areas. These findings emphasize the importance of reducing barriers to HPV vaccination, particularly in rural areas, to improve the reduction of cervical precancer and cancer incidence, toward the World Health Organization’s goals of eliminating cervical cancer.

Abstract

Disparities in human papillomavirus (HPV) vaccination exist between urban (metropolitan statistical areas (MSAs)) and rural (non-MSAs) regions. To address whether the HPV vaccine’s impact differs by urbanicity, we examined trends in cervical intraepithelial neoplasia grades 2 or 3 and adenocarcinoma in situ (collectively, CIN2+) incidence in MSAs and non-MSAs among Tennessee Medicaid (TennCare)-enrolled women aged 18–39 years and among the subset screened for cervical cancer in Tennessee, United States. Using TennCare claims data, we identified annual age-group-specific (18–20, 21–24, 25–29, 30–34, and 35–39 years) CIN2+ incidence (2008–2018). Joinpoint regression was used to identify trends over time. Age–period–cohort Poisson regression models were used to evaluate age, period, and cohort effects. All analyses were stratified by urbanicity (MSA versus non-MSA). From 2008–2018, 11,243 incident CIN2+ events (7956 in MSAs; 3287 in non-MSAs) were identified among TennCare-enrolled women aged 18–39 years. CIN2+ incident trends (2008–2018) were similar between women in MSAs and non-MSAs, with largest declines among ages 18–20 (MSA average annual percent change (AAPC): −30.4, 95% confidence interval (95%CI): −35.4, −25.0; non-MSA AAPC: −30.9, 95%CI: −36.8, −24.5) and 21–24 years (MSA AAPC: −14.8, 95%CI: −18.1, −11.3; non-MSA AAPC: −15.1, 95%CI: −17.9, −12.2). Significant declines for ages 18–20 years began in 2008 in MSAs compared to 2010 in non-MSAs. Trends were largely driven by age and cohort effects. These patterns were consistent among screened women. Despite evidence of HPV vaccine impact on reducing CIN2+ incidence regardless of urbanicity, significant declines in CIN2+ incidence were delayed in non-MSAs versus MSAs.

A systematic review of human papillomavirus vaccination among US adolescents

The human papillomavirus (HPV) causes many anogenital and oral cancers affecting young adults in the United States. Vaccination during adolescence can prevent HPV-associated cancers, but vaccine uptake among adolescents is low and influenced by factors serving as barriers and facilitators to HPV vaccination. In this systematic review, we synthesized research using the socioecological framework model to examine individual-level, relationship-level, community-level, and societal-level factors that influence HPV vaccine initiation and completion among US adolescents. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were used to guide the methodology for this review. An electronic search was conducted in January 2020 using PubMed, Cumulative Index of Nursing and Allied Health Literature, ProQuest Central, Scopus, and American Psychological Association PsycInfo databases. The Joanna Briggs Institute tools were used to assess the quality for the 57 studies included in this review. The most consistent influences of HPV vaccination included age at vaccination, awareness, and knowledge about HPV vaccination, socioeconomic status, insurance status, race/ethnicity, and preventative care behaviors at the individual level. Provider recommendation, familial/peer support of vaccination, and parental health behaviors were influences at the relationship level. Although fewer findings elucidated community-level and societal-level influences, high-poverty areas, high-risk communities with large proportions of racial/ethnic minority groups, healthcare facilities servicing children, and combined health policies appear to serve as facilitators of HPV initiation and completion. Findings from this review can inform culturally relevant and age-specific interventions and multi-level policies aiming to improve HPV vaccination coverage in the United States.

An innovative housing-related measure for individual socioeconomic status and human papillomavirus vaccination coverage: A population-based cross-sectional study

BACKGROUND

Human papillomavirus (HPV) is a known cause of anogenital (eg, cervical) and oropharyngeal cancers. Despite availability of effective HPV vaccines, US vaccination-completion rates remain low. Evidence is conflicting regarding the association of socioeconomic status (SES) and HPV vaccination rates. We assessed the association between SES, defined by an individual validated Housing-based Index of Socioeconomic Status (HOUSES), and HPV vaccination status.

METHODS

We conducted a cross-sectional study of children/adolescents 9-17 years as of December 31, 2016, living in southeastern Minnesota by using a health-record linkage system to identify study-eligible children/adolescents, vaccination dates, and home addresses matched to HOUSES data. We analyzed the relationship between HPV vaccination status and HOUSES using multivariable Poisson regression models stratifying by age, sex, race, ethnicity, and county.

RESULTS

Of 20,087 study-eligible children/adolescents, 19,363 (96.4%) were geocoded and HOUSES measures determined. In this cohort, 57.9% did not receive HPV vaccination, 15.8% initiated (only), and 26.3% completed the series. HPV vaccination-initiation and completion rates increased over higher SES HOUSES quartiles (P < .001). Rates of HPV vaccination initiation versus unvaccinated increased across HOUSES quartiles in multivariable analysis adjusted for age, sex, race, ethnicity, and county (1st quartile, referent; 2nd quartile, 0.97 [0.87-1.09]; 3rd quartile, 1.05 [0.94-1.17]; 4th quartile, 1.15 [1.03-1.28]; test for trend, P = .002). HOUSES was a stronger predictor of HPV vaccination completion versus unvaccinated (1st quartile referent; 2nd quartile, 1.06 [0.96-1.16]; 3rd quartile, 1.12 [1.03-1.23]; 4th quartile, 1.32 [1.21-1.44]; test for trend, P < .001). Significant interactions were shown for HPV vaccination initiation by HOUSES for sex (P = .009) and age (P = .006).

CONCLUSION

The study showed disparities in HPV vaccination by SES, with the highest HOUSES quartiles associated with increased rates of initiating and even greater likelihood of completing the series. HOUSES data may be used to target and tailor HPV vaccination interventions to undervaccinated populations.

Intention to Pay for HPV Vaccination among Women of Childbearing Age in Vietnam

The intention to pay for human papillomavirus (HPV) vaccination among women of childbearing age in Vietnam, where cervical cancer remains a significant public health concern, has been mostly lacking. To examine this issue, we conducted a cross-sectional study of 807 pregnant women in an urban and a rural district (Dong Da and Ba Vi) of Hanoi, Vietnam. The vast percentage of our respondents expressed a firm intention to vaccinate, especially women in rural areas (over 90.0%). However, on being informed of the current price of the HPV vaccine, their intention to vaccinate dropped to about one-fifth of overall respondents, i.e., only 4.4% of women in rural areas. It was also observed that the initial intention to get the HPV vaccination among women in the rural district was about ten times higher than that of women living in the metropolitan district. Those participants who had greater knowledge of cervical cancer and HPV vaccinations also had a significantly higher intention to vaccinate. Our findings underscore the need to develop a well-designed vaccination program in Vietnam and other countries in a similar situation to increase the adoption of HPV vaccination.

Challenges of using nationally representative, population-based surveys to assess rural cancer disparities

Population-based surveys provide important information about cancer-related health behaviors across the cancer care continuum, from prevention to survivorship, to inform cancer control efforts. These surveys can illuminate cancer disparities among specific populations, including rural communities. However, due to small rural sample sizes, varying sampling methods, and/or other study design or analytical concerns, there are challenges in using population-based surveys for rural cancer control research and practice. Our objective is three-fold. First, we examined the characterization of "rural" in four, population-based surveys commonly referenced in the literature: 1) Health Information National Trends Survey (HINTS); 2) National Health Interview Survey (NHIS); 3) Behavioral Risk Factor Surveillance System (BRFSS); and 4) Medical Expenditures Panel Survey (MEPS). Second, we identified and described the challenges of using these surveys in rural cancer studies. Third, we proposed solutions to address these challenges. We found that these surveys varied in use of rural-urban classifications, sampling methodology, and available cancer-related variables. Further, we found that accessibility of these data to non-federal researchers has changed over time. Survey data have become restricted based on small numbers (i.e., BRFSS) and have made rural-urban measures only available for analysis at Research Data Centers (i.e., NHIS and MEPS). Additionally, studies that used these surveys reported varying proportions of rural participants with noted limitations in sufficient representation of rural minorities and/or cancer survivors. In order to mitigate these challenges, we propose two solutions: 1) make rural-urban measures more accessible to non-federal researchers and 2) implement sampling approaches to oversample rural populations.

Trends in human papillomavirus (HPV) vaccination initiation among adolescents aged 13-17 by metropolitan statistical area (MSA) status, National Immunization Survey - Teen, 2013 - 2017

Disparities in HPV vaccination coverage by metropolitan statistical area (MSA) status were observed in the 2016 and 2017 National Immunization Survey – Teen (NIS-Teen). In 2017, HPV vaccination initiation (≥1dose) coverage was 11 percentage points lower for adolescents living in non-MSAs (mostly rural areas) and 7 percentage points lower among those living in MSA, non-principal cities (suburban areas) compared to those living in MSA, principal cities (mostly urban areas). In order to understand how this disparity has changed over time, we examined trends in HPV vaccine initiation by MSA status from 2013 to 2017. Weighted linear regression by survey year was used to estimate annual percentage point changes in HPV vaccination initiation. The five-year average annual percentage point increases in HPV vaccination initiation coverage were 5.2 in mostly urban areas, 4.9 for suburban areas, and 5.2 for mostly rural areas. Despite increases in each MSA area, coverage in mostly rural areas was consistently and significantly lower than coverage in mostly urban areas. Coverage was significantly lower among teens living in mostly rural areas regardless of poverty status, sex, and race/ethnicity except among black, non-Hispanic adolescents. There was no significant change in the magnitude of the disparity between mostly urban areas and mostly rural areas over time (p = .98). A better understanding of the facilitators and barriers to HPV vaccination in mostly rural areas is needed to identify and implement targeted strategies to improve HPV vaccination coverage and reduce these disparities.

Factors associated with not receiving HPV vaccine among adolescents by metropolitan statistical area status, United States, National Immunization Survey-Teen, 2016-2017

The 2016 and 2017 National Immunization Surveys-Teen (NIS-Teen) highlighted disparities in human papillomavirus (HPV) vaccination coverage by metropolitan statistical area (MSA) status. Coverage with ≥1 dose of HPV vaccine was significantly lower among teens in suburban and mostly rural areas than it was among those in mostly urban areas. Reasons underlying this disparity are poorly understood; this analysis sought to identify sociodemographic factors associated with not initiating the HPV vaccine series and to determine whether these factors differed by MSA status. Using NIS-Teen data for a sample of 41,424 adolescents from the 2016 and 2017 survey years, multivariate logistic regression was utilized to assess associations between various sociodemographic factors and non-initiation of the HPV vaccine series by MSA status. Adjusted prevalence ratios and 95% confidence intervals are reported. A secondary analysis assessed missed opportunities for HPV vaccination by MSA status and estimated what coverage could be if these missed opportunities had not occurred. Most factors associated with not receiving HPV vaccine were similar across all three MSAs, including living in the South, having a mother with some college education, not having an 11–12-year-old well-child visit, and not receiving a provider recommendation for vaccination. Others were associated with non-initiation of the HPV vaccine series in only specific MSAs. Teens in suburban areas (82.2%) were more likely to miss opportunities for HPV vaccination than those in mostly urban (79.3%) areas. Coverage with ≥1 dose of HPV vaccine in all three MSAs would be substantially higher if these missed opportunities had been eliminated.

HPV Vaccination Coverage Among US Teens Across the Rural-Urban Continuum

BACKGROUND

In this study, we used data from the National Immunization Survey-Teen (NIS-Teen) to examine HPV vaccination uptake by rural and urban residence defined by ZIP code.

METHODS

We used 2012-2013 NIS-Teen data to examine associations of HPV vaccination among teens aged 13-17 years with ZIP code measures of rural/urban (Rural-Urban Commuting Area (RUCA) codes, population density). Multivariable logistic regression was used to estimate the odds of HPV vaccination initiation (≥ 1 dose) and completion (≥ 3 doses).

RESULTS

HPV vaccination was lower among girls from isolated small rural towns (≥1 dose 51.0%; ≥3 doses 30.0%) and small rural towns (≥1 dose 50.2%; ≥3 doses 26.8%) than among urban girls (≥1 dose 56.0%; ≥3 doses 35.9%). Girls from small rural towns had lower odds of completion (0.74, 95% CI: 0.60-0.91) than girls from urban areas. HPV vaccination was lower among boys from isolated small rural towns (≥1 dose 17.3%; ≥3 doses 5.31%) and small rural towns (≥1 dose 18.7%; ≥3 doses 5.50%) than those in urban areas (≥1 dose 28.7%; ≥3 doses 10.7%). Boys in isolated small rural towns had statistically significantly lower odds of initiation (0.68, 95% CI: 0.52-0.88) and completion (0.63, 95% CI: 0.41-0.97) than urban boys. Girls and boys from high-poverty rural areas had lower odds of initiation and completion than did their counterparts from high-poverty urban areas.

CONCLUSION

Rural girls had lower odds of completing the HPV vaccine than their urban counterparts. Rural boys had lower odds than urban boys for HPV vaccination initiation and completion.

Sociodemographic predictors are associated with compliance to a vaccination-reminder in 9692 girls age 14, Denmark 2014-2015

We aimed to identify sociodemographic predictors of compliance after receiving a personalised reminder on lacking vaccinations against MMR (Measles, Mumps, Rubella) and/or HPV (Human Papilloma Virus) among parents of Danish adolescent girls. A nationwide register-based study, including all 14-year-old girls (15 May 2014-14 May 2015) lacking either MMR, HPV-vaccination or both. Vaccination-compliance following a postal reminder was modelled using multivariable logistic regression and included the following socio-demographic predictors: maternal age, education, employment and ethnicity. Birth order, number of siblings, family-structure, location of residence, and household income. The parents of 9692 girls received a reminder. Out of 4940 exclusively lacking an HPV-vaccine, 15.3% were subsequently vaccinated. Among 2026 only lacking an MMR vaccination, 8.5% were vaccinated. Among 2726 girls lacking both, 5% received an HPV, 4.4% an MMR and 5.4% received both vaccinations. We identified sociodemographic differences between reminderletter-compliers and non-compliers, also according to vaccination types. Non-western descendants were more likely to receive HPV-vaccination, although the association was only significant for those who only lacked HPV (OR 2.02, 95% 1.57-2.59). For girls only lacking an MMR, regional differences were identified. Among girls lacking both vaccines, girls of mothers with intermediate (OR 0.63, 0.42-0.95) or basic education (OR 0.43, 0.24-0.75) were less likely to be vaccinated compared to girls of higher educated mothers. Reminders were in particular effective in increasing HPV uptake among immigrants of non-Western ethnicity. We found reminders to be less effective among less educated mothers whose daughters lacked both vaccines. To increase the coverage in this group, additional interventions are needed.

Rural-Urban Differences in Cancer Incidence and Trends in the United States

Background: Cancer incidence and mortality rates in the United States are declining, but this decrease may not be observed in rural areas where residents are more likely to live in poverty, smoke, and forego cancer screening. However, there is limited research exploring national rural-urban differences in cancer incidence and trends.Methods: We analyzed data from the North American Association of Central Cancer Registries' public use dataset, which includes population-based cancer incidence data from 46 states. We calculated age-adjusted incidence rates, rate ratios, and annual percentage change (APC) for: all cancers combined, selected individual cancers, and cancers associated with tobacco use and human papillomavirus (HPV). Rural-urban comparisons were made by demographic, geographic, and socioeconomic characteristics for 2009 to 2013. Trends were analyzed for 1995 to 2013.Results: Combined cancers incidence rates were generally higher in urban populations, except for the South, although the urban decline in incidence rate was greater than in rural populations (10.2% vs. 4.8%, respectively). Rural cancer disparities included higher rates of tobacco-associated, HPV-associated, lung and bronchus, cervical, and colorectal cancers across most population groups. Furthermore, HPV-associated cancer incidence rates increased in rural areas (APC = 0.724, P < 0.05), while temporal trends remained stable in urban areas.Conclusions: Cancer rates associated with modifiable risks-tobacco, HPV, and some preventive screening modalities (e.g., colorectal and cervical cancers)-were higher in rural compared with urban populations.Impact: Population-based, clinical, and/or policy strategies and interventions that address these modifiable risk factors could help reduce cancer disparities experienced in rural populations. Cancer Epidemiol Biomarkers Prev; 27(11); 1265-74. ©2017 AACR.

Area-based socioeconomic factors and Human Papillomavirus (HPV) vaccination among teen boys in the United States

BACKGROUND

This study is the first to examine associations between several area-based socioeconomic factors and human papillomavirus (HPV) vaccine uptake among boys in the United States (U.S.).

METHODS

Data from the 2012-2013 National Immunization Survey-Teen restricted-use data were analyzed to examine associations of HPV vaccination initiation (receipt of ≥1 dose) and series completion (receipt of three doses) among boys aged 13-17 years (N = 19,518) with several individual-level and ZIP Code Tabulation Area (ZCTA) census measures. Multivariable logistic regression was used to estimate the odds of HPV vaccination initiation and series completion separately.

RESULTS

In 2012-2013 approximately 27.9% (95% CI 26.6%-29.2%) of boys initiated and 10.38% (95% CI 9.48%-11.29%) completed the HPV vaccine series. Area-based poverty was not statistically significantly associated with HPV vaccination initiation. It was, however, associated with series completion, with boys living in high-poverty areas (≥20% of residents living below poverty) having higher odds of completing the series (AOR 1.22, 95% CI 1.01-1.48) than boys in low-poverty areas (0-4.99%). Interactions between race/ethnicity and ZIP code-level poverty indicated that Hispanic boys living in high-poverty areas had a statistically significantly higher odds of  HPV vaccine initiation (AOR 1.43, 95% CI 1.03-1.97) and series completion (AOR 1.56, 95% CI 1.05-2.32)  than Hispanic boys in  low-poverty areas. Non-Hispanic Black boys in high poverty areas had higher odds of initiation (AOR 2.23, 95% CI 1.33-3.75) and completion (AOR 2.61, 95% CI 1.06-6.44) than non-Hispanic Black boys in low-poverty areas. Rural/urban residence and population density were also significant factors, with boys from urban or densely populated areas having higher odds of initiation and completion compared to boys living in non-urban, less densely populated areas.

CONCLUSION

Higher HPV vaccination coverage in urban areas and among racial/ethnic minorities in areas with high poverty may be attributable to factors such as vaccine acceptance, health-care practices, and their access to HPV vaccines through the Vaccines for Children Program, which provides free vaccines to uninsured and under-insured children. Given the low HPV vaccination rates among boys in the U.S., these results provide important evidence to inform public health interventions to increase HPV vaccination.