Trends in HPV vaccine initiation among adolescent females in North Carolina, 2008-2010

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.

Physician clinical decision support system prompts and administration of subsequent doses of HPV vaccine: A randomized clinical trial

BACKGROUND

HPV vaccine is effective in preventing several cancers and anogenital warts, yet rates of HPV vaccination series completion in the United States are low. A primary reason identified by parents for vaccinating children against HPV is a health care provider's recommendation. Although most clinicians embrace vaccine recommendations, they are not always carried out evenly and subsequent HPV vaccines are missed.

METHODS

Using an electronic health records-based decision support system (CHICA) clinicians were randomized to either usual practice or to receive an automated reminder to recommend the 2nd or 3rd dose of HPV vaccine. The reminder was delivered to clinicians of all intervention group eligible adolescents who had already initiated the vaccine series. Logistic regression models with generalized estimating equations were used for data analysis.

RESULTS

A total of 1285 clinical encounters were observed across 29 randomized pediatric providers over a 13-month time frame (50.7% control group, 49.3% intervention group). Overall, patients were 44.9% female, 59.4% Black, 22.1% Hispanic, and 48.8% were ages 11-12 yrs. Within the control group, 421 (64.7%) received a subsequent HPV vaccine, compared to 481 (75.9%) (OR: 1.72, (95% CI 1.35-2.19)). Adjusted analysis showed no difference between the groups (aOR 1.52 (95% CI 0.88-2.62)) or when examined by age (11-12yrs aOR 1.66, (95% CI 0.79-3.48)) and 13-17yrs (aOR 1.19, (95% CI 0.76-1.85)) or gender female (aOR 1.39 (95% CI 0.71-2.72)) and males (aOR 1.67 (95% CI 0.95-2.92)). When results were stratified by both age and gender, there was similarly no statistically significant effect between the two groups.

CONCLUSIONS

Automated physician reminders for subsequent 2nd and 3rd doses of HPV vaccination were used. Despite increased rates of vaccination in the intervention group, the differences did not reach the level of statistical significance. Future studies with multifaceted approaches may be needed to examine the efficacy of computer-based reminders.

CLINICAL TRIAL REGISTRATION

NCT02558803, "HPV Vaccination: Evaluation of Reminder Prompts for Doses 2 & 3".

Are we speaking the same language? an argument for the consistent use of terminology and definitions for childhood vaccination indicators

Vaccination indicators are used to measure the health status of individuals or populations and to evaluate the effectiveness of vaccination programs or policies. Ensuring that vaccination indicators are clearly and consistently defined is important for effective communication of outcomes, accurate program evaluation, and comparison between different populations, times, and contexts. The purpose of this commentary is to describe commonly used vaccination indicators and to highlight inconsistencies in how childhood vaccine researchers use and define these terms. The indicators we describe are vaccine coverage, uptake, and rate; vaccination status, initiation, and completion; and up-to-date, timely, partial, and incomplete vaccination. We conclude that many vaccination indicators are not explicitly defined within published research studies and/or are used quite differently across studies. We also note that the choice of indicator in a given study is often driven by program or vaccine specific factors, may be constrained by data availability, and should be chosen to best reflect the outcome of interest. We conclude that the use of consistent language and definitions would promote more effective communication of research findings. We also propose some standardized definitions for common indicators, with the goal of provoking discussion and debate on the issue.

Ranking States on Coverage of Cancer-Preventing Vaccines Among Adolescents: The Influence of Imprecision

OBJECTIVES

Identifying the best and worst states for coverage of cancer-preventing vaccines (hepatitis B [HepB] and human papillomavirus [HPV]) may guide public health officials in developing programs, such as promotion campaigns. However, acknowledging the imprecision of coverage and ranks is important for avoiding overinterpretation. The objective of this study was to examine states' vaccination coverage and ranks, as well as the imprecision of these estimates, to inform public health decision making.

METHODS

We used data on coverage of HepB and HPV vaccines among adolescents aged 13-17 from the 2011-2015 National Immunization Survey-Teen (n = 103 729 from 50 US states and Washington, DC). We calculated coverage, 95% confidence intervals (CIs), and ranks for vaccination coverage in each state, and we generated simultaneous 95% CIs for ranks using a Monte Carlo method with 100 000 simulations.

RESULTS

Across years, HepB vaccination coverage was 92.2% (95% CI, 91.8%-92.5%; states' range, 84.3% in West Virginia to 97.0% in Connecticut). HPV vaccination coverage was 57.4% (95% CI, 56.6%-58.2%; range, 41.8% in Kansas to 78.0% in Rhode Island) for girls and 31.0% (95% CI, 30.3%-31.8%; range, 19.0% in Utah to 59.3% in Rhode Island) for boys. States with the highest and lowest ranks generally had narrow 95% CIs; for example, Rhode Island was ranked first (95% CI, 1-1) and Kansas was ranked 51st (95% CI, 49-51) for girls' HPV vaccination. However, states with intermediate ranks had wider and more imprecise 95% CIs; for example, New York was 26th for girls' HPV vaccination coverage, but its 95% CI included ranks 18-35.

CONCLUSIONS

States' ranks of coverage of cancer-preventing vaccines were imprecise, especially for states in the middle of the range; thus, performance rankings presented without measures of imprecision could be overinterpreted. However, ranks can highlight high-performing and low-performing states to target for further research and vaccination promotion programming.

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.

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

OBJECTIVES

This study is among the first to examine metropolitan status differences in human papillomavirus (HPV) vaccine initiation and completion among United States adolescent girls and is unique in its focus on how maternal socioeconomic status and health care access moderate metropolitan status differences in HPV vaccination.

METHODS

Using cross-sectional data from 3573 girls aged 12-17 in the U.S. from the 2008-2010 Behavioral Risk Factor Surveillance System, we estimate main and interaction effects from binary logistic regression models to identify subgroups of girls for which there are metropolitan versus non-metropolitan differences in HPV vaccination.

RESULTS

Overall 34 % of girls initiated vaccination, and 19 % completed all three shots. On average, there were no metropolitan status differences in vaccination odds. However, there were important subgroup differences. Among low-income girls and girls whose mothers did not complete high school, those in non-metropolitan areas had significantly higher probability of vaccine initiation than those in metropolitan areas. Among high-income girls and girls whose mothers completed college, those in metropolitan areas had significantly higher odds of vaccine initiation than those in non-metropolitan areas. Moreover, among girls whose mothers experienced a medical cost barrier, non-metropolitan girls were less likely to initiate vaccination compared to metropolitan girls.

CONCLUSIONS

Mothers remain essential targets for public health efforts to increase HPV vaccination and combat cervical cancer. Public health experts who study barriers to HPV vaccination and physicians who come into contact with mothers should be aware of group-specific barriers to vaccination and employ more tailored efforts to increase vaccination.

Concomitant Adolescent Vaccination in the U.S., 2007-2012

INTRODUCTION

Concomitant (same-day) delivery of two or more vaccines to adolescents is effective, safe, and efficient. Increasing concomitant vaccination could improve coverage for recommended adolescent vaccines, but little is known about who receives vaccines concomitantly.

METHODS

Data came from healthcare provider-verified records on 70,144 adolescents (aged 13-17 years) in the 2008-2012 versions of the National Immunization Survey-Teen who had received at least one dose of tetanus, diphtheria, and acellular pertussis (Tdap) booster; meningococcal conjugate vaccine (MenACWY); or human papillomavirus (HPV) vaccine. Separately for each vaccine, multivariable logistic regression identified adolescent and household correlates of concomitant versus single vaccination, stratified by adolescent sex. Vaccination took place in 2007-2012, data collection in 2008-2012, and data analysis in 2015.

RESULTS

Among vaccinated adolescents, 51%-65% of girls and 25%-53% of boys received two vaccines concomitantly. Concomitant uptake of each vaccine increased over survey years (e.g., 2012 vs 2008: girls' Tdap booster, OR=1.88, 95% CI=1.56, 2.26; boys' Tdap booster, OR=2.62, 95% CI=2.16, 3.16), with the exception of HPV vaccination among boys. Additionally, concomitant vaccination was less common as adolescents got older and in the Northeast (all p<0.05). For MenACWY and HPV vaccine, concomitant uptake was less common for girls whose mothers had higher versus lower education and for boys who lived in metropolitan versus non-metropolitan areas (all p<0.05).

CONCLUSIONS

Missed opportunities for concomitant adolescent vaccination persist, particularly for HPV vaccine. Future interventions targeting groups with low rates of concomitant vaccination could improve population-level coverage with recommended vaccines.

Disparities in collaborative patient-provider communication about human papillomavirus (HPV) vaccination

BACKGROUND

Healthcare providers may vary their communications with different patients, which could give rise to differences in vaccination coverage. We examined demographic disparities in parental report of collaborative provider communication and implications for human papillomavirus (HPV) vaccination.

METHODS

Participants were 4,124 parents who completed the National Immunization Survey-Teen about daughters ages 13-17. We analyzed disparities in collaborative communication (mutual information exchange, deliberation, and decision) and whether they mediated the relationship between demographic characteristics and HPV vaccine initiation.

RESULTS

Half of parents (53%) in the survey reported collaborative communication. Poor, less educated, Spanish-speaking, Southern, and rural parents, and parents of non-privately insured and Hispanic adolescents, were least likely to report collaborative communication (all p<.05). These disparities in communication accounted for geographic variation in HPV vaccination, specifically, the higher rates of uptake in the Northeast versus the South (mediation z=2.31, p<.01) and in urban/suburban vs. rural areas (mediation z=2.87, p<.01). These disparities were also associated with vaccination among subgroups with relatively high coverage, minimizing what could have been even higher uptake among Hispanic compared to non-Hispanic white adolescents (mediation z=-3.04, p<.01) and non-privately versus privately insured adolescents (mediation z=-3.67, p<.001). Controlling for provider recommendation attenuated some of these associations (but all p<.10).

CONCLUSIONS

Collaborative communication showed widespread disparities, being least common among underserved groups. Collaborative communication helped account for differences-and lack of differences-in HPV vaccination among some subgroups of adolescent girls. Leveraging patient-provider communication, especially for underserved demographic groups, could improve HPV vaccination coverage.

Collaborative patient-provider communication and uptake of adolescent vaccines

RATIONALE

Recommendations from healthcare providers are one of the most consistent correlates of adolescent vaccination, but few studies have investigated other elements of patient-provider communication and their relevance to uptake.

OBJECTIVE

We examined competing hypotheses about the relationship of patient-driven versus provider-driven communication styles with vaccination.

METHODS

We gathered information about vaccine uptake from healthcare provider-verified data in the 2010 National Immunization Survey-Teen for tetanus, diphtheria, and pertussis (Tdap) booster, meningococcal vaccine, and human papillomavirus (HPV) vaccine (initiation among females) for adolescents ages 13-17. We categorized communication style in parents' conversations with healthcare providers about vaccines, based on parents' reports (of whether a provider recommended a vaccine and, if so, if conversations were informed, shared, or efficient) (N = 9021).

RESULTS

Most parents reported either no provider recommendation (Tdap booster: 35%; meningococcal vaccine: 46%; and HPV vaccine: 31%) or reported a provider recommendation and shared patient-provider communication (43%, 38%, and 49%, respectively). Provider recommendations were associated with increased odds of vaccination (all ps < 0.001). In addition, more provider-driven communication styles were associated with higher rates of uptake for meningococcal vaccine (efficient style: 82% vs. shared style: 77% vs. informed style: 68%; p < 0.001 for shared vs. informed) and HPV vaccine (efficient style: 90% vs. shared style: 70% vs. informed style: 33%; p < 0.05 for all comparisons).

CONCLUSION

Efficient communication styles were used rarely (≤2% across vaccines) but were highly effective for encouraging meningococcal and HPV vaccination. Intervention studies are needed to confirm that efficient communication approaches increase HPV vaccination among adolescents.

Parents' Recall and Reflections on Experiences Related to HPV Vaccination for Their Children

Human papillomavirus (HPV) vaccination coverage remains suboptimal in the United States. We conducted in-depth interviews with parents of adolescents from an urban primary care center serving a low-income minority population to describe their experiences. We identified the following themes: (a) parents of unvaccinated children generally had not discussed the vaccine with providers and had low awareness; (b) among unaware parents, provision of brief information generally resulted in positive comments about the vaccine; (c) vaccine was typically not requested by parents but rather offered by providers; (d) strength of the recommendations from providers varied, and vaccine was sometimes presented as optional or low priority; (e) parents had low awareness of the three-dose regimen and poor recall about completion; and (f) limited understanding of why boys should be vaccinated. More than 7 years after the introduction of HPV vaccine, there is substantial room for improving the way it is recommended and discussed by providers.

HPV Vaccination Completion and Compliance with Recommended Dosing Intervals Among Female and Male Adolescents in an Inner-City Community Health Center

Human papillomavirus (HPV) vaccination continues to lag behind other adolescent vaccines, especially in areas with pervasive disparities in HPV-related cancers. The purpose of this study was to examine HPV vaccine completion and dosing intervals among low-income adolescents in urban areas. The study included electronic health record data on HPV vaccination for 872 adolescents who received at least one dose of the HPV vaccine. Only 28.4% completed the 3-dose series. For the whole sample, HPV vaccine completion was higher for non-English speakers and among adolescents seen at Newark-South and East Orange sites. Completion was higher among non-English speaking female and Hispanic adolescents, females seen in Newark-South and East Orange sites, and insured Black adolescents. Completion was also dramatically lower among non-English speaking Black adolescents seen at Newark-North, Irvington, and Orange sites (12.5%) compared to other Black adolescents (22.0-44.4%). The mean dosing intervals were 5.5 months (SD = 4.6) between dose 1 and 2 and 10 months (SD = 6.1) between dose 1 and 3. Longer durations between vaccine doses were found among uninsured adolescents and those seen at Newark-North, Irvington, and Orange sites. Non-English speakers had longer duration between dose 1 and 3. Further, durations between dose 1 and 3 were dramatically longer among insured adolescents seen at Newark-North, Irvington, and Orange locations for the whole sample (M = 11.70; SD = 7.12) and among Hispanic adolescents (M = 13.45; SD = 8.54). Understanding how the study predictors facilitate or impede HPV vaccination is critical to reducing disparities in cervical and other HPV-related cancer, especially among Black, Hispanic, and low-income populations.

Correlates to Human Papillomavirus Vaccination Status and Willingness to Vaccinate in Low-Income Philadelphia High School Students

BACKGROUND

Little is known about the correlates of human papillomavirus (HPV) vaccination or willingness to be vaccinated in urban, minority adolescents.

METHODS

Using responses to the 2013 Youth Risk Behavior Survey in Philadelphia, a random sample of high schools provided weighted data representing 20,941 9th to 12th graders. Stratified by either having had or willingness to have the vaccine, bivariate analysis with sexual behavior, preventive health behaviors, mental health, substance use, and demographic characteristics were examined and then multivariable regression models were developed to estimate significant correlates.

RESULTS

Respondents were 52.3% female, 84.4% non-White, and 65.9% ≥16 years; 43% reported having had the HPV vaccine, and of those not vaccinated, 66% reported willingness to be vaccinated. Logistic regression models indicate that females (odds ratio [OR] = 3.12, p < .01) and those reporting human immunodeficiency virus (HIV) testing (OR = 2.10, p < .01) were more likely to be vaccinated. Those reporting condom use during last intercourse (OR = 0.40; p = .05) and current marijuana use (OR = 0.37; p = .03) were less likely to indicate willingness to be vaccinated.

CONCLUSIONS

Important areas for intervention include addressing misconceptions or feelings of "immunity," especially for those using condoms. Understanding the correlation between HIV testing and HPV vaccination is also an important intervention opportunity for schools hoping to increase adolescent vaccination rates.

Initiation of Human Papillomavirus Vaccination Among Predominantly Minority Female and Male Adolescents at Inner-City Community Health Centers

OBJECTIVES

We examined the prevalence and correlates of human papillomavirus (HPV) vaccine initiation among adolescents in low-income, urban areas.

METHODS

The study consisted of electronic health record data on HPV vaccination for 3180 adolescents (aged 10-20 years) at a multisite community health center in 2011.

RESULTS

Only 27% initiated the HPV vaccine. The adjusted odds ratio (AOR) of HPV vaccination was lower among older adolescents (AOR = 0.552; 95% confidence interval [CI] = 0.424, 0.718) and those seen by nonpediatric health care providers (HCPs; AOR = 0.311; 95% CI = 0.222, 0.435), and higher among non-English speakers (AOR = 1.409; 95% CI = 1.134, 1.751) and those seen at 2 site locations (AOR = 1.890; 95% CI = 1.547, 2.311). Insurance status was significant only among female and Hispanic adolescents. Language was not a predictor among Hispanic adolescents. Across all analyses, the interaction of age and HCP specialty was associated with HPV vaccination. Dramatically lower HPV vaccination rates were found among older adolescents seen by nonpediatric HCPs (3%-5%) than among other adolescents (23%-45%).

CONCLUSIONS

Improving HPV vaccination initiation in low-income urban areas is critical to reducing disparities in cervical and other HPV-related cancer, especially among Black, Hispanic, and low-income populations.

Effects of a Presidential Candidate's Comments on HPV Vaccine

During and after the 2011 Republican presidential debate, a candidate questioned the safety of HPV vaccine. The authors aimed to determine the effect of these comments on parents. A national sample of 327 parents with adolescent sons ages 11-17 years completed online surveys in fall 2010 (baseline, about 1 year before the debate) and 2011 (follow-up, about 1 month after the debate). The authors used regression models to examine the association of parents' awareness of the candidate's comments with HPV vaccine initiation among their sons, their willingness to get sons free HPV vaccine, and their beliefs about potential harms of HPV vaccine. Overall, 17% of parents reported hearing about the Republican presidential candidate's comments about HPV vaccine. Parents aware of the comments had a larger increase between baseline and follow-up in the belief that HPV vaccine might cause short-term health problems compared with parents who were not aware. Although the candidate's comments may have increased some parents' beliefs about the short-term harms of HPV vaccine, the comments had no effect on other beliefs, willingness to vaccinate, or behavior. Having accurate information about HPV vaccine that is readily available to the public during such controversies may diminish their effect.

Increasing human papillomavirus vaccine initiation among publicly insured Florida adolescents

PURPOSE

We evaluated the feasibility of a multilevel intervention to increase the human papillomavirus (HPV) vaccine initiation among adolescents.

METHODS

We used a four-arm factorial, quasi-experimental trial to assess feasibility and short-term, preliminary effectiveness of a health system-level, gender-specific postcard campaign and an in-clinic health information technology (HIT) system. Between August and November 2013, we tested the intervention among 11- to 17-year-olds without prior HPV vaccine claims in the Florida Medicaid or Children's Health Insurance Program encounters (2,773 girls and 3,350 boys) who attended or were assigned to primary care clinics in North Central Florida.

RESULTS

At least one postcard was deliverable to 95% of the parents. Most parents (91% boys' and 80% girls') who participated in the process evaluation survey (n = 162) reported seeking additional information about the vaccine after receiving the postcard. Only 8% (57 of 1,062) of the adolescents assigned to a HIT provider with an office visit during the study used the HIT system. When compared with arms not containing that component, HPV vaccine initiation increased with the postcard campaign (girls, odds ratio [OR] = 1.6; 95% confidence interval [CI] = 1.1-2.3 and boys, not significant), the HIT system (girls, OR = 1.5; 95% CI = 1.0-2.3 and boys, OR = 1.4; 95% CI = 1.0-2.0), and the combined HIT and postcard intervention (girls, OR = 2.4; 95% CI = 1.4-4.3 and boys, OR = 1.6; 95% CI = 1.0-2.5).

CONCLUSIONS

A system-level postcard campaign was feasible. Despite low recruitment to the in-clinic HIT system, the intervention demonstrated short-term, preliminary effectiveness similar to prior HPV vaccine interventions.

Early adoption of the human papillomavirus vaccine among Hispanic adolescent males in the United States

BACKGROUND

Human papillomavirus (HPV) infection is common among Hispanic males, but to the authors' knowledge little is known regarding HPV vaccination in this population. The authors examined the early adoption of the HPV vaccine among a national sample of Hispanic adolescent males.

METHODS

The authors analyzed provider-verified HPV vaccination data from the 2010 through 2012 National Immunization Survey-Teen (NIS-Teen) for Hispanic males aged 13 years to 17 years (n = 4238). Weighted logistic regression identified correlates of HPV vaccine initiation (receipt of ≥ 1 doses).

RESULTS

HPV vaccine initiation was 17.1% overall, increasing from 2.8% in 2010 to 31.7% in 2012 (P < .0001). Initiation was higher among sons whose parents had received a provider recommendation to vaccinate compared with those whose parents had not (53.3% vs 9.0%; odds ratio, 8.77 [95% confidence interval, 6.05-12.70]). Initiation was also higher among sons who had visited a health care provider within the previous year (odds ratio, 2.42; 95% confidence interval, 1.39-4.23). Among parents with unvaccinated sons, Spanish-speaking parents reported much higher intent to vaccinate compared with English-speaking parents (means: 3.52 vs 2.54; P < .0001). Spanish-speaking parents were more likely to indicate lack of knowledge (32.9% vs 19.9%) and not having received a provider recommendation (32.2% vs 17.7%) as the main reasons for not intending to vaccinate (both P < .05).

CONCLUSIONS

HPV vaccination among Hispanic adolescent males has increased substantially in recent years. Ensuring health care visits and provider recommendation will be key for continuing this trend. Preferred language may also be important for increasing HPV vaccination and addressing potential barriers to vaccination.

Urban and rural safety net health care system clinics: no disparity in HPV4 vaccine completion rates

OBJECTIVE

Safety net health care centers in the US serve vulnerable and underinsured females. The primary aim of this work was to determine if HPV4 dosing compliance differs between females who receive doses at rural vs. urban core safety net health care locations.

METHODS

Females exclusively receiving health care in the Truman Medical Center (TMC) safety net system at the urban core and rural locations were identified by their HPV4 vaccine records. Dates and number of HPV4 doses as well as age, gravidity, parity and race/ethnicity were recorded from the electronic medical record (EMR). Appropriate HPV4 dosing intervals were referenced from the literature.

RESULTS

1259 females, 10-26 years of age, received HPV4 vaccination at either the rural (23%) or urban core location (77%). At the rural location, 23% received three doses on time, equal to the 24% at the urban core. Females seen in the urban core were more likely to receive on-time doublet dosing than on-time triplet dosing (82% vs. 67%, p<0.001). Mistimed doses occurred equally often among females receiving only two doses, as well as those receiving three doses.

CONCLUSIONS

Compliance with on-time HPV4 triplet dose completion was low at rural and urban core safety net health clinics, but did not differ by location.

Provider-verified HPV vaccine coverage among a national sample of Hispanic adolescent females

BACKGROUND

Hispanic females have the highest cervical cancer incidence rate of any racial or ethnic group in the United States, yet relatively little research has examined human papillomavirus (HPV) vaccination among this fast-growing population. We examined HPV vaccination among a national sample of Hispanic adolescent females.

METHODS

We analyzed provider-verified vaccination data from the 2010-2011 National Immunization Survey-Teen for Hispanic females ages 13 to 17 years (n = 2,786). We used weighted logistic regression to identify correlates of HPV vaccine initiation (receipt of one or more doses), completion (receipt of three doses), and follow-through (receipt of three doses among those who initiated the series).

RESULTS

HPV vaccine initiation was 60.9%, completion was 36.0%, and follow-through was 59.1%. Initiation and completion were more common among older daughters and those whose parents had received a provider recommendation to vaccinate (all P < 0.05). Completion was less common among daughters who had moved from their birth state (P < 0.05). All vaccination outcomes were less common among daughters without health insurance (all P < 0.05). Vaccination did not differ by parents' preferred language (all P > 0.05), although intent to vaccinate was higher among Spanish-speaking parents (P < 0.01). Spanish-speaking parents were more likely to indicate lack of provider recommendation (20.2% vs. 5.3%) and cost (10.9% vs. 1.8%) as main reasons for not intending to vaccinate (both P < 0.05).

CONCLUSIONS

Many Hispanic females have not received HPV vaccine. Several factors, including provider recommendation and health insurance, are key correlates of vaccination.

IMPACT

HPV vaccination programs targeting Hispanics are needed and should consider how potential barriers to vaccination may differ by preferred language.

Vaccination interest and trends in human papillomavirus vaccine uptake in young adult women aged 18 to 26 years in the United States: an analysis using the 2008-2012 National Health Interview Survey

OBJECTIVES

Human papillomavirus (HPV) vaccines have been approved since 2006, yet vaccination rates remain low. We investigated HPV vaccination trends, interest, and reasons for nonvaccination in young adult women.

METHODS

We used data from the 2008-2012 National Health Interview Survey to analyze HPV vaccine uptake trends (≥ 1 dose) in women aged 18 to 26 years. We used data from the 2008 and 2010 National Health Interview Survey to examine HPV vaccination interest and reasons for nonvaccination among unvaccinated women.

RESULTS

We saw significant increases in HPV vaccination for all young women from 2008 to 2012 (11.6% to 34.1%); however, Hispanics and women with limited access to care continued to have lower vaccination rates. Logistic regression demonstrated lower vaccination interest among unvaccinated women in 2010 than 2008. Respondents in 2010 were significantly less likely to give lack of knowledge as a primary reason for nonvaccination.

CONCLUSIONS

Uptake of HPV vaccine has increased from 2008 to 2012 in young women. Yet vaccination rates remain low, especially among women with limited access to care. However, unvaccinated women with limited health care access were more likely to be interested in receiving the vaccine.

Barriers to human papillomavirus vaccination among US adolescents: a systematic review of the literature

IMPORTANCE

Since licensure of the human papillomavirus (HPV) vaccine in 2006, HPV vaccine coverage among US adolescents has increased but remains low compared with other recommended vaccines.

OBJECTIVE

To systematically review the literature on barriers to HPV vaccination among US adolescents to inform future efforts to increase HPV vaccine coverage.

EVIDENCE REVIEW

We searched PubMed and previous review articles to identify original research articles describing barriers to HPV vaccine initiation and completion among US adolescents. Only articles reporting data collected in 2009 or later were included. Findings from 55 relevant articles were summarized by target populations: health care professionals, parents, underserved and disadvantaged populations, and males.

FINDINGS

Health care professionals cited financial concerns and parental attitudes and concerns as barriers to providing the HPV vaccine to patients. Parents often reported needing more information before vaccinating their children. Concerns about the vaccine's effect on sexual behavior, low perceived risk of HPV infection, social influences, irregular preventive care, and vaccine cost were also identified as potential barriers among parents. Some parents of sons reported not vaccinating their sons because of the perceived lack of direct benefit. Parents consistently cited health care professional recommendations as one of the most important factors in their decision to vaccinate their children.

CONCLUSIONS AND RELEVANCE

Continued efforts are needed to ensure that health care professionals and parents understand the importance of vaccinating adolescents before they become sexually active. Health care professionals may benefit from guidance on communicating HPV recommendations to patients and parents. Further efforts are also needed to reduce missed opportunities for HPV vaccination when adolescents interface with the health care system. Efforts to increase uptake should take into account the specific needs of subgroups within the population. Efforts that address system-level barriers to vaccination may help to increase overall HPV vaccine uptake.

Racial disparities in human papillomavirus vaccination: does access matter?

PURPOSE

To examine the association between race/ethnicity and human papillomavirus (HPV) vaccine initiation and to determine how access to health care influences this relationship.

METHODS

We used nationally representative data from the National Survey of Family Growth to assess HPV vaccine initiation in 2,168 females aged 15-24 years. A series of regression analyses were performed to determine the independent effect of race/ethnicity on HPV vaccine initiation after controlling for sociodemographic variables and health care access measures. Age-stratified regression analyses were also performed to assess whether the relationship between race/ethnicity and HPV vaccine initiation differed among females aged 15-18 and 19-24 years.

RESULTS

There were significant racial/ethnic disparities in HPV vaccination; United States (US)-born Hispanics, foreign-born Hispanics, and African-Americans were less likely to have initiated vaccination than were whites (p < .001). Adjusting for sociodemographic characteristics attenuated the disparity for both US-born and foreign-born Hispanics (adjusted odds ratio [AOR], .76; 95% confidence interval [CI], .50-1.16; and AOR, .67; 95% CI, .37-1.19) but not for African-Americans (AOR, .47, 95% CI, .33-.66). Adding health care access measures further attenuated the disparity for US-born and foreign-born Hispanics (AOR, .85, 95% CI, .54-1.34; and AOR, .84, 95% CI, .45-1.55). However, African-Americans remained less likely than whites to have initiated vaccination (AOR, .49, 95% CI, .36-.68). These racial/ethnic trends were similar for females aged 15-18 and 19-24 years.

CONCLUSIONS

Lower rates of HPV vaccination among African-American females do not appear to be explained by differential access to health care. More research is necessary to elucidate factors contributing to HPV vaccination in this population.