Research article
Geographic Disparity, Area Poverty, and Human Papillomavirus Vaccination

https://doi.org/10.1016/j.amepre.2010.01.018Get rights and content

Background

A human papillomavirus (HPV) vaccine was approved by the Food and Drug Administration for use among women/girls in 2006. Since that time, limited research has examined HPV vaccine uptake among adolescent girls and no studies have examined the role of geographic disparities in HPV vaccination.

Purpose

The purpose of this study is to examine geographic disparity in the prevalence of human papillomavirus (HPV) vaccination and to examine individual-, county-, and state-level correlates of vaccination.

Methods

Three-level random intercept multilevel logistic regression models were fitted to data from girls aged 13–17 years living in six U.S. states using data from the 2008 Behavioral Risk Factor Surveillance System (BRFSS) and the 2000 U.S. census.

Results

Data from 1709 girls nested within 274 counties and six states were included. Girls were predominantly white (70.6%) and insured (74.5%). Overall, 34.4% of girls were vaccinated. Significant geographic disparity across states (variance=0.134, SE=0.065) and counties (variance=0.146, SE=0.063) was present, which was partially explained by state and county poverty levels. Independent of individual-level factors, poverty had differing effects at the state and county level: girls in states with higher levels of poverty were less likely whereas girls in counties with higher poverty levels were more likely to be vaccinated. Household income demonstrated a similar pattern to that of county-level poverty: Compared to girls in the highest-income families, girls in the lowest-income families were more likely to be vaccinated.

Conclusions

The results of this study suggest geographic disparity in HPV vaccination. Although higher state-level poverty is associated with a lower likelihood of vaccination, higher county-level poverty and lower income at the family level is associated with a higher likelihood of vaccination. Research is needed to better understand these disparities and to inform interventions to increase vaccination among all eligible girls.

Introduction

In 2009, an estimated 11,270 incident cases of cervical cancer will be diagnosed and 4070 women will die from it in the U.S.1 Widespread acceptance of the Pap and treatment for precancerous and cancerous lesions have resulted in impressive declines of more than 70% in both incidence and death during recent decades in the U.S.2 However, persistent disparities in cervical cancer incidence, stage, and mortality has been demonstrated across race/ethnicity and socioeconomically disadvantaged individuals and areas.3, 4, 5, 6, 7 Moreover, geographic disparities in Pap testing have been demonstrated, and the very populations at highest risk of cervical cancer (women who are poor, minority, less-educated, and those living in areas of greater socioeconomic deprivation, higher percentage African-American or Hispanic, and fewer healthcare providers) are often the least likely to obtain Paps.8, 9, 10, 11, 12, 13

In 2006, the U.S. Food and Drug Administration (FDA) approved Gardasil, a vaccine that prevents infection by two strains of the sexually transmitted human papillomavirus (HPV) found in approximately 70% of all cases of cervical cancer and two strains of HPV that cause approximately 90% of genital warts.14 In 2007, the Advisory Committee on Immunization Practices (ACIP) and the American Cancer Society issued guidelines recommending vaccination for women/girls15, 16 and most recently in 2009, ACIP extended its recommendations to include men/boys.17 Although approved by the FDA for children as young as 9 years, the guidelines recommend vaccination for boys and girls aged 11–12 years and, for the purposes of “catch up vaccination,” for adolescents and young adults as old as 26 years. In 2007, approximately 25% and in 2008, 37.2% of adolescent girls aged 13–17 years had at least initiated the three-injection vaccine series.18, 19, 20

With universal uptake of HPV vaccination, recommended screening, and treatment for precancerous lesions, incidence of invasive cervical cancer could be dramatically reduced. However, vaccination may be adopted unequally and may simply serve to widen existing cervical cancer disparities across SES, race, and geography. At up to $140 per dose for the three-injection vaccine series plus office and administration fees, the vaccine is costly, and few states mandate insurance coverage. Because geographic and socioeconomic disparities exist for uptake of the cheaper Pap, typically covered by insurance, it is likely that disparities will be seen in the uptake of the costlier HPV vaccination. On the other hand, ACIP-approved vaccines are eligible for funding through a variety of public programs, including the federal program Vaccines for Children,21 potentially lessening the potential for disparity. However, wide gaps in public financing for childhood vaccinations have been documented22 across U.S. states and are largest for the most expensive and newest vaccines. Further, persistent socioeconomic, racial, and geographic disparities in other publicly funded vaccinations have been documented in U.S. children,23, 24, 25, 26 suggesting that disparity is likely to be evident in HPV vaccination.

To examine the uptake of HPV vaccination among girls aged 13–17 years, this study examines geographic disparity in vaccination across six states in the U.S. and the individual- and area-level sociodemographic and socioeconomic correlates that may account for this disparity using the child HPV module of the 2008 Behavioral Risk Factor Surveillance System (BRFSS).

Section snippets

Data

All individual-level data were obtained from the public-use data files of the 2008 BRFSS,27 a national random-digit-dial telephone survey of the civilian non-institutionalized adult population in the U.S. Random child selection and population-based weighting are used to obtain representative data on the health conditions and behavioral risks of U.S. children aged ≤17 years. For every household with ≥1 child, one random child is selected. All data on the selected child are provided by the adult

Results

Adult respondents provided data on a total of 1709 adolescent girls aged 13–17 years nested within 274 counties, representing 8.7% of all U.S. counties. The counties were, in turn, nested within six states (i.e., Delaware, New York, Oklahoma, Pennsylvania, Texas, and West Virginia). The mean sample size was 6.2 (range=1–74) per county and 284.8 (range=128–284.8) per state. The percentage living in poverty did not differ between included and not included counties and states; however, included

Discussion

Geographic disparity in HPV vaccination among girls was demonstrated in six U.S. states using data from the first application of the BRFSS Child HPV Module. Overall, only one in three girls reported to have received ≥1 dose of the HPV vaccine. Notably, although a higher prevalence of poverty at the state level was associated with decreased odds, a higher prevalence of poverty at the county level was associated with increased odds of vaccination. Although seemingly contradictory, this indicates

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