Social inequalities in adolescent human papillomavirus (HPV) vaccination: A test of fundamental cause theory
Highlights
► We test whether SES and racial/ethnic disparities exist for HPV vaccine knowledge, health professional recommendation, and uptake. ► Lower SES and racial/ethnic minority parents have significantly lower odds of knowing about the vaccine. ► Health professional recommendation is negatively associated with lower SES and black racial/ethnic status. ► Lower SES and black adolescents have significantly lower odds of initiating and completing the HPV vaccine series. ► Disparities in adolescent HPV vaccination may maintain future disparities in cervical cancer among adult populations.
Introduction
Health inequalities by socioeconomic status (SES) and race/ethnicity have been well documented in scholarship concerning the social determinants of health and constitute ongoing, vexing public health problems (Carpiano, Link, & Phelan, 2008; Phelan, Link, & Tehranifar, 2010). Significant attention has been paid to better understanding the mechanisms that account for these associations – how social circumstances “get under the skin” to affect health outcomes (e.g., Adler & Stewart, 2010; Taylor, Repetti, & Seeman, 1997). In their seminal article on “Social Conditions as Fundamental Causes of Disease,” Link and Phelan (1995) theorize that due to the unequal distribution of health-beneficial resources in a society, health inequalities emerge and persist because persons who are more advantaged in terms of knowledge, money, status, and beneficial social connections are better positioned to avail themselves of health-promoting resources and innovations and, consequently, experience greater health and longevity than less advantaged persons. Since the publication of that article nearly twenty years ago, a growing body of research has empirically tested the fundamental cause theory and found support for its proposed mechanisms across a variety of health outcomes in their relation to SES and racial/ethnic status (see reviews by Carpiano et al. (2008) and Phelan et al. (2010)). Few studies, however, have (a) considered specific stages in the adoption of a treatment, or (b) specifically examined this theory with respect to the introduction of health-promoting innovations administered early in the life course that may act as latent mechanisms whereby an effect on morbidity and mortality is not immediately evident, but rather, would be revealed at a later stage of life.1
In the present study, we trace an example of a latent mechanism that is in the process of being created: knowledge and uptake of the human papillomavirus (HPV) vaccine, a relatively recent innovation that is primarily targeted at adolescent girls and may help prevent cervical (as well as other, less prevalent forms of) cancer—a disease that typically emerges later in adulthood and for which SES and racial/ethnic disparities have been well-documented. Using data from the 2008, 2009, and 2010 US National Immunization Survey – Teen (NIS-Teen) (U.S. Department of Health and Human Services (DHHS), 2009; DHHS, 2010; DHHS, 2011), we apply fundamental cause theory to test hypotheses regarding socioeconomic status (SES) and racial/ethnic disparities in three distinct stages of the adoption of this new treatment: (1) parent/guardian knowledge about the HPV vaccine, (2) health professional recommendation to receive the HPV vaccine, and (3) uptake of the HPV vaccine (both initiation and completion of the three shot series) by adolescent girls. Accordingly, we demonstrate a useful concept for medical sociology and social epidemiology, examine distinct stages in which disparities may arise, and raise the salience of latent mechanisms for understanding social inequalities in health.
Section snippets
Fundamental cause theory
Fundamental cause theory posits that health disparities have endured despite significant changes in diseases and the risk factors associated with them because social conditions embody “an array of resources, such as money, knowledge, prestige, power, and beneficial social connections that protect health no matter what mechanisms are relevant at any given time” (Phelan et al., 2010, p. S28). Such resources affect people's ability to avoid health risks and minimize the impact of disease once it
Dataset and sample
We test our hypotheses using public use data of the 2008, 2009, and 2010 administrations of the National Immunization Survey – Teen (NIS-Teen), a nationally representative sample detailing vaccination coverage in the United States and groups at risk of vaccine-preventable diseases (CDC, 2010b); DHHS, 2009; DHHS, 2010; DHHS, 2011. The study was exempt from ethical review because the data was publicly available. The NIS-Teen is a repeated cross-sectional random-digit-dialing household telephone
Results
Before presenting the results of our specific hypothesis tests, examination of the overall prevalence for each of our four dependent variables is informative for understanding the absolute levels of HPV vaccination knowledge, recommendation, initiation, and adoption within our sample. The descriptive statistics for 2008, 2009, and 2010 in Table 1 indicate a high prevalence of having heard about the vaccine (91.6% of respondents in the pooled sample), while just over half of the respondents
Discussion
Our study highlights how mechanisms created by human efforts and innovations may contribute to the emergence and persistence of health disparities, and how such disparities may emerge at various stages between knowledge and uptake. This focus is a central—yet relatively understudied—tenet of the fundamental cause theory of health disparities, which aims to understand how health disparities are generated over time, even as the risk factors for poor health and premature death change
Conclusion
Our examination of HPV vaccination disparities informs two important aspects of fundamental cause theory. First, in terms of understanding how mechanisms operate, the SES and racial/ethnic disparities observed for this relatively new health-promoting innovation occur within different stages of uptake—from initial knowledge through to adoption—thereby providing deeper insights into how SES and racial/ethnic background contribute to the persistence of health disparities.
Second, in terms of
Acknowledgments
Richard Carpiano contributed to this paper while receiving funding from Investigator Awards from the Michael Smith Foundation for Health Research and the Canadian Institutes of Health Research. The authors express their sincere appreciation to Bruce Link for his thoughtful conceptual comments on an earlier draft of this manuscript that informed some of the ideas presented here, as well as to the four anonymous peer reviewers for their detailed and constructive feedback.
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