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Vaccine 31 (2013) 3121– 3125

Contents lists available at SciVerse ScienceDirect

Vaccine

j o u r n a l h o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / v a c c i n e

rief report

orrelates of HPV vaccination among adolescent females from Appalachia and easons why their parents do not intend to vaccinate

aul L. Reiter a,b,c,∗, Mira L. Katz a,b,c, Electra D. Paskett a,b,c

Division of Cancer Prevention and Control, College of Medicine, The Ohio State University, United States Comprehensive Cancer Center, The Ohio State University, United States College of Public Health, The Ohio State University, United States

a r t i c l e i n f o

rticle history: eceived 14 February 2013 eceived in revised form 12 April 2013 ccepted 24 April 2013 vailable online 9 May 2013

a b s t r a c t

Limited research has examined HPV vaccination in Appalachia, a region with cervical cancer disparities. We analyzed 2008–2010 National Immunization Survey-Teen data for adolescent females ages 13–17 from Appalachia (n = 1951) to identify correlates of HPV vaccination and reasons why their parents do not intend to vaccinate. HPV vaccine initiation was 40.8%, completion was 27.7%, and follow-through was 67.8%. Vaccination outcomes tended to be higher among females who were older, had visited their

eywords: uman papillomavirus PV vaccine ppalachia ancer IS-Teen

healthcare provider in the last year, or whose parents reported receiving a provider recommendation to vaccinate. Only 41.0% of parents with unvaccinated daughters intended to vaccinate in the next year. The most common reasons for not intending to vaccinate were believing vaccination is not needed or not necessary (21.5%) and lack of knowledge (18.5%). Efforts to reduce missed opportunities for vaccination at healthcare visits and address reasons why parents are not vaccinating may help increase HPV vaccination in Appalachia

. Introduction

Several populations in the U.S. continue to suffer from cervical ancer disparities, including females from Appalachia. Appalachia s a 13-state region (from New York to Mississippi) containing about % of the U.S. population [1]. Parts of Appalachia have among the ighest cervical cancer incidence and mortality rates in the country 2,3]. Human papillomavirus (HPV) vaccination offers a strategy for educing these disparities. Guidelines currently recommend that ll females ages 11–12 receive three doses of HPV vaccine, with atch-up vaccination for ages 13–26 [4].

Most healthcare facilities in Appalachia have HPV vaccine avail- ble [5], and vaccine acceptability is fairly high among Appalachian dults [6,7]. We previously found that HPV vaccine uptake among dolescent females from Appalachia was generally comparable to he rest of the U.S. [8]. Although several studies have identified cor- elates of HPV vaccination [9], none have done so among adolescent

emales from Appalachia or identified reasons why Appalachian arents do not intend to vaccinate. Such information will be useful o future efforts to increase HPV vaccination in Appalachia.

∗ Corresponding author at: Division of Cancer Prevention and Control, College of edicine, The Ohio State University, Suite 525, 1590 North High Street, Columbus, hio 43201, United States. Tel.: +1 614 366 4265; fax: +1 614 293 5611.

E-mail address: [email protected] (P.L. Reiter).

2. Materials and methods

2.1. Study design

We analyzed data from the National Immunization Survey- Teen (NIS-Teen), an annual survey conducted by the Centers for Disease Control and Prevention (CDC) that monitors adolescent vaccination among 13–17 year-olds in the U.S. [10]. The NIS-Teen collects data using a random-digit-dialed telephone survey with parents/guardians (referred to as “parents”) of adolescents ages 13–17 and a mailed survey to adolescents’ healthcare providers. We report NIS-Teen data from 2008 to 2010 (all publicly available years at the time of analysis) on 1951 adolescent females from Appalachia with provider-verified vaccination records. Appalachian residence was established using county of residence and the Appalachian Regional Commission’s county classification scheme [11].

Data collection for the NIS-Teen was approved by the National Center for Health Statistics (NCHS) Research Ethics Review Board (ERB). Analysis of deidentified data from the survey is exempt from the federal regulations for the protection of human research par- ticipants. We accessed restricted data through the NCHS Research Data Center (RDC), including data on county of residence and par-

ents’ intent to vaccinate. Analysis of restricted data through the RDC is approved by the NCHS ERB. The Institutional Review Board at The Ohio State University determined this study was exempt from review.

dx.doi.org/10.1016/j.vaccine.2013.04.068

http://www.sciencedirect.com/science/journal/0264410X

http://www.elsevier.com/locate/vaccine

mailto:[email protected]

dx.doi.org/10.1016/j.vaccine.2013.04.068

3 cine 31 (2013) 3121– 3125

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Table 1 Characteristics of parents and adolescent daughters from Appalachia (n = 1951).

n (weighted %)

Year 2008 667 (32.9) 2009 630 (34.9) 2010 654 (32.2)

Daughter characteristics Age

13 years 424 (20.7) 14 years 382 (18.7) 15 years 401 (20.7) 16 years 393 (19.8) 17 years 351 (20.1)

Race/ethnicity White, non-Hispanic 1664 (80.6) Black, non-Hispanic 163 (12.1) Other 124 (7.3)

Visited healthcare provider in last year No 244 (14.6) Yes 1699 (85.4)

Healthcare coverage Through parent employer or union 1296 (63.3) Other insurance 559 (31.3) No insurance 93 (5.4)

Parent characteristics Mother’s age

<35 years 179 (9.9) 35–44 years 957 (50.7) 45+ years 815 (39.4)

Mother’s education High school or less 684 (44.3) Some college 597 (27.0) College graduate 670 (28.7)

Mother’s marital status Married 1457 (74.3) Other 494 (25.7)

Heard of HPV No 304 (16.4) Yes 1623 (83.6)

Heard of HPV vaccine No 101 (5.0) Yes 1835 (95.0)

Received provider recommendation to get daughter HPV vaccine No 856 (43.8) Yes 1045 (56.2)

Household characteristics Poverty status

Below poverty 309 (18.9) Above poverty, ≤$75,000 908 (50.7) Above poverty, >$75,000 658 (30.4)

Urbanicity Non-MSA 775 (36.9) MSA, non-central city 723 (38.8) MSA, central city 453 (24.3)

Appalachian subregion Northern 343 (32.3) North Central 402 (10.1) Central 200 (8.0) South Central 309 (19.0) Southern 696 (30.7)

Note. Totals may not sum to stated sample size due to missing data. Percents may

122 P.L. Reiter et al. / Vac

.2. Measures

We examined three dichotomous (yes or no) HPV vaccination utcomes: (1) initiation: receipt of at least one dose; (2) comple- ion: receipt of three doses; and (3) follow-through: completion mong initiators. Among parents with unvaccinated daughters, we xamined intent to vaccinate their daughters in the next year. Sur- eys asked these parents, “How likely is it that [TEEN] will receive PV shots in the next 12 months?” Response options included “very

ikely,” “somewhat likely,” “not sure/don’t know,” “not too likely,” nd “not likely at all.” Parents who indicated one of the latter three esponses were asked, “What is the main reason [TEEN] will not eceive HPV shots in the next 12 months?” This open-ended sur- ey item allowed parents to indicate multiple reasons, with the CDC oding responses into categories.

Parent surveys collected data on several characteristics Table 1). We used county of residence to determine which ppalachian subregion adolescent females resided in. Appalachia an be divided into five subregions (Northern, North Central, Cen- ral, South Central, and Southern) [11], which are contiguous areas ithin Appalachia with similar characteristics (e.g., demographics,

tc.).

.3. Data analysis

For each HPV vaccination outcome, we used logistic regression o first identify variables with p < 0.15 in univariable analyses. We hen entered these variables into a multivariable logistic regression

odel to produce adjusted odds ratios (ORs) and 95% confidence ntervals (CIs). Analyses applied sampling weights, accounted for he complex design of the NIS-Teen, and combined data from mul- iple survey years using recommended methods [12]. Frequencies re not weighted. Statistical tests using SAS Version 9.2 (Cary, NC) ere two-tailed with a critical alpha of 0.05.

. Results

.1. Initiation

About 40.8% (743/1951) of adolescent females had initiated the PV vaccine regimen (Table 2). Initiation increased from 32.4% in 008 to 45.4% in 2010. In multivariable analyses, initiation was ore common among adolescent females who had visited their

ealthcare provider in the last year (OR = 2.17, 95% CI: 1.42–3.34), hose parents had heard of HPV vaccine (OR = 2.53, 95% CI:

.14–5.63), or whose parents reported receiving a provider recom- endation for vaccination (OR = 4.07, 95% CI: 3.06–5.43). Initiation as lower among adolescent females from the Central (OR = 0.47,

5% CI: 0.28–0.78) or Southern (OR = 0.67, 95% CI: 0.47–0.95) sub- egions.

.2. Completion

Overall, 27.7% (482/1951) of adolescent females had completed he HPV vaccine regimen (increasing from 19.2% in 2008 to 34.5% n 2010; Table 2). Adolescent females who were 17 years old OR = 2.04, 95% CI: 1.26–3.31), had visited their healthcare provider n the last year (OR = 1.65, 95% CI: 1.00–2.72), had healthcare cover- ge other than through their parents’ employer or union (OR = 3.67, 5% CI: 1.32–10.20), or whose parents reported receiving a provider ecommendation for vaccination (OR = 2.71, 95% CI: 1.99–3.70) ere more likely to have completed the vaccine regimen, in multi-

ariable analyses. Completion was less common among adolescent emales from the North Central (OR = 0.54, 95% CI: 0.32–0.91), Cen- ral (OR = 0.33, 95% CI: 0.19–0.57), or Southern (OR = 0.48, 95% CI: .34–0.69) subregions.

not sum to 100% due to rounding. HPV = human papillomavirus; MSA = metropolitan statistical area.

3.3. Follow-through

Most Appalachian females who initiated the HPV vaccine regimen received all three doses (67.8% [482/743]; Table 2). Follow-through increased from 59.4% in 2008 to 76.1% in 2010. In multivariable analyses, follow-through was more common among adolescent females who were 17 years old (OR = 3.01, 95% CI:

1.48–6.11), had healthcare coverage other than through their parents’ employer or union (OR = 3.83, 95% CI: 1.04–14.09), or whose parents had heard of HPV (OR = 2.33, 95% CI: 1.28–4.24).

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Table 2 Correlates of HPV vaccination among adolescent females from Appalachia.

HPV vaccine initiationa HPV vaccine completionb HPV vaccine follow-throughc

Initiated weighted %

Univariable OR (95% CI)

Multivariable OR (95% CI)

Completed weighted %

Univariable OR (95% CI)

Multivariable OR (95% CI)

Followed Through weighted %

Univariable OR (95% CI)

Multivariable OR (95% CI)

Total 40.8 – – 27.7 – – 67.8 – – Year

2008 32.4 ref. ref. 19.2 ref. ref. 59.4 ref. ref. 2009 44.6 1.68 (1.23–2.31)* 1.58 (1.15–2.18)* 29.4 1.75 (1.20–2.55)* 1.58 (1.09–2.30)* 65.8 1.32 (0.79–2.18) 1.32 (0.78–2.23) 2010 45.4 1.74 (1.28–2.35)** 1.54 (1.11–2.15)* 34.5 2.22 (1.55–3.16)** 2.01 (1.39–2.92)** 76.1 2.18 (1.33–3.57)* 2.18 (1.27–3.73)*

Daughter characteristics Age

13 years 35.9 ref. ref. 20.8 ref. ref. 58.0 ref. ref. 14 years 43.0 1.34 (0.92–1.97) 1.34 (0.88–2.04) 29.4 1.58 (1.02–2.46)* 1.61 (1.00–2.58) 68.4 1.56 (0.83–2.93) 1.64 (0.84–3.21) 15 years 41.6 1.27 (0.87–1.85) 1.17 (0.77–1.76) 27.0 1.40 (0.91–2.18) 1.23 (0.77–1.98) 64.9 1.34 (0.72–2.47) 1.36 (0.73–2.55) 16 years 42.5 1.32 (0.90–1.95) 1.45 (0.95–2.22) 28.5 1.52 (0.97–2.38) 1.56 (0.98–2.49) 67.1 1.47 (0.79–2.75) 1.50 (0.81–2.79) 17 years 41.4 1.26 (0.83–1.92) 1.37 (0.89–2.13) 33.1 1.88 (1.17–3.02)* 2.04 (1.26–3.31)* 79.9 2.88 (1.47–5.66)* 3.01 (1.48–6.11)*

Race/ethnicity White, non-Hispanic 40.6 1.20 (0.71–2.02) – 28.3 1.30 (0.68–2.50) – 69.6 1.29 (0.58–2.88) – Black, non-Hispanic 44.8 1.42 (0.74–2.71) – 26.6 1.20 (0.54–2.65) – 59.4 0.83 (0.32–2.17) – Other 36.4 ref. – 23.2 ref. – 63.9 ref. –

Visited healthcare provider in last year No 22.6 ref. ref. 15.9 ref. ref. 70.2 ref. – Yes 43.9 2.68 (1.74–4.13)** 2.17 (1.42–3.34)** 29.7 2.25 (1.36–3.71)* 1.65 (1.00–2.72)* 67.7 0.89 (0.41–1.94) –

Healthcare coverage Through parent employer

or union 38.6 1.79 (0.97–3.31) 1.30 (0.64–2.65) 25.5 3.43 (1.41–8.36)* 2.21 (0.80–6.13) 66.0 3.63 (1.29–10.17)* 2.60 (0.73–9.23)

Other insurance 47.8 2.61 (1.38–4.92)* 1.83 (0.89–3.76) 35.3 5.48 (2.21–13.57)**

3.67 (1.32–10.20)*

73.9 5.29 (1.83–15.31)* 3.83 (1.04–14.09)*

No insurance 26.0 ref. ref. 9.1 ref. ref. 34.9 ref. ref. Parent characteristics

Mother’s age <35 years 39.2 ref. – 23.7 ref. – 60.5 ref. – 35–44 years 39.7 1.02 (0.65–1.60) – 27.1 1.20 (0.72–2.00) – 68.2 1.40 (0.71–2.77) – 45+ years 42.6 1.15 (0.73–1.82) – 29.5 1.35 (0.80–2.25) – 69.1 1.47 (0.74–2.91) –

Mother’s education High school or less 40.4 ref. – 26.3 ref. – 65.1 ref. – Some college 42.1 1.07 (0.79–1.45) – 28.7 1.13 (0.80–1.60) – 68.3 1.16 (0.71–1.88) – College graduate 40.2 0.99 (0.74–1.32) – 28.8 1.13 (0.82–1.57) – 71.6 1.35 (0.85–2.15) –

Mother’s marital status Married 38.4 0.68 (0.52–0.90)* 0.74 (0.53–1.02) 26.5 0.79 (0.58–1.08) 0.90 (0.64–1.27) 68.9 1.18 (0.77–1.80) – Other 47.8 ref. ref. 31.2 ref. ref. 65.3 ref. –

Heard of HPV No 35.5 ref. ref. 19.1 ref. ref. 53.9 ref. ref. Yes 42.0 1.32 (0.95–1.83) 0.79 (0.51–1.23) 29.5 1.77 (1.21–2.59)* 1.36 (0.84–2.20) 70.3 2.03 (1.20–3.43)* 2.33 (1.28–4.24)*

Heard of HPV vaccine No 18.4 ref. ref. 7.3 ref. ref. 39.9 ref. ref. Yes 42.1 3.24 (1.66–6.30)** 2.53 (1.14–5.63)* 29.0 5.15

(1.97–13.50)** 2.29 (0.79–6.65) 68.7 3.31 (0.99–11.06) 2.23 (0.44–11.43)

Provider recommendation to get daughter HPV vaccine No 21.8 ref. ref. 15.6 ref. ref. 71.9 ref. – Yes 55.7 4.52 (3.45–5.91)** 4.07 (3.06–5.43)** 37.6 3.25 (2.40–4.39)** 2.71 (1.99–3.70)** 67.5 0.81 (0.51–1.28) –

Household characteristics Poverty status

Below poverty 42.0 ref. – 27.3 ref. – 65.0 ref. – Above poverty, ≤$75,000 40.0 0.92 (0.65–1.30) – 27.2 1.00 (0.67–1.48) – 68.1 1.15 (0.68–1.95) – Above poverty, >$75,000 40.2 0.93 (0.65–1.33) – 26.4 0.96 (0.64–1.43) – 65.7 1.03 (0.60–1.77) –

3124 P.L. Reiter et al. / Vaccine 31 (2013) 3121– 3125

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Table 3 Main reasons why parents from Appalachia did not intend to get their adolescent daughters HPV vaccine in the next year (n = 587).a

n (weighted %)

Vaccination not needed or not necessary 116 (21.5) Lack of knowledge 99 (18.5) Daughter not sexually active 106 (17.1) Vaccine safety concern/side effects 73 (12.3) Did not receive provider recommendation 61 (9.7) Daughter not appropriate age 45 (6.3) Need more information/new vaccine 30 (4.0) Costs 21 (3.6) Family/parents’ decision 19 (2.5) Other reason 14 (2.4) Child fearful 12 (2.3) Handicapped/special needs/illness 9 (1.4) Don’t believe in vaccinations 5 (1.4) No doctor or doctor’s visit not scheduled 6 (1.2) Already up to date 6 (1.1) No obstetrician/gynecologist 3 (0.9) Child should make decision 6 (0.6) Not a school requirement 4 (0.5) Daughter already sexually active 1 (0.4) Religion/orthodox 1 (0.3) Increased sexual activity concern 2 (0.1) Effectiveness concern 2 (0.1) College shot 1 (0.1) Not available 1 (0.0) Time 0 (0.0)

a Includes parents with unvaccinated daughters who indicated “not likely at all,” “not too likely,” or “not sure/don’t know” about their daughters receiving HPV vac-

cine in the next year.

Follow-through was lower among adolescent females from the Central (OR = 0.36, 95% CI: 0.17–0.75) or Southern (OR = 0.36, 95% CI: 0.22–0.61) subregions.

3.3.1. Intent and reasons for not intending to vaccinate About 41.0% of parents with unvaccinated daughters indicated

their daughters were “somewhat likely” or “very likely” to receive HPV vaccine in the next year. Just over half (50.3%) said their daugh- ters were “not too likely” or “not likely at all” to receive the vaccine in the next year, while 8.7% were not sure. The most common main reasons for not intending to vaccinate were believing vaccination is not needed or not necessary (21.5%), lack of knowledge (18.5%), indicating daughters were not sexually active (17.1%), and concerns about vaccine safety or side effects (12.3%) (Table 3).

4. Discussion

Our results identify key leverage points for increasing HPV vac- cination in Appalachia. Correlates were similar across vaccination outcomes and to those identified among other U.S. populations [9]. Initiation and completion were higher among daughters who had visited their healthcare provider in the last year or whose parents had received a provider recommendation for vaccination. These results continue to demonstrate the important role that con- tact with the healthcare system plays in HPV vaccination [13]. Although about 85% of daughters had a healthcare visit within the last year, only about half of parents reported receiving a provider recommendation for vaccination. Thus, there are still many missed opportunities for vaccination. Interventions targeting providers may help reduce missed opportunities and increase HPV vaccina- tion in Appalachia.

Older adolescents had better rates of completion and follow- through, likely due to having more time and opportunities to receive all three doses. Adolescent females without healthcare coverage had lower rates of completion and follow-through. The

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accines for Children (VFC) Program offers vaccines at no cost to ertain children, including those without healthcare coverage [14]. owever, some parents may not know their children are eligible

or the VFC program and struggle to pay for three doses of HPV accine.

Vaccination outcomes tended to be lower in the Central nd Southern subregions of Appalachia. As discussed previously 8], differences may be due to these subregions having fewer ealthcare providers and higher levels of poverty [1,15]. These ubregions also contain states in the U.S. “Bible Belt”, many of hich are among the most religious and politically conservative

tates [16]. Conservative political views and religious beliefs have een associated with lower HPV vaccine acceptability and uptake 17–19].

Over half of parents with unvaccinated daughters indicated hey were unsure or not likely to vaccinate their daughters in the ext year, which is somewhat discouraging. To increase HPV vac- ination in Appalachia, efforts are needed to address reasons why ppalachian parents are not intending to vaccinate. Brief educa-

ion sessions for parents may help address several of these reasons e.g., lack of knowledge, concerns about vaccine safety, etc.), as such essions have been successful in improving knowledge and beliefs bout HPV vaccine [20].

Study strengths include a large sample from throughout the ntire Appalachian region and provider-verified vaccination data. he NIS-Teen was limited to households with landline telephones, hough our sample was demographically similar (race, education, tc.) to the larger Appalachian population [1]. It is also possible that rovider vaccination records may be incomplete. We did not have ata on community-level or state-level factors that might influence PV vaccination. Despite these limitations, we believe our results ill be highly useful to future efforts to increase HPV vaccination

n Appalachia.

cknowledgements

Supported by the National Cancer Institute at the National Insti- utes of Health (P50CA105632 and P30CA016058). We thank the esearch Data Center for their help with this study. Data for the IS-Teen are collected and managed by the Centers for Disease ontrol and Prevention (National Center for Health Statistics and he National Center for Immunization and Respiratory Diseases). he findings and conclusions in this paper are those of the authors nd do not necessarily represent the views of these organizations.

Conflict of interest: PLR and EDP have received research grants rom Merck Sharp & Dohme Corp., but neither has received hono- aria or consulting fees from this company. These funds were not sed to support this research study.

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1 (2013) 3121– 3125 3125

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