Abstract
Objectives. To assess national differences in human papillomavirus (HPV) vaccine uptake among young adults in the United States by gender, race/ethnicity, and sexual orientation.
Methods. We tested group differences in initiation and completion of the HPV vaccine series (i.e., 3 doses) by Rao–Scott χ2 test among 6444 respondents aged 18 to 30 years from the 2013 National Health Interview Survey.
Results. Among men, 5% reported receiving the HPV vaccine, with no differences in uptake by race/ethnicity or sexual orientation. By contrast, 30% of the women reported receiving the HPV vaccine, with women of color having lower odds of initiating and completing the vaccine series compared with White women.
Conclusions. In the United States, HPV vaccine rates are lagging in men and show disparities among women. Increasing HPV vaccine uptake and series completion among women of color and all men may provide considerable long-term public health benefits.
As of 2011, the US Advisory Committee on Immunization Practices has recommended routine human papillomavirus (HPV) vaccination for females (quadrivalent and bivalent) and males (quadrivalent only) at age 11 or 12; catch-up vaccination is encouraged to complete the 3-dose series by age 26 years for women and age 21 years for men (but can be administered up to age 26 years).1 In addition, HPV vaccination is recommended for priority populations (e.g., men who have sex with men) up to age 26 years. Recent studies have examined vaccination levels within subgroups, including adolescent females, adult men who have sex with men, and geographically restricted samples2–5; however, we lack a comprehensive national assessment of HPV vaccine uptake, especially data that permit comparisons across key subgroups. In response, we sought to estimate the population prevalence of HPV vaccination among US young adults (aged 18–30 years) and assess differences by gender, race/ethnicity, and sexual orientation.
METHODS
Data came from the 2013 National Health Interview Survey, a cross-sectional survey of the noninstitutionalized US population with oversampling of racial/ethnic minorities.6 The analytic sample consisted of 3441 women and 3003 men aged 18 to 30 years, of whom 51% and 53% were non-Hispanic White, respectively.
For this analysis, we created an indicator of self-reported sexual identity (heterosexual [women: n = 3304; men: n = 2902] vs gay, lesbian, or bisexual identity [women: n = 137; men: n = 101]). Dichotomous outcomes included ever receiving the vaccine and completion of the vaccine series (i.e., at least 3 doses of HPV vaccine). We tested group differences in outcomes by Rao–Scott χ2 test7,8 and quantified the effects of gender, race/ethnicity, and sexual orientation by multivariable logistic regression after we controlled for age, age at vaccine initiation, educational attainment, relationship status, insurance coverage, and usual source of medical care. All analyses were completed in SAS version 9.3 (SAS Institute, Cary, NC) using survey procedures to account for the complex sampling design.
RESULTS
Preliminary analyses found that a significantly larger proportion of women reported ever receiving HPV vaccine than did men (30% vs 5%; P < .001); thus, subsequent analyses were stratified by gender. Among men, we found no differences in HPV vaccine outcomes by race/ethnicity or sexual orientation (Table 1); however, among women, we found several differences. Final regression models quantified specific effects. (Full analyses available as a supplement to the online version of this article at http://www.ajph.org.)
TABLE 1—
Human Papillomavirus (HPV) Vaccination Estimates Among 2013 National Health Interview Survey Respondents Aged 18–30 Years, United States
| Women (n = 3441) |
Men (n = 3003) |
||||
| Overall (n = 6444), No. (%) | HPV Vaccine Series Initiation, No. (%)a or P | HPV Vaccine Series Completion, No. (%)b or P | HPV Vaccine Series Initiation, No. (%)a or P | HPV Vaccine Series Completion, No. (%)b or P | |
| Race/ethnicity | < .001 | < .001 | .23 | .23 | |
| White, non-Latino | 3339 (51.8) | 611 (34.0) | 452 (76.2) | 78 (5.8) | 27 (31.9) |
| Black, non-Latino | 985 (15.3) | 140 (24.4) | 58 (42.8) | 20 (3.9) | 6 (41.2) |
| Latino, any race | 1442 (22.4) | 183 (25.0) | 111 (62.4) | 30 (3.6) | 5 (12.9) |
| Other/multiple racec | 678 (10.5) | 90 (25.9) | 62 (72.3) | 11 (4.5) | 3 (38.4) |
| Sexual orientation | .08 | .13 | .73 | .19 | |
| Heterosexual | 6206 (96.3) | 969 (29.8) | 653 (70.7) | 131 (5.0) | 38 (29.9) |
| Gay/lesbian/bisexual | 238 (3.7) | 55 (40.0) | 30 (59.3) | 8 (5.6) | 3 (42.2) |
Note. Counts are unweighted; percentages are weighted to account for the complex survey design. HPV vaccine series initiation is defined as ≥ 1 dose. HPV vaccine series completion is defined as ≥ 3 doses.
Among respondents identifying in corresponding racial/ethnic or sexual orientation group.
Among respondents reporting HPV vaccine initiation.
Other/multiple race indicates individuals who indicated more than 1 race or other than White, Black, or Latino.
Compared with White women, Black women had 30% lower odds of HPV vaccine series initiation (adjusted odds ratio [AOR] = 0.70; 95% confidence interval [CI] = 0.51, 0.95), and women of other or multiple races had marginally lower but not statistically significant odds of HPV vaccine series initiation (AOR = 0.72; 95% CI = 0.50, 1.04). Among those who had initiated HPV vaccination, Black and Latina women had approximately one quarter and one half the odds, respectively, of completing the series as did White women (AOR = 0.24; 95% CI = 0.16, 0.37; and AOR = 0.58; 95% CI = 0.41, 0.84). Furthermore, compared with heterosexual women, lesbians and bisexual women had marginally higher but not statistically significant odds of HPV vaccine series initiation (AOR = 1.66; 95% CI = 0.94, 2.95).
DISCUSSION
To our knowledge, this was the first study to generate population estimates of HPV vaccination by gender, race/ethnicity, and sexual identity. We note 2 overarching findings. First, Black and Latina women had lower odds of initiating and completing HPV vaccination than did White women. This could further contribute to the existing cervical cancer disparities experienced by Latina and Black women.9 Second, regardless of race/ethnicity or sexual identity, men reported low levels of HPV vaccine initiation and completion, which could be a result of a lag in vaccination recommendations for men.1 Thus, efforts are warranted to increase HPV vaccine uptake and series completion among women of color and all men, which may provide considerable long-term public health benefits.
We urge ongoing surveillance of HPV vaccination levels across key population subgroups as a necessary step to address, and ultimately eliminate, HPV-related health disparities.
ACKNOWLEDGMENTS
This publication was supported by the Health Promotion and Disease Prevention Research Centers Program (cooperative agreement DP005021-01), funded by the Centers for Disease Control and Prevention.
Note. The contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.
HUMAN PARTICIPANT PROTECTION
Because this was a secondary analysis of a publicly available, de-identified data set, the study did not constitute human subjects research. No ethics board review was required.
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