Re: Human papillomavirus vaccine initiation in Asian Indians and Asian subpopulations: a case for examining disaggregated data in public health research

The recently published article by Budhwani and De¹ entitled ‘Human papillomavirus vaccine initiation in Asian Indians and Asian subpopulations: a case for examining disaggregated data in public health research’ is of interest given the dearth of publications that have examined human papillomavirus (HPV) vaccination outcomes among Asian-American subpopulations due to small sample sizes in many data sources. In their report, the authors conclude that Asian Indians had lower HPV vaccine initiation rates than other Asian subgroups and, therefore, recommend that future large-scale studies should disaggregate racial/ethnic groups.

We have several concerns with the conclusions that the authors draw from their results. First, in the discussion section, the authors state that Asian Indians had lower vaccination rates than other ‘Asians in aggregate’; however, no results are presented for the Asian subpopulations combined into one category. Second, the authors state that Asian Indians have the lowest HPV vaccine initiation rates of ‘any racial and ethnic group’; however, the confidence intervals for the HPV uptake for the full sample of Asian Indians, Native Americans, Chinese, and Other Asians appear to overlap, as the respective upper and lower bounds include 0.11; thus, the true prevalence of HPV initiation across these subpopulations may in fact be similar.

In addition, as mentioned by the authors, the low HPV uptake for Asian Indians may be explained by the high percentage (72%) of foreign born within this group. In fact, the authors report high variability in nativity across sub-populations. The fact that significant differences in HPV vaccine initiation between native born and foreign born are observed within all racial/ethnic subpopulations, whereas no racial/ethnic differences are observed within the foreign born (as presented in Table 2 from the article by Budhwani and De¹), suggests the need to stratify analyses by native born and foreign born rather than Asian subgroups.

Although the findings among Asian Indians and other Asian subpopulations presented by Budwhani and De¹ are not trivial, we argue that the results from this study¹ make a stronger case for recommending that future research should consider stratifying their analyses by nativity, rather than focusing on disaggregating racial/ethnic categories, as argued by the authors. Previous research² has indicated significant differences in vaccination rates among U.S.-born and foreign-born adults, also supporting the importance of stratifying by nativity.