Rural-urban differences in human papillomavirus vaccination among young adults in 8 U.S. states
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)ORULGD6WDWH8QLYHUVLW\/LEUDULHV 2021 Rural-urban differences in human papillomavirus vaccination among young adults in 8 U.S. states Minjee Lee, Mary A. Gerend and Eric Adjei Boakye The final published version of this article is available at https://doi.org/10.1016/j.amepre.2020.07.023. Follow this and additional works at DigiNole: FSU's Digital Repository. For more information, please contact lib-support@fsu.edu
1 Rural–Urban Differences in Human Papillomavirus Vaccination Among Young Adults in 8 U.S. States Minjee Lee, PhD, MPH,1,2 Mary A Gerend, PhD,3 Eric Adjei Boakye, PhD1,2 From the 1Department of Population Science and Policy, Southern Illinois University School of Medicine, Springfield, Illinois; 2Simons Cancer Institute, Southern Illinois University School of Medicine, Springfield, Illinois; and 3Department of Behavioral Sciences and Social Medicine, Florida State University College of Medicine, Tallahassee, Florida Address correspondence to: Minjee Lee, PhD, MPH, Department of Population Science and Policy, Southern Illinois University School of Medicine, 201 E Madison St., Springfield IL 62702. Email: mlee88@siumed.edu.
2 Each year, nearly 44,000 new cancers attributable to human papillomavirus (HPV) infection are diagnosed in the U.S., approximately 79% of which could have been prevented by HPV vaccination.1 HPV vaccination is routinely recommended for all adolescents aged 11–12 years, with catch-up vaccination recommended through age 26 years.2 For unvaccinated adults aged 27–45 years, a shared clinical decision-making approach to HPV vaccination is recommended.2 HPV vaccination rates in the U.S. are suboptimal. In 2018, a total of 68.1% of adolescents aged 13–17 years received ≥1 dose of HPV vaccine and 51.1% completed the series.3 For young adults aged 18–26 years, uptake is even lower. In 2014–2015, only 26.8% and 15.6% of young adults had initiated and completed the HPV vaccine series, respectively.4 Moreover, notable disparities in adolescent HPV vaccination by metropolitan statistical area have been reported with completion rates 15 percentage points lower among adolescents living in rural versus urban areas (40.7% vs 56.1%).3 Such trends are concerning, as the incidence of HPV-related cancers is higher in rural (versus urban) populations.5 The purpose of this study is to examine whether such rural–urban disparities in HPV vaccination exist among young adults aged 18–26 years in the U.S. A cross-sectional analysis was conducted in 2020 using data from the 2018 Behavioral Risk Factor Surveillance System. In 2018, a total of 8 states participated in an optional module focused on adult HPV vaccination (Alabama, Connecticut, Hawaii, Mississippi, Missouri, New Jersey, Tennessee, and Texas). Primary outcomes were self-reported HPV vaccine initiation (receipt of ≥1 dose) and completion (receipt of ≥3 doses). Rural–urban status was the main
3 independent variable and categorized into urban (National Center for Health Statistics Urban– Rural Classification=1, 2, 3, 4, or 5) and rural counties (Classification=6). Details of the survey questionnaire and methodology are available elsewhere.6 All respondents aged 18–26 years (N=34,461) were initially selected for inclusion. Limiting the sample to those respondents who lived in the 8 states participating in the HPV vaccination module reduced the sample size to n=4,285. Removing respondents who did not know if they had been vaccinated or did not answer the question resulted in a final sample of n=2,989. To account for the Behavioral Risk Factor Surveillance System complex survey design, survey weights (PROC SURVEYFREQ and SURVEYLOGISTIC) were used throughout all analyses. Weighted multivariable binary logistic regression models assessed the association between rural– urban status and HPV vaccination, adjusting for demographic, socioeconomic, and healthcare utilization factors. All tests were 2-sided. All statistical analyses were performed using SAS, version 9.4. The study was exempt from review by the University IRB owing to the use of publicly available de-identified data. Among 2,989 young adults, 248 adults (8.0%) reported rural residence (Appendix Table 1). Overall HPV vaccine initiation and completion rates were 34.2% and 15.5%, respectively. HPV vaccine coverage was lower among rural (initiation, 23.6%; completion, 12.6%) than urban residents (initiation, 35.1%; completion, 15.8%). In the adjusted models, rural residents remained less likely to initiate the HPV vaccine than urban residents (AOR=0.58, 95% CI=0.37, 0.92), but there was no difference in completion (Table 1).
4 This study is among the first to report HPV vaccination coverage among U.S. young adults aged 18–26 years in 8 states by rural–urban status. Similar to adolescents, disparities in HPV vaccine uptake by rural–urban residence were observed, with rural residents less likely to initiate the vaccine than their urban counterparts. Prior studies suggest that individuals living in rural areas face more barriers accessing preventive healthcare services (e.g., limited access, transportation issues) and report lower knowledge of HPV and HPV vaccine.7–9 The primary limitation of this study is the low number of states that assessed HPV vaccination in 2018. Other limitations include its cross-sectional design and reliance on self-reported HPV vaccination. Uptake of HPV vaccination among young adults is low, but worse for rural residents. Rural young adults are significantly less likely to have initiated the HPV vaccine than their urban counterparts. Future studies are needed to examine states characterized by large rural populations. Low rates of vaccination coupled with the high burden of HPV-related cancers point to the critical need for evidence-based interventions to increase HPV vaccination in rural communities.
5 No financial disclosures were reported by the authors of this paper.
6 1. Senkomago V, Henley SJ, Thomas CC, Mix JM, Markowitz LE, Saraiya M. Human papillomavirus-attributable cancers – United States, 2012–2016. MMWR Morb Mortal Wkly Rep. 2019;68(33):724–728. https://doi.org/10.15585/mmwr.mm6833a3. 2. Meites E, Szilagyi PG, Chesson HW, Unger ER, Romero JR, Markowitz LE. Human papillomavirus vaccination for adults: updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2019;68(32):698–702. https://doi.org/10.15585/mmwr.mm6832a3. 3. Walker TY, Elam-Evans LD, Yankey D, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years – United States, 2018. MMWR Morb Mortal Wkly Rep. 2019;68(33):718–723. https://doi.org/10.15585/mmwr.mm6833a2. 4. Adjei Boakye E, Lew D, Muthukrishnan M, et al. Correlates of human papillomavirus (HPV) vaccination initiation and completion among 18–26 year olds in the United States. Hum Vaccin Immunother. 2018;14(8):2016–2024. https://doi.org/10.1080/21645515.2018.1467203. 5. Zahnd WE, James AS, Jenkins WD, et al. Rural–urban differences in cancer incidence and trends in the United States. Cancer Epidemiol Biomarkers Prev. 2018;27(11):1265– 1274. https://doi.org/10.1158/1055-9965.epi-17-0430. 6. Monnat SM, Rhubart DC, Wallington SF. Differences in human papillomavirus vaccination among adolescent girls in metropolitan versus non-metropolitan areas: considering the moderating roles of maternal socioeconomic status and health care
7 access. Matern Child Health J. 2016;20(2):315–325. https://doi.org/10.1007/s10995-015- 1831-x. 7. Mohammed KA, Subramaniam DS, Geneus CJ, et al. Rural–urban differences in human papillomavirus knowledge and awareness among U.S. adults. Prev Med. 2018;109:39– 43. https://doi.org/10.1016/j.ypmed.2018.01.016. 8. Swiecki-Sikora AL, Henry KA, Kepka D. HPV Vaccination coverage among U.S. teens across the rural–urban continuum. J Rural Health. 2019;35(4):506–517. https://doi.org/10.1111/jrh.12353. 9. Meilleur A, Subramanian SV, Plascak JJ, Fisher JL, Paskett ED, Lamont EB. Rural residence and cancer outcomes in the United States: issues and challenges. Cancer Epidemiol Biomarkers Prev. 2013;22(10):1657–1667. https://doi.org/10.1158/1055- 9965.epi-13-0404.
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Table 1. Association Between Rural–Urban Status and HPV Vaccine Uptake Among Young Adults Aged 18–26 Years: BRFSS, 2018
HPV vaccine initiation HPV vaccine completion
Urban–rural status COR (95% CI) AOR (95% CI) COR (95% CI) AOR (95% CI)
Urban 1.00 1.00 1.00 1.00
Rural 0.56 (0.34, 0.93) 0.58 (0.37, 0.92) 0.79 (0.44, 1.42) 0.79 (0.46, 1.34)
Notes: Boldface indicates statistical significance (p9
Appendix Table 1. Characteristics of Study Respondents Aged 18–26 Years by Rural–Urban
Status: Behavioral Risk Factor Surveillance System (BRFSS), 2018
Characteristics Total Urban Rural p-value
Unweighted observations 2,989 2,741 248
Percent adults 100.0 92.0 8.0
Mean age, years (SD) 21.9 (0.1) 21.8 (0.1) 22.1 (0.3) 0.15
Sex
Female 48.7 49.1 43.5 0.39
Male 51.3 50.9 56.5
Race/ethnicity
Non-Hispanic White 47.9 46.5 64.7 0.03
Non-Hispanic Black 13.6 14.0 9.3
Hispanic 28.9 29.4 23.8
Non-Hispanic other 9.6 10.2 2.2
Marital status
Married 20.8 20.0 30.3 0.04
Not married 79.2 80.0 69.7
Educational attainment
College graduate or higher 12.7 13.2 6.9 0.27
Some college or associate degree 34.7 34.9 31.9
High school diploma 42.2 41.6 49.3
Less than high school degree 10.5 10.4 11.8
Income level
≥$50,000 30.5 30.1 34.8 0.47
$25,000–$49,999 19.5 19.7 17.5You can also read
