title: Geographic disparity, area poverty, and human papillomavirus vaccination.
abstract: BACKGROUND
  A human papillomavirus (HPV) vaccine was approved by the Food and Drug Administration for use among women/girls in 2006. Since that time, limited research has examined HPV vaccine uptake among adolescent girls and no studies have examined the role of geographic disparities in HPV vaccination.
  
  
  OBJECTIVE
  The purpose of this study is to examine geographic disparity in the prevalence of human papillomavirus (HPV) vaccination and to examine individual-, county-, and state-level correlates of vaccination.
  
  
  METHODS
  Three-level random intercept multilevel logistic regression models were fitted to data from girls aged 13-17 years living in six U.S. states using data from the 2008 Behavioral Risk Factor Surveillance System (BRFSS) and the 2000 U.S. census.
  
  
  RESULTS
  Data from 1709 girls nested within 274 counties and six states were included. Girls were predominantly white (70.6%) and insured (74.5%). Overall, 34.4% of girls were vaccinated. Significant geographic disparity across states (variance=0.134, SE=0.065) and counties (variance=0.146, SE=0.063) was present, which was partially explained by state and county poverty levels. Independent of individual-level factors, poverty had differing effects at the state and county level: girls in states with higher levels of poverty were less likely whereas girls in counties with higher poverty levels were more likely to be vaccinated. Household income demonstrated a similar pattern to that of county-level poverty: Compared to girls in the highest-income families, girls in the lowest-income families were more likely to be vaccinated.
  
  
  CONCLUSIONS
  The results of this study suggest geographic disparity in HPV vaccination. Although higher state-level poverty is associated with a lower likelihood of vaccination, higher county-level poverty and lower income at the family level is associated with a higher likelihood of vaccination. Research is needed to better understand these disparities and to inform interventions to increase vaccination among all eligible girls.
authors.affiliation: Division of Health Behavior Research, Washington University School of Medicine, Saint Louis, Missouri 63108, USA. spruitt@dom.wustl.edu
authors.forename: Sandi L
authors.initials: SL
authors.lastname: Pruitt
authors.forename: Mario
authors.initials: M
authors.lastname: Schootman
mesh_terms: D000293:Adolescent; D040343:Behavioral Risk Factor Surveillance System; D019352:Censuses; D005260:Female; D005843:Geography; D054625:Healthcare Disparities; D006801:Humans; D017589:Immunization Programs / Q000706:statistics & numerical data*; D016015:Logistic Models; D030361:Papillomavirus Infections / Q000517:prevention & control; D053918:Papillomavirus Vaccines / Q000627:therapeutic use*; D011203:Poverty; D014481:United States
chemical_list: D053918:Papillomavirus Vaccines
references.citation: J Adolesc Health. 2004 May;34(5):414-9
references.pmid: 15093796
references.citation: MMWR Morb Mortal Wkly Rep. 2008 Oct 10;57(40):1100-3
references.pmid: 18846032
references.citation: Prev Med. 2008 Feb;46(2):87-98
references.pmid: 17942147
references.citation: CA Cancer J Clin. 2004 Mar-Apr;54(2):78-93
references.pmid: 15061598
references.citation: MMWR Morb Mortal Wkly Rep. 2009 Sep 18;58(36):997-1001
references.pmid: 19763075
references.citation: Vaccine. 1999 Oct 29;17 Suppl 3:S19-24
references.pmid: 10559531
references.citation: J Epidemiol Community Health. 2001 Feb;55(2):111-22
references.pmid: 11154250
references.citation: Biometrics. 2000 Sep;56(3):909-14
references.pmid: 10985236
references.citation: Pediatrics. 2004 Jul;114(1):187-95
references.pmid: 15231927
references.citation: Cancer. 2006 Feb 1;106(3):664-9
references.pmid: 16378349
references.citation: Obstet Gynecol. 2008 May;111(5):1103-10
references.pmid: 18448742
references.citation: Vaccine. 2009 May 21;27(24):3195-200
references.pmid: 19446191
references.citation: J Urban Health. 2009 Mar;86(2):183-95
references.pmid: 19127435
references.citation: MMWR Recomm Rep. 2007 Mar 23;56(RR-2):1-24
references.pmid: 17380109
references.citation: Int J STD AIDS. 2003 May;14(5):300-6
references.pmid: 12803935
references.citation: MMWR Morb Mortal Wkly Rep. 2008 Sep 5;57(35):961-6
references.pmid: 18772851
references.citation: Am J Public Health. 2009 Jun;99(6):1137-42
references.pmid: 19372507
references.citation: Policy Brief UCLA Cent Health Policy Res. 2009 Feb;(PB2009-3):1-6
references.pmid: 19288623
references.citation: Cancer Epidemiol Biomarkers Prev. 2009 Oct;18(10):2579-99
references.pmid: 19815634
references.citation: Am J Epidemiol. 2005 Jan 1;161(1):81-8
references.pmid: 15615918
references.citation: J Epidemiol Community Health. 2006 Mar;60(3):202-7
references.pmid: 16476748
references.citation: Int J Cancer. 2003 Jul 10;105(5):687-91
references.pmid: 12740919
references.citation: Prev Med. 2007 Aug-Sep;45(2-3):107-14
references.pmid: 17628649
references.citation: J Fam Pract. 2007 Apr;56(4):267-8
references.pmid: 17403324
references.citation: CA Cancer J Clin. 2002 Nov-Dec;52(6):342-62
references.pmid: 12469763
references.citation: Am J Epidemiol. 2002 Sep 1;156(5):471-82
references.pmid: 12196317
references.citation: CA Cancer J Clin. 2007 Jan-Feb;57(1):7-28
references.pmid: 17237032
references.citation: J Adolesc Health. 2009 May;44(5):437-45
references.pmid: 19380090
references.citation: Cancer. 2004 Sep 1;101(5):1051-7
references.pmid: 15329915
references.citation: JAMA. 2009 Aug 19;302(7):781-6
references.pmid: 19690311
references.citation: Sex Transm Dis. 2007 Jul;34(7):468-71
references.pmid: 17139233
references.citation: Cancer. 2008 Nov 15;113(10 Suppl):2910-8
references.pmid: 18980274
references.citation: Ethn Dis. 2007 Spring;17(2 Suppl 2):S2-8-13
references.pmid: 17684807
references.citation: Am J Prev Med. 2003 May;24(4):301-9
references.pmid: 12726867
references.citation: Am J Health Behav. 2007 Jul-Aug;31(4):434-45
references.pmid: 17511578
references.citation: Cancer. 2003 Mar 15;97(6):1528-40
references.pmid: 12627518
references.citation: JAMA. 2007 Aug 8;298(6):638-43
references.pmid: 17684186
references.citation: Cancer Causes Control. 2007 Aug;18(6):627-34
references.pmid: 17497223
references.citation: Cancer. 2008 Nov 15;113(10 Suppl):2855-64
references.pmid: 18980204
references.citation: Pediatrics. 2008 Mar;121(3):e547-52
references.pmid: 18310176
references.citation: Soc Sci Med. 2008 Jan;66(2):260-75
references.pmid: 18022299
references.citation: Prev Med. 2004 Oct;39(4):704-12
references.pmid: 15351536
references.citation: J Adolesc Health. 2008 Sep;43(3):239-45
references.pmid: 18710678
references.citation: Clin Pharmacol Ther. 2007 Dec;82(6):760-3
references.pmid: 17971822