title: Human papillomavirus vaccine coverage among females aged 11 to 17 in Texas counties: an application of multilevel, small area estimation.
abstract: BACKGROUND
  Local data are often used to plan and evaluate public health interventions and policy. With increasingly fewer public resources to collect sufficient data to support direct estimation of local outcomes, methods for deriving small area estimates are vital. The purpose of this study is to describe the county-level geographic distribution of human papillomavirus (HPV) vaccine coverage among adolescent females in Texas using multilevel small area estimation.
  
  
  METHODS
  Multilevel (individual, county, public health region) random-intercept logit models were fit to HPV vaccination data (≥1 dose Gardasil) from the 2008 Behavioral Risk Factor Surveillance System. Using the parameter estimates from the final model, we simulated 10,000 data sets for each regression coefficient from the normal distribution and applied them to the logit model to estimate HPV vaccine coverage in each county.
  
  
  RESULTS
  County-level coverage estimates ranged from 7% to 29%, compared with the state average of 18% (95% confidence interval [CI], 13.59-21.88). Many Southwestern border and metropolitan counties exhibited high coverage estimates. Low coverage estimates were noted in the Panhandle, Southeastern border region, and Northeast. Significant correlations were observed between HPV vaccination and Hispanic ethnicity, county poverty, and public health region poverty.
  
  
  CONCLUSIONS
  Harnessing the flexibility of multilevel small area models to estimate HPV vaccine coverage at the county level, we have provided data that may inform the development of health education programs/policies, the provision of health services, and the planning of new research studies. Additionally, we have provided a framework for modeling other health outcomes at the county level using national survey data.
authors.affiliation: Division of Quantitative Sciences, Department of Biostatistics, MD Anderson Cancer Center, Houston, Texas, USA. jmeberth@mailbox.sc.edu
authors.forename: Jan M
authors.initials: JM
authors.lastname: Eberth
authors.forename: Md Monir
authors.initials: MM
authors.lastname: Hossain
authors.forename: Jasmin A
authors.initials: JA
authors.lastname: Tiro
authors.forename: Xingyou
authors.initials: X
authors.lastname: Zhang
authors.forename: James B
authors.initials: JB
authors.lastname: Holt
authors.forename: Sally W
authors.initials: SW
authors.lastname: Vernon
mesh_terms: D000293:Adolescent; D040343:Behavioral Risk Factor Surveillance System; D002648:Child; D005260:Female; D015438:Health Behavior; D019538:Health Care Surveys; D000068857:Human Papillomavirus Recombinant Vaccine Quadrivalent, Types 6, 11, 16, 18; D006801:Humans; D017589:Immunization Programs / Q000458:organization & administration; D016015:Logistic Models; D055361:Multilevel Analysis; D030361:Papillomavirus Infections / Q000517:prevention & control* / Q000821:virology; D053918:Papillomavirus Vaccines / Q000008:administration & dosage*; D011159:Population Surveillance; D011203:Poverty; D017062:Small-Area Analysis; D012959:Socioeconomic Factors; D013781:Texas; D014611:Vaccination / Q000706:statistics & numerical data*
chemical_list: D000068857:Human Papillomavirus Recombinant Vaccine Quadrivalent, Types 6, 11, 16, 18; D053918:Papillomavirus Vaccines