title: Determinants of geographic inequalities in HPV vaccination in the most populated region of France.
abstract: BACKGROUND
  In France, there are recommendations and reimbursements for human papillomavirus (HPV) vaccination but no HPV vaccination programs. Therefore, vaccination is largely determined by parents' initiative, which can lead to inequalities. The objective of this study was to determine the factors associated with poorer vaccination coverage rates in the most populated region of France.
  
  
  METHODS
  The data of this study were obtained from the National Health Insurance between 2011 and 2013. Correlations between vaccination initiation rate (at least 1 dose reimbursed) and socio-demographic/cultural factors were assessed using Pearson's product-moment correlation coefficient. Multivariate analyses were performed using logistic regression.
  
  
  RESULTS
  In total, 121,636 girls received at least one HPV vaccine dose. The vaccination rate for girls born from 1996 to 1999 was 18.7%. Disparities in vaccination coverage rates were observed between the 8 departments of the region, ranging from 12.9% to 22.6%. At the department level, unemployment, proportion of immigrants and foreigners, and coverage by CMU health insurance ("Couverture Maladie Universelle", a health insurance plan for those who are not otherwise covered through business or employment and who have a low income) were significantly inversely correlated with vaccination rates, whereas urban residence, medical density, income and use of medical services were not related to coverage. In the multivariate model, only the percentage of foreigners remained independently associated with lower vaccination coverage. At the individual level, the use of medical services was a strong driver of HPV vaccination initiation.
  
  
  CONCLUSIONS
  We observed geographic disparities in HPV vaccination initiation coverage. Even if no clear factor was identified as a vaccination determinant, we observed a failure of vaccination only based on parents' initiative. Therefore, an organized policy on HPV vaccination, such as school-based programs, can help improve coverage rates.
authors.affiliation: Department of Surgical Oncology, Institut Curie-René Huguenin, 35 rue Dailly, St Cloud, France.|Equipe d'Accueil 7285, Risk and Safety in Clinical Medicine for Women and Perinatal Health, University Versailles-Saint-Quentin, 2 avenue de la source de la Bièvre, Montigny-le-Bretonneux, France.
authors.forename: Delphine
authors.initials: D
authors.lastname: Héquet
authors.affiliation: Department of Surgical Oncology, Institut Curie-René Huguenin, 35 rue Dailly, St Cloud, France.|Equipe d'Accueil 7285, Risk and Safety in Clinical Medicine for Women and Perinatal Health, University Versailles-Saint-Quentin, 2 avenue de la source de la Bièvre, Montigny-le-Bretonneux, France.
authors.forename: Roman
authors.initials: R
authors.lastname: Rouzier
mesh_terms: D000293:Adolescent; D054242:Emigrants and Immigrants / Q000706:statistics & numerical data; D005260:Female; D005602:France; D005843:Geography; D006801:Humans; D007348:Insurance, Health / Q000706:statistics & numerical data; D015999:Multivariate Analysis; D030361:Papillomavirus Infections / Q000191:economics / Q000276:immunology / Q000517:prevention & control* / Q000821:virology; D053918:Papillomavirus Vaccines / Q000008:administration & dosage / Q000191:economics*; D012959:Socioeconomic Factors; D014611:Vaccination / Q000191:economics / Q000706:statistics & numerical data*
chemical_list: D053918:Papillomavirus Vaccines