Correlates for Completion of 3-Dose Regimen of HPV Vaccine in Female Members of a Managed Care Organization

doi:10.4065/84.10.864

Mayo Clinic Proceedings

Volume 84, Issue 10, October 2009, Pages 864-870

https://doi.org/10.4065/84.10.864 Get rights and content

OBJECTIVE

To examine the rate and correlates of completion of the quadrivalent human papillomavirus vaccine (HPV4) 3-dose regimen because nonadherence to the regimen may adversely affect vaccine efficacy.

PARTICIPANTS AND METHODS

Female members of Kaiser Permanente Southern California who were 9 to 26 years old, received the first dose of HPV4 between October 2006 and March 2007, and maintained health plan membership 12 months afterward were identified and followed up for regimen completion. We examined the following: (1) demographics/socioeconomic status, (2) primary care physician characteristics, (3) historical health service utilization, (4) women's health-related conditions, and (5) selected immune-related conditions for their association with completion in 2 age groups: 9 to 17 years and 18 to 26 years. Multivariable log-binomial regression was used to directly estimate relative risk (RR).

RESULTS

Of the 34,193 females who initiated HPV4, the completion rate was 41.9% in the 9- to 17-year-old group and 47.1% in the 18- to 26-year-old group. Black race (RR, 0.70; 95% confidence interval [CI], 0.64-0.77) and lower neighborhood education level were associated with lower regimen completion. However, those in the 9- to 17-year-old group who were covered by the state-subsidized program Medi-Cal were more likely to complete the regimen (RR, 1.14; 95% CI, 1.07-1.22). Historical hospitalizations and emergency department visits (RR, 0.92; 95% CI, 0.87-0.96; and RR, 0.96; 95% CI, 0.94-0.98 per visit, respectively) and having a pediatrician were also predictors of noncompletion. A history of sexually transmitted diseases, abnormal Papanicolaou test results, and immune-related conditions (eg, asthma/infections) were not associated with regimen completion.

CONCLUSION

These findings suggest that factors such as race or socioeconomic status should be considered when human papillomavirus vaccination programs are being designed and evaluated.

Section snippets

PARTICIPANTS AND METHODS

As the largest managed care organization in southern California, KPSC serves more than 3 million members. Members of KPSC are broadly representative of the diverse racial/ethnic and socioeconomic backgrounds of the source population in southern California. By nature of the prepaid managed care system, members of KPSC have relatively equal health care coverage. In particular, HPV4 is offered to eligible female members without additional out-of-pocket cost (variations in office visit copay exist

RESULTS

A total of 34,193 females aged 9 through 26 years received the first dose of HPV4 between October 2006 and March 2007 (ie, 9.5% of all female members in this age range who maintained health plan membership during that period), and 29,598 maintained their health plan membership for the following 12 months. These 29,598 females (24,676 in the 9- to 17-year-old age group and 4922 in the 18- to 26-year-old age group) were included in the study. Among them, 12,663 (42.8%) completed the 3-dose

DISCUSSION

In the current study, the rate of completion of the 3-dose regimen of HPV4 in a 12-month period was less than 50% among those who initiated the vaccination. Higher neighborhood education levels, Medi-Cal status for adolescent girls, and history of allergy were positive predictors for regimen completion. In contrast, black and Hispanic adolescent girls, young women who had a pediatrician PCP, and a history of hospitalizations/emergency department visits were correlates for nonadherence to the

CONCLUSION

Black and Hispanic adolescent girls, females who reside in neighborhoods with lower average education levels, young women who have a pediatrician PCP, and those with histories of several hospitalizations/emergency department visits were less likely to complete the 3-dose regimen of HPV4. These findings provide useful insight for developing public health programs to enhance proper HPV vaccination, targeting populations susceptible to nonadherence. Of note, our findings represent the early

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Cited by (76)

Disparities in Human Papillomavirus Vaccine Series Completion by Adolescent Males: A Retrospective Cohort Study
2020, Academic Pediatrics
Human papillomavirus (HPV) vaccine has been recommended for male patients for the prevention of genital warts and precancerous anal lesions since 2009. Our objective was to characterize race and insurance-based disparities in HPV vaccine completion among male patients who initiated the HPV vaccine series.
This was a retrospective cohort study of adolescent male patients in a primary care network who initiated the HPV vaccine series from October 2009 to December 2013. We measured vaccine series completion as the primary outcome. We evaluated associations between outcomes and race and insurance status, controlling for potential confounders and effect modification with multivariable logistic regression. Analyses were stratified by vaccine recommendation era (permissive vs routine).
In total, 42% of males in the cohort (16,691) completed the vaccine series. In the permissive vaccine era (2009–2011), non-black patients (53%) were more likely to complete than black patients (32%) and non-Medicaid patients (49%) were more likely to complete than Medicaid patients (33%). These differences persisted in the routine recommendation era (2012–2013). In both the permissive and routine eras, Medicaid insurance was associated with a larger reduction in the predicted probability of vaccine series completion for non-black patients. Adherence to the recommended vaccination schedule was low, with a median time to completion of 8.9 months. Using the updated completion schedule (2016), we found that completion rates were greater (54.1%) with continued differences based on race (60% vs 45.7% for non-black vs black patients) and insurance (57.4% vs 46.4% completion for non-Medicaid vs Medicaid patients).
We found significant disparities in HPV vaccine series completion rates among male patients based on race and insurance, unchanged based on era of initiation or visit frequency.
Factors influencing Human papillomavirus (HPV) vaccination series completion in Mississippi Medicaid
2020, Vaccine
Citation Excerpt :
There were disparities in HPV vaccine completion based on age, gender and race/ethnicity in our study. Younger age has consistently been reported as a significant predictor of series completion across most previous studies [13,15,16,27,29–31]. CDC-funded VFC program pays for vaccinations for children below 19 years of age that qualify for Medicaid, are uninsured, or are American Indian/Alaskan Native [23].
To identify factors associated with Human Papillomavirus (HPV) vaccine series completion among vaccine initiators in Mississippi Medicaid.
2013–2018 Mississippi Medicaid administrative claims data were analyzed. Female and male beneficiaries aged 9 to 26 years who initiated HPV vaccination in the identification period were assessed for completion of age-appropriate number of recommended doses within a period of 12 months. Sex-stratified multivariable logistic regression was used to examine factors associated with HPV vaccine series completion in the study sample.
A total of 18,110 female and 18,186 male beneficiaries initiated HPV vaccine between January 1, 2014 and June 30, 2017. Most of the initiators belonged to ages 11 to 12 years, African American race, managed care plans and Central Mississippi public health region. The vaccine series completion rate was 34% for females and 30% for males. Younger age at initiation was a significant predictor of vaccine series completion in both sexes. Specifically, initiators in age groups 9 to 10 and 11 to 12 years, respectively, had greater odds of completion, while initiators aged 15 to 26 years had lower odds of completion compared to initiators aged 13 to 14 years. Female and male beneficiaries in managed care plans (vs. fee-for-service) and of African American race (vs. Caucasians) had lower odds of completing the vaccine series. Female and male beneficiaries who initiated HPV vaccine series with a pediatrician had the highest completion rates.
HPV vaccination series completion rate in Mississippi Medicaid was suboptimal despite the high HPV-related cancer incidence in the state. HPV vaccine series completion is influenced by various sociodemographic factors. There is a need for robust education and public health programs to encourage completion of recommended doses.
Predictors of Human Papillomavirus Vaccine Completion Among Low-Income Latina/o Adolescents
2019, Journal of Adolescent Health
The purpose of this longitudinal study was to identify individual and interpersonal factors associated with human papillomavirus (HPV) vaccine series completion in a sample of low-income Latina/o adolescent girls and boys.
Caregiver–adolescent dyads (N = 161) were recruited from a rural Federally Qualified Health Center in southwest Florida when the adolescent (aged 11–17 years) received the first dose of HPV vaccine. Dyads completed a baseline assessment that measured demographic and cultural characteristics, past medical history, provider–patient communication, HPV knowledge, health beliefs about completing the series, and the adolescent's experience receiving the first dose. Using multivariable logistic regression, we identified caregiver- and adolescent-related factors associated with series completion (receipt of three doses of HPV vaccine within 1 year of initiation) as indicated in the adolescent's medical record and state immunization registry.
Within 1 year of initiation, 57% (n = 92) completed the three-dose series. Missed opportunities for completion were observed for 20% of the sample who returned to the clinic. Caregiver-related predictors of completion included education, self-efficacy to complete the series, and knowledge of the required number of doses. Adolescent-related predictors included age, influenza vaccination within the past 2 years, having a chronic medical condition, reason for the baseline visit, and receipt of written information about HPV vaccination from a health care provider.
Findings highlight important opportunities for improving completion of the HPV vaccine series among Latina/o adolescents. Intervention efforts should involve health care providers and parent–adolescent dyads and prioritize evidence-based strategies for reducing missed opportunities for series completion.
“We brought our culture here with us”: A qualitative study of perceptions of HPV vaccine and vaccine uptake among East African immigrant mothers
2019, Papillomavirus Research
HPV vaccine studies in East African communities are few and focus mainly on Somali women and girls. We examined how HPV vaccine perceptions and uptake are shaped among Somali, Ethiopian, and Eritrean mothers.
We convened three focus groups in Somali, Amharic, and Tigrinya with mothers of 11–17 year old children. The Socio-Context Framework (social, cultural, and religious factors) and Andersen's Behavioral Model (predisposing, enabling, and need for care factors) informed question development.
Negative vaccine perceptions, lack of HPV vaccine knowledge, and concerns about side effects emerged as predisposing factors. Having a provider who engages parents on HPV vaccination and takes responsibility for vaccine-related risks emerged as enabling factors. Availability of vaccine information resources (e.g., person-to-person, word of mouth education for parents) were also enabling factors. Need for care factors included having comprehensive vaccine information, strong recommendation from a doctor, and validation from a co-ethnic medical professional. Women exerted strong social influence on vaccine uptake (social), had concerns about pork gelatin in vaccines (religious), and felt discussions about sex with children were culturally unacceptable (cultural).
Strategies for vaccine uptake among East African immigrants need to address factors that shape HPV vaccine perceptions for adolescents, caregivers, and providers.
Caregiver and adolescent factors associated with delayed completion of the three-dose human papillomavirus vaccination series
2018, Vaccine
Delayed completion of human papillomavirus vaccination (4vHPV) series is common. We sought to identify factors associated with delay.
This substudy was part of a large prospective, multi-site study recruiting 9–17 year old girls at the time of their third 4vHPV dose to assess immunogenicity associated with prolonged dosing intervals. At participating sites, parents/legal guardians (caregivers) of all enrolled girls (9–17 years old) and enrolled girls aged 14–17 years were approached for participation. Caregivers completed a questionnaire measuring adolescent and caregiver sociodemographic characteristics, caregiver attitudes and beliefs about on-schedule HPV vaccination and HPV vaccine safety, adolescent’s health behaviors, barriers to accessing health care, provider office vaccination practices and a Rapid Estimate of Adult Literacy in Medicine (REALM). Participating girls completed a separate questionnaire measuring their attitudes and beliefs about on-schedule HPV vaccination and HPV vaccine safety. Delay was defined as receiving the third 4vHPV dose >12 months after the first. Bivariate, multinomial logistic regression and multivariate logistic regression analyses were used to identify factors predicting delayed completion.
Questionnaires were completed by 482 caregivers and 386 adolescents; 422 caregivers completed a REALM. Delayed 4vHPV dosing occurred in most adolescents (67%). In multivariate analyses, predictors of delayed completion included caregiver demographic factors (self-reported black vs. white race and high school or less education vs. college or more) and an interaction between caregiver’s inability to get an immunization appointment as soon as needed and adolescent’s type of insurance.
Caregiver’s race and educational level, accessibility of immunization appointments, and adolescent’s insurance type were found to be related to delays in completion of 4vHPV, but caregiver or adolescent attitudes and beliefs about on-schedule HPV vaccination or HPV vaccine safety were not. Therefore, interventions to improve adherence to recommended vaccination schedules could benefit from a focus on improving access to immunizations.
ClinicalTrials.gov (NCT01030562).
Can high overall human papillomavirus vaccination coverage hide sociodemographic inequalities? An ecological analysis in Canada
2016, Vaccine
Human papillomavirus (HPV) vaccination programs have been implemented in more than 50 countries. These programs offer tremendous promise of reducing HPV-related disease burden. However, failure to achieve high coverage among high-risk groups may mitigate program success and increase inequalities. We examined sociodemographic inequalities in HPV vaccination coverage in 4 Canadian provinces (Quebec (QC), Ontario (ON), Manitoba (MB), British Columbia (BC)).
We obtained annual HPV vaccination coverage of pre-adolescent girls at provincial and regional levels, from the start of programs to 2012/2013. Regions refer to administrative areas responsible for vaccine implementation and monitoring (there are 18/36/10/16 regions in QC/ON/MB/BC). We obtained regions’ sociodemographic characteristics from Statistics Canada Census. We used univariate weighted linear regression to examine the associations between regions’ sociodemographic characteristics and HPV vaccination coverage.
Provincial HPV vaccination coverage is generally high (QC:78%; ON:80%; MB:64%, BC:69%, 2012/13). QC had the highest provincial vaccination coverage since the program start, but had the greatest inequalities. In QC, regional HPV vaccination coverage was lower in regions with higher proportions of socially deprived individuals, immigrants, and/or native English speakers (p < 0.0001). These inequalities remained stable over time. Regional-level analysis did not reveal inequalities in ON, MB and BC.
School-based HPV vaccination programs have resulted in high vaccination coverage in four Canadian provinces. Nonetheless, high overall coverage did not necessarily translate into equality in coverage. Future work is needed to understand underlying causes of inequalities and how this could impact existing inequalities in HPV-related diseases and overall program success.

View all citing articles on Scopus

: This work was supported by a research grant from Merck & Co, Inc [EPI08014.036.02]. Drs Chao, Slezak, and Jacobsen received research funding from Merck & Co, Inc, to work on this study and a related study, and Dr Jacobsen is an unpaid consultant for Merck & Co, Inc. Dr Velicer is an employee of Merck & Co, Inc.

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ORIGINAL ARTICLECorrelates for Completion of 3-Dose Regimen of HPV Vaccine in Female Members of a Managed Care Organization

OBJECTIVE

PARTICIPANTS AND METHODS

RESULTS

CONCLUSION

Section snippets

PARTICIPANTS AND METHODS

RESULTS

DISCUSSION

CONCLUSION

Lancet Oncol

Ann Epidemiol

J Pediatr Adolesc Gynecol

High sustained efficacy of a prophylactic quadrivalent human papillomavirus types 6/11/16/18 L1 virus-like particle vaccine through 5 years of follow-up

Br J Cancer

Quadrivalent human papillomavirus vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP)

MMWR Recomm Rep

ORIGINAL ARTICLE
Correlates for Completion of 3-Dose Regimen of HPV Vaccine in Female Members of a Managed Care Organization