Longitudinal Predictors of Human Papillomavirus Vaccination Among a National Sample of Adolescent Males

Objectives. We conducted a longitudinal study to examine human papillomavirus (HPV) vaccine uptake among male adolescents and to identify vaccination predictors.Methods. In fall 2010 and 2011, a national sample of parents with sons aged 11 to 17 years (n = 327) and their sons (n = 228) completed online surveys. We used logistic regression to identify predictors of HPV vaccination that occurred between baseline and follow-up.Results. Only 2% of sons had received any doses of HPV vaccine at baseline, with an increase to 8% by follow-up. About 55% of parents who had ever received a doctor’s recommendation to get their sons HPV vaccine did vaccinate between baseline and follow-up, compared with only 1% of parents without a recommendation. Fathers (odds ratio = 0.29; 95% confidence interval = 0.09, 0.80) and non-Hispanic White parents (odds ratio = 0.29; 95% confidence interval = 0.11, 0.76) were less likely to have vaccinated sons. Willingness to get sons HPV vaccine decreased from baseline to follow-up among parents (P < .001) and sons (P = .003).Conclusions. Vaccination against HPV remained low in our study and willingness to vaccinate may be decreasing. Physician recommendation and education about HPV vaccine for males may be key strategies for improving vaccination.Quadrivalent human papillomavirus (HPV) vaccine against types 6, 11, 16, and 18 is approved to protect against genital warts (caused mostly by HPV types 6 and 111) and anal cancer (caused mostly by HPV types 16 and 182) in males.3 About 4% of men in the United States report a previous diagnosis of genital warts,4 and about 2250 new cases of anal cancer occur annually among males in the United States.5 Given the high levels of HPV concordance among sexual partners,6 vaccinating males may also have indirect health benefits for their partners.7 United States guidelines began including HPV vaccine for males in October 2009.8 The Advisory Committee on Immunization Practices first provided a permissive recommendation, recommending the 3-dose quadrivalent vaccine series for males aged 9 to 26 years but not making it part of their routine vaccination schedule.8 In October 2011, the Advisory Committee on Immunization Practices updated its stance on HPV vaccine for males and recommended routine vaccination of boys aged 11 to 12 years with catch-up vaccination for males aged 13 to 21 years.9 The updated recommendation continues to allow HPV vaccine to be given to males aged as young as 9 years and up to 26 years.9Although numerous studies have examined HPV vaccine uptake among females,10 data on HPV vaccine uptake among males are sparse. Despite mostly encouraging early levels of parental acceptability of the vaccine for males,11–13 initial estimates found that only about 2% of male adolescents in the United States had received any doses of HPV vaccine by the end of 2010.14,15 Recent data suggest that this increased to about 8% by the end of 2011.16 We are not aware of any studies that have examined predictors of vaccine uptake among males.Our study addresses several important gaps in the existing literature. We provide the first longitudinal examination of HPV vaccination among males and identify predictors of vaccine uptake. In doing so, we used data from both parents and their adolescent sons because many adolescents are involved in vaccination decisions.17 We also examined longitudinal changes in vaccine acceptability among parents and sons and parents’ reasons for not getting their sons HPV vaccine, because these data may provide valuable insight about future HPV vaccine uptake among males.     

Human Papillomavirus Vaccination Among Young Adult Gay and Bisexual Men in the United States

Objectives. We examined human papillomavirus (HPV) vaccination among gay and bisexual men, a population with high rates of HPV infection and HPV-related disease.Methods. A national sample of gay and bisexual men aged 18 to 26 years (n = 428) completed online surveys in fall 2013. We identified correlates of HPV vaccination using multivariate logistic regression.Results. Overall, 13% of participants had received any doses of the HPV vaccine. About 83% who had received a health care provider recommendation for vaccination were vaccinated, compared with only 5% without a recommendation (P < .001). Vaccination was lower among participants who perceived greater barriers to getting vaccinated (odds ratio [OR] = 0.46; 95% confidence interval [CI] = 0.27, 0.78). Vaccination was higher among participants with higher levels of worry about getting HPV-related disease (OR = 1.54; 95% CI =  1.05, 2.27) or perceived positive social norms of HPV vaccination (OR = 1.57; 95% CI =  1.02, 2.43).Conclusions. HPV vaccine coverage is low among gay and bisexual men in the United States. Future efforts should focus on increasing provider recommendation for vaccination and should target other modifiable factors.Oncogenic human papillomavirus (HPV) types (mainly types 16 and 18) cause an estimated 93% of anal cancers, 63% of oropharyngeal cancers, and 36% of penile cancers among men in the United States.1 Nononcogenic HPV types 6 and 11 cause almost all anogenital warts.2 Gay and bisexual men have high rates of HPV infection and HPV-related disease. A recent review suggests that more than 50% of HIV-negative gay and bisexual men have an anogenital HPV infection.3 About 7% of gay and bisexual men report a history of genital warts.4 Anal cancer is also of great concern, with incidence among HIV-negative gay and bisexual men estimated to be 35 cases per 100 000 population.5 The anal cancer incidence rate among all men in the United States is just 1.6 cases per 100 000 population.6US guidelines began including the quadrivalent HPV vaccine (against HPV types 6, 11, 16, and 18) for males in October 2009.7 The Advisory Committee on Immunization Practices (ACIP) first provided a permissive recommendation that allowed the HPV vaccine to be given to males aged 9 to 26 years but did not include the vaccine in their routine vaccination schedule.7 In October 2011, the ACIP began recommending routine vaccination for boys aged 11 to 12 years with catch-up vaccination for males aged 13 to 21 years.8 Importantly, the ACIP recommends HPV vaccination for men who have sex with men through age 26 years.8The HPV vaccine series consists of 3 doses, with the second dose administered 1 to 2 months after the first dose, and the third dose is administered 6 months after the first dose.7 The quadrivalent HPV vaccine is currently approved to protect males against genital warts and anal cancer.9 Despite recommendations, recent data suggest that fewer than 21% of males in the United States have received any doses of the HPV vaccine.10–14Although several HPV-related disparities exist among gay and bisexual men, little research has addressed HPV vaccination among this population. Past studies have shown that knowledge about HPV and the HPV vaccine tends to be modest among gay and bisexual men.15–19 Many gay and bisexual men have indicated their willingness to get the HPV vaccine, with estimates ranging from 36% to 86%.16,18–20 Data on actual HPV vaccine coverage are sparse; a past study found only 7% of 68 young adult gay and bisexual men had received any doses of the HPV vaccine.11 This study was, however, conducted before the ACIP recommendation for routine vaccination of males.We built on this past research by examining HPV vaccination among a national sample of young adult gay and bisexual men in the recommended age range for HPV vaccination (18–26 years). We identified correlates of vaccination and why young adult gay and bisexual men are not getting the HPV vaccine. These data will help inform future programs for increasing HPV vaccination among this high-risk population.     

Initiation of Human Papillomavirus Vaccination Among Predominantly Minority Female and Male Adolescents at Inner-City Community Health Centers

Objectives. We examined the prevalence and correlates of human papillomavirus (HPV) vaccine initiation among adolescents in low-income, urban areas.Methods. The study consisted of electronic health record data on HPV vaccination for 3180 adolescents (aged 10–20 years) at a multisite community health center in 2011.Results. Only 27% initiated the HPV vaccine. The adjusted odds ratio (AOR) of HPV vaccination was lower among older adolescents (AOR = 0.552; 95% confidence interval [CI] = 0.424, 0.718) and those seen by nonpediatric health care providers (HCPs; AOR = 0.311; 95% CI = 0.222, 0.435), and higher among non-English speakers (AOR = 1.409; 95% CI = 1.134, 1.751) and those seen at 2 site locations (AOR = 1.890; 95% CI = 1.547, 2.311). Insurance status was significant only among female and Hispanic adolescents. Language was not a predictor among Hispanic adolescents. Across all analyses, the interaction of age and HCP specialty was associated with HPV vaccination. Dramatically lower HPV vaccination rates were found among older adolescents seen by nonpediatric HCPs (3%–5%) than among other adolescents (23%–45%).Conclusions. Improving HPV vaccination initiation in low-income urban areas is critical to reducing disparities in cervical and other HPV-related cancer, especially among Black, Hispanic, and low-income populations.Human papillomavirus (HPV) infection is a known risk factor for the development of several cancers. Between 2004 and 2008, there was a national average of 33 369 HPV-associated cancers annually, including cervical, vulvar, vaginal, penile, anal, and oropharyngeal cancers.1 The Centers for Disease Control and Prevention estimates 26 000 new HPV-associated cancers each year, 18 000 for women and 8000 for men,1 which could be prevented through the HPV vaccine.According to the US Cancer Statistics Working Group,2 there are pervasive disparities in national morbidity and mortality rates of HPV-related cancers for Black and Hispanic individuals. Cervical cancer is more common among Black and Hispanic women and results in disproportionately higher mortality for Black women. In 2009, the national age-adjusted cervical cancer incidence rates (per 100 000) for Hispanic and Black women (10.9 and 10.0, respectively) were higher than the rate for White women (7.6).2 The national age-adjusted cervical cancer mortality rate (per 100 000) for Black women (4.2) is considerably higher than the rates for White and Hispanic women (2.1 and 2.9, respectively).2 Also, Black women have higher morbidity and mortality rates of vaginal cancer. Morbidity and mortality rates of penile cancers are significantly higher among Black and Hispanic men. Black men have higher morbidity and mortality rates of anal cancer.2 In addition to race/ethnicity, incidence rates of penile, cervical, and vaginal cancers increase with higher poverty rates.3 Factors that contribute to cancer disparities among Black, Hispanic, and low-income populations include higher exposure to risk factors such as smoking, physical inactivity, and HPV infection as well as lack of access to early detection and treatment services.4New Jersey had the 10th highest morbidity rate for cervical cancer nationally for 2006 through 2010.5 According to the New Jersey State Cancer Registry, cervical cancer morbidity from 2005 to 2009 was significantly higher in the Greater Newark area (relative risk = 1.86; the study target area) than other areas in the state, as well as among women who are Black, Hispanic, foreign-born, non–English-speaking, uninsured, with lower income and education, unmarried, unemployed, and living in a rented residence.6 According to a community health needs assessment for the City of Newark in 2013,7 52.4% of the residents are Black, 33.8% are Hispanic, and 30% are foreign-born, compared with 13%, 18%, and 20%, respectively, in the state. Also, 28.4% of the residents are below the federal poverty level compared with 9.4% statewide, and 28% are uninsured compared with 8.4% statewide. A significant proportion of the residents has less than a high-school education (30%) and a low level of English proficiency (25%).7Transmission of HPV can be reduced through limiting the number of sexual partners, delaying the initiation of sexual activity, practicing safe sex, and getting vaccinated.8 Two vaccines have been approved by the Food and Drug Administration for protection against HPV: the quadrivalent vaccine (Gardasil, Merck, Kenilworth, NJ) for female and male individuals aged 9 to 26 years,9 and the bivalent vaccine (Cervarix, GlaxoSmithKline, Middlesex, England) for female individuals aged 10 to 25 years.10 The HPV vaccine requires a series of 3 injections within 6 months. Markowitz et al.11 examined the rates of HPV infection among female individuals before and after the vaccine was introduced in 2006, by using data from the National Health and Nutrition Examination Surveys for 2003 through 2010. They found that for female adolescents aged 14 to 19 years, there was a 55.7% reduction in vaccine-type HPV infection rate (HPV types 6, 11, 16, and 18) and a 50% reduction in high-risk vaccine-type HPV infection rate (HPV types 16 and 18). There was also an 88% decrease among the sexually active women in their rate of vaccine-type HPV infection when they compared those who were vaccinated to those who were not vaccinated.11 Niccolai et al.12 also found significant decline in the rates of high-grade cervical lesions from 2008 to 2011 among women aged 21 to 24 years in Connecticut. Unfortunately, this trend was attenuated in urban areas as well as areas with higher concentrations of Black, Hispanic, and low-income populations.12According to the National Immunization Survey—Teen (NIS-Teen),13 HPV vaccine initiation rates for female adolescents were 44.3% in 2009, 48.7% in 2010, 53.0% in 2011, and 53.8% in 2012. This reflects minimal improvement in 2011, no improvement in 2012, and reaching a plateau for female vaccination at a level dramatically lower than the goal of 80% completion rate for girls aged 13 to 15 years set by Healthy People 2020. In site-based studies, HPV vaccine initiation among female adolescents ranged between 9.4% and 62.9%.14–21 Also, initiation for female adolescents was lower for Spanish speakers,22 those who were uninsured,23–25 those with shorter duration of enrollment in health insurance,26 in nonpediatric settings,21,24 among those who have not had a preventive visit in the past 12 months,21,24,27–30 and with mothers’ lack of knowledge about HPV infection or vaccine.18,27,28,31,32 Some studies reported lower initiation among younger female adolescents,15,18,21,24,29,30 whereas others reported the opposite.21,26 Several studies have shown the importance of health care providers’ (HCPs’) recommendations for HPV vaccine initiation among female adolescents.16,28,30,31,33According to NIS-Teen,13 HPV vaccine initiation rates for male adolescents were 1.4% in 2010, 8.3% in 2011, and 20.8% in 2012. This reflects low but steady improvement in HPV vaccination rates among male adolescents. In site-based studies, HPV vaccine initiation among male adolescents ranged between 1.1% and 30%.14,34–37 Literature is lacking on factors associated with HPV vaccine initiation among male adolescents. One study reported lower levels of knowledge among Black and Hispanic parents about the use of HPV vaccine for male adolescents.35 A few studies indicated the importance of HCPs’ recommendation for HPV vaccine initiation among male adolescents.14,35,36,38Pervasive disparities exist in HPV vaccination among Black, Hispanic, and low-income groups, and more specifically in the study target area. Even though the NIS-Teen data for 2011 and 2012 show slightly higher HPV vaccination among Black and low-income groups,39,40 several studies have demonstrated a significant and continuing trend of lower HPV vaccination among Black and Hispanic adolescents,14,15,17,24,26,41,42 as well as in low-income and urban areas.22,33,41,43 Vaccination disparities in urban areas (compared with suburban or rural areas) may be attributed to residential segregation, differential distribution of health clinics and health professionals, and unequal access to a broad range of services.44–46 As urban areas, particularly the Greater Newark area, have high proportions of immigrants who may be hesitant to seek health care services because of cultural or language barriers or concerns about immigration status,7 a study of adolescents’ adherence to public health recommendations in underserved, inner-city areas is warranted and important.Literature is lacking information on correlates of HPV vaccination among Black and Hispanic adolescents in low-income urban areas, who represent populations with the greatest disparities in cervical cancer and other HPV-related cancers compared with White and higher-income groups. Therefore, the purpose of this study was to examine the correlates of HPV vaccine initiation in a sample of predominantly Black and Hispanic adolescents at inner-city community health centers. The study addresses gaps in knowledge about the correlates of HPV vaccination among both male and female adolescents as well as a low-income predominantly minority population with pervasive disparities in cervical cancer morbidity and mortality.1–3,5,6     

Racial/Ethnic Disparities in Health Care Receipt Among Male Cancer Survivors

Objectives. We examined racial/ethnic disparities in health care receipt among a nationally representative sample of male cancer survivors.Methods. We identified men aged 18 years and older from the 2006–2010 National Health Interview Survey who reported a history of cancer. We assessed health care receipt in 4 self-reported measures: primary care visit, specialist visit, flu vaccination, and pneumococcal vaccination. We used hierarchical logistic regression modeling, stratified by age (< 65 years vs ≥ 65 years).Results. In adjusted models, older African American and Hispanic survivors were approximately twice as likely as were non-Hispanic Whites to not see a specialist (odds ratio [OR] = 1.78; 95% confidence interval [CI] = 1.19, 2.68 and OR = 2.09; 95% CI = 1.18, 3.70, respectively), not receive the flu vaccine (OR = 2.21; 95% CI = 1.45, 3.37 and OR = 2.20; 95% CI = 1.21, 4.01, respectively), and not receive the pneumococcal vaccine (OR = 2.24; 95% CI = 1.54, 3.24 and OR = 3.10; 95% CI = 1.75, 5.51, respectively).Conclusions. Racial/ethnic disparities in health care receipt are evident among older, but not younger, cancer survivors, despite access to Medicare. These survivors may be less likely to see specialists, including oncologists, and receive basic preventive care.Gender and racial/ethnic disparities in health care utilization are prevalent. Men are less likely than are women to use health care services, including physician office visits and preventive care visits.1,2 Minorities are also less likely to use health care services than are non-Hispanic Whites.3–6 Contributors to these disparities include low socioeconomic status7–10 and lack of health insurance.7,8,11,12 Even after controlling for socioeconomic status and health insurance coverage, racial/ethnic disparities in health care utilization persist.4 These disparities are associated with poorer health and higher mortality rates among minorities and have important implications for survival and well-being for men with serious and chronic health conditions such as cancer.5Although numerous studies have documented racial/ethnic disparities in cancer screening, diagnosis, treatment, and mortality,10,13–18 little is known about how racial/ethnic disparities in health care among posttreatment cancer survivors influence follow-up care. Such care includes monitoring and managing late and long-term effects and follow-up tests to monitor for recurrence and detect second cancers. Management of noncancer comorbidities (e.g., diabetes) and preventive health care19 (e.g., vaccinations) are also recommended for cancer survivors.20–22 Follow-up care may include visits to both primary care and specialist providers.13,23–25 It is strongly recommended that cancer survivors receive lifelong follow-up care because of increased risk of recurrence, morbidity, and mortality.19Prior studies have used administrative data to explore this issue,13,24,26,27 but few of these studies have focused on male cancer survivors and none included younger survivors who are not covered by Medicare. Additionally, it is not known how patterns of health care receipt might differ among men with and without a history of cancer.We assessed racial/ethnic disparities in health care receipt among adult male cancer survivors and men without cancer using the National Health Interview Survey (NHIS).28 We first wanted to compare cancer survivors to a noncancer group to shed light on whether the disparities are specific to cancer or reflect underlying disparities. We explored (1) racial/ethnic disparities in health care receipt among cancer survivors compared with men with no cancer history, (2) racial/ethnic disparities in cancer survivors, and (3) the extent to which predisposing, enabling, and need factors explain racial/ethnic disparities in health care receipt among male cancer survivors.     

Vaccination Interest and Trends in Human Papillomavirus Vaccine Uptake in Young Adult Women Aged 18 to 26 Years in the United States: An Analysis Using the 2008–2012 National Health Interview Survey

Objectives. Human papillomavirus (HPV) vaccines have been approved since 2006, yet vaccination rates remain low. We investigated HPV vaccination trends, interest, and reasons for nonvaccination in young adult women.Methods. We used data from the 2008–2012 National Health Interview Survey to analyze HPV vaccine uptake trends (≥ 1 dose) in women aged 18 to 26 years. We used data from the 2008 and 2010 National Health Interview Survey to examine HPV vaccination interest and reasons for nonvaccination among unvaccinated women.Results. We saw significant increases in HPV vaccination for all young women from 2008 to 2012 (11.6% to 34.1%); however, Hispanics and women with limited access to care continued to have lower vaccination rates. Logistic regression demonstrated lower vaccination interest among unvaccinated women in 2010 than 2008. Respondents in 2010 were significantly less likely to give lack of knowledge as a primary reason for nonvaccination.Conclusions. Uptake of HPV vaccine has increased from 2008 to 2012 in young women. Yet vaccination rates remain low, especially among women with limited access to care. However, unvaccinated women with limited health care access were more likely to be interested in receiving the vaccine.Human papillomavirus (HPV) is widespread among young females in the United States, with an estimated prevalence of 59.8% in women aged 20 to 24 years in 2007 to 2010.1 Persistent infection with high-risk strains of HPV has been linked to development of certain cancers, including cervical, oropharyngeal, and anal cancers, with an estimated 13.2 per 100 000 women diagnosed annually with HPV-associated cancers between 2004 and 2008.2 Since 2006, 2 HPV vaccines have been approved by the Food and Drug Administration that safely3 and effectively1 prevent infection with several high-risk HPV strains.2Since 2006, the Advisory Committee on Immunization Practices has recommended that 3 doses of the HPV vaccine be administered to young females aged 11 to 26 years, with a focus on early vaccination.4,5 Data for 18- to 26-year-old women from the adult version of the 2007 National Immunization Survey estimated that 10% of young women had initiated the HPV vaccination series.6 For the same year, vaccine initiation among California women aged 18 to 27 years was estimated to be 11.0%.7 In 2011, vaccination rates (≥ 1 dose) among young women aged 19 to 26 years had increased to 29.5%.8 Vaccination rates for adolescents were more favorable (53.8% for ≥ 1 dose, 33.4% for ≥ 3 doses for 13- to 17-year-old adolescents in 2012³), but are far from the national goal of 80% vaccination completion for 13- to 15-year-old adolescents by 2020.9Despite these low vaccine initiation and even lower completion rates, few studies have examined reasons for nonvaccination of young adult women, and no study has specifically studied how these reasons may have changed over time.6,10–13 A recent study focusing on parental attitudes showed an increase in parents not intending to vaccinate adolescent daughters and citing safety concerns as one of the main reasons for nonvaccination.14 Furthermore, previous studies of trends in HPV vaccination have focused primarily on adolescents.3,15,16 However, with high levels of nonvaccination continuing in 2011 for both the main target group and young adults, it is critical to understand trends in vaccination and risk factors for nonvaccination in this age group, as these young women can still benefit from receiving the HPV vaccine and promote greater herd immunity.Therefore, using nationally representative data from the National Health Interview Survey (NHIS) for young women, our aim was to (1) estimate trends in HPV vaccination uptake (≥ 1 dose) in women aged 18 to 26 years from 2008 to 2012, (2) examine HPV vaccination interest among young unvaccinated women in 2008 and 2010, and (3) investigate reasons for nonvaccination among women who were not interested in receiving the vaccine in 2008 and 2010. Both vaccination interest, defined as whether an unvaccinated woman was interested in receiving the HPV vaccine in the survey, and reasons for nonvaccination for unvaccinated women, who were not interested or undecided, were only assessed in the 2008 and 2010 NHIS.     

Quadrivalent Human Papillomavirus Vaccine Uptake in Adolescent Boys and Maternal Utilization of Preventive Care and History of Sexually Transmitted Infections

Objectives. We examined whether maternal utilization of preventive care and history of sexually transmitted infections (STIs) predicted quadrivalent human papillomavirus vaccine (HPV4) uptake among adolescent boys 1 year following the recommendation for permissive use of HPV4 for males.Methods. We linked maternal information with electronic health records of 254 489 boys aged 9 to 17 years who enrolled in Kaiser Permanente Southern California health plan from October 21, 2009, through December 21, 2010. We used multivariable Poisson regression with robust error variance to examine whether HPV4 initiation was associated with maternal uptake of influenza vaccine, Papanicolaou (Pap) screening, and history of STIs.Results. We identified a modest but statistically significant association between initiation of HPV4 series and maternal receipt of influenza vaccine (rate ratio [RR] = 1.16; 95% confidence interval [CI] = 1.07, 1.26) and Pap screening (RR = 1.13; 95% CI = 1.01, 1.26). Boys whose mothers had a history of genital warts were more likely to initiate HPV4 (RR = 1.47; 95% CI = 0.93, 2.34), although the association did not reach statistical significance (P = .1).Conclusions. Maternal utilization of preventive care and history of genital warts may influence HPV4 uptake among adolescent boys. The important role of maternal health characteristics and health behaviors needs be considered in intervention efforts to increase vaccine uptake among boys.In October 2009, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) recommended that quadrivalent human papillomavirus vaccine (HPV4) may be given to males aged 9 to 26 years at the discretion of the patient’s health care provider (permissive use) to reduce the likelihood of acquiring genital warts (condyloma acuminata).1 However, uptake among eligible males was low following this recommendation for permissive use, with only an estimated 2% of male adolescents initiating the vaccine.2 As the national data indicated that uptake among females remained suboptimal for a few years following the recommendation for routine vaccination in females,3 human papillomavirus (HPV) vaccination of males offers an opportunity to achieve herd immunity in the whole population. On the basis of these considerations and the clinical trial data indicating HPV4’s high efficacy for prevention of genital warts and grade 2 or 3 anal intraepithelial neoplasia (AIN2/3, a precursor of anal cancer) in males, in October 2011, the ACIP recommended routine use of HPV4 in boys aged 11 or 12 years. The ACIP also recommended vaccination with HPV4 for males aged 13 through 21 years who have not been vaccinated previously or who have not completed the 3-dose series; men aged 22 through 26 years may be vaccinated.4Parents are involved in deciding whether their adolescent children get vaccinated regardless of whether the vaccine is recommended for routine use, because parental consent is typically required for adolescent HPV vaccination.5,6 Previous experience with HPV vaccination in female adolescents suggests that the decision to vaccinate their children with HPV vaccines is often affected by parents’ knowledge about HPV infection, attitudes toward the vaccine, and parental history of sexually transmitted infections (STIs) or HPV-related disease.7,8 In a previous study, we found that mothers’ Papanicolaou (Pap) screening behavior was associated with their daughters’ uptake of HPV4 in an insured population.9 Therefore, we hypothesized that previous maternal utilization of Pap screening might reflect a positive attitude toward prevention of HPV infection. In addition, mothers with a history of STIs, especially genital warts, might be familiar with preventive measures for HPV infection, which might influence their decision to vaccinate their children with HPV4 vaccine. We hypothesized that this influence might be even more important for HPV4 uptake among adolescent boys when the vaccine was initially recommended for permissive use among males in the United States.In this study, we sought to determine whether initiation of HPV4 in a large cohort of insured boys aged 9 to 17 years was associated with maternal utilization of preventive care and history of STIs during the time period when the vaccine was indicated for permissive use in males.     

Self-Reported Experience of Racial Discrimination and Health Care Use in New Zealand: Results From the 2006/07 New Zealand Health Survey

Objectives. We investigated whether reported experience of racial discrimination in health care and in other domains was associated with cancer screening and negative health care experiences.Methods. We used 2006/07 New Zealand Health Survey data (n = 12 488 adults). We used logistic regression to examine the relationship of reported experience of racial discrimination in health care (unfair treatment by a health professional) and in other domains (personal attack, unfair treatment in work and when gaining housing) to breast and cervical cancer screening and negative patient experiences adjusted for other variables.Results. Racial discrimination by a health professional was associated with lower odds of breast (odds ratio [OR] = 0.37; 95% confidence interval [CI] = 0.14, 0.996) and cervical cancer (OR = 0.51; 95% CI = 0.30, 0.87) screening among Maori women. Racial discrimination by a health professional (OR = 1.57; 95% CI = 1.15, 2.14) and racial discrimination more widely (OR = 1.55; 95% CI = 1.35, 1.79) were associated with negative patient experiences for all participants.Conclusions. Experience of racial discrimination in both health care and other settings may influence health care use and experiences of care and is a potential pathway to poor health.Racism is increasingly recognized as an important determinant of health and driver of ethnic health inequalities.1 Regardless of its health effects, racism breaches fundamental human rights and is morally wrong. It is important to understand how racism operates as a health risk to develop interventions that reduce ethnic inequalities in health within a context of eliminating racism.2Racism is an organized system that categorizes racial/ethnic groups and structures opportunity, leading to inequities in societal goods and resources and a racialized social order.3–5 Racism operates via institutional and individual practices (racial discrimination) and varies in form and type.6,7 The pathways whereby racism leads to poor health are also multiple, with direct and indirect mechanisms such as race-based assaults and violence, physiological and psychological stress mechanisms, differential exposures to health risk factors, differential access to and experiences of health care, and differential access to goods, resources, and power in society.6,8–10Research on racism and health, particularly self-reported racism, has increased. Self-reported experience of racism has been linked to multiple health measures (including mental and physical health outcomes and health risk factors) across a variety of countries and for different ethnic groups.10–12 Research on how self-reported experience of racism may negatively affect health has largely focused on racism as a stressor with mental and physical health consequences.10,13 Comparatively less evidence is available on how experience of racism may influence health service use,10 although this is another potentially important pathway to poor health.14,15Studies on the association between self-reported racism and health care experience and use have included racism experienced within the health care system, outside of the health care system, or both.16–19 Health care measures have included use of specific services such as cancer screening19–24 and receipt of optimal care,20,25 measures of unmet need,16,26 measures of adherence to care,17,27,28 and measures of satisfaction and experiences with care.18,29–31Various mechanisms have been suggested to explain how the experience of racism may negatively affect health care use, experiences of health care, and subsequent poor health. Experiences of racism within the health care system may influence health by shaping decision making of both providers and patients and influencing future health behaviors, including future health care use behaviors and potential disengagement from the health care system.14,18,26 Experiences of racism in wider society also may lead to general mistrust and avoidance of dominant culture institutions, including health care systems.15,30 This is supported by evidence that both experiences of racism and general discrimination within and outside of health care have been associated with negative health care use measures.15,16,19,22New Zealand has a population of approximately 4.4 million people, with the major ethnic groupings being Maori (indigenous peoples, 15% of the population), European (77%), Pacific (7%), and Asian (10%).32 Ethnic inequalities in health and socioeconomic status persist, with racism a potentially important contributor to these inequalities.33 Previous research in New Zealand has shown reported experience of racial discrimination by a health professional to be higher among non-European ethnic groups with experiences of racial discrimination in different settings associated with multiple health outcomes and risk factors.34In this study, we focused on the relationship between racial discrimination and health service use and experience, an area not previously examined in New Zealand. We provide important information on how racial discrimination may affect health care use as a possible pathway to poor health outcomes and ethnic health inequalities in New Zealand. In addition, our study contributes to the limited evidence on racial discrimination and health care internationally.Primary health care in New Zealand is available to all residents and is usually provided at general practices. Costs of visits are universally subsidized by government to enable lower patient copayments with additional limited provision for extra funding based on high need.35 Currently, 2 publicly funded national cancer screening programs are available.36 Breast cancer screening is free to all eligible women through BreastScreen Aotearoa. Cervical cancer screening usually incurs a fee and is available through patients’ usual primary care provider or specific cervical cancer screening providers.We specifically examined the association between self-reported experience of racial discrimination and the use of health care in 2 domains—cancer screening and negative patient perceptions of health care encounters. We hypothesized that experience of racial discrimination both within and outside the health care system may negatively affect how individuals use and experience health care.     

Factors Explaining Racial/Ethnic Disparities in Rates of Physician Recommendation for Colorectal Cancer Screening

Objectives. Physician recommendation plays a crucial role in receiving endoscopic screening for colorectal cancer (CRC). This study explored factors associated with racial/ethnic differences in rates of screening recommendation.Methods. Data on 5900 adults eligible for endoscopic screening were obtained from the National Health Interview Survey. Odds ratios of receiving an endoscopy recommendation were calculated for selected variables. Planned, sequenced logistic regressions were conducted to examine the extent to which socioeconomic and health care variables account for racial/ethnic disparities in recommendation rates.Results. Differential rates were observed for CRC screening and screening recommendations among racial/ethnic groups. Compared with Whites, Hispanics were 34% less likely (P < .01) and Blacks were 26% less likely (P < .05) to receive this recommendation. The main predictors that emerged in sequenced analysis were education for Hispanics and Blacks and income for Blacks. After accounting for the effects of usual source of care, insurance coverage, and education, the disparity reduced and became statistically insignificant.Conclusions. Socioeconomic status and access to health care may explain major racial/ethnic disparities in CRC screening recommendation rates.Colorectal cancer (CRC) is the third most common cause of cancer death in the United States and a major cause of cancer morbidity.1 Annually in the United States, an estimated 150 000 people are diagnosed and 50 000 people die from this disease.2 With early detection and removal of precancerous polyps, CRC can be preventable, with a 5-year survival rate as high as 90%.3,4Current CRC screening guidelines consist of sigmoidoscopy every 5 years and colonoscopy every 10 years for those aged 50 to 75 years.4 Although an annual fecal occult blood test is also recommended, sigmoidoscopy and colonoscopy have higher sensitivity and specificity for the detection of cancerous lesions.5 Sensitivity ranges from 25% to 87% for fecal occult blood test, compared with 92% to 95% for endoscopy (sigmoidoscopy and colonoscopy).6 Colonoscopy, the most widely used test for CRC detection and prevention, is considered the gold standard because it can detect and remove precancerous polyps, and a positive result from any other screening test must be followed by this advanced modality.1,7,8 Endoscopy has played a major role in the decreasing trend of CRC mortality in the United States9,10Still, minority groups—especially Blacks—carry a disproportionately higher CRC burden.1,11 From the 1980s to 2007—a period of advance in early detection and treatment—the inequality between Blacks and Whites increased to a 44% difference in CRC mortality rates.1 This disparity could be attributable in part to the fact that, compared with Whites, members of racial/ethnic minority groups were less likely to be screened and diagnosed at the localized, more treatable stage of CRC.1 These lower screening rates partially account for the higher rates of late stage detection and subsequent increases in CRC morbidity and mortality rates among racial/ethnic minorities and low-income populations.1,10,12 Thus, it is necessary to promote utilization of effective screening methods, such as endoscopy, to detect CRC in its early stages, especially among minority groups.Trends in CRC screening from 1992 to 2005 show widening gaps between Whites and minority groups: the disparity increased to 10.3% for Blacks and to 20.5% for Hispanics.13,14 Lower rates of cancer screening, including CRC screening, have been strongly associated with lower rates of physician recommendation, particularly among low-income populations, racial/ethnic minority groups, and women.15,16The health care provider’s role in CRC screening is essential because a physician recommendation is necessary for endoscopic screening.17,18 A study found that more than 90% of people who did not undergo endoscopic screening reported not receiving the necessary recommendation.16 A systematic review discovered that patients identified physician recommendation as the sole CRC-screening facilitator and absence of recommendation as the only barrier.19 It is thus crucial to identify factors that influence the likelihood of receiving a CRC screening recommendation.The present study seeks to build on the work of 2 previous analyses of CRC-screening barriers and predictors among respondents to the 2000 National Health Interview Survey (NHIS). Seeff et al. found that “frequent doctor visits in the past year” was the strongest predictor of CRC screening.20 Among the barriers, a “lack of awareness of the need to be screened” was most common, followed by “not receiving a physician recommendation.”20 In bivariate analysis, Coughlin and Thompson found that, among screening-eligible adults who had visited a physician in the past year, members of racial/ethnic minority groups were less likely than Whites to receive an endoscopy recommendation.21 The study mainly focused on reasons for having CRC screenings.We used multivariate analyses and planned sequenced logistic regression to explore patient factors that may explain unequal rates of physician recommendation for endoscopy among Blacks and Hispanics compared with Whites. Factors deemed to have relative importance in terms of statistical significance may help indicate areas of intervention to improve rates of physician recommendation for CRC screening in disadvantaged populations.     

Insurance Continuity and Human Papillomavirus Vaccine Uptake in Oregon and California Federally Qualified Health Centers

Objectives. We examined the association between insurance continuity and human papillomavirus (HPV) vaccine uptake in a network of federally qualified health clinics (FQHCs).Methods. We analyzed retrospective electronic health record data for females, aged 9–26 years in 2008 through 2010. Based on electronic health record insurance coverage information, patients were categorized by percent of time insured during the study period (0%, 1%–32%, 33%–65%, 66%–99%, or 100%). We used bilevel multivariable Poisson regression to compare vaccine-initiation prevalence between insurance groups, stratified by race/ethnicity and age. We also examined vaccine series completion among initiators who had at least 12 months to complete all 3 doses.Results. Significant interactions were observed between insurance category, age, and race/ethnicity. Juxtaposed with their continuously insured peers, patients were less likely to initiate the HPV vaccine if they were insured for less than 66% of the study period, aged 13 years or older, and identified as a racial/ethnic minority. Insurance coverage was not associated with vaccine series completion.Conclusions. Disparities in vaccine uptake by insurance status were present in the FQHCs studied here, despite the fact that HPV vaccines are available to many patients regardless of ability to pay.Cervical cancer is a significant public health challenge in the United States. Approximately 12 300 women were expected to be diagnosed with cervical cancer in 2013, and 4030 were expected to die from the disease.1 The burden of cervical cancer disproportionately affects minority, low-income, and uninsured populations.2–4 The primary risk factor for virtually all cervical cancer is infection with certain types of human papillomavirus (HPV). Effective vaccines have been developed against HPV-16 and HPV-18, which alone are responsible for approximately 70% of cervical cancer cases.5–7 These vaccines hold great potential for reducing disparities in cervical cancer morbidity and mortality, if utilization can be encouraged in populations most at risk for cervical cancer.Federally Qualified Health Centers (FQHCs) serve the primary health care needs of more than 20 million patients in the United States, many of whom are low income, minorities or uninsured,8 and are thus an ideal setting in which to study the utilization of HPV vaccination among populations at highest risk for cervical cancer.9 However, few investigators have directly examined HPV vaccination rates in such settings,9–11 in part because of a lack of readily available data. Consequently, factors affecting HPV vaccine uptake in FQHCs are not well understood. In particular, the role of insurance coverage remains unclear.To date, studies of HPV vaccination rates in FQHCs have modeled insurance as a static variable, determined at a single visit or at the time services were rendered.9–11 This approach might be unsuitable when considering the association between insurance and HPV vaccine series completion, which requires multiple visits over several months,12 and may not accurately reflect the experience of FQHC patients whose coverage can change frequently affecting health care utilization.13–16 Furthermore, defining insurance status from a single visit prevents consideration of insurance duration or coverage continuity as potential factors influencing vaccine uptake. Among Medicaid enrolled patients, who constitute almost 40% of FQHC patients nationally,8 duration of insurance enrollment has been associated with HPV vaccine initiation, with longer enrollment being a predictor for initiating the vaccine series.17,18 Other researchers have demonstrated that, compared with being uninsured or sporadically insured, having continuous insurance coverage is positively associated with the receipt of preventive services in FQHCs, despite the fact that patients can receive care regardless of insurance coverage in these settings.16,19,20Existing studies of HPV vaccination in FQHCs have also been limited to patients younger than 19 years,9–11 precluding examination of insurance effects across the full age range for which the vaccine is recommended (9–26 years).12 In FQHC settings, the role insurance plays in vaccine uptake likely differs with age, as HPV vaccine is free for eligible children and adolescents younger than 19 years through the federal Vaccine for Children (VFC) program,21 but no similar program exists for patients aged 19 to 26 years. A better understanding of how insurance coverage and other factors affect uptake among female FQHC patients aged 19 to 26 years is needed to allow design of future interventions to reduce cervical cancer disparities in underserved populations.We leveraged electronic health record (EHR) data from a network of FQHCs to examine the association between insurance continuity and HPV vaccination in a large cohort of female patients (9–26 years of age) who accessed care between 2008 and 2010. We hypothesized that HPV vaccine uptake in our study population would be affected by insurance continuity, with lower rates of vaccine series initiation and completion among uninsured and discontinuously insured patients, compared with the continuously insured. We also hypothesized that insurance-related disparities would be most pronounced among women older than 18 years, who are ineligible for VFC. Our study helps fill a gap in published research by assessing the uptake of HPV vaccine in FQHC patients, including those older than 18 years, and applying EHRs to gather objective longitudinal data on insurance coverage and HPV vaccination rates in this population.     

Geographic Poverty and Racial/Ethnic Disparities in Cervical Cancer Precursor Rates in Connecticut, 2008–2009

Objectives. We examined associations of geographic measures of poverty, race, ethnicity, and city status with rates of cervical intraepithelial neoplasia grade 2 or higher and adenocarcinoma in situ (CIN2+/AIS), known precursors to cervical cancer.Methods. We identified 3937 cases of CIN2+/AIS among women aged 20 to 39 years in statewide surveillance data from Connecticut for 2008 to 2009. We geocoded cases to census tracts and used census data to calculate overall and age-specific rates. Poisson regression determined whether rates differed by geographic measures.Results. The average annual rate of CIN2+/AIS was 417.6 per 100 000 women. Overall, higher rates of CIN2+/AIS were associated with higher levels of poverty and higher proportions of Black residents. Poverty was the strongest and most consistently associated measure. However, among women aged 20 to 24 years, we observed inverse associations between poverty and CIN2+/AIS rates.Conclusions. Disparities in cervical cancer precursors exist for poverty and race, but these effects are age dependent. This information is necessary to monitor human papillomavirus vaccine impact and target vaccination strategies.Genital human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, with an estimated 6.2 million adolescents and young adults newly infected every year.1 The prevalence of infection ranges from 27% to 45% among young women, and nearly 40% of women acquire HPV within 2 years of initiating sexual activity.2–4 HPV is also an important public health problem because persistent infection with a high-risk HPV type is a necessary cause of cervical cancer.5–7 Women living in poverty and racial/ethnic minorities continue to bear a disproportionate burden of cervical cancer incidence and mortality despite the decrease in rates that has resulted from widespread cervical cancer screening.8,9 In 1998 to 2003, US incidence rates of invasive cervical cancer were 12.6 per 100 000 among Black women, 14.2 among Hispanics, and 8.4 among Whites; mortality rates showed similar disparities.10 This pattern continued through 2007.11 In a study from Massachusetts and Rhode Island, incidence rates in areas with 20% or higher and less than 5% of the population living in poverty were 17.6 and 9.2 per 100 000, respectively.12 Data from a study in New York City revealed neighborhood poverty to be an important predictor of cervical cancer mortality.13Precursors to cervical cancer are cervical intraepithelial neoplasia grades 2, 2/3, and 3 (CIN2+) and adenocarcinoma in situ (AIS). CIN2+/AIS diagnoses are an important public health problem not only because they are precursors to invasive disease, but also because they are common diagnoses that impose substantial health care costs and patient burden. Approximately 500 000 women are diagnosed each year with high-grade cervical disease, and these diagnoses account for annual health care costs of $450 million.14–16 At the individual level, a diagnosis of CIN2+ results in an average of 7 to 8 office visits and 20 months of follow-up.16 Many women also experience adverse psychological consequences following a diagnosis, such as fear of cancer, anxiety, distress, and concern about future fertility, along with medical procedures and difficulties with sexual relationships.17 Disparities in precancerous lesions have not been directly examined, to the best of our knowledge. Data from 2 studies reveal noticeably higher rates of precancerous lesions among low-income women in a national screening program (4.6–7.4/1000 women) than among health plan enrollees (1.5/1000), who were likely of higher socioeconomic status18,19; however this is not a direct or precise comparison.Since 2006, the Food and Drug Administration has approved 2 HPV vaccines that protect against 2 high-risk HPV types (HPV 16/18), which cause approximately 70% of cervical cancers. These vaccines have proven efficacy of 95% or higher in protecting against HPV 16/18–associated cervical lesions in HPV-naive women.20,21 The Advisory Committee on Immunization Practices recommends routine use of either vaccine in a 3-dose regimen for girls aged 11 or 12 years and catch-up vaccination through age 26 years.22 These vaccines have the potential to reduce disparities in cervical cancer. However, the extent to which this is realized will depend on high vaccine coverage for populations at greatest risk for outcomes associated with HPV infection. If vaccine coverage is not adequate and targeted, current disparities in cervical cancer may widen rather than narrow.HPV vaccination programs may affect cervical cancer precursors and associated procedures within years rather than the decades it will take to measure impact on cervical cancer.21,23–26 Therefore, determining the burden of cervical cancer precursors should be a public health priority because this information can be used to target vaccination strategies and provide a baseline for monitoring vaccine impact and disparities over time. We examined disparities in CIN2+/AIS rates in Connecticut, a state with mandatory reporting of these conditions, during prevaccine impact years 2008 to 2009, by geographic sociodemographic measures of poverty, race, ethnicity, and city status. We chose the first 3 measures because they are the most commonly used indicators of disparities in cervical cancer.8,10,12,13 We included a city measure because we hypothesized that disparities may exist along an urban gradient. Our results fill a key knowledge gap because few states mandate CIN2+/AIS reporting, and no statewide analysis of cervical cancer precursors and geographic measures has been reported.     

Adolescent Immunization Coverage and Implementation of New School Requirements in Michigan, 2010

Objectives. We examined the effect of Michigan’s new school rules and vaccine coadministration on time to completion of all the school-required vaccine series, the individual adolescent vaccines newly required for sixth grade in 2010, and initiation of the human papillomavirus (HPV) vaccine series, which was recommended but not required for girls.Methods. Data were derived from the Michigan Care Improvement Registry, a statewide Immunization Information System. We assessed the immunization status of Michigan children enrolled in sixth grade in 2009 or 2010. We used univariable and multivariable Cox regression models to identify significant associations between each factor and school completeness.Results. Enrollment in sixth grade in 2010 and coadministration of adolescent vaccines at the first adolescent visit were significantly associated with completion of the vaccines required for Michigan’s sixth graders. Children enrolled in sixth grade in 2010 had higher coverage with the newly required adolescent vaccines by age 13 years than did sixth graders in 2009, but there was little difference in the rate of HPV vaccine initiation among girls.Conclusions. Education and outreach efforts, particularly regarding the importance and benefits of coadministration of all recommended vaccines in adolescents, should be directed toward health care providers, parents, and adolescents.Although most vaccine-preventable diseases in the United States are at historically low levels, pertussis, or whooping cough, has steadily increased over the past 20 years. A national epidemic in 2010 resulted in more annual cases than at any time in the previous 60 years,1 and those numbers were exceeded in 2012,2 highlighting the continued importance of timely immunization, the need to regularly review updated recommendations, the value of vaccination coverage assessment, and the usefulness of evaluating factors associated with age-appropriate immunization.Vaccines recommended for adolescents aged 11 through 12 years by the Advisory Committee on Immunization Practices (ACIP) in 2010 included a single dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap)3; a single dose of meningococcal conjugate vaccine (MCV4)4; a 3-dose series of human papillomavirus (HPV) vaccine for girls5; annual seasonal influenza vaccine6; and catch-up of other childhood-recommended vaccines, including varicella.7 All of these recommendations were of several years’ duration (Tdap 2006; MCV4 2005; HPV [for girls] and varicella catch-up 2007).The National Immunization Survey–Teen 2009 estimated immunization coverage levels for adolescents aged 13 through 17 years nationally and by state. Michigan’s Tdap coverage in this age group was lower than the national average (46.2% vs 55.6%), but otherwise Michigan’s coverage for MCV4 (52.6%), documented varicella history or 2 or more doses of varicella vaccine (74.9%), and 2 or more doses of varicella vaccine in adolescents with no history of disease (47.7%) was comparable to national rates.8 Vaccine coverage rates for children aged 11 through 12 years have lagged noticeably behind those of older adolescents in Michigan.9 In January 2010, vaccination levels for Michigan adolescents aged 11 through 12 years were 34.3% for Tdap, 29.0% for MCV4, and 69.3% for history of varicella or 2 or more doses of vaccine10—well below Healthy People 2020 goals.11Adolescents are challenging to reach because they infrequently present for preventive care, and opportunities for vaccination are often missed at these and at problem-centered visits.12–14 Concerns related to delivery, consent, and cost exist at the adolescent, parent, and provider level.14,15 Successful interventions to increase adolescent immunization coverage have involved immunization tracking, telephone or mail reminder or recall, home visits, text message reminders, standing orders, and reinforcement through direct provider recommendation.16–19 ACIP recommends simultaneous administration (i.e., coadministration) of all needed doses when 2 or more vaccines are indicated,20 a practice that, if more widely implemented, could dramatically improve coverage in adolescents.21 School entry laws are another particularly effective strategy to increase vaccination coverage in adolescents.22,23New rules for Michigan schools were enacted in January 2010 and became effective in November 201024; schools were required to report student immunization levels by February 2011. These rules reflected national recommendations and included new requirements for children aged 11 through 18 years who were either starting sixth grade or, if enrolled in a different grade, new entrants to a school district: 1 dose of Tdap if 5 years had elapsed since the last dose of tetanus- and diphtheria-containing vaccine, 1 dose of MCV4, and a catch-up second dose of varicella vaccine or current laboratory evidence of immunity or reliable history of disease. These new requirements were in addition to the vaccines that had been required for sixth-grade entry since 2002: 4 doses of tetanus- and diphtheria-containing vaccine (or 3 doses if the first dose was administered on or after the seventh birthday), 3 doses of polio vaccine, 2 doses of measles-mumps-rubella (MMR) vaccine, 3 doses of hepatitis B vaccine, and 1 dose of varicella vaccine. Like most other states, Michigan allows parents or guardians to waive state-mandated vaccinations for their child for medical or religious reasons. Michigan is also one of only 19 states where parents or guardians may waive state-mandated vaccinations for personal (philosophical) beliefs25; prior to 2010, approximately 3% of Michigan’s sixth graders had 1 or more of the required vaccinations waived annually.26We examined school-required and female HPV vaccine coverage in children enrolled in sixth grade in the 2009 or 2010 school year at Michigan schools to determine whether the new sixth-grade requirements for 2010 and vaccine coadministration (i.e., administering more than 1 vaccine at different anatomical sites during the same visit) were associated with completion, and decreased time to completion, of all the required vaccines. We also assessed time to initiation of the HPV vaccine series in girls, a vaccine series that was ACIP recommended but not required under the school rules.     

Trust,Medication Adherence,and Hypertension Control in Southern African American Men

We examined the relationship between trust in the medical system, medication adherence, and hypertension control in Southern African American men. The sample included 235 African American men aged 18 years and older with hypertension. African American men with higher general trust in the medical system were more likely to report better medication adherence (odds ratio [OR] = 1.06), and those with higher self-efficacy were more likely to report better medication adherence and hypertension control (OR = 1.08 and OR = 1.06, respectively).Trust remains an important issue with African Americans (AAs), particularly in the South where its history of mistreatment and racial discrimination at times were highly prevalent.1 Racial and ethnic minorities are more prone than are Whites to distrust the health care establishment, and historically, minority men have had less access to culturally competent providers.2–4 Southern AAs are more likely than are Whites to report perceived racial barriers to care,5 and AA men are more likely than are AA women to report perceived discrimination.6–10 Perceived discrimination and mistreatment are associated with poorer medical adherence and delays in seeking health care.11–14 In addition, higher levels of trust in the health care system are associated with better adherence to recommended care, greater patient satisfaction, and better outcomes.15–18 This has significant implications considering that AA men develop hypertension (HTN) at an earlier age, have higher rates of advanced (stage 3) HTN, are more likely to experience HTN complications, and are less likely to achieve HTN-control compared with White men.19–21 The rates of HTN are even higher in the South for AA men, accounting, in part, for higher stroke (80% higher) and cardiovascular mortality (50% higher) in this subpopulation compared with other groups in other regions.21–23The goal of this brief study was to assess the relationship between trust in the medical, medication adherence,24 and HTN control25 among Southern AA men. Other covariates were perceived discrimination, perceived racism, self-efficacy, and participation in medical decision-making. This study is based on the Race and Health Outcomes Model developed by Williams et al.26     

The State of Research on Racial/Ethnic Discrimination in The Receipt of Health Care

Objectives. We conducted a review to examine current literature on the effects of interpersonal and institutional racism and discrimination occurring within health care settings on the health care received by racial/ethnic minority patients.Methods. We searched the PsychNet, PubMed, and Scopus databases for articles on US populations published between January 1, 2008 and November 1, 2011. We used various combinations of the following search terms: discrimination, perceived discrimination, race, ethnicity, racism, institutional racism, stereotype, prejudice or bias, and health or health care. Fifty-eight articles were reviewed.Results. Patient perception of discriminatory treatment and implicit provider biases were the most frequently examined topics in health care settings. Few studies examined the overall prevalence of racial/ethnic discrimination and none examined temporal trends. In general, measures used were insufficient for examining the impact of interpersonal discrimination or institutional racism within health care settings on racial/ethnic disparities in health care.Conclusions. Better instrumentation, innovative methodology, and strategies are needed for identifying and tracking racial/ethnic discrimination in health care settings.Racial/ethnic minorities suffer disproportionate morbidity and mortality from chronic diseases, including cancer, heart disease, diabetes, and stroke. US racial/ethnic health disparities are a consequence of several factors including the disproportionate prevalence of less healthy lifestyles, low socioeconomic status, resource-poor neighborhood environments, and poorer access to care. Another factor is the poorer care received by minority patients after they enter the health care system. The 2005 National Healthcare Disparities Report indicated that White patients receive better quality of care than 53% of Hispanic, 43% of African American, 38% of American Indian/Alaska Native, and 22% of Asian and Pacific Islander patients.1 An updated report in 2010 showed no changes in disparities in 30 of 41 quality core measures for Hispanics, 40 of 47 measures for African Americans, 13 of 19 measures for Asians, and 15 of 22 measures for American Indian or Alaska Natives compared with Non-Hispanic Whites.2 Efforts to eliminate these disparities are hampered by the lack of a full understanding of all proximal causes including any role that racial/ethnic discrimination within the health care system might play.Racial discrimination is defined as “(1) differential treatment on the basis of race that disadvantages a racial group and, (2) treatment on the basis of inadequately justified factors that disadvantage a racial group,”^3(p39) and has been linked to racial/ethnic disparities in health outcomes. Not all discrimination occurs at the individual level or is intended. Seemingly benign policies, practices, structures, and regulations also have the potential to be discriminatory and are collectively referred to as institutional racism. Individual level discrimination and institutional racism may compound the negative effects of other health determinants,4 thereby placing racial/ethnic minorities in double jeopardy.Results of a recent nationwide poll of the United States showed that 74% of African Americans, 69% of other non-Whites, and 30% of Whites report personally experiencing general race-based discrimination.5 Research studies have shown that general experiences with racial/ethnic discrimination are associated with a variety of adverse health outcomes including higher mortality6; lower use of cancer screening7; elevated blood pressure8,9; higher levels of C-reactive protein10; substance use11,12; mental and physical health13,14 including mood, anxiety, and psychiatric disorders12; increased depressive symptoms15; weight gain16; high body mass index17; and smoking.18 Not all studies, however, have found a significant association between general race/ethnicity-based discrimination and health.19,20 Although racial/ethnic discrimination within health care settings and health systems has also been implicated in health disparities,21 little is known about the empirical evidence supporting its prevalence or the association with poor health outcomes.We provide a review of the scientific literature on the prevalence, perception of and effect of racial/ethnic discrimination and institutional racism within health care settings. Our specific objectives were to examine the extent to which recent literature addressed the following research questions:

1. What research methods are currently being used to measure receipt of discriminatory health care?
2. What is the current prevalence of racial/ethnic discrimination in health care settings?
3. Has the perception of or receipt of discriminatory health care changed over time?
4. How does racial/ethnic discrimination influence health in health care settings?
5. How do system level factors, such as institutional practices, policies and regulations contribute to discriminatory health care services?

This review summarizes results of recent research, identifies currently used instrumentation and methodology, and identifies areas where additional research is needed and is a resource for researchers with interest in working in this topic area.     

Connecting Race and Place: A County-Level Analysis of White,Black, and Hispanic HIV Prevalence,Poverty, and Level of Urbanization

Objectives. We evaluated the role of poverty in racial/ethnic disparities in HIV prevalence across levels of urbanization.Methods. Using national HIV surveillance data from the year 2009, we constructed negative binomial models, stratified by urbanization, with an outcome of race-specific, county-level HIV prevalence rates and covariates of race/ethnicity, poverty, and other publicly available data. We estimated model-based Black–White and Hispanic–White prevalence rate ratios (PRRs) across levels of urbanization and poverty.Results. We observed racial/ethnic disparities for all strata of urbanization across 1111 included counties. Poverty was associated with HIV prevalence only in major metropolitan counties. At the same level of urbanization, Black–White and Hispanic–White PRRs were not statistically different from 1.0 at high poverty rates (Black–White PRR = 1.0, 95% confidence interval [CI] = 0.4, 2.9; Hispanic–White PRR = 0.4, 95% CI = 0.1, 1.6). In nonurban counties, racial/ethnic disparities remained after we controlled for poverty.Conclusions. The association between HIV prevalence and poverty varies by level of urbanization. HIV prevention interventions should be tailored to this understanding. Reducing racial/ethnic disparities will require multifactorial interventions linking social factors with sexual networks and individual risks.Within the United States, disparities in diagnosed HIV prevalence among the 3 major racial/ethnic groups (White, Black, and Hispanic) are striking. At the end of 2009, 43% of people living with an HIV diagnosis were Black, 35% White, and 19% Hispanic.1 Concurrently, Blacks constituted only 12% of the population, non-Hispanic Whites 65%, and Hispanics 16%.2 In the 46 states with confidential name-based HIV reporting since at least January 2007, the estimated diagnosed HIV prevalence rate at the end of 2009 was 952 per 100 000 people among Blacks (near the threshold for a generalized epidemic),1 320 per 100 000 among Hispanics, and 144 per 100 000 among Whites; compared with Whites, therefore, Blacks and Hispanics were respectively 6.6 times and 2.2 times more likely to be living with an HIV diagnosis.A number of mechanisms, primarily structural and social factors, have been proposed to explain these stark racial/ethnic disparities in HIV prevalence.3,4 Structural factors, such as oppression and mistrust in government, may hinder receptivity to prevention outreach and increase HIV prevalence.3 Social constructs (e.g., homophobia and HIV stigma) may discourage open discussion of risk behaviors and limit HIV testing and treatment. Additionally, limited access to health care resources has been identified as a key driver of racial/ethnic health disparities.5 Finally, Black men are more likely than White men to be both incarcerated and infected with HIV while incarcerated.6,7 All of these factors are, in turn, associated with poverty.8 However, specific relationships among these multiple factors and racial/ethnic HIV prevalence disparities, and variation of these relationships across levels of urbanization, are not well understood.Previous analyses of national surveillance and survey data in the United States have focused on associations between HIV prevalence rates, poverty, and race exclusively in urban areas, finding no disparities in poverty-adjusted HIV prevalence rates among heterosexuals in urban settings.9,10 Furthermore, among heterosexuals living in US urban areas with high AIDS prevalence, HIV prevalence rates among those living at or below the poverty line were 2.2 times as high as rates among those living above the poverty line.10 A more recent analysis of US surveillance data confirmed the complex associations between demographics, social determinants of health, and AIDS diagnosis rates.8However, variation in these factors across the urban–rural continuum may limit generalizability of these findings to nonurban settings, where similar research is lacking. In 2009, the proportions of Black and Hispanic Americans living in poverty were roughly twice that of White Americans.11 For all races/ethnicities, the proportion living in poverty is greater in rural areas than in urban areas.12 Additionally, rural areas, with lower HIV prevalence, are more likely to be medically underserved, with reduced access to HIV care and treatment.13In the context of these complex sociodemographic associations, previously observed associations in the United States between poverty and racial/ethnic disparities in HIV may differ outside of urban areas. Therefore, using publicly available county-level data, we first describe the association between poverty and HIV prevalence by race/ethnicity across levels of urbanization. We subsequently examine racial/ethnic disparities in HIV prevalence across levels of urbanization, after controlling for poverty. We hypothesized that, in all strata of urbanization, poverty-adjusted Black–White and Hispanic–White HIV prevalence rate ratios (PRRs) would statistically differ from 1.0.     

Hepatitis C Testing,Infection, and Linkage to Care Among Racial and Ethnic Minorities in the United States, 2009–2010

Objectives. We estimated rates and determinants of hepatitis C virus (HCV) testing, infection, and linkage to care among US racial/ethnic minorities.Methods. We analyzed the Racial and Ethnic Approaches to Community Health Across the US Risk Factor Survey conducted in 2009–2010 (n = 53 896 minority adults).Results. Overall, 19% of respondents were tested for HCV. Only 60% of those reporting a risk factor were tested, with much lower rates among Asians reporting injection drug use (40%). Odds of HCV testing decreased with age and increased with higher education. Of those tested, 8.3% reported HCV infection. Respondents with income of $75 000 or more were less likely to report HCV infection than those with income less than $25 000. College-educated non-Hispanic Blacks and Asians had lower odds of HCV infection than those who did not finish high school. Of those infected, 44.4% were currently being followed by a physician, and 41.9% had taken HCV medications.Conclusions. HCV testing and linkage to care among racial/ethnic minorities are suboptimal, particularly among those reporting HCV risk factors. Socioeconomic factors were significant determinants of HCV testing, infection, and access to care. Future HCV testing and prevention activities should be directed toward racial/ethnic minorities, particularly those of low socioeconomic status.Hepatitis C virus (HCV) infection affects almost 3 million Americans and is the leading cause of death associated with liver disease in the United States.1,2 Racial disparities in the prevalence of HCV infection have previously been documented: Non-Hispanic Blacks have the highest prevalence of HCV infection in the United States, about twice that reported among non-Hispanic Whites.1 Fewer data exist on the prevalence of hepatitis C among the Latino population, and they have been derived mainly from the National Health and Nutrition Examination Survey, in which only Mexican Americans were represented.1,3,4 Even more limited data are available on the prevalence of HCV infection among Asians and American Indians/Alaska Natives (AI/ANs), with most of the studies localized to specific states or facilities.5–8 More important is the dearth of data regarding the prevalence of hepatitis C testing and access to care—information critical to public health planning and policy—among racial/ethnic minorities in the United States. Early identification and treatment of hepatitis C infection are essential to prevent liver cancer and associated health care costs.9,10 Over the 10-year period from 2010 to 2019, the direct medical cost of chronic HCV infection is projected to exceed $10.7 billion, and the societal cost of premature mortality is estimated at $54.2 billion.11Studies have reported that several minority communities have disproportionately lower socioeconomic status, greater barriers to access to health care, and greater risks for and burden of disease compared with Whites or the general population living in the same geographical area.12–14 Socioeconomic factors have been postulated to play a role in access to care and treatment of hepatitis C.15–17 However, very few studies have assessed the role played by socioeconomic factors in hepatitis C testing and infection among racial/ethnic minorities. Not all racial/ethnic minorities were included in these studies, and the majority failed to control for traditional HCV infection risk factors.1,4,18 The Centers for Disease Control and Prevention’s recommendations for HCV testing are based on presence of HCV risk factors, hence the need to control for them while assessing the determinants of hepatitis C testing and infection.19In 2006, 1 of every 4 US residents identified themselves as being a racial/ethnic minority,20 and the US Census Bureau has projected that by 2050 minority populations will make up approximately 50% of the US population.21 Thus, a need exists for more information about hepatitis C among the different racial/ethnic groups in the United States to be able to design evidence-based prevention interventions and avoid the projected increases in medical expenses.11The objectives of this study were to assess hepatitis C testing, infection, and access to health care and treatment among racial/ethnic minorities in the United States and to examine whether demographic, socioeconomic, and hepatitis C risk factors influence hepatitis C testing, infection, and access to care in this population.     

Colorectal Cancer Screening Among the Homeless Population of New York City Shelter-Based Clinics

Objectives. We determined colorectal cancer (CRC) screening rates, predictors, and barriers in 2 major New York City shelter-based clinics.Methods. We extracted screening rates, sociodemographic characteristics, and factors associated with homelessness from medical records of domiciled and homeless patients aged 50 years and older (n = 443) with at least 3 clinic visits between 2010 and 2012.Results. The majority of patients were African American or Hispanic, 76% were male, and 60.7% were homeless (mean = 2.4 years; SD = 2.8 years). Domiciled patients were more likely than homeless patients to be screened (41.3% vs 19.7%; P < .001). Homeless and domiciled patients received equal provider counseling, but more homeless patients declined screening (P < .001). In logistic regression, gender, race, duration of homelessness, insurance status, substance and alcohol abuse, chronic diseases, and mental health were not associated with screening, but housing, provider counseling, and older age were.Conclusions. Proposed interventions to improve CRC screening include respite shelter rooms for colonoscopy prepping, patient navigators to help navigate the health system and accompany patients to and from the procedure, counseling at all clinical encounters, and tailored patient education to address misconceptions.Colorectal cancer (CRC) is the third most common cancer and the second leading cause of cancer death in the Unites States, with 53 000 largely preventable deaths annually.1,2 CRC screening reduces morbidity and mortality by 60% and is considered the standard of care.3 The US Preventive Services Task Force (USPSTF) recommends CRC screening for all adults aged 50 to 75 years and for high-risk adults until age 85 years: a fecal occult blood test (FOBT) once per year, flexible sigmoidoscopy every 5 years with an FOBT every 3 years, or screening colonoscopy every 10 years.2 Despite recommendations, screening rates for CRC remain lower than for other types of cancer.1Little is known about CRC screening practices in the homeless population,4 but this population is expanding. An estimated 3.5 million Americans experience homelessness each year, and an estimated 633 782 people experience homelessness each night in the United States.5,6 More than 15% of these individuals are chronically homeless, and more than 18% of the homeless are older than 50 years.5,7 This population is aging and has a large component of persons born during the latter part of the baby boom era. Men aged 45 to 54 years are at the highest risk for homelessness, and many of them are veterans.8 These individual are entering their 50s and are due for CRC screening.2,9,10 New York State''s homeless population surpasses the national average, and the rate of chronic homelessness is rising.5 New York City is experiencing an all-time high of homelessness, with more than 28 000 adults sleeping each night in the municipal shelter system11 and approximately 3000 living on the streets.12Barriers to CRC screening include low rates of provider recommendation and patients’ lack of CRC knowledge,13–15 invasiveness, extensive preparation, discomfort, inability to pay for screening or follow-up care or lack of medical insurance,13 lack of trust in physicians, embarrassment, absence of symptoms, and fatalistic views about cancer.16 Screening rates are particularly low in minority and low-income populations, and these groups suffer higher rates of CRC mortality, in part because cancers are detected at a later stage.1,4 Other risk factors for never having or not being up-to-date with screening recommendations are Hispanic ethnicity, low education level, low income, recent immigration status, lack of a primary care physician, and no visit to a physician in the past year.17 Interventions implemented in primary care settings to improve CRC screening rates among racial and ethnic minorities have helped improve rates significantly.18Homeless persons are especially vulnerable and suffer worse health than domiciled ethnic and minority populations. The homeless have high rates of physical illness, mental illness, and substance abuse and are at increased risk for premature death.10,19 They are less likely to have a primary care provider and to adhere to medication regimens.10 Subsistence needs often take priority over health care that is not seen as urgent, such as preventive care. Furthermore, past experiences of discrimination in the health care setting decrease their likelihood of seeking health care again.16,19A considerable portion of nondomiciled Americans would likely benefit from CRC screening. We compared CRC screening rates among a New York City homeless population and an underserved population that used the same health facilities for adherence to USPSTF recommendations and identified predictors of and barriers to screening among the homeless population.     

H1N1 Influenza Vaccination During Pregnancy and Fetal and Neonatal Outcomes

Objectives. We evaluated the relationship between maternal H1N1 vaccination and fetal and neonatal outcomes among singleton births during the 2009–2010 H1N1 pandemic.Methods. We used a population-based perinatal database in Ontario, Canada, to examine preterm birth (PTB), small-for-gestational-age (SGA) births, 5-minute Apgar score below 7, and fetal death via multivariable regression. We compared outcomes between women who did and did not receive an H1N1 vaccination during pregnancy.Results. Of the 55 570 mothers with a singleton birth, 23 340 (42.0%) received an H1N1 vaccination during pregnancy. Vaccinated mothers were less likely to have an SGA infant based on the 10th (adjusted risk ratio [RR] = 0.90; 95% confidence interval [CI] = 0.85, 0.96) and 3rd (adjusted RR = 0.81; 95% CI = 0.72, 0.92) growth percentiles; PTB at less than 32 weeks’ gestation (adjusted RR = 0.73; 95% CI = 0.58, 0.91) and fetal death (adjusted RR = 0.66; 95% CI = 0.47, 0.91) were also less likely among these women.Conclusions. Our results suggest that second- or third-trimester H1N1 vaccination was associated with improved fetal and neonatal outcomes during the recent pandemic. Our findings need to be confirmed in future studies with designs that can better overcome concerns regarding biased estimates of vaccine efficacy.During the 2009–2010 H1N1 influenza pandemic, early case reports documented more severe illness among pregnant women than among the general population, as well as higher rates of hospitalization and intensive care unit admissions.1,2 Later reports confirmed the disproportionately severe clinical course among pregnant women infected with H1N1 influenza.3–6 Public health organizations7–9 and professional associations10,11 strongly encouraged pregnant women to receive an H1N1 vaccination, and recent evidence suggests that the intensive vaccination campaign resulted in higher maternal vaccination rates during the pandemic than had been documented in previous influenza seasons.12–14Recommendations for routine vaccination of all pregnant women with inactivated influenza vaccine have been in place in Canada and the United States for a number of years.15–18 Nevertheless, seasonal vaccination rates prior to the 2009–2010 pandemic year were low in the United States,19–22 ranging from 0.7% to 20% (estimates were not available for Canada). In both countries, misconceptions about the risk of complications from influenza infection during pregnancy23 and concerns about safety12,23 are commonly cited reasons for not receiving an influenza vaccination, whereas care provider recommendations have been shown to increase vaccination rates.12,14,24Despite ongoing maternal concerns about vaccine safety, no evidence of serious harmful effects following influenza vaccination during pregnancy has been reported in the available studies on this topic19–21,25–32; thus, vaccination is promoted as the best way of preventing maternal morbidity from influenza infection.31 Theoretically, maternal influenza vaccination should also benefit the fetus by averting maternal illness and associated hyperthermia and other morbidity.28,31 Recent studies have reported a lower risk of preterm birth (PTB)33 and small-for-gestational-age (SGA) infants33,34 among women receiving an influenza vaccination during their pregnancy. However, the impact of maternal influenza vaccination on fetal and neonatal outcomes has not been extensively evaluated, possibly as a result of low immunization rates and limited sample sizes that preclude assessment of rare outcomes.In Ontario, Canada, the 2009 pandemic H1N1 vaccination campaign started on October 26, 2009; high-priority groups, including pregnant women, were targeted. During the pandemic, Better Outcomes Registry & Network (BORN) Ontario collected influenza immunization information from all pregnant women who gave birth in the province. Using this large, population-based birth cohort, we examined the association between maternal H1N1 influenza vaccination and fetal and neonatal outcomes.     

Community Poverty and Trends in Racial/Ethnic Survival Disparities Among People Diagnosed With AIDS in Florida, 1993–2004

Objectives. We described the racial/ethnic disparities in survival among people diagnosed with AIDS in Florida from 1993 to 2004, as the availability of highly active antiretroviral therapy (HAART) became widespread. We determined whether these disparities decreased after controlling for measures of community-level socioeconomic status.Methods. We compared survival from all causes between non-Hispanic Blacks and non-Hispanic Whites vis-a-vis survival curves and Cox proportional hazards models controlling for demographic, clinical, and area-level poverty factors.Results. Racial/ethnic disparities in survival peaked for those diagnosed during the early implementation of HAART (1996–1998) with a Black-to-White hazard ratio (HR) of 1.72 (95% confidence interval [CI] = 1.62, 1.83) for males and 1.40 (95% CI = 1.24, 1.59) for females. These HRs declined significantly to 1.48 (95% CI = 1.35, 1.64) for males and nonsignificantly to 1.25 (95% CI = 1.05, 1.48) for females in the 2002 to 2004 diagnosis cohort. Disparities decreased significantly for males but not females when controlling for baseline demographic factors and CD4 count and percentage, and became nonsignificant in the 2002 to 2004 cohort after controlling for area poverty.Conclusions. Area poverty appears to play a role in racial/ethnic disparities even after controlling for demographic factors and CD4 count and percentage.The HIV/AIDS epidemic has disproportionately affected the non-Hispanic Black population in the United States. In 2008, an estimated 545 000 non-Hispanic Blacks were living with HIV/AIDS.1 The estimated prevalence of HIV infection for 2008 among non-Hispanic Blacks was 18.2 per 1000 population, more than 7 times higher than the estimated rate for non-Hispanic Whites (non-Hispanic Whites; 2.4 per 1000).1 Non-Hispanic Blacks as a group not only have a higher prevalence of HIV/AIDS, but once infected also have a lower survival rate. The 3-year survival rate in the United States for people diagnosed with AIDS between 2001 and 2005 was 80% among non-Hispanic Blacks compared with 84% for non-Hispanic Whites, 83% for Hispanics, and 88% for Asians,2 further contributing to the disparities in the HIV mortality rate of 16.8 per 100 000 among non-Hispanic Blacks compared with 1.6 per 100 000 among non-Hispanic Whites during 2007.3 Race/ethnicity is a fundamentally social as opposed to a biological construct,4,5 and survival disparities between non-Hispanic Blacks and non-Hispanic Whites have not generally been seen in settings with universal health care access such as in the Veterans Administration health care system,6 the military health care system,7 or a health maintenance organization.8 Therefore, potentially modifiable social explanations for the observed racial/ethnic disparities in survival should be examined.A most remarkable advance in medical treatment in the past century was the development of highly active antiretroviral therapy (HAART). It led to a significant improvement in survival from HIV/AIDS, 9–12 but racial/ethnic disparities in HIV/AIDS survival remain2, 13–16 and in New York City appeared to widen.17 Despite these well-recognized health disparities, there is a critical gap in the knowledge about why the disparity exists. Two population-based studies, both in San Francisco, California (a city that has provided free HIV care for those who cannot afford it), found that Black race was no longer associated with survival between 1996 and 2001 after controlling for neighborhood socioeconomic status (SES), and that this SES effect seemed to be related to HAART use.18,19 However, in a study using HIV surveillance data from 33 states, racial/ethnic disparities in 5-year survival after HIV diagnosis between 1996 and 2003 persisted after adjusting for county-level SES and other factors.20 The objective of this study was to describe the racial/ethnic disparities in AIDS survival in Florida among people diagnosed with AIDS between 1993 and 2004 (a period spanning the time before and during the widespread availability of HAART) and to determine if these disparities decrease after controlling for community-level SES.     

Contribution of Communication Inequalities to Disparities in Human Papillomavirus Vaccine Awareness and Knowledge

Objectives. We examined the association of Internet-related communication inequalities on human papillomavirus (HPV) vaccine awareness and infection knowledge.Methods. We drew data from National Cancer Institute’s 2007 Health Information National Trends Survey (n = 7674). We estimated multivariable logistic regression models to assess Internet use and Internet health information seeking on HPV vaccine awareness and infection knowledge.Results. Non–Internet users, compared with general Internet users, had significantly lower odds of being aware of the HPV vaccine (odds ratio [OR] = 0.42; 95% confidence interval [CI] = 0.34, 0.51) and knowing that HPV causes cervical cancer (OR = 0.70; 95% CI = 0.52, 0.95). Among general health information seekers, non–Internet seekers compared with Internet information seekers exhibit significantly lower odds of HPV vaccine awareness (OR = 0.59; 95% CI = 0.46, 0.75), and of knowing about the link between HPV infection and cervical cancer (OR = 0.79; 95% CI = 0.63, 0.99) and the sexual transmission of HPV (OR = 0.71; 95% CI = 0.57, 0.89). Among cancer information seekers, there were no differences in outcomes between Internet seekers and non–Internet seekers.Conclusions. Use of a communication channel, such as the Internet, whose use is already socially and racially patterned, may widen observed disparities in vaccine completion rates.In 2006, the Food and Drug Administration approved the first vaccine for the 4 major types of human papillomavirus (HPV), 2 of which cause approximately 70% of cervical cancer cases in the United States.1 Many health officials and researchers have indicated that appropriate uptake of the vaccine could serve as a way to eliminate disparities in cervical cancer rates seen throughout the United States.2 However, according to the Centers for Disease Control and Prevention’s (CDC’s) most recent National Immunization Survey–Teen, only 37% of US female adolescents aged 13 to 17 years initiated the HPV vaccine series (≥ 1 dose) in 2008 and a mere 18% of teens completed the necessary 3-dose series.3More important than the overall low series completion rates nationally are the noted disparities across racial and social groups. Several large-scale studies, including the 2008 National Immunization Survey, have reported that, although African American and Hispanic girls are more likely to initiate the series, they are less likely to complete the 3-dose series compared with their White counterparts.4–6 In addition, reports indicate that girls living in poorer states and in neighborhoods with low education levels, and those who rely on public insurance are also less likely to complete the vaccine series compared with girls living in wealthier states and in neighborhoods with higher aggregate education levels, and those who are covered by private insurance.4,6,7 If these racial and social disparities in completion rates continue, they may further exacerbate what is already an unequal burden of cervical cancer among these groups of women.We suggest that the discrepancy between initiation and completion rates may in part be attributable to the well-documented knowledge gaps among lower–socioeconomic status (SES) and minority parents, caregivers, and other influential adults about what HPV is, how it is spread, and how it can be prevented across these vulnerable groups.8–10 The initiation shot typically occurs during a well-child visit along with a host of other vaccinations, raising the issue as to whether patients and guardians are truly informed of what vaccinations they are receiving, but completion shots need to be separately scheduled. Knowledge and awareness therefore may play a larger role in the decision-making process as to whether a child or adolescent will complete the series because they will occur outside the normal doctor’s visit.What is less known, and what needs to be examined to reduce the disparities in completion rates, are the driving factors behind these knowledge gaps. We argue that communication is one thread that could potentially connect the different levels of social determinants that could ultimately explain individual health status and population-level health because of the different functions it serves.11–13 If so, communication inequalities—differences among social groups in accessing, seeking, processing, and using health information—could play an important role in shaping HPV-related knowledge gaps, which may, in turn, influence vaccine completion rates.11 In the case of HPV, there are a number of communication inequalities that warrant examination. For example, disparities in completion rates may in part be influenced by a breakdown in patient–provider communication. However, there is a substantial body of evidence indicating the ever-growing reliance on the Internet, over physicians, as an important source of health information.11 Therefore, we offer that HPV-related knowledge gaps and communication inequalities may primarily be a product of (1) the vaccine manufacturer’s reliance on Internet-based direct-to-consumer advertising (DTCA) as the main information delivery system for both the infection and the vaccine, combined with (2) differential access and use of the Internet among those of low SES and minority populations.Merck’s Gardasil is one of the first cancer vaccines for prophylactic use, and as such, they created a lucrative market with revenue estimates close to $3.2 billion by the year 2012.14 Because Merck has a large financial stake in the success of the vaccine, industry analysts report that an overwhelming majority of the messages and information that the public receives about HPV and the vaccine are somehow linked to the pharmaceutical developer.14,15 If one considers how limited public health funds are, there is a perceived benefit of having a large pharmaceutical company with a substantial marketing budget take on the burden of educating the public about the harmful effects of the disease while advertising its product.The goal of print and television DTCA, however, is to make consumers aware of the brand name of a drug and to drive them to perform external searching or, rather, information seeking, which is the purposive and deliberate seeking of information on a topic because of its salience and need.16 External information seeking is recognized in the health marketing industry as the way consumers can expand their knowledge of the drugs represented.17 Moreover, research shows that consumers are increasingly turning to the Internet, over other channels, to search for more information about a drug they saw on television.18,19 With increased advertising spending, concerns have been raised that print and TV DTCA may mislead consumers with unbalanced and incomplete information making the reliance on external searching, specifically Internet information seeking, even more crucial.19Unfortunately, reliance on Internet-based external searches to provide needed information for informed decision-making on HPV vaccination could only exacerbate existing knowledge gaps. Research has shown that education is strongly associated with consumer information seeking as well as with time spent looking for the information.20 Research also shows that DTCA is not appropriate for low-literacy audiences as the information provided is too complex and written at a high reading grade level.21–23 There is the additional consideration that many low-SES and minority groups lack Internet access as well as the needed computer literacy skills to adequately search the Internet for health-related information.24 Recent analyses of the National Cancer Institute’s Health Information National Trends Survey (HINTS) 2007 offer further evidence of digital disparities. Although overall penetration of Internet access in the United States has increased to 70%, the digital divide remains with nearly half of Hispanics and non-Hispanic Blacks lacking Internet access even after controlling for other important variables. The same is true across socioeconomic strata with adults with lower education levels and income having significantly lower odds of Internet access compared with their higher-SES peers.25 Additional research on the 2007 HINTS data also highlight disparities in online health information seeking with lower odds of using the Internet as a first source of health information among those with lower incomes and education levels, and for Blacks compared with Whites.26 Moreover, limited computer literacy skills could potentially interact with limited health literacy skills among low-SES and minority groups to not only inhibit the initiation of Internet-based health information seeking but also result in procuring misinformation because of improper Web searching. This misinformation could negatively impact HPV and vaccine knowledge as well vaccination uptake and completion rates.Our goal was to examine the association between Internet-based communication and knowledge of the HPV vaccine with the hope of identifying more effective approaches to improve completion rates among underserved groups. In light of the Internet-based communication strategy for the HPV vaccine emphasized by Merck, we hypothesized that those individuals and groups that do not rely on the Internet for health information are likely to have lower levels of awareness and knowledge of both HPV and the HPV vaccine.