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Role of Insurance, Income, and Affordability in Human Papillomavirus Vaccination
Nadereh Pourat, PhD; and Jenna M. Jones, MPH
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Role of Insurance, Income, and Affordability in Human Papillomavirus Vaccination

Nadereh Pourat, PhD; and Jenna M. Jones, MPH
Compared with insured adults, uninsured adults in California had less knowledge of the human papillomavirus vaccine and were less likely to be vaccinated.
Predictors of Having Heard of the HPV Vaccine. The  odds of having heard of the vaccine were lower for those who were uninsured (odds ratio [OR] 0.5) and those with public HMO coverage (0.5), but higher for those with private PPO compared with private HMO coverage (Table 2). Adults with family incomes under 100% of FPL had lower odds than those with incomes at or above 300% of FPL. The odds of forgoing or delaying needed medical care were not significant. The odds of having heard of the vaccine were also lower for Latinos and Asian Americans, and higher for those with some college education and single adults without children.

Predictors of Having Received at Least 1 Dose of HPV Vaccine. Among adults who had heard of the vaccine, the odds of having received at least 1 dose of the vaccine were lower for uninsured individuals (0.3) compared with those who had private HMO coverage. The odds were higher for younger adults and for those who received the flu shot. Poverty level and having forgone or delayed needed care were not significant. Predictors of Having Received All 3 Doses of HPV Vaccine. Among adults who had received at least 1 dose of the HPV vaccine, the odds of having completed the vaccine series were not significantly affected by insurance coverage or poverty, or by having forgone or delayed needed medical care due to cost/no insurance. However, the odds were lower for adults who did not get or delayed needed medical care in the past 12 months for other reasons (0.04) compared with those who did not forgo or delay care. The odds were lower for younger adults and Latinos.

Predictors of Interest in Receiving the HPV Vaccine. Among adults who had not previously heard of the vaccine, insurance did not play a significant role in the odds of being interested in the vaccine, but the odds were lower for those earning between 100% and 299% of FPL (0.7) compared with those earning 300% or more of FPL. The odds were higher for those who had forgone or delayed care due to cost/no insurance (1.6). The odds were higher for those who received the flu vaccine.

Predictors of Willingness to Pay for HPV Vaccine. Among adults who were interested in receiving the vaccine, the odds of being willing to pay $360 for the vaccine did not differ by insurance, poverty, or having forgone or delayed care due to cost/no insurance. However, the odds were lower for those who had forgone or delayed needed medical care for other reasons (0.4). The odds also were lower for those with some college education.

Parents of Daughters Aged 8 to 17 Years

Predictors of Having Heard of the HPV Vaccine. The odds of having heard of the vaccine were lower among the parents who were uninsured (0.6) compared with those who had private HMO coverage (Table 3). Also, the odds were lower for parents with incomes between 100% and 299% of FPL (0.7) compared with those who had incomes at or above 300% of FPL. The odds were higher for parents who had forgone or delayed getting needed medical care due to cost/no insurance (1.8).The odds were lower for all nonwhite groups and those in fair or poor health, but higher in college-educated parents and those who had received a flu shot.

Predictors of Having Received at Least 1 Dose of HPV Vaccine. Among parents who had heard of the vaccine, insurance and poverty level were not significant predictors, but daughters of parents who had forgone or delayed needed medical care in the past year due to cost/no insurance had lower odds (0.6) of initiating the vaccine series. The odds were higher for parents 56 years and older, Latinos, and those who had received a flu shot.

Predictors of Having Received All 3 Doses of HPV Vaccine. Among parents whose daughters who had received at least 1 dose of the HPV vaccine, insurance status, poverty level, and having forgone or delayed getting needed medical care did not predict the odds of parents having their daughter complete the series. The odds were lower for parents with some college education.

Predictors of Interest in Following Physician Recommendation to Vaccinate. Among parents who had not vaccinated their daughters, the odds of interest in following physician recommendation to do so were higher for those with public HMO coverage (1.9) compared with those parents who had private HMO coverage. The odds did not differ by poverty or having forgone or delayed needed medical care. Latinos, single parents, and those who had received a flu shot had higher odds, and African Americans had lower odds.

Predictors of Willingness to Pay for HPV Vaccine. Among parents who were interested in following their physician’s recommendation to vaccinate, the odds of willingness to pay $360 for vaccination did not differ by insurance but were lower for those who earned less than 100% of FPL (0.3) and 100% to 299% of FPL (0.5). The odds were also lower for parents who had forgone or delayed needed medical care due to cost/no insurance (0.5). Latinos had higher odds, and Asian Americans and those in fair or poor health had lower odds.

DISCUSSION

We found an independent association between 1 or more of the enabling predictors of HPV vaccination and all the outcome variables, except for having received all 3 vaccine doses for young girls. Insurance, poverty level, and affordability played different roles in models that examined knowledge of HPV vaccine, rates of vaccination, intent to vaccinate, and willingness to pay. The relationship of specific independent variables to the dependent variables requires further discussion. For example, the question on delayed or forgone care was not specific to HPV vaccination, and the impact of this variable on HPV knowledge, vaccination, and interest is likely to reflect general difficulties in access to services due to costs or lack of insurance. For those individuals, any services requiring cost sharing may be unaffordable. Also, further research is also required into other reasons for delayed or forgone care that led to lower rates of completion of the series or willingness to pay by adults.

Adult age differentials in vaccine initiation may indicate perceptions of older adults about vaccine necessity, perhaps due to the level of sexual activity or previous exposure to HPV. Parental age differentials (daughters of older parents were more likely to have received at least 1 dose of vaccine) may reflect the perceptions of parents about when vaccination should be initiated. The negative association of college education and willingness to pay among adults may indicate their knowledge of low-cost sources of the vaccine. But the negative association of parental education and completion of the 3-dose series requires further investigation. The negative association of parental fair or poor health with knowledge and willingness to vaccinate may reflect the competing demands parents face in seeking needed care for themselves and preventive care for their children.

This study has the following limitations. The data were collected between June 2007 and March 2008. For some respondents only 1 year had passed since the availability of the first vaccine. The rates of vaccine initiation in our data were close to those identified in the National Health Interview Survey by the end of 2008: 11.7% of women aged 18 to 26 years and 22.5% of girls aged 11 to 17 years had initiated the vaccine.19,20 However, our data primarily represent 2007, and the national rates of vaccine initiation or intention to vaccinate for 2007 may have been lower than those in our data. Data from the National Immunization Survey were collected for women aged 18 to 26 years for 2007 and indicated that 78.9% had knowledge of the vaccine and 10% had initiated it.21 Data were available for teens aged 13 to 17 years and showed an increase from 2008 to 2009 for the first dose (37.2%-44.3%) and the third dose (17.9%-26.7%).22 Despite the limitation of California data, our findings represent the earliest data on knowledge of the vaccine and vaccine initiation among teens, and intention to vaccinate and willingness to pay for all age-eligible females. Also, our data were not confounded by system-level differences or population variations among states.

Lack of data on sexual health behaviors, religious and moral beliefs, and vaccine efficacy in CHIS prevented us from directly assessing the role of these factors. The small sample size of adults who completed the vaccine series may have led to fewer significant variables. The differences in the rates of vaccine initiation and completion may be because many respondents had responded to the survey shortly after the receipt of the first or second dose and prior to receipt of the final dose. HPV vaccination requires approximately 6 months, with each dose administered in 2-month intervals.23 We also lacked data on how many vaccinated children or adults obtained the vaccine through the VFC or other free sources. Finally, we did not discuss results with probability values greater than .05 because of the lower level of certainty about the contribution of those variables.

The patterns of HPV vaccination specified in our study may follow the patterns in national hepatitis B vaccination rates,24,25 which rose from zero in 1993 to 67% in 2000 for adolescents ages 13 to 15.26 However, the observed access barriers to HPV vaccination should be addressed for rates to improve evenly among all eligible populations. Our findings indicated that vaccine costs seem to be a barrier to vaccine initiation among uninsured adults. Insurance, income, and experiences of delayed or forgone care also played a role in vaccine initiation, interest in receipt of vaccine, and in some cases willingness to pay for vaccine, which could reflect either knowledge of low-cost or free vaccine or concerns about affordability. Potential barriers due to affordability of the vaccine for individuals with and without coverage should be addressed by reducing the price, providing subsidies, or limiting cost sharing for populations who do not benefit from existing programs or those who find any costs associated with vaccination unaffordable. Increased demand for HPV vaccination is likely to be challenging to VFC and the immunization grant program, given past funding limitations. Healthcare reform may change the relationship between affordability and HPV vaccination rates after 2014, but barriers to vaccination may persist.

Significant and widespread media and advertising campaigns by both vaccine manufacturers and the Centers for Disease Control and Prevention followed the release of the first HPV vaccine. These campaigns were aimed at raising awareness of the link between HPV infections and cervical cancer, and the availability of HPV vaccines. Our findings indicate the failure of these campaigns to reach lower income adults and parents, adults with public HMO coverage, Latino and Asian American adults and parents, and African American parents. Also, these campaigns seem to have reached adults with private PPO coverage, college-educated adults and parents, and single adults without children, but not their counterparts with private HMO coverage, lower education, or married adults.

 
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