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Human Papillomavirus Vaccination Estimates Among Adolescents in the Mississippi Delta Region: National Immunization Survey‑Teen, 2015–2017

David Yankey, PhD1; Laurie D. Elam-Evans, PhD1; Connie L. Bish, PhD2; Shannon K. Stokley, DrPH1 (View author affiliations)

Suggested citation for this article: Yankey D, Elam-Evans LD, Bish CL, Stokley SK. Human Papillomavirus Vaccination Estimates Among Adolescents in the Mississippi Delta Region: National Immunization Survey‑Teen, 2015–2017. Prev Chronic Dis 2020;17:190234. DOI: http://dx.doi.org/10.5888/pcd17.190234.

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Summary

What is already known about this topic?

Routine human papillomavirus (HPV) vaccination is recommended for children aged 11 or 12 years to prevent HPV and associated cancers.

What is added by this report?

Geographic disparities in HPV vaccine coverage exist in the Mississippi Delta Regional Authority (DRA) counties and other counties in Delta states, compared with states outside the Delta region.

What are the implications for public health practice?

Efforts to improve coverage are needed, particularly in the DRA region and other counties in Delta states. Providing parents and guardians with information and strong, compelling recommendations can improve HPV vaccination coverage.

Abstract

Introduction

The Delta Regional Authority (DRA) consists of 252 counties and parishes in 8 states in the US Mississippi Delta region. DRA areas have high rates of disease, including cancers related to the human papillomavirus (HPV). HPV vaccination coverage in the DRA region has not been documented.

Methods

We analyzed data for 63,299 adolescents aged 13 to 17 years in the National Immunization Survey-Teen, 2015–2017. We compared HPV vaccination initiation coverage estimates (≥1 dose) in the DRA region with coverage estimates in areas in the 8 Delta states outside the DRA region and non-Delta states. We examined correlates of HPV vaccination coverage initiation and reasons parents did not intend to vaccinate adolescents.

Results

Vaccination rates in the DRA region (n = 2,317; 54.3%) and in Delta areas outside the DRA region (n = 6,028; 56.2%) were similar, but these rates were significantly lower than rates in non-Delta states (n = 54,954; 61.4%). Inside the DRA region, reasons for parents’ vaccine hesitancy or refusal were similar to those expressed by parents in the Delta areas outside the DRA region. Some parents believed that the vaccine was not necessary or had concerns about vaccine safety.

Conclusion

HPV vaccination coverage in the DRA region is similar to coverage in other Delta counties and parishes, but it is significantly lower than in non-Delta states. Activities to address parental concerns and improve provider recommendations for the vaccine in the DRA region are needed to increase HPV vaccination rates.

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Introduction

The Delta Regional Authority (DRA) was established in 2000 by the US Congress to support economic development and improve living standards for approximately 10 million residents in 252 designated counties and parishes in 8 Mississippi Delta states: Alabama, Arkansas, Illinois, Kentucky, Louisiana, Mississippi, Missouri, and Tennessee (Figure) (1). Counties in the DRA region are significantly disadvantaged, and 43.3% are classified as in persistent poverty, versus 11.2% in the nation as a whole (2).

United States’ Delta Regional Authority (DRA) counties and parishes.

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Figure.

United States’ Delta Regional Authority (DRA) counties and parishes. [A text version for this figure is also available.]

Residents of the Delta region have a poorer health status than do other US residents (3). Residents in the DRA region are more likely than other US residents to have a high body mass index, high blood pressure, diabetes, and are more likely to smoke and die of cancer (4,5). Although DRA counties are uniquely disadvantaged, they are located in Mississippi Delta states where other counties have similar demographic factors. Despite similarities, compared with counties in these states but outside the DRA region, DRA counties have substantially worse health indicators, such as those associated with social determinants of health and cardiovascular disease morbidity and mortality (6,7).

A 2005 county-level analysis indicated that DRA counties had a median cancer mortality rate that was approximately 8.5% higher than in counties in Delta states outside the DRA region (8). Overall, residents inside DRA areas have a substantially higher incidence of human papilloma virus (HPV)-associated cancers than US residents overall (9), particularly cervical cancer (10), as well as a higher incidence of sexually transmitted infections other than HPV (11).

The Advisory Committee on Immunization Practices (ACIP) recommends routine vaccination of children aged 11 or 12 years with HPV vaccine to prevent HPV-associated cancers (12,13). Despite this recommendation, HPV vaccination coverage has remained low nationally relative to other recommended vaccines (14). Coverage of HPV vaccine in DRA areas has not been documented.

The objective of this analysis was to 1) better understand HPV vaccination coverage among adolescents in DRA areas and how it compares to the rest of the nation, 2) examine the association of sociodemographic and health care-related factors with HPV vaccination, and 3) examine HPV vaccination intentions and reasons for hesitancy among parents of unvaccinated adolescents.

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Methods

The National Immunization Survey-Teen (NIS-Teen) is a random-digit–dialed telephone survey of parents or guardians of adolescents aged 13 to 17 years. NIS-Teen also includes a survey mailed to all vaccination providers identified by the parent and those who consented to contact for vaccination history (15). NIS-Teen uses a national probability sample of households in the United States, which includes all 50 states, the District of Columbia, and selected local areas.

We analyzed NIS-Teen data from 2015, 2016, and 2017, collected from households by way of landlines and cellular telephones (16,17). Provider-reported vaccination records were used to determine all HPV vaccination coverage estimates among adolescents. In this analysis, adolescents without adequate provider data were excluded; NIS-Teen methodology assigns provider phase weights to control for both provider nonresponse and for adolescents without adequate provider data for other reasons (18,19). Details of the NIS-Teen methodology, including how multiple survey years of vaccination data are combined to produce a synthesized immunization history and a description of the weighting procedure, have been published (16,17). The 2015–2017 NIS-Teen was approved by the National Center for Health Statistics Research Ethics Review Board, and the NORC (National Opinion Research Center) at the University of Chicago Institutional Review Board.

We included data from 63,299 adolescents, aged 13 to 17 years, in 2015–2017 NIS-Teen. Inclusion criteria required that adolescents have adequate provider data (ie, vaccination history documentation from provider reports) to determine whether they were up-to-date with vaccinations. The Council of American Survey Research Organizations (CASRO) landline response rates were 56.4% for 2015, 55.5% for 2016, and 51.5% for 2017. CASRO response rates for the cell phone sample were 29.8% for 2015, 29.5% for 2016, and 23.5% for 2017 (20). The annual number of adolescents with completed household interviews and adequate provider data in the sample was 21,875 (49.8%) for 2015; 20,475 (48.8%) for 2016; and 20,949 (48.1%) for 2017 (20).

We categorized our study population into 3 geographic areas: inside DRA areas (n = 2,317), Delta areas outside the DRA (counties and parishes outside the DRA in the 8 Mississippi Delta states, n = 6,028), and non-Delta states (the District of Columbia and the remaining United States that are outside the Mississippi Delta, n = 54,954). We examined a dichotomous outcome of HPV vaccine initiation (≥1 HPV vaccine dose or not vaccinated). We compared HPV vaccination initiation coverage estimates in the DRA region to coverage estimates in the other 2 geographic areas. We also estimated HPV vaccination initiation coverage for selected covariates, including demographic characteristics (sex, age, and race/ethnicity of adolescent mother’s education, marital status, income-to-poverty ratio [IPR, total family income divided by the federal poverty level], and residence), health insurance, and access to care variables for adolescents (preventive care visit at 11–12 years, received provider recommendation for HPV, total number of vaccination providers, number of physician contacts in the past year, and type of facility providing the vaccinations). Among parents with adolescents unvaccinated for HPV, we examined intent to vaccinate their adolescents in the next year by asking parents, “How likely is it that [TEEN] will receive HPV shots in the next 12 months?” Response options included “very likely,” “somewhat likely,” “not sure or don’t know,” “not too likely,” and “not likely at all.” Parents who indicated the last 3 responses were asked, “What is the main reason [TEEN] will not receive HPV shots in the next 12 months?” This open-ended question allowed parents to indicate multiple reasons, and we identified the top 5 reasons from verbatim responses.

We conducted statistical analyses by using SAS-callable SUDAAN release 11.0.1 (RTI International) to account for the complex sampling design of the NIS-Teen data. Point estimates and their 95% confidence intervals (CIs) were weighted to be representative of the areas from which the households were sampled. We used bivariate analyses to describe the distribution across selected sociodemographic characteristics. We used t tests to identify significant differences (P < .05) in the proportion of categories between the DRA region and Delta areas outside the DRA authority and non-Delta states. We also conducted a multivariable logistic regression analysis to produce adjusted prevalence ratios (APRs) and 95% CIs by using a standard statement in SUDAAN procedures to produce such estimates (model-adjusted risk). We used χ2 tests to identify covariates that were associated with HPV vaccination initiation in each of the 3 geographic areas.

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Results

Demographic characteristics differed substantially between adolescents living inside DRA areas and adolescents living in Delta areas outside the DRA or in non-Delta states (Table 1). We found a significantly higher proportion of non-Hispanic black adolescents, adolescents living in rural areas, and adolescents living in a household with an IPR below 133% in the DRA region. A significantly smaller proportion of adolescents inside the DRA region had a mother who had graduated from college or was married, and a higher percentage had mothers aged 34 or younger. Adolescents living in the DRA region also differed significantly in health care access and use, and they were more likely to be enrolled in Medicaid, to have had 4 or more physician contacts in the previous year, to have 2 or 3 vaccination providers, to have received all of their vaccinations in public facilities or a mix of facilities, and to be less likely to report receiving a provider recommendation for the HPV vaccination.

Unadjusted HPV vaccination initiation coverage estimates among adolescents in the DRA region were significantly lower (54.3%) than in non-Delta states (61.4%) but similar to coverage in Delta areas outside the DRA region (56.2%) (Table 2). These findings persisted after adjusting for sociodemographic and health care–related variables. Despite the difference in coverage among the 3 areas, unadjusted results demonstrated that HPV vaccination initiation coverage followed a similar pattern in each geographic area. In all 3 geographic areas, HPV vaccination initiation coverage was significantly higher among girls, adolescents who were non-Hispanic white, adolescents whose mother had less than a high school education, adolescents whose mother was not currently married, adolescents who had a well-child visit at age 11 or 12, adolescents who had Medicaid (compared with those having private insurance), adolescents who had received a provider recommendation for HPV vaccination, and adolescents who resided in an urban area (Table 2). However, after adjusting for sociodemographic and health care characteristics, the factors that remained significantly associated with HPV vaccination initiation coverage varied by geographic area.

In DRA areas, characteristics independently associated with higher rates of HPV vaccination initiation coverage (ie, APR >1 and P value <.05) among adolescents were having a mother who was divorced, widowed, or separated compared with a married mother, having Medicaid health insurance compared with having only private insurance, having received a provider recommendation for HPV vaccination compared with no provider recommendation, and residing in urban areas compared with rural areas (Table 2). Lower HPV vaccination initiation coverage (ie, 0 < APR < 1 and P value <.05) was found among adolescents whose mothers were high school graduates or had some college compared with mothers having less than a high school education, and those with a household IPR of 133% to less than 322% compared with those having a household IPR of 503% or more.

In the Delta region outside the DRA, factors associated with higher HPV vaccination initiation coverage were identification as non-Hispanic black, Hispanic, or other race/ethnicity compared with adolescents identified as non-Hispanic white; having a mother who was divorced, widowed, or separated, compared with a married mother; receipt of a provider recommendation for HPV vaccination compared with no provider recommendation; and residing in urban or suburban areas compared with rural areas (Table 2). Factors associated with lower HPV vaccination initiation coverage were being male; being aged 13 compared with aged 17; having a mother who was a high school graduate or had some college, compared with a mother having less than a high school education; having a household IPR from 133% to less than 503% compared with those having a household IPR of 503% or more; being uninsured compared with having only private insurance; and having received all vaccinations at an “other” facility compared with an all private facility.

In non-Delta states, factors associated with higher HPV vaccination initiation coverage among adolescents were identification as non-Hispanic black, Hispanic, or other compared with non-Hispanic white; having a mother who had never married compared with a married mother; having received a preventive care visit at age 11 or 12 compared with no visit; having Medicaid health insurance compared with only private insurance; having received a provider recommendation for HPV vaccination compared with no provider recommendation; having had at least 1 physician contact in the past year compared with no physician contact; having vaccinations in a mix of facility types compared with solely in private facilities; and residing in rural areas compared with residing in urban or suburban areas (Table 2).

Outside the Delta, factors associated with lower HPV vaccination initiation coverage were being male compared with female; being aged 13 to 16 compared with 17; having a mother who was a high school graduate compared with a mother with less than a high school education; having a mother aged 35 years or more compared with 34 years or less; having a household IPR of 133% to less than 503% compared with a household IPR of 503% or more; and having 2 or more vaccination providers compared with only 1 (Table 2).

In the DRA, among adolescents without any HPV vaccinations, 49.8% of parents reported a very likely or somewhat likely intent for their adolescent to receive the HPV vaccine in the next 12 months (Table 3). Among parents who did not intend to get their adolescent vaccinated (ie, those who responded not too likely, not likely at all, and not sure or don’t know), the most common reasons for not intending to get the HPV vaccine were that vaccination is not necessary, not having received a recommendation for HPV vaccine from the provider, concerns about vaccine safety or side effects, lack of knowledge about the vaccine, and believing that their adolescents were not sexually active (Table 3). These results were not significantly different from findings in Delta areas outside the DRA or the non-Delta states.

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Discussion

The DRA is a subset of the most distressed counties and parishes in 8 states of the southeastern United States. Overall, HPV vaccination coverage inside the DRA region was similar to that in Delta areas outside the DRA but significantly lower than in non-Delta states. Although vaccination coverage was lower in the DRA region, the pattern of coverage was similar to the other 2 geographic areas; however, factors that remained significantly associated with coverage differed after adjusting for demographic characteristics, health insurance, and access to care variables. In the Delta states, factors associated with vaccination coverage included mother’s marital status, mother’s education level, poverty level, any Medicaid health insurance, residence in an urban area, and receiving a provider recommendation for HPV vaccination.

Among adolescents living in the DRA region, HPV vaccination initiation coverage was 19 percentage points higher for those with any Medicaid health insurance, compared with adolescents having private insurance coverage. The higher coverage might likely be because of the availability of vaccines through the VFC (Vaccines for Children) program in the United States (21), which provides vaccines at no cost to eligible children (ie, those without health insurance, who are Medicaid eligible, of American Indian or Alaska Native descent, or whose insurance does not cover the cost of vaccination). Although uninsured children can receive vaccines through the VFC program, vaccination coverage in the DRA region was low (44.5%) but similar to children with private insurance (44.1%). Additional efforts are needed to promote the use of the VFC program among those who are insured. Furthermore, although uninsured children face additional challenges beyond cost to receiving vaccines, understanding challenges to HPV vaccination for privately insured children is also needed.

Although provider recommendation for vaccination was associated with HPV vaccination initiation in all 3 geographic areas, children inside the DRA region were less likely to have received a provider recommendation for HPV vaccination than children outside the DRA region. Previous research has indicated that both the source and manner of recommendation influence parental receptiveness to HPV vaccination (22,23); physicians are a trusted source of vaccination information and could be a crucial influence for increasing HPV vaccination in the DRA region and elsewhere. An announcement that includes a statement that assumes parents are ready to vaccinate results in higher vaccination coverage (22). CDC has developed resources incorporating these communication principles to demonstrate how to give an effective recommendation (24) that might be helpful for clinicians inside the DRA region and elsewhere. Among unvaccinated adolescents, the most common reason their parents did not intend to vaccinate them with the HPV vaccine was the belief that the vaccine was not necessary because their child was unlikely to have initiated sexual activity. This was a prevalent reason across all 3 geographic areas. Recent research has tested and identified effective messages to address these questions and concerns from parents (24). Messages emphasizing cancer prevention were more effective in increasing confidence to vaccinate among parents, whereas messages emphasizing urgency to vaccinate were counterproductive. Effective communication messages to providers are needed to improve their confidence and ability to discuss HPV vaccination with patients. To reach parents and adolescents with limited access to health care providers, engaging partners serving these populations (eg, the Special Supplemental Nutrition Program for Women, Infants, and Children [WIC]) might also be helpful.

Although a higher proportion of adolescents with 2 or 3 providers lived in the DRA region, compared with the other 2 geographic areas, vaccination coverage was not associated with the number of providers among adolescents in the DRA region. Those who have several health care providers might have their medical histories dispersed to multiple providers, and follow-up might be difficult or unlikely. Record scattering, shown to affect vaccination coverage for young children, might also contribute to lower HPV vaccination coverage (25). Encouraging providers to report vaccines they administer to their state immunization information system could help consolidate vaccination records and facilitate timely vaccination decisions during health care encounters.

Thirty-six percent of adolescents in the DRA region received all of their vaccinations at private facilities. Receipt of all vaccinations from private facilities was more common in the other 2 geographic areas. Additional research is needed to determine if this finding results from fewer private facilities operating in the DRA or a reduced likelihood among private facilities in the DRA region to stock and administer HPV vaccines.

This study has several strengths. First, NIS-Teen includes provider-reported vaccination data, which are more reliable than parental recall or vaccination shot cards. Second, multiple years of data were combined to increase sample size and study power to allow detailed analysis of this underserved geographic area. Third, although NIS-Teen was previously limited to households with landline telephones, this data set included cell phone sampling frames as well, which was instrumental in increasing how the data represented the target population.

Our study also had limitations. First, incomplete provider vaccination records and lack of data on community- or county-level factors that might influence HPV vaccination could have limited the scope of this study. Second, after weighting adjustments to mitigate bias from incomplete data in the sample frame and nonresponses, some bias may remain (16). Third, provider recommendation is also subject to recall bias. Finally, some estimates may be unreliable because of the small sample size. Despite these limitations, we believe our findings can raise awareness among providers and policy makers in the DRA region regarding disparities in HPV vaccination coverage, the need for strategies to increase HPV vaccination, and the target populations to consider for enhanced efforts.

Although factors related to HPV vaccine initiation are similar in the 3 areas studied, overall vaccination levels are lower in the Delta (both inside and outside the DRA region). Lower vaccination levels are likely correlated with the unique sociodemographic and health care characteristics of the areas, which are likely also responsible for disparities in HPV vaccination initiation across the 3 geographic areas. In the DRA region, assisting providers in effectively recommending HPV vaccination could be a primary strategy to increase coverage, as recommendations were closely associated with HPV vaccine initiation. Existing resources to help communicate HPV vaccine recommendations might need to be evaluated to ensure cultural appropriateness. To help identify strategies to increase HPV vaccination, additional research is needed to understand the barriers to vaccination in the Delta region, especially differences between uninsured and privately insured adolescents.

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Acknowledgments

We thank Mary Ann Kirkconnell Hall for her editorial review. The findings and conclusions in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. No funding was obtained for this study. The authors have no financial relationships relevant to this study and no conflicts of interest to disclose. No copyrighted material or copyrighted surveys, instruments, or tools were used in the analysis of data.

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Author Information

Corresponding Author: David Yankey, PhD, Immunization Services Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, Mail Stop H24-4 Atlanta, GA 30329-4027. Telephone: 404-639-8685. Email: DYankey@cdc.gov.

Author Affiliations: 1National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia. 2National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.

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References

  1. Delta Regional Authority. About Delta Regional Authority. 2019. https://dra.gov/about-dra/about-delta-regional-authority/. Accessed February 11, 2019.
  2. Delta Regional Authority. Today’s Delta. A research tool for the region. https://www.dra.gov/images/uploads/content_files/Todays_Delta_FINAL_print-w-borders.pdf. Accessed May 30, 2019.
  3. Glasmeier A. An atlas of poverty in America: one nation, pulling apart 1960–2003. New York (NY): Routledge; 2014.
  4. Cosby AG, Bowser DM. The health of the Delta Region: a story of increasing disparities. J Health Hum Serv Adm 2008;31(1):58–71. PubMed
  5. Zahnd WE, Jenkins WD, Mueller-Luckey GS. Cancer mortality in the Mississippi Delta Region: descriptive epidemiology and needed future research and interventions. J Health Care Poor Underserved 2017;28(1):315–28. CrossRef PubMed
  6. Gennuso KP, Jovaag A, Catlin BB, Rodock M, Park H. Assessment of factors contributing to health outcomes in the eight states of the Mississippi Delta Region. Prev Chronic Dis 2016;13: 150440. CrossRef PubMed
  7. Mendy VL, Vargas R. Trends in major risk factors for cardiovascular disease among adults in the Mississippi Delta region, Mississippi Behavioral Risk Factor Surveillance System, 2001–2010. Prev Chronic Dis 2015;12:E21. CrossRef PubMed
  8. Felix H, Stewart MK. Health status in the Mississippi River Delta region. South Med J 2005;98(2):149–54. CrossRef PubMed
  9. Henley SJ, Singh S, King J, Wilson R, Ryerson B; Centers for Disease Control and Prevention. Invasive cancer incidence — United States, 2010. MMWR Morb Mortal Wkly Rep 2014;63(12):253–9. PubMed
  10. Castle PE, Gage JC, Partridge EE, Rausa A, Gravitt PE, Scarinci IC. Human papillomavirus genotypes detected in clinician-collected and self-collected specimens from women living in the Mississippi Delta. BMC Infect Dis 2013;13(1):5. CrossRef PubMed
  11. Barger AC, Pearson WS, Rodriguez C, Crumly D, Mueller-Luckey G, Jenkins WD. Sexually transmitted infections in the Delta Regional Authority: significant disparities in the 252 counties of the eight-state Delta Region Authority. Sex Transm Infect 2018;94(8):611–5. CrossRef PubMed
  12. Markowitz LE, Dunne EF, Saraiya M, Lawson HW, Chesson H, Unger ER; Centers for Disease Control and Prevention (CDC); Advisory Committee on Immunization Practices (ACIP). Quadrivalent human papillomavirus vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2007;56(RR-2):1–24. PubMed
  13. Centers for Disease Prevention and Control. Advisory Committee on Immunization Practices (ACIP) recommended immunization schedules for persons aged 0 through 18 years and adults aged 19 years and older — United States, 2013. Erratum in MMWR Surveill Summ 2013;62(13):256. MMWR Surveill Summ 2013;62(1):1–30.
  14. Walker TY, Elam-Evans LD, Yankey D, Markowitz LE, Williams CL, Mbaeyi SA, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years — United States, 2017. Erratum in MMWR Morb Mortal Wkly Rep 2018;67(33):1164. CrossRef PubMed
  15. Jain N, Singleton JA, Montgomery M, Skalland B. Determining accurate vaccination coverage rates for adolescents: the National Immunization Survey-Teen 2006. Public Health Rep 2009;124(5):642–51. CrossRef PubMed
  16. Centers for Disease Control and Prevention. Adding households with cell phone service to the National Immunization Survey (NIS), 2011. Atlanta (GA): Centers for Disease Control and Prevention; 2012. https://www.cdc.gov/vaccines/imz-managers/coverage/nis/child/dual-frame-sampling.html. Accessed May 30, 2019.
  17. Centers for Disease Control and Prevention. National Immunization Survey-Teen: a user’s guide for the 2017 public-use data file. Atlanta (GA): Centers for Disease Control and Prevention; 2019. https://www.cdc.gov/vaccines/imz-managers/nis/downloads/NIS-TEEN-PUF17-DUG.pdf. Accessed May 30, 2019.
  18. Smith PJ, Rao JN, Battaglia MP, Ezzati-Rice TM, Daniels D, Khare M; Centers for Disease Control and Prevention/National Center for Health Statistics. Compensating for provider nonresponse using response propensities to form adjustment cells: the National Immunization Survey. Vital Health Stat 2 2001;(133):1–17. PubMed
  19. Wolter KK, Smith PJ, Khare M, Welch B, Copeland KR, Pineau VJ, et al. . Statistical methodology of the National Immunization Survey, 2005–2014. Vital Health Stat 1 2017;(61):1–107
  20. Centers for Disease Control and Prevention. NIS-Teen data and documentation for 2015 to present. Atlanta (GA): Centers for Disease Control and Prevention; 2018. https://www.cdc.gov/vaccines/imz-managers/nis/datasets-teen.html. Accessed May 30, 2019.
  21. Centers for Disease Control and Prevention. Vaccines for Children Program (VFC). Atlanta (GA): Centers for Disease Control and Prevention; 2016. https://www.cdc.gov/vaccines/programs/vfc/index.html. Accessed June 21, 2019.
  22. Brewer NT, Hall ME, Malo TL, Gilkey MB, Quinn B, Lathren C. Announcements versus conversations to improve HPV vaccination coverage: a randomized trial. Pediatrics 2017;139(1):e20161764. CrossRef PubMed
  23. Shah PD, Calo WA, Gilkey MB, Boynton MH, Alton Dailey S, Todd KG, et al. Questions and concerns about HPV vaccine: a communication experiment. Pediatrics 2019;143(2):e20181872. CrossRef PubMed
  24. Centers for Disease Control and Prevention. Human papillomavirus: #HowIRecommend vaccination video series. Atlanta (GA): Centers for Disease Control and Prevention; 2018. https://www.cdc.gov/vaccines/howirecommend/adolescent-vacc-videos.html. Accessed June 21, 2019.
  25. Stokley S, Rodewald LE, Maes EF. The impact of record scattering on the measurement of immunization coverage. Pediatrics 2001;107(1):91–6. CrossRef PubMed

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Tables

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Table 1. Characteristics of Adolescents Aged 13–17 Years by Geographic Area, National Immunization Survey–Teen, United States, 2015–2017
Characteristic All Surveyed Adolescents in the United States Mississippi Delta States Non-Delta States
DRA Counties Delta Areas Outside DRA
Sample Size Weighted% (95% CI) Sample Size Weighted% (95% CI) Sample Size Weighted% (95% CI) Sample Size Weighted% (95% CI)
Overall 63,299 100.0 (—) 2,317 3.0 (2.8–3.1) 6,028 9.9 (9.7–10.1) 54,954 87.1 (86.9–87.3)
Interview year 63,299 100.0 (—) 2,317 100.0 (—) 6,028 100.0 (—) 54,954 100.0 (—)
2015 21,875 33.3 (32.9–33.8) 819 34.9 (32.9–37.0) 2,060 33.2 (32.3–34.1) 18,996 33.3 (32.8–33.8)
2016 20,475 33.3 (32.9–33.8) 771 33.8 (31.8–35.9) 1,907 33.1 (32.2–34.1) 17,797 33.3 (32.9–33.8)
2017 20,949 33.3 (32.9–33.8)a 727 31.3 (29.2–33.3) 2,061 33.7 (32.7–34.6) 18,161 33.4 (32.9–33.9)a
Sex 63,299 100.0 (—) 2,317 100.0 (—) 6,028 100.0 (—) 54,954 100.0 (—)
Male 33,285 51.1 (50.3–51.8) 1,258 51.9 (49.3–54.5) 3,142 50.8 (49.2–52.4) 28,885 51.1 (50.2–51.9)
Female 30,014 48.9 (48.2–49.7) 1,059 48.1 (45.5–50.7) 2,886 49.2 (47.6–50.8) 26,069 48.9 (48.1–49.8)
Age of adolescent at interview, y 63,299 100.0 (—) 2,317 100.0 (—) 6,028 100.0 (—) 54,954 100.0 (—)
13 12,968 19.8 (19.2–20.3) 498 21.6 (19.6–23.8) 1,228 19.9 (18.6–21.2) 11,242 19.7 (19.0–20.3)
14 13,252 19.9 (19.3–20.5) 453 19.5 (17.5–21.7) 1,206 19.1 (17.9–20.4) 11,593 20.0 (19.3–20.7)
15 12,770 21.0 (20.4–21.6) 474 20.9 (18.9–23.1) 1,251 20.6 (19.4–21.9) 11,045 21.0 (20.4–21.7)
16 12,811 20.5 (19.9–21.1)a 457 18.2 (16.4–20.2) 1,270 21.4 (20.1–22.7)a 11,084 20.5 (19.8–21.1)a
17 11,498 18.9 (18.3–19.4) 435 19.7 (17.7–21.9) 1,073 19.0 (17.7–20.3) 9,990 18.8 (18.2–19.5)
Adolescent’s race/ethnicity 63,299 100.0 (—) 2,317 100.0 (—) 6,028 100.0 (—) 54,954 100.0 (—)
Non-Hispanic white 38,728 52.9 (52.1–53.6) 1,322 51.0 (48.4–53.5) 3,959 63.5 (61.9–65.0)a 33,447 51.7 (50.9–52.5)
Non-Hispanic black 5,961 13.9 (13.4–14.4)b 700 38.2 (35.6–40.8) 743 14.9 (13.7–16.1)b 4,518 12.9 (12.4–13.5)b
Hispanic 11,715 23.2 (22.5–23.9)a 148 4.8 (4.0–5.9) 834 13.3 (12.3–14.4)a 10,733 25.0 (24.2–25.8)a
Other 6,895 10.1 (9.6–10.5)a 147 6.0 (5.0–7.3) 492 8.4 (7.5–9.3)a 6,256 10.4 (9.9–10.9)a
Mother’s education 63,299 100.0 (—) 2,317 100.0 (—) 6,028 100.0 (—) 54,954 100.0 (—)
<High school graduate 7,725 13.3 (12.8–13.9) 335 12.0 (10.5–13.6) 830 10.8 (9.9–11.7) 6,560 13.7 (13.0–14.3)a
High school graduate 10,020 22.5 (21.8–23.2)b 497 28.9 (26.5–31.5) 1,070 23.6 (22.1–25.1)b 8,453 22.1 (21.4–22.9)b
>High school graduate, some college 16,311 24.9 (24.2–25.5)b 694 30.8 (28.5–33.2) 1,647 26.9 (25.5–28.3)b 13,970 24.4 (23.7–25.1)b
College graduate 29,243 39.3 (38.6–40.0)a 791 28.3 (26.2–30.5) 2,481 38.8 (37.2–40.3)a 25,971 39.8 (39.0–40.5)a
Mother’s marital status 59,126 100.0 (—) 2,136 100.0 (—) 5,617 100.0 (—) 51,373 100.0 (—)
Married 44,381 67.7 (66.9–68.4)a 1,348 51.9 (49.1–54.6) 4,050 65.5 (63.8–67.1)a 38,983 68.4 (67.6–69.3)a
Divorced, widowed, or separated 10,729 23.3 (22.6–24.0)b 511 30.2 (27.6–32.8) 1,120 24.4 (23.0–26.0)b 9,098 22.9 (22.2–23.7)b
Never married 4,016 9.1 (8.6–9.5)b 277 18.0 (15.8–20.4) 447 10.1 (9.1–11.2)b 3,292 8.6 (8.1–9.1)b
Mother’s age, y 63,299 100.0 (—) 2,317 100.0 (—) 6,028 100.0 (—) 54,954 100.0 (—)
≤34 5,151 8.8 (8.4–9.2)b 303 14.5 (12.7–16.4) 575 9.6 (8.7–10.6)b 4,273 8.5 (8.0–9.0)b
35–44 25,998 43.7 (42.9–44.4)b 1,072 49.0 (46.4–51.5) 2,688 46.2 (44.6–47.8) 22,238 43.2 (42.4–44.0)b
≥45 32,150 47.5 (46.8–48.3)a 942 36.6 (34.2–39.1) 2,765 44.2 (42.6–45.8)a 28,443 48.3 (47.5–49.1)a
Adolescent had preventive care visit at age 11 or 12 62,875 100.0 (—) 2,299 100.0 (—) 6,000 100.0 (—) 54,576 100.0 (—)
Yes 57,452 90.9 (90.4–91.3) 2,053 89.7 (88.1–91.2) 5,476 90.7 (89.7–91.6) 49,923 91.0 (90.4–91.4)
No 5,423 9.1 (8.7–9.6) 246 10.3 (8.8–11.9) 524 9.3 (8.4–10.3) 4,653 9.0 (8.6–9.6)
Income-to-poverty ratio 63,299 100.0 (—) 2,317 100.0 (—) 6,028 100.0 (—) 54,954 100.0 (—)
<133% 16,687 32.0 (31.3–32.8)b 869 42.6 (40.0–45.2) 1,837 32.8 (31.3–34.4)b 13,981 31.6 (30.8–32.4)b
133% to <322% 17,243 28.1 (27.4–28.7) 665 30.4 (28.0–32.9) 1,754 30.9 (29.4–32.4) 14,824 27.7 (26.9–28.4)b
322% to <503% 13,132 18.2 (17.7–18.7)a 387 14.0 (12.5–15.8) 1,183 18.2 (17.0–19.4)a 11,562 18.3 (17.7–18.9)a
≥503% 16,237 21.7 (21.1–22.3)a 396 13.0 (11.6–14.6) 1,254 18.1 (17.0–19.3)a 14,587 22.4 (21.8–23.1)a
Health insurance statusc 63,299 100.0 (—) 2,317 100.0 (—) 6,028 100.0 (—) 54,954 100.0 (—)
Private only 36,269 51.6 (50.8–52.3)a 1,014 37.9 (35.5–40.3) 3,302 52.8 (51.2–54.4)a 31,953 51.9 (51.1–52.7)a
Any Medicaid 19,717 37.1 (36.3–37.8)b 1,053 51.8 (49.3–54.4) 2,169 38.5 (36.9–40.0)b 16,495 36.4 (35.6–37.2)b
Otherd 4,885 7.1 (6.7–7.4) 164 6.8 (5.6–8.2) 359 4.9 (4.3–5.5)b 4,362 7.3 (7.0–7.7)
Uninsured 2,428 4.3 (4.0–4.6) 86 3.5 (2.7–4.6) 198 3.9 (3.2–4.6) 2,144 4.4 (4.0–4.7)
Provider recommended HPV vaccination 57,740 100.0 (—) 2,071 100.0 (—) 5,519 100.0 (—) 50,150 100.0 (—)
Yes 42,603 71.7 (71.0–72.4)a 1,311 63.5 (60.8–66.0) 3,765 68.4 (66.8–69.9)a 37,527 72.4 (71.6–73.2)a
No 15,137 28.3 (27.6–29.0)b 760 36.5 (34.0–39.2) 1,754 31.6 (30.1–33.2)b 12,623 27.6 (26.8–28.4)b
No. of providers 63,109 100.0 (—) 2,312 100.0 (—) 6,013 100.0 (—) 54,784 100.0 (—)
1 36,114 59.3 (58.6–60.0)a 1,201 53.2 (50.6–55.7) 3,379 57.3 (55.7–58.8)a 31,534 59.7 (58.9–60.5)a
2 or 3 17,345 26.4 (25.7–27.0)b 739 32.6 (30.3–35.1) 1,757 29.5 (28.1–31.0)b 14,849 25.8 (25.1–26.5)b
≥4 9,650 14.3 (13.8–14.9) 372 14.2 (12.5–16.0) 877 13.2 (12.2–14.3) 8,401 14.5 (13.9–15.1)
No. of physician contacts in the past year 62,668 100.0 (—) 2,283 100.0 (—) 5,975 100.0 (—) 54,410 100.0 (—)
None 8,356 15.2 (14.6–15.8)a 267 12.8 (11.1–14.8) 738 13.4 (12.3–14.6) 7,351 15.5 (14.8–16.1)a
1 17,801 30.0 (29.3–30.7)a 568 25.6 (23.3–27.9) 1,622 29.1 (27.6–30.6)a 15,611 30.3 (29.5–31.1)a
2 or 3 22,914 35.2 (34.5–35.9) 852 36.3 (33.9–38.8) 2,275 37.5 (36.0–39.1) 19,787 34.9 (34.1–35.7)
≥4 13,597 19.6 (19.0–20.1)b 596 25.3 (23.1–27.6) 1,340 20.0 (18.8–21.3)b 11,661 19.3 (18.7–20.0)b
Type of facility where vaccinations were received 62,872 100.0 (—) 2,301 100.0 (—) 5,990 100.0 (—) 54,581 100.0 (—)
All private 31,374 53.4 (52.7–54.2)a 810 36.0 (33.5–38.5) 2,804 47.6 (46.0–49.2)a 27,760 54.7 (53.9–55.5)a
All public 9,205 14.8 (14.3–15.4)b 570 26.1 (23.9–28.5) 1,060 17.3 (16.1–18.5)b 7,575 14.1 (13.6–14.8)b
All hospital 7,222 9.7 (9.3–10.1)a 187 8.2 (6.9–9.8) 565 9.5 (8.6–10.5) 6,470 9.8 (9.3–10.2)a
Mixede 13,135 18.9 (18.3–19.4)b 677 27.1 (24.9–29.4) 1,401 22.9 (21.6–24.2)b 11,057 18.1 (17.5–18.8)b
Otherf 1,936 3.2 (2.9–3.5) 57 2.6 (1.9–3.5) 160 2.8 (2.3–3.3) 1,719 3.3 (3.0–3.6)
Metropolitan Statistical Area (MSA) 63,299 100.0 (—) 2,317 100.0 (—) 6,028 100.0 (—) 54,954 100.0 (—)
Urban 25,628 40.4 (39.7–41.1)a 572 27.8 (25.5–30.3) 2,388 37.6 (36.1–39.0)a 22,668 41.1 (40.3–41.9)a
Suburban 24,989 47.1 (46.3–47.8)a 796 34.7 (32.3–37.1) 2,345 44.6 (43.1–46.2)a 21,848 47.8 (47.0–48.6)a
Rural 12,682 12.6 (12.2–12.9)b 949 37.5 (35.1–40.0) 1,295 17.8 (16.7–19.0)b 10,438 11.1 (10.7–11.5)b

Abbreviations: CI, confidence interval; HPV, human papillomavirus; DRA, Delta Regional Authority.
a P < .05; value significantly higher than value for similar group in DRA counties; determined by multivariable logistic regression analysis.
b P < .05; value significantly lower than value for similar group in DRA counties; determined by χ2 test.
c Insurance categories are mutually exclusive.
d Includes Indian Health Service (IHS), Children’s Health Insurance Programs (CHIP), and some private insurers.
e Mixed indicates that a combination of facility types was listed (private, public, hospital, and STD/school/teen clinics) for the adolescent.
f Includes military health care facilities; Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics; and pharmacies.

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Table 2. Unadjusted and Adjusted Logistic Regression Analysis for Vaccination Coverage Estimates (≥1 HPV Dose) Among Adolescents Aged 13–17 Years, by Geographic Area for Selected Sociodemographic Characteristics, National Immunization Survey-Teen, United States, 2015–2017
Characteristic All Surveyed Adolescents in United States Mississippi Delta States Non-Delta States
DRA Counties Delta Areas Outside DRA
Unadjusted % (95% CI)a APR, % (95% CI) Unadjusted % (95% CI)a APR, % (95% CI) Unadjusted % (95% CI)a APR, % (95% CI)a Unadjusted % (95% CI)a APR, % (95% CI)
Overall 60.7 (60.0–61.4)b 54.3 (51.7–56.8) Ref 56.2 (54.6–57.8) 1.01 (.95–1.06) 61.4 (60.6–62.2)b 1.06 (1.01–1.11)b
Interview year
2015 56.1 (54.9–57.4)b 0.91 (0.88–0.93)b 50.0 (45.8–54.3)b 0.96 (0.86–1.08) 51.1 (48.4–53.9)b 0.90 (0.84–0.97)b 56.9 (55.5–58.3)b 0.91 (0.88–0.94)b
2016 60.4 (59.2–61.6)b 0.95 (0.93–0.98)b 55.4 (50.9–59.8) 1.04 (0.93–1.17) 56.5 (53.6–59.2)b 0.97 (0.91–1.04)b 61.0 (59.7–62.4)b 0.95 (0.92–0.98)b
2017 65.5 (64.3–66.7) Ref 57.9 (53.2–62.4) Ref 61.0 (58.3–63.6)b Ref 66.3 (65.0–67.6) Ref
Sex
Male 56.1 (55.1–57.1)b 0.93 (0.91–0.96)b 48.8 (45.3–52.4)b 0.91 (0.83–1.00) 51.5 (49.2–53.7)b 0.94 (0.88–0.99)b 56.9 (55.8–58.0)b 0.94 (0.91–0.96)b
Female 65.5 (64.5–66.5) Ref 60.2 (56.5–63.8) Ref 61.1 (58.9–63.3) Ref 66.1 (65.0–67.3) Ref
Age of adolescent at interview, y
13 55.6 (54.0–57.2)b 0.86 (0.83–0.89)b 51.6 (46.1–57.1) 0.96 (0.83–1.11) 45.6 (42.1–49.1)b 0.78 (0.70–0.86)b 56.9 (55.1–58.7)b 0.86 (0.83–0.90)b
14 59.3 (57.7–60.9)b 0.89 (0.86–0.93)b 53.7 (47.7–59.5) 0.92 (0.79–1.07) 57.0 (53.4–60.6) 0.92 (0.84–1.00) 59.7 (57.9–61.5)b 0.89 (0.86–0.93)b
15 61.8 (60.2–63.4)b 0.94 (0.91–0.98)b 57.8 (52.2–63.2) 1.06 (0.93–1.21) 57.4 (53.9–60.8) 0.95 (0.87–1.03) 62.4 (60.6–64.2)b 0.94 (0.90–0.97)b
16 62.2 (60.7–63.7)b 0.95 (0.92–0.98)b 55.5 (49.9–61.1) 1.01 (0.88–1.16) 61.5 (58.1–64.8) 1.03 (0.95–1.12) 62.5 (60.8–64.2)b 0.94 (0.90–0.97)b
17 64.6 (63.0–66.2) Ref 52.9 (46.9–58.9) Ref 59.3 (55.6–62.9) Ref 65.6 (63.9–67.4) Ref
Adolescent’s race/ethnicity
Non-Hispanic white 55.3 (54.5–56.2) Ref 46.8 (43.4–50.2) Ref 50.7 (48.7–52.6) Ref 56.3 (55.3–57.2) Ref
Non-Hispanic black 65.3 (63.3–67.2)b 1.07 (1.03–1.12)b 60.8 (56.2–65.1)b 1.03 (0.91–1.15) 65.3 (60.9–69.4)b 1.15 (1.05–1.26)b 65.7 (63.4–68.0)b 1.07 (1.02–1.12)b
Hispanic 69.4 (67.5–71.1)b 1.15 (1.11–1.20)b 69.6 (60.2–77.6)b 1.21 (1.01–1.45) 70.4 (66.2–74.3)b 1.29 (1.18–1.40)b 69.3 (67.4–71.2)b 1.14 (1.10–1.19)b
Other 62.5 (60.3–64.7)b 1.10 (1.06–1.15)b 64.5 (54.9–73.0)b 1.12 (0.94–1.34) 59.6 (54.1–64.9)b 1.13 (1.02–1.25)b 62.8 (60.4–65.1)b 1.10 (1.05–1.14)b
Mother’s education
<High school graduate 71.8 (69.7–73.8) Ref 65.6 (59.0–71.6) Ref 64.9 (60.7–68.8) Ref 72.6 (70.3–74.8) Ref
High school graduate 61.1 (59.4–62.7)b 0.88 (0.84–0.92)b 54.2 (48.8–59.5)b 0.86 (0.74–1.00) 58.0 (54.4–61.6)b 0.97 (0.87–1.07) 61.7 (59.9–63.5)b 0.87 (0.83–0.92)b
>High school graduate, some college 57.0 (55.5–58.4)b 0.82 (0.78–0.86)b 54.5 (49.9–59.1)b 0.80 (0.69–0.92)b 53.9 (50.9–56.9)b 0.86 (0.78–0.96)b 57.5 (55.8–59.1)b 0.82 (0.78–0.87)b
College graduate 59.1 (58.0–60.1)b 0.87 (0.83–0.92)b 49.3 (45.0–53.7)b 0.86 (0.74–1.01) 54.3 (51.8–56.7)b 0.91 (0.81–1.01) 59.8 (58.7–61.0)b 0.87 (0.83–0.92)b
Mother’s marital status
Married 58.1 (57.3–59.0) Ref 46.1 (42.8–49.4) Ref 52.8 (50.8–54.7) Ref 59.0 (58.1–60.0) Ref
Divorced, widowed, or separated 61.8 (60.1–63.4)b 1.03 (1.00–1.07)b 62.2 (57.0–67.2)b 1.23 (1.10–1.38)b 58.8 (55.2–62.2)b 1.10 (1.02–1.18)b 62.1 (60.2–64.0)b 1.02 (0.98–1.06)
Never married 70.0 (67.6–72.3)b 1.09 (1.04–1.14)b 63.4 (56.0–70.3)b 1.17 (0.99–1.40) 67.8 (62.3–72.9)b 1.11 (0.99–1.24) 70.8 (68.1–73.4)b 1.09 (1.03–1.15)b
Mother’s age, y
≤34 66.5 (64.1–68.9) Ref 56.5 (49.3–63.3) Ref 53.4 (48.2–58.5) Ref 68.8 (66.1–71.4) Ref
35–44 60.8 (59.7–61.9)b 0.93 (0.89–0.97)b 59.3 (55.6–62.8) 1.10 (0.94–1.29) 57.4 (55.0–59.7) 1.05 (0.94–1.17) 61.3 (60.0–62.5)b 0.91 (0.86–0.96)b
≥45 59.5 (58.5–60.5)b 0.93 (0.88–0.97)b 46.8 (42.7–50.8)b 0.94 (0.78–1.12) 55.6 (53.2–57.9) 1.04 (0.93–1.17) 60.3 (59.2–61.3)b 0.91 (0.86–0.96)b
Adolescent had preventive care visit at age 11 or 12
Yes 61.6 (60.9–62.3)b 1.08 (1.02–1.13)b 55.9 (53.1–58.6)b 1.12 (0.94–1.34) 57.4 (55.8–59.1)b 1.10 (0.97–1.24) 62.3 (61.4–63.1)b 1.07 (1.02–1.13)b
No 53.8 (51.2–56.3) Ref 42.3 (34.8–50.2) Ref 45.6 (40.1–51.2) Ref 55.2 (52.3–58.0) Ref
Income-to-poverty ratio
<133% 67.8 (66.5–69.1)b 1.01 (0.96–1.06) 63.0 (58.9–66.9)b 0.99 (0.84–1.17) 63.4 (60.5–66.1) 1.01 (0.91–1.13) 68.5 (67.0–70.0)b 1.01 (0.96–1.06)
133% to <322% 56.2 (54.8–57.5)b 0.93 (0.89–0.96)b 48.0 (43.1–52.9) 0.84 (0.73–0.98)b 50.7 (47.7–53.7)b 0.88 (0.81–0.96)b 57.2 (55.6–58.7)b 0.93 (0.90–0.97)b
322% to <503% 55.0 (53.4–56.6)b 0.95 (0.92–0.98)b 46.3 (40.1–52.5) 0.94 (0.82–1.07) 49.4 (45.9–52.9)b 0.89 (0.82–0.97)b 55.8 (54.1–57.6)b 0.96 (0.92–0.99)b
≥503% 60.8 (59.4–62.3) Ref 49.1 (43.2–55.0) Ref 59.4 (56.0–62.8) Ref 61.2 (59.7–62.7) Ref
Health insurance coveragec
Private only 56.9 (56.0–57.8) Ref 44.1 (40.3–48.0) Ref 52.8 (50.7–55.0) Ref 57.7 (56.6–58.7) Ref
Any Medicaid 67.8 (66.6–69.0)b 1.10 (1.06–1.14)b 62.9 (59.2–66.4)b 1.22 (1.06–1.42)b 62.3 (59.7–64.9)b 1.06 (0.98–1.16) 68.7 (67.3–70.1)b 1.10 (1.05–1.15)b
Otherd 56.8 (54.3–59.3) 1.00 (0.95–1.05) 50.9 (41.2–60.5) 0.93 (0.73–1.19) 55.7 (49.1–62.2) 1.03 (0.90–1.18) 57.1 (54.3–59.8) 1.00 (0.95–1.05)
Uninsured 51.2 (47.4–55.0)b 0.94 (0.87–1.02) 44.5 (31.7–58.2) 1.16 (0.85–1.58) 41.9 (33.3–51.1)b 0.76 (0.60–0.97)b 52.3 (48.1–56.5)b 0.95 (0.87–1.03)
Provider recommended HPV vaccination
Yes 71.3 (70.4–72.1)b 1.95 (1.86–2.04)b 68.0 (64.7–71.1)b 2.07 (1.79–2.40)b 67.8 (65.9–69.6)b 2.02 (1.83–2.22)b 71.7 (70.8–72.6)b 1.94 (1.84–2.04)b
No 36.8 (35.3–38.3) Ref 32.2 (28.1–36.6) Ref 33.1 (30.3–36.1) Ref 37.5 (35.7–39.2) Ref
No. of providers
1 62.5 (61.5–63.4) Ref 55.8 (52.3–59.3) Ref 58.2 (56.1–60.3) Ref 63.1 (62.1–64.1) Ref
2 or 3 59.2 (57.8–60.6)b 0.93 (0.90–0.96)b 52.9 (48.4–57.4) 1.03 (0.93–1.15) 55.0 (52.0–57.9) 0.96 (0.89–1.03) 60.0 (58.4–61.6)b 0.92 (0.89–0.95)b
≥4 56.7 (54.7–58.6)b 0.89 (0.85–0.93)b 52.0 (45.3–58.6) 1.00 (0.84–1.18) 51.0 (46.7–55.2)b 0.92 (0.83–1.01) 57.4 (55.2–59.6)b 0.89 (0.85–0.93)b
No. of physician contacts in the past year
None 53.4 (51.3–55.5) Ref 53.1 (45.4–60.7) Ref 48.6 (44.0–53.2) Ref 53.9 (51.6–56.2) Ref
1 59.2 (57.8–60.6)b 1.07 (1.02–1.11)b 49.5 (44.3–54.7) 0.86 (0.72–1.02) 54.8 (51.8–57.9)b 1.04 (0.94–1.15) 60.0 (58.4–61.5)b 1.07 (1.02–1.13)b
2 or 3 63.3 (62.2–64.5)b 1.12 (1.07–1.17)b 54.0 (49.8–58.1) 0.92 (0.79–1.08) 58.2 (55.6–60.7)b 1.07 (0.97–1.17) 64.3 (63.0–65.5)b 1.13 (1.08–1.18)b
≥4 63.6 (62.1–65.0)b 1.12 (1.07–1.17)b 59.0 (53.9–63.9) 0.97 (0.82–1.14) 59.2 (55.8–62.5)b 1.10 (0.99–1.22) 64.3 (62.6–65.9)b 1.12 (1.07–1.18)b
Type of facility where vaccinations were obtained
All private 60.7 (59.7–61.7) Ref 56.3 (52.0–60.5) Ref 57.5 (55.2–59.8) Ref 61.1 (60.0–62.2) Ref
All public 60.7 (58.9–62.6) 1.00 (0.96–1.04) 52.7 (47.4–57.9) 0.92 (0.80–1.06) 54.3 (50.4–58.2) 0.97 (0.88–1.06) 62.1 (60.0–64.3) 1.01 (0.96–1.06)
All hospital 64.6 (62.6–66.6)b 1.03 (0.99–1.07) 61.9 (52.3–70.6) 1.00 (0.85–1.18) 59.4 (54.2–64.4) 0.97 (0.88–1.08) 65.3 (63.0–67.5)b 1.04 (1.00–1.09)
Mixede 61.0 (59.4–62.6) 1.06 (1.02–1.10)b 51.3 (46.5–56.1) 0.94 (0.82–1.07) 55.9 (52.5–59.2) 1.02 (0.94–1.10) 62.2 (60.4–64.0) 1.07 (1.03–1.11)b
Otherf 53.6 (49.0–58.1)b 0.92 (0.85–1.00)b 56.7 (41.1–71.1) 1.15 (0.93–1.44) 44.0 (34.5–53.8)b 0.79 (0.64–0.99)b 54.4 (49.4–59.4)b 0.93 (0.85–1.01)
Metropolitan Statistical Area (MSA)
Urban 66.1 (65.0–67.3)b 1.13 (1.10–1.17)b 61.7 (56.4–66.7)b 1.14 (1.00–1.29)b 63.5 (61.0–65.9)b 1.17 (1.07–1.28)b 66.5 (65.3–67.7)b 1.13 (1.09–1.18)b
Suburban 58.3 (57.2–59.3)b 1.05 (1.02–1.09)b 53.6 (49.3–57.8) 1.06 (0.95–1.19) 54.8 (52.3–57.3)b 1.11 (1.01–1.21)b 58.8 (57.6–59.9)b 1.05 (1.00–1.09)b
Rural 52.3 (50.8–53.8) Ref 49.5 (45.4–53.5) Ref 44.4 (40.9–48.0) Ref 54.1 (52.3–55.9) Ref

Abbreviations: APR, adjusted prevalence ratio; CI, confidence interval; DRA, Delta Regional Authority; HPV, human papillomavirus; Ref, reference.
a Percentages are weighted; estimates with 95% CI >20 might not be reliable.
b P < .05 by t test for comparison with reference group.
c Insurance categories are mutually exclusive.
d Includes Indian Health Service (IHS), Children’s Health Insurance Programs (CHIP), and some private insurers.
e “Mixed” indicates that a combination of facility types was listed (private, public, hospital, and STD/school/teen clinics) for the adolescent and not just one type.
f Includes military health care facilities, Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics, and pharmacies.

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Table 3. Survey Responses Among Parents Whose Adolescent Child Had Not Yet Received HPV Vaccination, National Immunization Survey-Teen, United States, 2015–2017a
Questions and Responses All Surveyed Teens in the United States Mississippi Delta States Non-Delta States
DRA Counties Delta Outside DRA
No. of parents who answered question, “How likely is it that [TEEN] will receive HPV shots in the next 12 months?” 40,929 1,633 4,156 35,140
Responses
Very likely 28.9 (28.1–29.8) 28.2 (25.5–31.1) 28.6 (26.9–30.4) 29.0 (28.1–30.0)
Somewhat likely 24.1 (23.3–24.9) 21.6 (19.2–24.2) 23.6 (22.0–25.3) 24.2 (23.4–25.2)
Not too likely 16.8 (16.1–17.4) 18.2 (16.0–20.7) 17.3 (15.8–18.8) 16.6 (15.9–17.4)
Not likely at all 26.7 (25.9–27.5) 28.5 (25.9–31.3) 26.9 (25.2–28.6) 26.6 (25.7–27.5)
Not sure or don’t know 3.5 (3.2–3.9) 3.4 (2.4–4.7) 3.7 (3.0–4.5) 3.5 (3.2–3.9)
No. of parents who answered open-ended question, “What is the main reason [TEEN] will not receive HPV shots in the next 12 months?”b 19,263 842 2,023 16,398
Responses
Not needed or not necessary 20.6 (19.4–21.9) 20.8 (16.9–25.3) 19.6 (17.1–22.5) 20.8 (19.4–22.2)
Safety concern or side effects 17.3 (16.2–18.3) 15.4 (12.0–19.7) 16.4 (14.1–19.0) 17.4 (16.3–18.6)
Not recommended 13.1 (12.0–14.3) 15.5 (11.9–20.0) 12.7 (10.6–15.2) 13.0 (11.8–14.4)
Lack of knowledge 10.9 (10.0–12.0) 11.9 (8.9–15.6) 12.6 (10.4–15.1) 10.7 (9.6–11.8)
Teen not sexually active 10.3 (9.3–11.4) 9.9 (7.3–13.3) 8.4 (6.8–10.4) 10.6 (9.5–11.8)

Abbreviations: DRA, Delta Regional Authority; HPV, human papillomavirus.
a All values are weighted percentages (95% confidence intervals).
b Responses are from parents and guardians who responded, “not too likely,” “not likely at all,” or “not sure or don’t know” when asked how likely it was that the teen would receive an HPV vaccination in the next year.

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