Spatial Access to Vaccines for Children Providers in South Carolina: Implications for HPV Vaccination

Radhika Ranganathan, MPhil¹; Whitney E. Zahnd, PhD^1,2; Sayward E. Harrison, PhD^3,4; Heather M. Brandt, PhD^1,5,6; Swann Arp Adams, PhD^1,6,7,8; Jan M. Eberth, PhD^1,2,6,8 (View author affiliations)

Suggested citation for this article: Ranganathan R, Zahnd WE, Harrison SE, Brandt HM, Adams SA, Eberth JM. Spatial Access to Vaccines for Children Providers in South Carolina: Implications for HPV Vaccination. Prev Chronic Dis 2020;17:200300. DOI: http://dx.doi.org/10.5888/pcd17.200300.

PEER REVIEWED

Panel A shows the location of VFC providers by rural and urban Zip Code Tabulation Areas (ZCTAs). Panel B shows the age-eligible population for the VFC programs by tertiles. Panel C shows spatial accessibility by tertile of accessibility score for both rural and urban ZCTAs. Accessibility was defined as supply (ie, VFC provider locations) of and demand for services (ie, children and adolescents age-eligible for the VFC program) within a specified catchment area (ie, 30 minutes’ drive time). Panel D shows spatial accessibility cold spots and hot spots (areas of low access [cold spots] and high access [hot spots]) across ZCTAs. Sources: South Carolina Department of Health and Environmental Control (VFC data, 2019) and the American Community Survey (2013–2017). [A text version of this figure is also available.]

Top

Background

The Advisory Committee on Immunization Practices recommends routine human papillomavirus (HPV) vaccination for male and female adolescents aged 11 or 12 years, beginning as early as age 9, with catch-up vaccination for all people through age 26, and shared clinical decision making before vaccination decisions for those aged 27 to 45 (1,2). Although uptake of HPV vaccination has increased since its initial recommendation (2006 for girls; 2011 for boys), rural populations have lower rates of initiation and completion compared with their urban counterparts, particularly in the southern United States (3). To improve rural HPV vaccination rates, several policy recommendations have been made, including increasing access to the Vaccines for Children (VFC) program through federally qualified health centers, rural health clinics, health departments, and other settings, including pharmacies (4).

The VFC program is a federally funded program that provides vaccines at no cost for certain populations (5). Children through age 18 years who are uninsured, underinsured, Medicaid eligible, or of American Indian/Alaska Native descent can access free HPV vaccination through VFC-enrolled providers.

In South Carolina, rural residents aged 13 to 17 years have lower rates of HPV vaccination initiation (62.2% in 2018) compared with their urban counterparts (79.8% in metropolitan central cities vs 66.8% in metropolitan noncentral cities) (6). To better understand potential drivers of this rural–urban disparity, our objective was to examine spatial access to VFC-enrolled clinics across rural and urban areas of South Carolina.

Top

Data Sources and Map Logistics

We obtained and geocoded addresses of publicly accessible VFC-enrolled providers from the South Carolina Department of Health and Environmental Control. Nonpublicly accessible VFC providers (eg, juvenile detention centers) were excluded. We also obtained Zip Code Tabulation Area–level (ZCTA, which are geographic approximations of zip codes) population estimates of persons under the age of 18 (ie, age grouping of available data that are most congruent with VFC eligibility criteria) from the 2013–2017 American Community Survey (7). We then performed the 2-step floating catchment area (2SFCA) method in ArcGIS 10.5.1 (Esri) to determine spatial access to VFC providers at the ZCTA–level. The 2SFCA method considers the supply (ie, VFC provider locations) of and demand for services (ie, children and adolescents) within a specified catchment area (ie, 30 minutes’ drive time) to generate a score indicating access to VFC providers for each ZCTA. Thus, for example, a ZCTA may have many VFC providers, but if the 30-minute catchment area has a large population, it will have a smaller access score compared with ZCTAs with fewer providers but a relatively smaller population. Potential values can range from 0 (no access within 30 minutes) to 1 (an improbable 1:1 VFC provider:child ratio). Additional details about this approach are detailed elsewhere (8). We calculated travel distance from the centroid of each ZCTA to the nearest VFC provider, which enables us to determine proximity to VFC providers but does not account for potential demand for services. ZCTAs were categorized as rural or urban using rural–urban commuting area primary codes, with a code of 4 or more categorized as rural (9).

We then performed Optimized Hot Spot Analysis by using the Getis-Ord Gi* tool (10). This statistic identifies where areas of high access (hot spots) and low access (cold spots) are clustered, while adjusting for false discovery rates and spatial dependence. We examined rural–urban differences in VFC providers by type (eg, public health department), spatial accessibility scores, distance to the nearest VFC provider, and hot spots and cold spots by using independent t tests and χ² analyses for continuous and categorical variables, respectively.

Top

Highlights

South Carolina has 493 public VFC providers across rural and urban ZCTAs (panel A). Rural and urban VFC providers varied by type, with the largest proportion of rural providers (41.1%) at federally designated health care centers and the largest proportion of urban providers (55.6%) at private clinics (P < .001) (Table 1).

Panel B shows the number of children under age 18 within each ZCTA, by tertile. Panel C shows rural and urban ZCTAs by tertiles of access scores. Panel D shows the findings of the Getis-Ord Gi* analysis of these data, indicating hot spots (ie, clusters of high access) primarily toward the southernmost rural tip of the state and toward the northeastern part of the state. Rural ZCTAs had higher mean access scores compared with urban ZCTAs (0.000548 vs 0.000419, P < .001) (Table 2). There was no difference in distance to the nearest VFC provider across rural and urban ZCTAs (7.50 vs 6.47 miles, P = .06). A higher proportion of rural ZCTAs (16.0%) was in hot spots compared with urban ZCTAs (4.7%) (P < .001).

Top

Actions

We found that children and adolescents in rural ZCTAs in South Carolina have greater access to VFC providers than those in urban ZCTAs, as demonstrated by higher mean accessibility scores across rural ZCTAs, comparable distances to the nearest VFC provider in urban ZCTAs, and a higher proportion of rural ZCTAs in hot spots. This information suggests that lower HPV vaccination initiation and completion rates in rural South Carolina are likely due to factors other than limited spatial access to VFC providers. Previous studies found lower levels of HPV awareness and knowledge among rural residents compared with urban residents (11). Additionally, providers are less likely to engage in collaborative communication about HPV and HPV vaccination with rural parents (11). Educational interventions, awareness campaigns, and enhanced provider training may be effective ways to improve uptake, especially considering the relatively high availability of VFC programs in many rural areas in the state (12).

Identifying clusters with limited access to VFC providers may help health care systems, public health departments, and policy makers engage in targeted efforts to increase VFC enrollment and thereby expand access to vaccination for vulnerable children and adolescents. Reducing out-of-pocket costs associated with vaccination, implementing vaccination programs in schools and child care centers, and offering vaccinations through home health visits and at pharmacies are also recommended, evidence-based strategies (13,14). Previous studies have shown the utility of using GIS approaches to identify low access areas and target them for additional programs (15).

The Community Preventive Services Task Force has also identified multiple provider-level or systems-level strategies to increase vaccine uptake, such as the use of provider reminder systems and standing orders (16). Understanding the distribution and diversity of VFC providers across rural and urban areas may help inform planning for and delivery of these types of interventions. We found that more than half of rural VFC providers are in federally designated community-based clinics. Community-based clinics are important for expanding access to HPV vaccination for rural populations, and are optimal sites for implementing systems, tools, and protocols that improve vaccination rates (4).

Top

Acknowledgments

This study was supported by the Federal Office of Rural Health Policy (FORHP), Health Resources and Services Administration (HRSA), US Department of Health and Human Services (HHS) under cooperative agreement no. U1CRH30539. The information, conclusions, and opinions expressed in this article are those of the authors and no endorsement by FORHP, HRSA, or HHS is intended or should be inferred. No copyrighted material was used in this article.

Top

Author Information

Corresponding Author: Whitney E. Zahnd, PhD, Rural and Minority Health Research Center, Arnold School of Public Health, University of South Carolina, 220 Stoneridge Dr, Ste 204, Columbia, SC 29210. Telephone: 803-576-6057. Email: zahnd@mailbox.sc.edu.

Author Affiliations: ¹Rural and Minority Health Research Center, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina. ²Big Data Health Science Center, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina. ³Department of Psychology, College of Arts and Sciences, University of South Carolina, Columbia, South Carolina. ⁴South Carolina SmartState Center for Healthcare Quality, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina. ⁵Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina. ⁶Cancer Prevention and Control Program, University of South Carolina, Columbia, South Carolina. ⁷College of Nursing, University of South Carolina, Columbia, South Carolina. ⁸Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina.

Top

References

1. Meites E, Szilagyi PG, Chesson HW, Unger ER, Romero JR, Markowitz LE. Human papillomavirus vaccination for adults: updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 2019;68(32):698–702. CrossRef PubMed
2. Meites E, Kempe A, Markowitz LE. Use of a 2-dose schedule for human papillomavirus vaccination — updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep 2016;65(49):1405–8. CrossRef PubMed
3. Williams CL, Walker TY, Elam-Evans LD, Yankey D, Fredua B, Saraiya M, et al. Factors associated with not receiving HPV vaccine among adolescents by metropolitan statistical area status, United States, National Immunization Survey—Teen, 2016–2017. Hum Vaccin Immunother 2020;16(3):562–72. CrossRef PubMed
4. Vanderpool RC, Stradtman LR, Brandt HM. Policy opportunities to increase HPV vaccination in rural communities. Hum Vaccin Immunother 2019;15(7–8):1527–32. CrossRef PubMed
5. Centers for Disease Control and Prevention. Vaccines for Children program (VFC). https://www.cdc.gov/vaccines/programs/vfc/index.html. Accessed May 13, 2020.
6. Centers for Disease Control and Prevention. 2019 adolescent HPV vaccination coverage dashboard. https://www.cdc.gov/vaccines/imz-managers/coverage/teenvaxview/data-reports/hpv/dashboard/2019.html. Accessed November 17, 2020.
7. US Census Bureau. American Community Survey data. https://www.census.gov/programs-surveys/acs/data.html. Accessed January 20, 2020.
8. Luo W, Wang F. Measures of spatial accessibility to health care in a GIS environment: synthesis and a case study in the Chicago region. Environ Plann B Plann Des 2003;30(6):865–84. CrossRef
9. US Department of Agriculture. 2010 Rural–urban commuting area codes. http://www.ers.usda.gov/data-products/rural-urban-commuting-area-codes/documentation/. Accessed August 25, 2020.
10. Wang F. Chapter 8: spatial statistics and applications. In: Wang F. Quantitative methods and socio-economic applications in GIS. Boca Raton (FL): CRC Press; 2015:163–192.
11. Moss JL, Gilkey MB, Rimer BK, Brewer NT. Disparities in collaborative patient–provider communication about human papillomavirus (HPV) vaccination. Hum Vaccin Immunother 2016;12(6):1476–83. CrossRef PubMed
12. Mohammed KA, Subramaniam DS, Geneus CJ, Henderson ER, Dean CA, Subramaniam DP, et al. Rural–urban differences in human papillomavirus knowledge and awareness among US adults. Prev Med 2018;109:39–43. CrossRef PubMed
13. Jacob V, Chattopadhyay SK, Hopkins DP, Murphy Morgan J, Pitan AA, Clymer JM, et al. Increasing coverage of appropriate vaccinations: a Community Guide systematic economic review. Am J Prev Med 2016;50(6):797–808. CrossRef PubMed
14. Community Preventive Services Task Force. Vaccination programs: community-based interventions implemented in combination. https://www.thecommunityguide.org/findings/vaccination-programs-community-based-interventions-implemented-combination. Accessed May 29, 2020.
15. Lofters AK, Gozdyra P, Lobb R. Using geographic methods to inform cancer screening interventions for South Asians in Ontario, Canada. BMC Public Health 2013;13(1):395. CrossRef PubMed
16. Community Preventive Services Task Force. CPSTF findings for increasing vaccination. https://www.thecommunityguide.org/content/task-force-findings-increasing-vaccination. Accessed November 24, 2020.

Top

Tables

^a Analysis using data from the South Carolina Department of Health and Environmental Control (VFC data, 2019) and the American Community Survey (2013–2017).
^b Includes federally qualified health centers, rural health clinics, and other community health centers.

^a Analysis using data from the South Carolina Department of Health and Environmental Control (VFC data, 2019) and the American Community Survey (2013–2017). Clusters are identified as areas of high access (hot spots) and low access (cold spots).
^b P value from χ² test.
^c The supply (ie, VFC provider locations) of and demand for services (ie, children and adolescents) within a specified catchment area (ie, 30 minutes’ drive time).
^d From independent t test.

Top