Document Type

Dissertation

Degree

Doctor of Philosophy (PhD)

Department

Public Health

First Advisor's Name

Purnima Madhivanan

First Advisor's Committee Title

Associate Professor

Second Advisor's Name

Mary Jo Trepka

Second Advisor's Committee Title

Professor

Third Advisor's Name

Tan Li

Third Advisor's Committee Title

Assistant Professor

Fourth Advisor's Name

Timothy F. Page

Fourth Advisor's Committee Title

Associate Professor

Fifth Advisor's Name

Dionne P. Stephens

Fifth Advisor's Committee Title

Associate Professor

Keywords

HPV, infection, vaccination, policy, impact

Date of Defense

6-6-2016

Abstract

In the United States, the South has a disproportionate burden of cervical cancer, yet research reporting regional prevalence of human papillomavirus (HPV) infection is scarce. Since 2008, Virginia has passed a HPV vaccine mandate and Louisiana a HPV education bill. This dissertation estimated the prevalence of HPV infection among females and assessed the impact of Virginia’s and Louisiana’s HPV vaccination policy on vaccination among adolescent females.

The first manuscript estimated the prevalence of HPV infection using data from 4,250 females collected during the 2007–2010 National Health and Nutrition Examination Survey. Among 14–26 year-olds, the prevalence of high-risk oncogenic HPV was 25.6% (95% CI: 22.4 ̶ 33.3) in the South and 29.1% (95% CI: 24.8 ̶ 33.8) in the rest of the country (p= 0.15). Among 27–59 year-olds, infection rates were 20.9% (95% CI: 17.4 ̶ 24.9) for the South and 14.5% (95% CI: 12.9 ̶ 16.3) for the rest of the country (p=0.0001).

The second manuscript assessed the impact of Virginia’s HPV vaccine mandate on vaccination using National Immunization Survey-Teen 2008-2012 data (n=3,203). A difference-in-differences estimation and logistic regression analysis were performed with South Carolina and Tennessee serving as comparison states. Virginia’s mandate was not associated with an increase in vaccination rates. Physician recommendation was strongly associated with vaccination in the Virginia-South Carolina (aOR=10.3; p=0.0001) and Virginia-Tennessee analyses (aOR=9.33; 95%CI: 6.11 ̶ 14.3).

The third manuscript assessed the impact of Louisiana’s HPV education policy on vaccination using difference-in-differences estimation and logistic regression analysis, with Alabama and Mississippi as comparison states (n=2,327). There was no evidence that the policy increased vaccination rates. Physician recommendation was associated with vaccination in the Louisiana-Alabama (aOR=7.74; 95% CI: 5.22 ̶ 11.5) and Louisiana-Mississippi comparison (aOR=7.05; 95% CI: 4.6 ̶ 10.5).

This study found a higher prevalence of HPV infection among females aged 27 ̶ 59 years in the South compared to the rest of the country. Additionally, physician recommendation was strongly associated with vaccination despite HPV policy implementation. These findings highlight the importance of physician recommendation for HPV vaccination and the need for recommended cervical cancer screening, particularly in the South.

Identifier

FIDC000732

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