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Abstract

Objectives:

Despite cancer prevention benefits associated with the human papillomavirus (HPV) vaccine, uptake in the United States is relatively low among males and females. Our objective was to use the Healthy People 2020 social determinants of health framework to determine the availability and characteristics of data on economic, educational, social, health care, and community factors affecting HPV vaccine uptake in the United States.

Methods:

We included the most recent data sets from 6 publicly available, US-based, federally funded surveys that contained at least 1 measure of HPV vaccination among adolescents and young adults. We searched each data set for any social determinants of health measures within the 5 domains of the framework: economic stability, education, social and community context, health and health care, and neighborhood and built environment.

Results:

The social determinants of health domains of education, economic stability, and health and health care appeared in all data sets. The domains of social and community context and neighborhood and built environment appeared in only 3 data sets. Even when domains were represented, we discovered gaps in the data sets, in which only limited measures of the social determinants were available.

Conclusion:

The addition of questions about the social determinants of health to the surveys that generate these data sets, particularly in the domains of social and community context and neighborhood and built environment, would strengthen the ability of public health researchers, policy makers, and professionals to identify associations between the social determinants of health and HPV vaccine uptake.

Keywords

HPV public data sets social determinants vaccine uptake

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States and a causal agent for genital warts and cervical, anal, vaginal, vulvar, penile, and oropharyngeal cancers.^1,2 Primary prevention for HPV-related genital warts and cancers is available through a safe and effective vaccine. A 2-shot series is usually recommended for adolescents aged 11 or 12. For those who do not start the series of shots as adolescents, vaccination is still recommended up to age 26 (a “catch-up” vaccination, which involves 3 shots).² In 2006, the Advisory Committee on Immunization Practices recommended routine vaccination for girls aged 11 or 12. In 2011, the recommendation for routine HPV vaccination expanded to boys aged 11 or 12.³

Despite these recommendations and the prevention benefits associated with the HPV vaccine, uptake in the United States is relatively low among males and females.^2,4 As of 2017, 68.6% of adolescent females and 62.6% of adolescent males aged 13-17 had received at least 1 HPV vaccine dose, and 48.6% of adolescents aged 13-17 had completed the recommended 2-shot series.⁴ In comparison, Scotland, which has a successful school-based HPV immunization program, reported 2017 vaccination rates >90%.⁵ The most recent HPV vaccination rates in the United States may have been even lower if not for the passage of the Patient Protection and Affordable Care Act in 2010. With implementation of the Affordable Care Act, more adolescents were covered by insurance and had access to preventive health care, and insurance carriers were required to cover HPV vaccination. Although the Affordable Care Act may have positively influenced HPV vaccine uptake, there is room for improvement.⁶

One approach to increasing HPV vaccine uptake in the United States is to assess the social determinants of health that may influence uptake of the HPV vaccine.⁵ Data on HPV vaccination from multiple large US surveys can be used to assess sociodemographic factors that influence uptake. Although they are not designed to measure the social determinants of health, these surveys often include questions about sociodemographic factors, and some of the responses may also serve as proxies for the social determinants of health. The social determinants of HPV vaccine uptake have been assessed in various countries (eg, England, Madagascar), but each country has its own unique policies, cultures, and social norms that make it important to study social determinants of health within those country-dependent contexts.^7
-9 In the United States, it is unclear in the literature whether the databases resulting from national surveys sufficiently measure the social determinants of health that might influence HPV vaccine uptake. Thus, more deeply examining these social determinants of health in US databases could provide information about the sociodemographic factors related to HPV vaccine uptake that might enable structural-level, barrier-reducing policy interventions and, potentially, improvements in HPV vaccination rates.

The social-ecological model of health promotion posits that factors influencing health exist at multiple levels, including the individual, interpersonal, community, and societal levels.¹⁰ According to this model, interpersonal factors are close relationships (peers, partners, and family members) that may influence health, community factors are relationships among organizations and networks, and societal factors are the social and cultural norms, as well as the health, economic, educational, and social policies, that may play a role in health and prevention of disease.¹⁰ Although sociodemographic factors influencing HPV vaccine uptake in the United States have been examined extensively at the individual and interpersonal levels (by examining attitudes, beliefs, knowledge, and communication),^11

-15 these factors have been investigated to a lesser degree at the community and societal levels.^16
-18

The influence of community- and societal-level factors on HPV vaccine uptake might be more thoroughly investigated by using a social determinants of health framework. The integration of a social determinants of health framework into public health research has become a national priority. Healthy People 2020 has a formal social determinants of health framework to help set national objectives for improving the health of all Americans.¹⁹ Rather than focusing on the individual and interpersonal factors that influence health (eg, individual knowledge, beliefs, and attitudes or interactions among persons), this comprehensive framework concentrates on the broad range of economic, educational, social, health care, and community factors affecting health. Despite the availability of this comprehensive framework, little public health research has been conducted by using this framework or one similar to it.²⁰

The primary objective of our study was to use the Healthy People 2020 social determinants of health framework to determine the availability and characteristics of data on economic, educational, social, health care, and community factors that affect HPV vaccine uptake in publicly available, US-based, federally funded databases. A secondary objective was to identify and enumerate any gaps in data so that researchers working on the databases and other researchers could use this information to strengthen the data on sociodemographic factors that are available in the future, particularly for use in determining public health policies and practices related to HPV vaccination.

Methods

To identify data sets for inclusion in our study, we examined websites of the Centers for Disease Control and Prevention, the National Center for Health Statistics (NCHS), and the Inter-university Consortium for Political and Social Research. For the purposes of this study, we chose data sets from publicly available, US-based, federally funded surveys that contained at least 1 measure of HPV vaccination among adolescents and young adults. We included data sets regardless of whether both sexes and all ages were represented.

Once we identified the data sets to include, a single co-author (S.B.M.) extracted and reviewed the public data dictionaries (ie, online files that allow users to view the survey questions) for each data set. Then, to search each data set for social determinants of health variables, we used the definitions for the Healthy People 2020 social determinants of health framework.¹⁹ This framework consists of 5 domains, each of which has 3 or 4 key areas (Table 1). The domain (and key area) variables that we searched for in the databases were as follows: economic stability (poverty, employment, food security, housing stability), education (high school graduation, enrollment in higher education, language and literacy, early childhood education and development), social and community context (social cohesion, discrimination, civic participation, incarceration), health and health care (access to health care, access to primary care, health literacy), and neighborhood and built environment (access to healthy foods, crime and violence, environmental conditions, quality of housing).

Table 1.

Domains and key areas of the Healthy People 2020 social determinants of health framework,^a identified in 6 publicly available, US-based, federally funded data sets from surveys that ask about human papillomavirus (HPV) vaccination, 2007-2016^b

	Data Set^c
Social Determinants of Health Domains and Key Areas^a	BRFSS 2015	NIS-Teen 2016	NHANES 2015-2016	NHIS 2015	NSFG 2013-2015	NSCH 2007
Economic stability domain
Poverty	X	X	X	X	X	X
Employment	X		X	X	X	X
Food security			X	X	X
Housing stability	X	X	X	X	X	X
Education domain
High school graduation	X	X	X	X	X	X
Enrollment in higher education	X	X	X	X	X	X
Language and literacy			X	X	X	X
Early childhood education and development				X		X
Social and community context domain
Social cohesion				X		X
Discrimination
Civic participation
Incarceration					X
Health and health care domain
Access to health care	X	X	X	X	X	X
Access to primary care	X	X	X	X	X	X
Health literacy	X
Neighborhood and built environment domain
Access to healthy foods
Crime and violence						X
Environmental conditions				X		X
Quality of housing			X			X

Abbreviations: BRFSS, Behavioral Risk Factor Surveillance System; NHANES, National Health and Nutrition Examination Survey; NHIS, National Health Interview Survey; NIS-Teen, National Immunization Survey-Teen; NSCH, National Survey of Children’s Health; NSFG, National Survey of Family Growth.

^aThe Healthy People 2020 social determinants of health framework¹⁹ contains 5 domains, and each domain includes 3 or 4 key areas. The definitions for the key areas were used to identify social determinants of health measures in each data set.

^bEach database was analyzed back to January 2006, when the HPV vaccine first became available. The data set representing the most recent version of each database (ranging from 2007-2016) in which there was information about HPV vaccination was used to search for measures on the social determinants of health.

^cData sets from the following surveys were used: 2015 BRFSS,²¹ 2016 NIS-Teen,²² 2015-2016 NHANES,²³ 2015 NHIS,²⁴ 2013-2015 NSFG,²⁵ and 2007 NSCH.²⁶

Within each data set, we reviewed surveys as far back as January 2006, when the HPV vaccine first became available. However, for this study, we used only the most recent version of each data set that contained information about HPV vaccination. Because we used the most recent versions of data sets and because some of the data sets stopped including information about HPV vaccination (eg, the National Survey of Children’s Health [NSCH] after 2007), we analyzed data sets from 2007-2016.

The 6 data sets that we included in our study were the 2015 Behavioral Risk Factor Surveillance System (BRFSS),²¹ 2016 National Immunization Survey–Teen (NIS-Teen),²² the 2015-2016 National Health and Nutrition Examination Survey (NHANES),²³ the 2015 National Health Interview Survey (NHIS),²⁴ the 2013-2015 National Survey of Family Growth (NSFG),²⁵ and the 2007 NSCH²⁶ (Table 2).

Table 2.

Descriptions of data sets from 6 publicly available, US-based, federally funded databases that contain human papillomavirus (HPV) vaccination information and were used to search for social determinants of health factors, 2007-2016^a

Data Set	Description
2015 Behavioral Risk Factor Surveillance System²¹	Collects nationally representative data from the US population on health risk behaviors, chronic diseases, and preventive servicesSponsored by the Centers for Disease Control and Prevention’s (CDC’s) National Center for Chronic Disease Prevention and Health Promotion, Division of Population HealthBegan collecting nationwide data in 1993 from adults aged ≥18Uses in-house interviewers and telephone surveyors to collect data
2016 National Immunization Survey–Teen²²	Collects information about adolescents aged 13-17Sponsored by National Center for Immunization and Respiratory Diseases, as part of CDCBegan surveys in 1994Consists of household telephone surveys of parent and/or guardian and vaccination surveys of health care providers (with appropriate permission)
2015-2016 National Health and Nutrition Examination Survey²³	Collects nationally representative data on the health and nutrition status of adults and childrenMajor program of National Center for Health Statistics (NCHS), as part of CDCBegan collecting data in the 1960sUses home interviews and mobile centers equipped for physical examinations and health measurements
2015 National Health Interview Survey²⁴	Collects representative data on the noninstitutionalized US populationConducted by NCHS, as part of CDCBegan collecting data in 1957For each selected family, obtains information from single sample adult and child (if present)Uses household interviews and computer-assisted personal interviews (CAPIs)
2013-2015 National Survey of Family Growth²⁵	Collects nationally representative information about families, including relationships, sexual health, and general healthConducted by NCHS, as part of CDCBegan collecting data in 1973Uses in-person interviews and CAPIs for sensitive questions involving participants aged 15-49
2007 National Survey of Children’s Health²⁶	Collects nationally representative information about physical and emotional health and overall well-being of children aged 0-17Conducted by NCHS, as part of CDCBegan conducting surveys in 2003Uses state and local area integrated telephone survey

^aEach database was analyzed back to January 2006, when the HPV vaccine first became available. The data set representing the most recent version of each database (ranging from 2007-2016) in which there was information about HPV vaccination was used to search for measures on the social determinants of health.

Results

HPV Vaccination

Each of the 6 data sets contained at least 2 items on HPV vaccine uptake and/or completion (Table 3). The age range of participants who were asked about HPV vaccination differed among the 6 surveys. In addition, the NSFG and NSCH surveys asked questions about HPV vaccination only among females, which limited the data available about males to the other 4 data sets.

Table 3.

Survey participants and human papillomavirus (HPV) vaccination survey questions used in data sets from 6 publicly available, US-based, nationally funded databases, 2007-2016^a

Data Set	Survey Participants	Questions About HPV Vaccination
2015 Behavioral Risk Factor Surveillance System²¹	Men and women aged 18-49	Have you ever had the HPV vaccination?How many HPV shots did you receive?
2016 National Immunization Survey–Teen²²	Males and females aged 13-17	Has [teen] ever received HPV shots?How many HPV shots did [teen] ever receive?
2015-2016 National Health and Nutrition Examination Survey²³	Males and females aged 9-59	Have you ever received 1 or more doses of HPV vaccine?Which of the HPV vaccines did you receive: Cervarix, Gardasil, or Gardsil 9?How old were you when you received your first dose of [Cervarix/Gardasil/Gardasil 9/Gardasil or Gardasil 9/the vaccine]?How many doses of [Cervarix/Gardasil/Gardasil 9/Gardasil or Gardasil 9/the vaccine] have you received?
2015 National Health Interview Survey²⁴	Males and females aged 8-64	Have you ever received an HPV shot or vaccine [adults]?How old were you when you received your first HPV shot?How many HPV shots did you receive?
2013-2015 National Survey of Family Growth²⁵	Females aged <25	Have you received the cervical cancer vaccine, also known as the HPV shot or Gardasil?How old were you when you received your first HPV vaccine shot?Which occurred first, your first sexual intercourse or your first HPV vaccine shot?
2007 National Survey of Children’s Health²⁶	Females aged 12-17	Has [S.C.] ever received any HPV shots?Please tell me how many HPV shots [S.C.] has received.

Overview of Social Determinants of Health Framework

None of the 6 data sets contained measures pertaining to all key areas of the social determinants of health as defined by the Healthy People 2020 social determinants of health framework (Table 1). The number of key areas covered by each data set varied. The NSCH contained data on measures pertaining to the most key areas (n = 13), and the NIS-Teen contained data on measures pertaining to the fewest key areas (n = 6).

Three social determinants of health domains appeared in all 6 data sets: education, economic stability, and health and health care (Table 1). The domain of social and community context appeared in only the NHIS, NSFG, and NSCH data sets, and the domain of neighborhood and built environment appeared in only the NHANES, NHIS, and NSCH data sets.

Economic stability domain

Each data set included measures pertaining to at least 2 of the 4 key areas in the economic stability domain (Table 4). Three data sets (NHANES, NHIS, and NSFG) included measures pertaining to all 4 key areas (poverty, employment, food security, and housing stability) of the economic stability domain. All 6 data sets included at least 1 measure pertaining to poverty and housing stability. All data sets except NIS-Teen also included a measure pertaining to employment. Finally, 3 data sets (NHANES, NHIS, and NSFG) included a measure pertaining to food security.

Table 4.

Measures included in data sets from 6 publicly available, US-based, federally funded databases, by domains and key areas^a of the Healthy People 2020 social determinants of health framework, 2007-2016^b

Key Area and Data Set^c	Measure
Economic stability domain
Key area: poverty
BRFSS	Combined family income
NIS-Teen	Combined family income^d
NHANES	Combined family income^d; sources of income; receipt of public assistance
NHIS	Combined family income^d; sources of income
NSFG	Individual income^d; combined family income^d; sources of income; receipt of public assistance
NSCH	Combined family income; receipt of public assistance
Key area: employment
BRFSS	Currently employed; 4 additional questions related to employment
NHANES	Employment^e; reason if not working^e; 7 additional questions related to employment
NHIS	Employment^e; reason if not working^e; ever held job; 11 additional questions related to employment
NSFG	Employment^d,e; full-time or part-time; ever worked at job for regular pay; number of jobs worked^e; spousal employment
NSCH	Parental employment; anyone in household employed^d
Key area: food security
NHANES	Worry about food running out; food did not last^d; could not afford balanced meals^d; 9 additional questions related to food security
NHIS	Always able to afford food in past 30 days; worry about affording food; 7 additional questions related to food security
NSFG	Family member hungry because could not afford food^d
Key area: housing stability
BRFSS	House or apartment owned, rented, or other arrangement
NIS-Teen	House or apartment owned, rented, or other arrangement
NHANES	House or apartment owned or rented
NHIS	Length of time living in present neighborhood
NSFG	Ever in foster care system; number of different settings; time spent in foster care; living at same address on April 1, 2010
NSCH	Ever in foster care system; whether adoption finalized
Education domain
Key area: education
BRFSS	Highest level of education
NIS-Teen	Current grade level in school or reported as not in school; parental highest level of education
NHANES	Highest level of education
NHIS	Family highest level of education
NSFG	Obtained high school diploma, GED, or both
NSCH	Parental highest level of education
Key area: enrollment in higher education
BRFSS	Highest level of education
NIS-Teen	Maternal highest level of education
NHANES	Highest level of education
NHIS	Family’s highest level of education
NSFG	Highest level of education; mother’s highest level of education; has college/university degrees; type of degrees; expects to go back to school in the future
NSCH	Parental highest level of education
Key area: language and literacy
NHANES	Language spoken in home
NHIS	Language used most often; how well each family member speaks English
NSFG	Language spoken in home
NSCH	Language spoken in home
Key area: early childhood education and development
NHIS	Child attended Head Start; child receipt of special education or early intervention services; physician ever told child had developmental delay, learning disability, speech problems
NSCH	Early childhood developmental screening; 4 additional questions related to early childhood
Social and community context domain^f
Key area: social cohesion
NHIS	Whether people in neighborhood help each other out; neighbors count on each other; neighbors can be trusted; neighborhood is close-knit
NSCH	Whether people in neighborhood help each other out; neighbors look out for each other’s children; parents feel they can count on neighbors; parents trust neighbors to help child
Key area: incarceration
NSFG	Number of times and length of time in jail, prison, or juvenile detention
Health and health care domain
Key area: access to health care
BRFSS	Health insurance coverage; primary source of coverage; 4 additional questions related to health insurance
NIS-Teen	Teen covered by health insurance; 7 additional questions related to health insurance
NHANES	Health insurance coverage; type of coverage; Medicare; Medicaid; if plans cover cost of prescriptions; any time with no coverage^d
NHIS	How health insurance compares to 1 year ago; 29 additional questions related to health insurance
NSFG	Health insurance coverage^d; number of months without coverage; covered on parents’ private plan
NSCH	Health insurance coverage^d; Medicaid; 5 additional questions related to health insurance
Key area: access to primary care
BRFSS	One person considered personal provider; any time where needed to see a physician but could not due to cost^d; 3 additional questions related to access to care
NIS-Teen	Age at last checkup; whether had an 11- or 12-year-old well-child examination; last checkup before age 12; number of times teen saw physician^d
NHANES	Place usually go when need health advice or sick; 10 additional questions related to access to care
NHIS	Asked of child and other family members: place usually go when need health advice; 17 additional questions related to access to care
NSFG	Visited physician^d; reason did not see a physician^d; 3 additional questions related to access to care
NSCH	Place usually go when child needs health advice or is sick; type of place; 10 additional questions related to access to care; 9 additional questions related to access to care
Key area: health literacy
BRFSS	Difficulty getting advice or information about health topics; understanding information health providers give; understanding written health information
Neighborhood and built environment domain^g
Key area: crime and violence
NSCH	Perceived neighborhood safety
Key area: environmental conditions
NHIS	Roads, sidewalks, paths, or trails to walk near home; shops within walking distance; 4 additional questions related to environmental conditions
NSFG	Neighborhood amenities and condition; sidewalks, parks, recreation centers, or libraries
Key area: quality of housing
NHANES	Number of rooms
NSCH	Poorly kept or rundown housing; litter on sidewalks and streets; vandalism

Abbreviations: BRFSS, Behavioral Risk Factor Surveillance System; NHANES, National Health and Nutrition Examination Survey; NHIS, National Health Interview Survey; NIS-Teen, National Immunization Survey–Teen; NSCH, National Survey of Children’s Health; NSFG, National Survey of Family Growth.

^aThe Healthy People 2020 social determinants of health framework¹⁹ contains 5 domains, and each domain has 3 or 4 key areas. Data sets lacking relevant measures in key areas are not listed.

^cData sources: 2015 BRFSS,²¹ 2016 NIS-Teen,²² 2015-2016 NHANES,²³ 2015 NHIS,²⁴ 2013-2015 NSFG,²⁵ and 2007 NSCH.²⁶

^dIn past 12 months.

^eIn past week.

^fNo measures pertaining to key areas of discrimination and civic participation appeared in any data set.

^gNo measures pertaining to key area of access to healthy foods appeared in any data set.

Education domain

Each data set included measures pertaining to the key areas of high school graduation and enrollment in higher education (Table 4). Four data sets (NHANES, NHIS, NSFG, and NSCH) included a measure pertaining to the key area of language and literacy, and 2 data sets (NHIS and NSCH) included a measure pertaining to early childhood education and development.

Social and community context domain

None of the data sets included measures pertaining to the key areas of discrimination and civic participation (Table 4). Only 2 data sets (NHIS and NSCH) included measures pertaining to the key area of social cohesion, and only the NSFG data set included a measure pertaining to incarceration.

Health and health care domain

All 6 data sets included measures pertaining to the key areas of access to health care and access to primary care (Table 4). Only the BRFSS included measures pertaining to health literacy.

Neighborhood and built environment domain

None of the data sets included measures pertaining to the key area of access to healthy foods (Table 4). However, 2 data sets (NHIS and NSCH) included measures pertaining to environmental conditions, 2 data sets (NHANES and NSCH) included measures pertaining to quality of housing, and 1 data set (NSCH) included a measure pertaining to crime and violence.

Discussion

Identifying social determinants of health factors that contribute to health disparities is a public health priority.¹⁹ We discovered numerous gaps in data on social determinants of health measures in national databases that include information about HPV vaccination. We also identified inconsistencies in the presence of social determinants of health measures in national surveys. For example, whereas all 6 data sets contained information about access to health care (most often these were results of survey questions about health insurance), only the BRFSS data set contained measures pertaining to health literacy. This finding is noteworthy because health literacy skills enable persons to make informed decisions about their health and, as such, may influence HPV vaccine uptake.²⁷

All data sets included measures in the economic stability domain. On one hand, high vaccine costs are not a proven barrier to vaccination for lower-income persons who are not covered by Medicaid or the Vaccines for Children Program. On the other hand, the economic stability domain (as measured by poverty, employment, food security, and housing stability) may influence the rate of HPV vaccine uptake. Before implementation of the Affordable Care Act, the economic stability domain may have played an even bigger role in HPV vaccine uptake than it does currently because of both the high cost of the vaccine and the fewer numbers of persons with health insurance coverage.^28,29

All 6 data sets contained measures pertaining to the key areas of high school graduation and enrollment in higher education in the education domain, yet only 2 data sets included measures pertaining to all 4 key areas in this domain. This finding suggests that the surveys could be improved by asking about more than just levels of advancement through the education system, for example, early childhood education and literacy.

None of the data sets included measures pertaining to the key areas of discrimination or civic participation in the social and community context domain. Furthermore, most of the data sets also lacked measures pertaining to the key areas of incarceration (n = 5) and social cohesion (n = 6). Yet measures pertaining to all 4 of the key areas in this domain may contribute to disparities in HPV vaccine uptake. For example, parental incarceration may affect whether a child or teen is vaccinated. In addition, community cohesion, particularly as it applies to developing positive attitudes about HPV vaccination, could play a role in herd protection (ie, when a sufficient proportion of a population is made immune to an infectious disease [eg, through vaccination] to make its spread from person to person unlikely) from HPV.³⁰ Interestingly, family structure was a key area previously included in the social and community context domain in the Healthy People 2020 social determinants of health framework, but it was removed in the 2015 update.

All 6 data sets contained measures pertaining to the key areas of access to primary care and access to health insurance in the health and health care domain. This information is important because HPV vaccines are typically delivered in a health care setting, and health insurance coverage is often required to gain access to this setting. Conversely, only 1 data set (BRFSS) included measures pertaining to the key area of health literacy. Health literacy plays a potentially important role in HPV vaccination, because low levels of understanding about HPV and the HPV vaccine could be associated with a reduced likelihood of adopting protective behaviors, including vaccination.³¹

Most of the data sets in our study included only a few measures pertaining to key areas in the neighborhood and built environment domain. Yet measures in the key areas of access to healthy foods, crime and violence, environmental conditions, and quality of housing may each be relevant as proxy measures for social stability and are therefore relevant to vaccination. Low levels of social stability may contribute to disparities in HPV vaccination rates; as such, including survey questions about these measures may be valuable for assessing these disparities.

Overall, most of the data sets evaluated in this study contained measures pertaining to most of the social determinants of health domains and key areas. The NSCH and NHIS data sets had the best coverage of key areas of the social determinants of health. However, even these 2 data sets provided only limited information about the social and environmental factors that might affect HPV vaccine uptake. We acknowledge that the surveys generating these data sets may not have been built for studying the social determinants of health. However, because the social determinants of health framework is used as a guiding framework to assess public health issues, integration of more of these social determinants of health measures into future surveys is important.

Limitations

This study had several limitations. First, we did not extract data on race/ethnicity from the data sets because these data were not included in the Healthy People 2020 social determinants of health framework that we used. However, the relationship between race/ethnicity and HPV vaccine uptake may be confounded by underlying differences in social class, which would tend to be captured by using other social determinants of health factors.^32,33 Second, we included the older 2007 data set version from the NSCH database because subsequent versions of this database (2008-2016) did not include any questions on HPV vaccination. We would advocate for national data sets to retain questions on HPV vaccine uptake and completion measures in their questionnaires to allow trends in this priority area to be followed. Third, 2 of the surveys used to generate the data sets in our study were limited to females aged 11-26, and age ranges differed among all surveys. Limiting the age range and sex studied could make future research difficult to compare, especially because in 2018, the FDA approved vaccine uptake for males and females up to age 45.³⁴ National surveys should include HPV vaccination questions for males and females and for the entire age range for which HPV vaccination is recommended. Although approaches to HPV and its vaccine have historically been feminized, sex-neutral approaches to HPV vaccination should be pursued in the future.³⁵ Future evaluations should test for multicollinearity between the various social determinants of health predictor variables to reduce unstable coefficient estimates and difficulty interpreting results.

Conclusions

Most publicly available, US-based, federally funded data sets that include data on HPV vaccination lack comprehensive measures of the social determinants of health. Future research should examine the gaps in social determinants of health data in these data sets. Adding questions about the social determinants of health to the surveys that generate these data sets, particularly in the domains of social and community context and neighborhood and built environment, would strengthen the ability of public health researchers, policy makers, and professionals to identify associations between the social determinants of health and HPV vaccination. It could also lead to improved HPV vaccine uptake and prevention of HPV-related diseases.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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