Cancer Causes & Control

, Volume 29, Issue 10, pp 927–936 | Cite as

Intersectional nativity and racial/ethnic disparities in human papillomavirus vaccination initiation among U.S. women: a national population-based study

  • Madina AgénorEmail author
  • Sarah Abboud
  • Jazmine Garcia Delgadillo
  • Ashley E. Pérez
  • Sarah M. Peitzmeier
  • Sonya Borrero
Original paper



Overall, foreign-born women are less likely than U.S.-born women to have initiated human papillomavirus (HPV) vaccination. However, foreign-born women are a racially/ethnically diverse population, and race/ethnicity is an independent predictor of HPV vaccination.


Using 2011–2015 National Health Interview Survey data, we used multivariable logistic regression to estimate odds ratios for foreign-born black, Latina, and Asian women compared to foreign-born white women and U.S.-born white women, adjusting for sociodemographic factors. We added socioeconomic factors followed by health care access indicators, which we conceptualized as potential mediators, to each model to assess whether they helped explain observed disparities.


Foreign-born Asian ([odds ratio=] 0.43; [95% confidence interval:] 0.29–0.65) and Latina (0.46; 0.32–0.68) women had significantly lower adjusted odds of initiating HPV vaccination compared to foreign-born white women. Foreign-born white (0.64; 0.45–0.90), black (0.44; 0.29, 0.67), Latina (0.29; 0.24–0.35), and Asian (0.28; 0.21–0.38) women had significantly lower adjusted odds of HPV vaccination initiation compared to U.S.-born white women. Socioeconomic factors only explained HPV vaccination initiation disparities between foreign-born Latina women and foreign-born and U.S.-born white women. Health care access indicators modestly explained disparities between foreign-born white, black, and Latina women and U.S.-born white women only.


We observed pronounced HPV vaccination initiation disparities among foreign-born women in relation to race/ethnicity and between foreign-born women from minoritized racial/ethnic backgrounds and U.S.-born white women. Research on nativity disparities in HPV vaccination should take into account race/ethnicity, and vice versa. Interventions that seek to facilitate HPV vaccination among foreign-born women are needed and should address the unique needs of those from minoritized racial/ethnic backgrounds to promote cancer equity.


Human papillomavirus vaccination Nativity status Race/ethnicity Health disparities Women 



We thank the National Center for Health Statistics and 2011–2015 National Health Interview Survey participants for the data used in this study. Madina Agénor and Sarah Abboud are supported by R25MH087217 awarded by the National Institute of Mental Health at the National Institutes of Health. The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.


  1. 1.
    Ferlay J, Soerjomataram I, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F (2015) Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012. Int J Cancer 136:E359–E386CrossRefPubMedGoogle Scholar
  2. 2.
    Pew Research Center (2017) Facts on U.S. immigrants, 2015: statistical portrait of the foreign-born population in the United States. Accessed 28 Apr 2018
  3. 3.
    Seeff LC, McKenna MT (2003) Cervical cancer mortality among foreign-born women living in the United States, 1985 to 1996. Cancer Detect Prev 27:203–208CrossRefPubMedGoogle Scholar
  4. 4.
    Downs LS, Smith JS, Scarinci I, Flowers L, Parham G (2008) The disparity of cervical cancer in diverse populations. Gynecol Oncol 109:S22–S30CrossRefPubMedGoogle Scholar
  5. 5.
    Montealegre JR, Zhou R, Amirian ES, Follen M, Scheurer ME (2013) Nativity disparities in late-stage diagnosis and cause-specific survival among Hispanic women with invasive cervical cancer: an analysis of surveillance, epidemiology, and end results data. Cancer Causes Control 24:1985–1994CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Viens LJ, Henley SJ, Watson M, Markowitz LE, Thomas CC, Thompson TD, Razzaghi H, Saraiya M (2016) Human papillomavirus-associated cancers—United States, 2008–2012. MMWR 65:661–666PubMedGoogle Scholar
  7. 7.
    Bates JH, Hofer BM, Parikh-Patel (2008) Cervical cancer incidence, mortality, and survival among Asian subgroups in California, 1990–2004. Cancer 113:2955–2963CrossRefPubMedGoogle Scholar
  8. 8.
    Downs LS, Smith JS, Scarinci I, Flowers L, Parham G (2008) The disparity of cervical cancer in diverse populations. Gynecol Oncol 109:S22–S30CrossRefPubMedGoogle Scholar
  9. 9.
    Beavis AL, Gravitt PE, Rositch AF (2017) Hysterectomy-corrected cervical cancer mortality rates reveal a larger racial disparity in the United States. Cancer 123:1044–1050CrossRefPubMedGoogle Scholar
  10. 10.
    Singh GPMB (2004) Health, life expectancy, and mortality patterns among immigrant populations in the United States. Can J Public Health 95:I-14–I-21Google Scholar
  11. 11.
    Walboomers JMM et al (1999) Human papillomavirus is a necessary cause of invasive cervical cancer worldwide. J Pathol 189:12–19CrossRefPubMedGoogle Scholar
  12. 12.
    Markowitz LE, Liu G, Hariri S, Steinau M, Dunne EF, Unger ER (2016) Prevalence of HPV after introduction of the vaccination program in the United States. Pediatrics 137:1–9CrossRefGoogle Scholar
  13. 13.
    Lu P, Rodriguez-Lainz A, O’Halloran A, Greby S, Williams WW (2014) Adult vaccination disparities among foreign-born populations in the U.S., 2012. Am J Prev Med 47:722–733CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    De P, Budhwani (2017) Human papillomavirus (HPV) vaccine initiation in minority Americans. Public Health 144:86–91CrossRefPubMedGoogle Scholar
  15. 15.
    Williams WW, Lu PJ, O’Halloran A, Bridges CB, Pilishvili T, Hales CM, Markowitz LE (2014) Noninfluenza vaccination coverage among adults—United States, 2012. MMWR 63:95–102PubMedGoogle Scholar
  16. 16.
    Daniel-Ulloa J, Gilbert P, Parker E (2016) Human papillomavirus vaccination in the United States: uneven uptake by gender, race/ethnicity, and sexual orientation. Am J Public Health 106:746–747CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Williams W, Lu P, O’Halloran A, Kim D, Grohskopf L, Pilishvili T et al (2016) Surveillance of vaccination coverage among adult populations—United States, 2014. MMWR Surveill Summ 65:1–36CrossRefPubMedGoogle Scholar
  18. 18.
    Curtis C, Dorell C, Yankey D, Jeyarajah J, Chesson H, Saraiya M et al (2014) National human papillomavirus vaccination coverage among adolescents aged 13–17 years—National Immunization Survey-Teen, United States, 2011. MMWR Suppl 63:61–70PubMedGoogle Scholar
  19. 19.
    Polonijo A, Carpiano R (2013) Social inequalities in adolescent human papillomavirus (HPV) vaccination: a test of fundamental cause theory. Soc Sci Med 82:115–125CrossRefPubMedGoogle Scholar
  20. 20.
    Agénor M, Pérez AE, Peitzmeier SM, Borrero S (2018) Racial/ethnic disparities in human papillomavirus vaccination initiation and completion among U.S. women in the post-Affordable Care Act era. Ethn Health. CrossRefPubMedGoogle Scholar
  21. 21.
    Gelman A, Miller E, Schwarz E, Akers A, Jeong K, Borrero S (2013) Racial disparities in human papillomavirus vaccination: does access matter? J Adolesc Health 53:756–762CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Collins PH, Bilge S (2016) Intersectionality. Polity Press, CambridgeGoogle Scholar
  23. 23.
    Bowleg L (2012) The problem with the phrase women and minorities: intersectionality—an important theoretical framework for public health. Am J Public Health 102:1267–1273CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Parsons VL, Moriarity C, Jonas K, Moore TF, Davis KE, Tompkins L (2014) Design and estimation for the National Health Interview Survey, 2006–2015. Vital Health Stat 2 165:1–53Google Scholar
  25. 25.
    Markowitz L, Dunne EF, Saraiya M, Chesson HW, Curtis CR, Gee J, Bocchini JA, Unger ER, Center for Disease Control and Prevention (CDC) (2014) Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 63:1–30PubMedGoogle Scholar
  26. 26.
    Lipton BJDS (2015) ACA provisions associated with increase in percentage of young adult women initiating and completing the HPV vaccine. Health Aff 34:757–764CrossRefGoogle Scholar
  27. 27.
    MacKinnon D, Fairchild A, Fritz M (2007) Mediation analysis. Annu Rev Psychol 58:593–614CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Office of Disease Prevention and Health Promotion (2015) Immunization and infectious diseases. Accessed 28 Apr 2018
  29. 29.
    Rolnick SJ, Parker ED, Nordin JD, Hedblom BD, Wei F, Kerby T et al (2013) Self-report compared to electronic medical record across eight adult vaccines: do results vary by demographic factors? Vaccine 31:3928–3935CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Bruni L, Diaz M, Barrionuevo-Rosas L, Herrero R, Bray F, Bosch FX et al (2016) Global estimates of human papillomavirus vaccination coverage by region and income level: a pooled analysis. Lancet Glob Health 4:e453–e463CrossRefPubMedGoogle Scholar
  31. 31.
    Owsianka B, Ganczak M (2015) Evaluation of human papilloma virus (HPV) vaccination strategies and vaccination coverage in adolescent girls worldwide. Przegl Epidemiol 69:53–58, 151–155Google Scholar
  32. 32.
    Nogueira-Rodrigues A, Bukowski A, Paulino E, St Louis J, Barrichello A, Sternberg C et al (2017) An alert to Latin America: current human papillomavirus vaccination trends highlight key barriers to successful implementation. Cancer 123:2193–2199CrossRefPubMedGoogle Scholar
  33. 33.
    Andrus JK, Lewis MJ, Goldie SJ, Garcia PJ, Winkler JL, Ruiz-Matus C et al (2008) Human papillomavirus vaccine policy and delivery in Latin America and the Caribbean. Vaccine 26:L80–L87CrossRefPubMedGoogle Scholar
  34. 34.
    Franco EL, Tsu V, Herrero R, Lazcano-Ponce E, Hildesheim A, Munoz N et al (2008) Integration of human papillomavirus vaccination and cervical cancer screening in Latin America and the Caribbean. Vaccine 26:L88–L95CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Setiawan D, Oktora MP, Hutubessy R, Riewpaiboon A, Postma MJ (2017) The health-economic studies of HPV vaccination in Southeast Asian countries: a systematic review. Expert Rev Vaccines 16:933–943CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Sankaranarayanan R (2015) HPV vaccination: the most pragmatic cervical cancer primary prevention strategy. Int J Gynaecol Obstet 131:S33–S35CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Perlman S, Wamai RG, Bain PA, Welty T, Welty E, Ogembo JG (2014) Knowledge and awareness of HPV vaccine and acceptability to vaccinate in sub-Saharan Africa: A systematic review. PLoS ONE 9:e90912CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Gee GC, Ponce N (2010) Associations between racial discrimination, limited English proficiency, and health-related quality of life among 6 Asian ethnic groups in California. Am J Public Health 100:888–895CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Sentell T, Braun KL (2012) Low health literacy, limited English proficiency, and health status in Asians, Latinos, and other racial/ethnic groups in California. J Health Commun 17:82–99CrossRefPubMedPubMedCentralGoogle Scholar
  40. 40.
    Derose KP, Bahney BW, Lurie N, Escarce JJ (2009) Review: immigrants and health care access, quality, and cost. Med Care Res Rev 66:355–408CrossRefPubMedGoogle Scholar
  41. 41.
    Okafor MT, Carter-Pokras OD, Picot SJ, Zhan M (2013) The relationship of language acculturation (English proficiency) to current self-rated health among African immigrant adults. J Immigr Minor Health 15:499–509CrossRefPubMedGoogle Scholar
  42. 42.
    Lucas JW, Barr-Anderson DJ, Kington RS (2003) Health status, health insurance, and health care utilization patterns of immigrant Black men. Am J Public Health 93:1740–1747CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Feagin J, Bennefield Z (2014) Systemic racism and US health care. Soc Sci Med 103:7–14CrossRefPubMedGoogle Scholar
  44. 44.
    Sheppard VB, Williams KP, Wang J, Shavers V, Mandelblatt JS (2014) An examination of factors associated with healthcare discrimination in Latina immigrants: the role of healthcare relationships and language. J Natl Med Assoc Summer 106:15–22CrossRefGoogle Scholar
  45. 45.
    Viruell-Fuentes EA, Miranda PY, Abdulrahim S (2012) More than culture: structural racism, intersectionality theory, and immigrant health. Soc Sci Med 75:2099–2106CrossRefPubMedGoogle Scholar
  46. 46.
    Perez D, Sribney WM, Rodriguez MA (2009) Perceived discrimination and self-reported quality of care among Latinos in the United States. J Gen Intern Med 24:548–554CrossRefPubMedPubMedCentralGoogle Scholar
  47. 47.
    McGhee E, Harper H, Ume A, Baker M, Diarra C, Uyanne J et al (2017) Elimination of cancer health disparities through the acceleration of HPV vaccines and vaccinations: a simplified version of the President’s Cancer Panel Report on HPV vaccinations. Vaccine 8Google Scholar
  48. 48.
    Stephens DP, Thomas TL (2013) Cultural values influencing immigrant Haitian mothers’ attitudes toward human papillomavirus vaccination for daughters. J Black Psychol 39:156–168CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Gerend MA, Shepherd MA, Lustria ML, Shepherd JE (2016) Predictors of provider recommendation for HPV vaccine among young adult men and women: Findings from a cross-sectional survey. Sex Transm Infect 92:104–107CrossRefPubMedGoogle Scholar
  50. 50.
    Rosenthal SL, Weiss TW, Zimet GD, Ma L, Good MB, Vichnin MD (2011) Predictors of HPV vaccine uptake among women aged 19–26: importance of a physician’s recommendation. Vaccine 29:890–895CrossRefPubMedGoogle Scholar
  51. 51.
    Bruno DM, Wilson TE, Gany F, Aragones A (2014) Identifying human papillomavirus vaccination practices among primary care providers of minority, low-income and immigrant patient populations. Vaccine 32:4149–4154CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Pierre Joseph N, Clark J, Mercilus G, Wilbur M, Figaro J, Perkins R (2014) Racial and ethnic differences in HPV knowledge, attitudes, and vaccination rates among low-income African-American, Haitian, Latina, and Caucasian young adult women. J Pediatr Adolesc Gynecol 27:83–92CrossRefPubMedGoogle Scholar
  53. 53.
    Anderson A, Taylor Z, Georges R, Carlson-Cosentino M, Nguyen L, Salas M et al (2017) Primary care physicians’ role in parental decision to vaccinate with HPV vaccine: learnings from a South Texas Hispanic patient population. J Immigr Minor Health. CrossRefGoogle Scholar
  54. 54.
    Epstein RM, Fiscella K, Lesser CS, Stange KC (2010) Why the Nation needs a policy push on patient-centered health care. Health Aff 29:1489–1495CrossRefGoogle Scholar
  55. 55.
    Fenton AT, Elliott MN, Schwebel DC, Berkowitz Z, Liddon NC, Tortolero SR et al (2017) Unequal interactions: examining the role of patient-centered care in reducing inequitable diffusion of a medical innovation, the human papillomavirus (HPV) vaccine. Soc Sci Med 200:238–248CrossRefPubMedGoogle Scholar
  56. 56.
    President’s CP (2014) Accelerating HPV vaccine uptake: urgency for action to prevent cancer. A report to the President of the United States from the president’s cancer panel. National Cancer Institute, BethesdaGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  1. 1.Department of Social and Behavioral SciencesHarvard T.H. Chan School of Public HealthBostonUSA
  2. 2.Department of Women, Children and Family Health ScienceUniversity of Illinois at Chicago College of NursingChicagoUSA
  3. 3.Department of Social and Behavioral SciencesUniversity of California San Francisco School of NursingSan FranciscoUSA
  4. 4.Department of Health Behavior and Biological SciencesUniversity of Michigan School of NursingAnn ArborUSA
  5. 5.Division of General Internal Medicine, Department of MedicineUniversity of Pittsburgh School of MedicinePittsburghUSA
  6. 6.Center for Health Equity Research and PromotionVA Pittsburgh Healthcare SystemPittsburghUSA

Personalised recommendations