Purpose

To examine the association between race/ethnicity and human papillomavirus (HPV) vaccine initiation and to determine how access to health care influences this relationship.

Methods

We used nationally representative data from the National Survey of Family Growth to assess HPV vaccine initiation in 2,168 females aged 15-24 years. A series of regression analyses were performed to determine the independent effect of race/ethnicity on HPV vaccine initiation after controlling for sociodemographic variables and health care access measures. Age-stratified regression analyses were also performed to assess whether the relationship between race/ethnicity and HPV vaccine initiation differed among females aged 15-18 and 19-24 years.

Results

There were significant racial/ethnic disparities in HPV vaccination; United States (US)-born Hispanics, foreign-born Hispanics, and African-Americans were less likely to have initiated vaccination than were whites (p < .001). Adjusting for sociodemographic characteristics attenuated the disparity for both US-born and foreign-born Hispanics (adjusted odds ratio [AOR], .76; 95% confidence interval [CI], .50-1.16; and AOR, .67; 95% CI, .37-1.19) but not for African-Americans (AOR, .47, 95% CI, .33-.66). Adding health care access measures further attenuated the disparity for US-born and foreign-born Hispanics (AOR, .85, 95% CI, .54-1.34; and AOR, .84, 95% CI, .45-1.55). However, African-Americans remained less likely than whites to have initiated vaccination (AOR, .49, 95% CI, .36-.68). These racial/ethnic trends were similar for females aged 15-18 and 19-24 years.

Conclusions

Lower rates of HPV vaccination among African-American females do not appear to be explained by differential access to health care. More research is necessary to elucidate factors contributing to HPV vaccination in this population.

Objective

Unintended pregnancy is common and disproportionately occurs among low-income women. We conducted a qualitative study with low-income women to better typologize pregnancy intention, understand the relationship between pregnancy intention and contraceptive use, and identify the contextual factors that shape pregnancy intention and contraceptive behavior.

Study design

Semistructured interviews were conducted with low-income, African-American and white women aged 18-45 recruited from reproductive health clinics in Pittsburgh, PA, to explore factors that influence women's pregnancy-related behaviors. Narratives were analyzed using content analysis and the constant comparison method.

Results

Among the 66 participants (36 African-American and 30 white), we identified several factors that may impede our public health goal of increasing the proportion of pregnancies that are consciously desired and planned. First, women do not always perceive that they have reproductive control and therefore do not necessarily formulate clear pregnancy intentions. Second, the benefits of a planned pregnancy may not be evident. Third, because preconception intention and planning do not necessarily occur, decisions about the acceptability of a pregnancy are often determined after the pregnancy has already occurred. Finally, even when women express a desire to avoid pregnancy, their contraceptive behaviors are not necessarily congruent with their desires. We also identified several clinically relevant and potentially modifiable factors that help to explain this intention-behavior discrepancy, including women's perceptions of low fecundity and their experiences with male partner contraceptive sabotage.

Conclusion

Our findings suggest that the current conceptual framework that views pregnancy-related behaviors from a strict planned behavior perspective may be limited, particularly among low-income populations.

Implications

This study identified several cognitive and interpersonal pathways to unintended pregnancy among low-income women in Pittsburgh, PA, including perceptions of low reproductive control, perceptions of low fecundity and male partner reproductive coercion.

Over the past decade, increasing attention has been paid to intervening in individuals' health in the "preconception" period as an approach to optimizing pregnancy outcomes. Increasing attention to the structural and social determinants of health and to the need to prioritize reproductive autonomy has underscored the need to evolve the preconception health framework to center race equity and to engage with the historical and social context in which reproduction and reproductive health care occur. In this commentary, we describe the results of a meeting with a multidisciplinary group of maternal and child health experts, reproductive health researchers and practitioners, and Reproductive Justice leaders to define a new approach for clinical and public health systems to engage with the health of nonpregnant people. We describe a novel "Reproductive and Sexual Health Equity" framework, defined as an approach to comprehensively meet people's reproductive and sexual health needs, with explicit attention to structural influences on health and health care and grounded in a desire to achieve the highest level of health for all people and address inequities in health outcomes. Principles of the framework include centering the needs of and redistributing power to communities, having clinical and public health systems acknowledge historical and ongoing harms related to reproductive and sexual health, and addressing root causes of inequities. We conclude with a call to action for a multisectoral effort centered in equity to advance reproductive and sexual health across the reproductive life course.