Human Papillomavirus Vaccination, Online Health Information Seeking, and Health Literacy among Transgender and Gender Nonbinary People

BACKGROUND: Human Papillomavirus (HPV) is the most common sexually-transmitted infection in the U.S. and is associated with a number of cancers. A vaccine that can prevent 90% of HPV-associated cancers has been available since 2006, yet millions of young adults remain unvaccinated. Low vaccination uptake has been observed in cisgender sexual minority communities and less is known about HPV vaccination among transgender and gender nonbinary (TGNB) people. The aims of this dissertation were: (a) to identify facilitators for and barriers to HPV vaccination among gender minority people; (b) to compare HPV vaccination rates, HPV risk and situational factors like barriers to care, access to care, preventive care, HPV knowledge and Internet use in a sample of TGNB people and cisgender sexual minority people; and (c) to explore the association of online health information and HPV vaccination receipt among TGNB people compared to cisgender sexual minority people and determine if eHealth Literacy or general health literacy moderate this relationship. METHODS: The dissertation comprised three studies. First, an integrative review of the literature included searches of three electronic databases to identify and appraise studies that explore patient-, provider- and system-level HPV vaccination barriers among gender minority people. Second, guided by the Integrative Model of eHealth Use, a cross-sectional secondary analysis of The Population Research in Identities and Disparities for Equality (PRIDE) Study Annual Questionnaire 2018-19, compared the rate of HPV vaccination among TGNB and cisgender sexual minority people and described situation factors (e.g., barriers to care, access to care, preventive care), Internet use, HPV knowledge, HPV risk, and HPV vaccination among these communities. Third, a novel cross-sectional online survey of TGNB and cisgender sexual minority participants recruited from The PRIDE Study, also guided by the Integrative Model of eHealth Use, explored the association between online health information seeking and receipt of HPV vaccine, and whether eHealth literacy and/or general health literacy moderate this relationship. Statistical methods for the cross-sectional studies included prevalence ratios (PR) using robust Poisson statistics and multivariable logistic regression with post hoc Bonferroni-Holm correction. RESULTS: The integrative review identified six cross-sectional studies and one qualitative study that explored HPV vaccine barriers and facilitators among gender minority people. The majority of the studies included <10% gender minority participants. Key barriers to vaccination identified were misperceptions of risk at patient-level, bias towards vaccinating female assigned individuals at the provider-level and population effects of recommendations for girls-only at the policy-level. The cross-sectional secondary analysis of The PRIDE Study 2018-19 Annual Questionnaire and included N = 5,500 responses and found that: (a) the prevalence of ever receiving HPV vaccine was 1.2 times greater among TGNB participants than cisgender participants (PR 1.2; 95% CI, 1.1-1.3); (b) the prevalence of ever receiving HPV vaccine was 2.4 times greater among transgender men who were assigned female at birth compared to transgender women who were assigned male at birth (PR 2.4; 95% CI, 2.0-2.8); and (c) no differences in vaccination initiation and vaccination completion based on gender identity, sex assigned at birth, sex organs born with, or current sex organs. The cross-sectional novel online survey of PRIDE participants yielded N = 3,258 responses (response rate 19.6%). After controlling for covariates including age, race/ethnicity and educational attainment, we found that TGNB as compared to cisgender participants had increased odds (aOR=1.5=; 95% CI, 1.1-2.2) of reporting receipt of HPV vaccine ever and decreased odds (aOR=0.7; 95% CI, 0.5-0.9) of ever receiving of HPV vaccine when they looked for info on vaccines in the past year. Conversely, TGNB participants had over twice the odds (aOR=2.4; 95% CI, 1.1-5.6) of ever receiving HPV vaccine if they visited a social networking site like Facebook or Instagram in the past year. There were no moderating effects observed from eHealth or general health literacy. CONCLUSIONS: TGNB communities are understudied in terms of HPV vaccination and the existing literature shows misperceptions about the need of HPV vaccination among TGNB communities at both the patient and provider level. TGNB participants were more likely to have ever received HPV vaccine compared to cisgender sexual minority participants in the cross-sectional secondary analysis of The PRIDE Study 2018-19 Annual Questionnaire which may be attributed to high primary engagement in the cohort. Finally, online health information seeking about vaccines was associated with decreased receipt of HPV vaccine (ever) whereas social media use increased HPV vaccine receipt (ever) among TGNB participants compared to cisgender sexual minority participants. These conflicting findings suggest that the quality of online health information relating HPV vaccines, how, when and why TGNB people search for health information online may affect health behaviors like HPV vaccination. More research is warranted to explore how online health information seeking may influence personal health decision-making among TGNB communities

Prevalence of 12 Common Health Conditions in Sexual and Gender Minority Participants in the All of Us Research Program

Importance: Limited data describe the health status of sexual or gender minority (SGM) people due to inaccurate and inconsistent ascertainment of gender identity, sex assigned at birth, and sexual orientation. Objective: To evaluate whether the prevalence of 12 health conditions is higher among SGM adults in the All of Us Research Program data compared with cisgender heterosexual (non-SGM) people. Design, setting, and participants: This cross-sectional study used data from a multidisciplinary research consortium, the All of Us Research Program, that links participant-reported survey information to electronic health records (EHR) and physical measurements. In total, 372 082 US adults recruited and enrolled at an All of Us health care provider organization or by directly visiting the enrollment website from May 31, 2017, to January 1, 2022, and were assessed for study eligibility. Exposures: Self-identified gender identity and sexual orientation group. Main outcomes and measures: Twelve health conditions were evaluated: 11 using EHR data and 1, body mass index (BMI; calculated as weight in kilograms divided by height in meters squared), using participants' physical measurements. Logistic regression (adjusting for age, income, and employment, enrollment year, and US Census division) was used to obtain adjusted odds ratios (AORs) for the associations between each SGM group and health condition compared with a non-SGM reference group. Results: The analytic sample included 346 868 participants (median [IQR] age, 55 [39-68] years; 30 763 [8.9%] self-identified as SGM). Among participants with available BMI (80.2%) and EHR data (69.4%), SGM groups had higher odds of anxiety, depression, HIV diagnosis, and tobacco use disorder but lower odds of cardiovascular disease, kidney disease, diabetes, and hypertension. Estimated associations for asthma (AOR, 0.39 [95% CI, 0.24-0.63] for gender diverse people assigned male at birth; AOR, 0.51 [95% CI, 0.38-0.69] for transgender women), a BMI of 25 or higher (AOR, 1.65 [95% CI, 1.38-1.96] for transgender men), cancer (AOR, 1.15 [95% CI, 1.07-1.23] for cisgender sexual minority men; AOR, 0.88 [95% CI, 0.81-0.95] for cisgender sexual minority women), and substance use disorder (AOR, 0.35 [95% CI, 0.24-0.52] for gender diverse people assigned female at birth; AOR, 0.65 [95% CI, 0.49-0.87] for transgender men) varied substantially across SGM groups compared with non-SGM groups. Conclusions and relevance: In this cross-sectional analysis of data from the All of Us Research Program, SGM participants experienced health inequities that varied by group and condition. The All of Us Research Program can be a valuable resource for conducting health research focused on SGM people.</p