State-Level Voting Patterns and Adolescent Vaccination Coverage in the United States, 2014

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To examine state-level associations between voting patterns and adolescent coverage for at least 1 dose of human papillomavirus (HPV), tetanus-containing (Tdap), and meningococcal (MCV4) vaccination.


We classified states as “blue” (Democratic affiliation) or “red” (Republican affiliation) based on the Presidential election results in 2012. We used multivariable models to adjust for potential confounding by sociodemographic and health care access characteristics and vaccination policies. For HPV, separate models were fitted for boys and girls.


Adolescent vaccination coverage was significantly higher in blue states than red states for each vaccine (P < .05). The adjusted percent differences between blue and red states were 10.2% for HPV among girls, 24.9% for HPV among boys, 6.2% for tetanus-containing vaccine, and 14.1% for MCV4.


State-level voting patterns are independently and significantly associated with coverage for routinely recommended adolescent vaccines. These differences may reflect population-level differences in cultural norms and social values.

Public Health Implications

Strategies to increase coverage at the individual, community, or structural level should consider local political settings that may facilitate or hinder effectiveness.

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