Research Article: Vaccination differences among U.S. adults by their self-identified sexual orientation, National Health Interview Survey, 2013–2015

Date Published: March 7, 2019

Publisher: Public Library of Science

Author(s): Anup Srivastav, Alissa O’Halloran, Peng-Jun Lu, Walter W. Williams, Sonja S. Hutchins, Jose A. Bauermeister.


Very few studies have explored the associations between self-identified sexual orientation and comprehensive vaccination coverage. Most of the previous studies that reported health disparities among lesbian, gay and bisexual populations were not based on a nationally representative sample of U.S. adults, limiting the generalizability of the findings. Starting in 2013, the National Health Interview Survey (NHIS) included questions to ascertain the adult’s self-identified sexual orientation that allowed national level vaccination estimation by sexual orientation. This study examined associations of self-reported vaccination coverage for selected vaccines among U.S. adults by their sexual orientation.

We analyzed combined data from 2013–2015 NHIS, a nationally representative probability-based health survey of the noninstitutionalized U.S. population ≥18 years. For vaccines other than influenza, weighted proportions were calculated. Influenza coverage was calculated using the Kaplan-Meier procedure. Multivariable logistic regression models were used to calculate adjusted prevalence differences for each vaccine overall and stratified by sexual orientation and to identify factors independently associated with vaccination.

Significant differences were observed by sexual orientation for self-reported receipt of human papillomavirus (HPV), hepatitis A (HepA), hepatitis B (HepB), and influenza vaccination. Bisexual females (51.6%) had higher HPV coverage than heterosexual females (40.2%). Gay males (40.3% and 53.6%, respectively) had higher HepA and HepB coverage than heterosexual males (25.4% and 32.6%, respectively). Bisexual females (33.9% and 58.5%, respectively) had higher HepA and HepB coverage than heterosexual females (23.5% and 38.4%, respectively) and higher HepB coverage than lesbian females (45.4%). Bisexual adults (34.1%) had lower influenza coverage than gay/lesbian (48.5%) and heterosexual adults (43.8%). Except for the association of having self-identified as gay/lesbian orientation with greater likelihood of HepA, HepB, and influenza vaccination, sexual orientation was not associated with higher or lower likelihood of vaccination. Health status or other behavioral characteristics studied had no consistent relationship with vaccination among all populations.

Differences were identified in vaccination coverage among the U.S. adult population by self-reported sexual orientation. This study is the first to assess associations of sexual orientation with a comprehensive list of vaccinations. Findings from this study can serve as a baseline for monitoring changes over time. All populations could benefit from improved vaccination.

Partial Text

Comprehensive vaccination is critical in preventing the acquisition and transmission of many serious communicable infections [1–10]. Influenza vaccination is recommended for all adults each year. Other adult vaccinations are recommended for specific populations based on a person’s age, health conditions, behavioral risks, occupation, travel, and other indications (

The NHIS was approved by the Research Ethics Review Board (ERB number, 2009–16) of the National Center for Health Statistics, CDC and designated as “Public Health Non-Research” during the determination for applicability of human subjects’ regulations, because the activity is not intended to include applicable research, but to access the implementation, coverage, performance, and/or satisfaction with an existing public health program, service, function, intervention or recommendation. Data security was addressed and written informed consent was sought.

Table 1 presents the percent distribution of sexual orientation by selected demographic, access to healthcare, health behavior, and health condition characteristics. Among adults aged ≥18 years, 97.6% self-identified as heterosexual, 1.6% as gay/lesbian, and 0.7% as bisexual. Respondents identifying as gay/lesbian and bisexual were more likely to report current smoking, consuming five or more alcoholic drinks in one day at least once in the past year, testing for HIV, and to have asthma compared with respondents identifying as heterosexual. Respondents identifying as gay/lesbian and bisexual differed from respondents identifying as heterosexual on a number of other demographic and access characteristics (Table 1).

Significant differences were observed by sexual orientation for HepA, HepB, and influenza vaccination. Gay/lesbian orientation was associated with a greater likelihood of influenza vaccination. Gay male sexual orientation was associated with greater likelihood of HepA and HepB vaccination.

This study helps document differences in self-reported vaccination coverage by self-identified sexual orientation among U.S. adults aged 18 years and over and is the first to assess associations of sexual orientation with a comprehensive list of vaccinations. Findings from this study can serve as a baseline for monitoring vaccination coverage changes over time, and can assist the development of targeted strategies to improve the health status of lesbian, gay, and bisexual populations. Annual data on sexual orientation from the NHIS can be useful in monitoring the impact of policies and interventions directed at improving the health of those who identify as gay, lesbian and bisexual.




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