Acceptance of the HPV vaccine among women, parents, community leaders, and healthcare providers in Ohio Appalachia

Influenza Vaccine Hesitancy among Cancer Survivors in China: A Multicenter Survey

BACKGROUND

Cancer survivors are at higher risk of developing severe complications from influenza due to their compromised immune systems. Despite their increased vulnerability to influenza and the availability of vaccines, vaccine hesitancy among cancer survivors remains a significant public health concern in China.

METHODS

A multicenter, cross-sectional study was conducted among cancer survivors in China from January to December 2023. A total of 500 participants were recruited from the oncology departments of five tertiary hospitals. A structured, self-administered questionnaire was used to collect data on socio-demographic characteristics, cancer-related information, medical history, lifestyle factors, and influenza vaccine hesitancy. Univariate and multivariate logistic regression analyses were performed to identify factors associated with influenza vaccine hesitancy.

RESULTS

The response rate was 97.0% (485/500). Among all participants, 204 (42.06%) reported vaccine hesitancy. The results of multiple logistic regression showed that the longer the end of anti-cancer treatment, without a history of adverse vaccine reactions, and the level of family support played a protective role in vaccine hesitancy. Current rehabilitation status, frequent colds, not being informed by doctors about vaccination, exercising, lack of community vaccination education programs, and concerns about vaccine safety were risk factors that increase vaccine hesitancy.

CONCLUSIONS

A high proportion of cancer survivors in our study reported influenza vaccine hesitancy. Addressing concerns about vaccine safety, improving access to vaccination services, and enhancing doctor-patient communication are crucial for increasing influenza vaccine uptake in this vulnerable population.

Rural-Urban Disparities in HPV Vaccination Coverage Among Adolescents in the Central Part of the State of Illinois, USA

Human Papillomavirus (HPV) is associated with six cancers and widespread immunization with HPV vaccine could reduce the number of these cancers. Although HPV vaccination rates are available for the state of Illinois and the city of Chicago, data are limited for specific areas. We assessed rates of HPV vaccine initiation and completion among adolescents in central Illinois and identified factors associated with initiation and completion. This was a retrospective study of adolescents (aged 11-17) who receive care at the Southern Illinois University Medicine Department of Pediatrics. The outcome variables were HPV vaccination initiation (receipt of ≥ 1 dose) and completion (receipt of ≥ 2 or 3 doses, depending on age of initiation). Multivariable logistic regressions were used to identify factors associated with HPV vaccine uptake. A total of 9,351 adolescents were included in the study. Overall, HPV vaccine initiation was 46.2% and completion was 24.7%. In adjusted analyses, adolescents residing in rural areas were 38% and 24% less likely to initiate (aOR = 0.62; 95 CI: 0.54-0.72) and complete (aOR = 0.76; 95 CI: 0.65-0.88) the HPV vaccine compared with those residing in urban areas. Similarly, adolescents were less likely to initiate and complete the HPV vaccine if they were not update to date on the hepatitis A, meningococcal, or Tdap vaccinations. HPV vaccination rates in central Illinois were low, and far below the national average and the Illinois state average. Future directions should include interventions to increase HPV vaccine uptake, particularly in rural areas.

'God will protect us': Belief in God/Higher Power's ability to intervene and COVID-19 vaccine uptake

BACKGROUND

Vaccines represent one of the best ways to counter the COVID-19 pandemic. However, vaccine hesitancy among the population limits the effectiveness of vaccines. Recent research has explored the role of religion in vaccine hesitancy, but in doing so has encountered a "black box" problem. There is a relationship between religion and vaccine hesitancy, but the explanation for why remains unclear.

PURPOSE

The purpose of this study is to explore the relationship between religion and vaccine hesitancy. We propose that how an individual conceptualizes God/a higher power is associated with getting vaccinated for COVID-19.

METHODS

We use data from a nationally representative survey of U.S. adults, collected using the Amerispeak® probability-based panel via the National Opinion Research Center (NORC) at the University of Chicago. We examine the association between individuals' views of God/a higher power as both a supervisory and an intervening figure on vaccine uptake and likelihood of getting vaccinated through logistic regressions.

RESULTS

We find that belief in God's/a higher power's supervision is not significantly associated with the odds of COVID-19 vaccine uptake or vaccination intent. However, belief in God's/a higher power's ability to intervene in the world is significantly and negatively associated with the odds of COVID-19 vaccine uptake and the odds of having received or planning to receive a COVID-19 vaccine. In addition, in models where belief in the ability of God/a higher power to intervene are included, Christian nationalism ceases to have a statistically significant association with intent to receive a COVID-19 vaccine.

CONCLUSIONS AND IMPLICATIONS

These findings suggest that how individuals conceptualize God/a higher power is associated with their willingness to get the COVID-19 vaccine. Given this, those who see God/a higher power as more involved in the world may contribute to delays in achieving herd immunity. This information benefits those working on vaccination campaigns in understanding the beliefs of some of those who are most hesitant to get vaccinated. In addition, this intervention mechanism could also mediate other negative relationships between religion and other science and health-related concerns.

Successful Multi-Level HPV Vaccination Intervention at a Rural Healthcare Center in the Era of COVID-19

Objectives: To develop and test a human papillomavirus (HPV) vaccination intervention that includes healthcare team training activities and patient reminders to reduce missed opportunities and improves the rate of appointment scheduling for HPV vaccination in a rural medical clinic in the United States.

Methods: The multi-level and multi-component intervention included healthcare team training activities and the distribution of patient education materials along with technology-based patient HPV vaccination reminders for parents/caregivers and young adult patients. Missed vaccination opportunities were assessed pre- and post-intervention (n = 402 and n = 99, respectively) by retrospective chart review and compared using Pearson χ². The patient parent/caregiver and young adult patient population (n = 80) was surveyed following the reminder messages and penalized logistic regression quantified unadjusted odds of scheduling a visit.

Results: Missed opportunities for HPV vaccination declined significantly from the pre-intervention to the post-intervention period (21.6 vs. 8.1%, respectively, p = 0.002). Participants who recalled receipt of a vaccination reminder had 7.0 (95% CI 2.4–22.8) times higher unadjusted odds of scheduling a visit compared with those who did not recall receiving a reminder. The unadjusted odds of confirming that they had scheduled or were intending to schedule a follow-up appointment to receive the HPV vaccine was 4.9 (95% CI 1.51–20.59) times greater among those who had not received the vaccine for themselves or for their child.

Conclusions: Results from this intervention are promising and suggest that vaccination interventions consisting of provider and support staff education and parent/caregiver and patient education materials, and reminders can reduce missed opportunities for vaccinations in rural settings.

Christian nationalism and COVID-19 vaccine hesitancy and uptake

Understanding COVID-19 vaccine hesitancy and uptake is vital for informing public health interventions. Prior U.S. research has found that religious conservatism is positively associated with anti-vaccine attitudes. One of the strongest predictors of anti-vaccine attitudes in the U.S. is Christian nationalism—a U.S. cultural ideology that wants civic life to be permeated by their particular form of nationalist Christianity. However, there are no studies examining the relationship between Christian nationalism and COVID-19 vaccine hesitancy and uptake. Using a new nationally representative sample of U.S. adults, we find that Christian nationalism is one of the strongest predictors of COVID-19 vaccine hesitancy and is negatively associated with having received or planning to receive a COVID-19 vaccine. Since Christian nationalists make up approximately 20 percent of the population, these findings could have important implications for achieving herd immunity.

Access to Health Care in Appalachia: Perception and Reality

INTRODUCTION

Health disparities such as cancer and diabetes are well documented in Appalachia. These disparities contribute to health status, and by many indicators, Appalachian people are less healthy than those who live in other parts of the country. Access to health care is one factor that contributes to health disparities. Access to care is complex and involves both intrinsic and extrinsic aspects, including satisfaction with quality of care. This research sought to compare Appalachian to non-Appalachian communities in terms of perceptions of access to care.

METHODS

We implemented a statewide survey to quantify perceptions of multiple components of access to care, including satisfaction with quality of care. We compared survey results to quantitative data from the County Health Rankings to document consistency with perceptions of access to care. We used chi-square analysis to compare Appalachian with non-Appalachian respondents.

RESULTS

More than 600 people completed the survey. Results of the survey identify significant differences between Appalachian and non-Appalachian residents' perceptions of access to care and their satisfaction with health care. Specifically, Appalachian residents are less satisfied with convenience, information, quality, and courtesy of health care. They perceive providers relying on stereotypes when communicating with patients.

IMPLICATIONS

Examining and documenting perceptions of health care is important because it could lead to improving access by focusing on cultural competency in addition to more resource intensive strategies. Health disparities in Appalachia might be minimized by being more compassionate and understanding of people who live here.

Practice-, provider- and patient-level facilitators of and barriers to HPV vaccine promotion and uptake in Georgia: a qualitative study of healthcare providers' perspectives

Georgia experiences higher human papillomavirus (HPV)-associated cancer burden and lower HPV vaccine uptake compared with national estimates. Using the P3 model that concomitantly assesses practice-, provider- and patient-level factors influencing health behaviors, we examined facilitators of and barriers to HPV vaccine promotion and uptake in Georgia. In 2018, we conducted six focus groups with 55 providers. Questions focused on multilevel facilitators of and barriers to HPV vaccine promotion and uptake. Our analysis was guided by the P3 model and a deductive coding approach. We found that practice-level influences included organizational priorities of vaccinations, appointment scheduling, immunization registries/records, vaccine availability and coordination with community resources. Provider-level influences included time constraints, role, vaccine knowledge, self-efficacy to discuss HPV vaccine and vaccine confidence. Patient-level influences included trust, experiences with vaccine-preventable diseases, perceived high costs, perceived side effects and concerns with sexual activity. Findings suggest that interventions include incentives to boost vaccine rates and incorporate appointment scheduling technology. An emphasis should be placed on the use of immunization registries, improving across-practice information exchange, and providing education for providers on HPV vaccine. Patient-provider communication and trust emerge as intervention targets. Providers should be trained in addressing patient concerns related to costs, side effects and sexual activity.

Family Planning Practices in Appalachia: Focus Group Perspectives on Service Needs in the Context of Regional Substance Abuse

Reproductive health disparities in the Appalachian region may be driven by barriers to healthcare access. However, the barriers specific to accessing family planning services in Appalachia have not yet been identified from the perspectives of Appalachian community members. Moreover, it is unclear how community members might perceive elevated levels of opioid use in the region to impact family planning practices. To fill this gap in knowledge, the current qualitative study explored community perspectives about family planning in Appalachia in the context of the opioid epidemic for the purpose of developing a survey instrument based on these responses. We conducted three video call focus group interviews with community stakeholders, those who live, work and are invested in Appalachia (N = 16), and analyzed the responses using Levesque, Harris, and Russell's (2013) five pillars of healthcare access as a framework to categorize family planning practices and perceptions of service needs in the context of regional substance abuse: (1) approachability, (2) acceptability, (3) availability and accommodation, (4) affordability, and (5) appropriateness. Subthemes within each of these five categories were also identified. Our findings highlight stakeholder concerns around a lack of knowledge about and access to family planning services in Appalachia. Community members also expressed concern around the lack of availability of substance use treatment services, which may negatively impact family planning use and access in the region.

Family Planning Practices in Appalachia: Focus Group Perspectives on Service Needs in the Context of Regional Substance Abuse

Reproductive health disparities in the Appalachian region may be driven by barriers to healthcare access. However, the barriers specific to accessing family planning services in Appalachia have not yet been identified from the perspectives of Appalachian community members. Moreover, it is unclear how community members might perceive elevated levels of opioid use in the region to impact family planning practices. To fill this gap in knowledge, the current qualitative study explored community perspectives about family planning in Appalachia in the context of the opioid epidemic for the purpose of developing a survey instrument based on these responses. We conducted three video call focus group interviews with community stakeholders, those who live, work and are invested in Appalachia (N = 16), and analyzed the responses using Levesque, Harris, and Russell’s (2013) five pillars of healthcare access as a framework to categorize family planning practices and perceptions of service needs in the context of regional substance abuse: (1) approachability, (2) acceptability, (3) availability and accommodation, (4) affordability, and (5) appropriateness. Subthemes within each of these five categories were also identified. Our findings highlight stakeholder concerns around a lack of knowledge about and access to family planning services in Appalachia. Community members also expressed concern around the lack of availability of substance use treatment services, which may negatively impact family planning use and access in the region.

Small area estimation of human papillomavirus vaccination coverage among school-age children in Alabama counties

OBJECTIVES

This study estimated county-level human papillomavirus (HPV) vaccination initiation rates in Alabama and determined whether disparities existed between counties in the Mississippi Delta region (MDR) and Appalachian region (AR).

STUDY DESIGN

This study used an observational cross-sectional design.

METHODS

We used small area estimation methodology to estimate rates of medical provider-verified HPV vaccine initiation among school-age children in Alabama. Data for the study were retrieved from the 2015 National Immunization Survey (n = 22,205) and the US Census Bureau.

RESULTS

The predictive model results showed that older age (odds ratio [OR] = 1.22, 95% confidence interval [CI] = 1.16, 1.29) was positively associated with vaccination initiation and black (OR = 0.79, 95% CI = 0.71, 0.87), white (OR = 0.56, 95% CI = 0.52, 0.60), and 'other' race/ethnicities (OR = 0.78, 95% CI = 0.70, 0.86), compared with Hispanics, and was negatively associated with vaccination initiation. The median (x̃)-modeled HPV vaccination initiation rate for all Alabama counties was 50.83% (interquartile range = 5.00%). Modeled HPV vaccination initiation rates were lowest in AR counties (x̃ = 49.81%), followed by counties not in the AR or MDR (x̃ = 53.26%) and MDR counties (x̃ = 54.90%).

CONCLUSIONS

Culturally sensitive school-based HPV vaccine delivery programs are needed for children living in AR counties in Alabama.

Beliefs around childhood vaccines in the United States: A systematic review

BACKGROUND

While childhood vaccines are safe and effective, some parents remain hesitant to vaccinate their children, which has led to outbreaks of vaccine preventable diseases. The goal of this systematic review was to identify and summarize the range of beliefs around childhood vaccines elicited using open-ended questions, which are better suited for discovering beliefs compared to closed-ended questions.

METHODS

PubMed, Embase, and PsycINFO were searched using keywords for childhood vaccines, decision makers, beliefs, and attitudes to identify studies that collected primary data using a variety of open-ended questions regarding routine childhood vaccine beliefs in the United States. Study designs, population characteristics, vaccine types, and vaccine beliefs were abstracted. We conducted a qualitative analysis to conceptualize beliefs into themes and generated descriptive statistics.

RESULTS

Of 1727 studies identified, 71 were included, focusing largely on parents (including in general, and those who were vaccine hesitant or at risk of hesitancy). Seven themes emerged: Adverse effects was most prominent, followed by mistrust, perceived lack of necessity, pro-vaccine opinions, skepticism about effectiveness, desire for autonomy, and morality concerns. The most commonly described beliefs included that vaccines can cause illnesses; a child's immune system can be overwhelmed if receiving too many vaccines at once; vaccines contain harmful ingredients; younger children are more susceptible to vaccine adverse events; the purpose of vaccines is profit-making; and naturally developed immunity is better than that acquired from vaccines. Nearly a third of the studies exclusively assessed minority populations, and more than half of the studies examined beliefs only regarding HPV vaccine.

CONCLUSIONS

Few studies used open-ended questions to elicit beliefs about vaccines. Many of the studies that did so, focused on HPV vaccine. Concerns about vaccine safety were the most commonly stated beliefs about childhood vaccines, likely because studies were designed to capture barriers and challenges to vaccination.

Human Papillomavirus Vaccine Uptake, Knowledge, and Acceptance for Youth: A Systematic Review of Appalachia

Though vaccine uptake and public support have risen since the release of the first HPV vaccines, the United States has far lower initiation and completion rates for the HPV vaccine series in comparison to other vaccines indicated for youth. Disparities are even greater in the Appalachian regions. Understanding factors contributing to these discrepancies is vital to improving vaccine rates in Appalachia. A comprehensive literature search identified all articles pertaining to HPV vaccination in children and adolescents living in Appalachia. The final 15 articles were included in a systematic review of the topic.

Exploring variation in parental worries about HPV vaccination: a latent-class analysis

Background. Prior research has identified diverse worries that parents have about HPV vaccination. We sought to understand how parents prioritize worries and to identify subgroups of parents according to shared patterns of worry. Methods. We surveyed a national sample of 431 U.S. parents of adolescents who reported never having talked to their child's healthcare provider about HPV vaccination. Parents completed a best-worst scaling experiment designed to prioritize 11 common worries about HPV vaccination. The experiment used a balanced incomplete block design to present 11 choice tasks consisting of repeated subsets of worries. We used conditional logistic regression to prioritize worries and latent class models with 1-10 classes to identify subgroups of parents with shared worries. Results. Parents most often worried about long-term side effects of HPV vaccination, which about one-third (36%) ranked as their top worry. Other common top-ranked worries were how new the vaccine is (12%), motives of drug companies (12%), short-term side effects (10%), and that it may be unnecessary (10%). Latent class analyses suggested a relatively large number of distinct worry profiles, with most classes characterized by a worry about long-term side effects in combination with one other worry. Discussion. Our findings suggest that providers should be prepared to address concerns about long-term side effects, as this worry was prioritized across many subgroups of parents. However, to best address worry, a tailored, rather than targeted, communication approach may be needed.

Cancer-Related Beliefs and Perceptions in Appalachia: Findings from 3 States

BACKGROUND

Appalachians experience increased rates of cancer incidence and mortality compared to non-Appalachians. Many factors may contribute to the elevated cancer burden, including lack of knowledge and negative beliefs about the disease.

METHODS

Three National Cancer Institute (NCI)-designated cancer centers with Appalachian counties in their respective population-based geographic service areas-Kentucky, Ohio, and Pennsylvania-surveyed their communities to better understand their health profiles, including 5 items assessing cancer beliefs. Weighted univariate and bivariate statistics were calculated for each of the 3 state's Appalachian population and for a combined Appalachian sample. Weighted multiple linear regression was used to identify factors associated with a cancer beliefs composite score. Data from the combined Appalachian sample were compared to NCI's Health Information National Trends Survey (HINTS).

RESULTS

Data from 1,891 Appalachian respondents were included in the analysis (Kentucky = 798, Ohio = 112, Pennsylvania = 981). Significant differences were observed across the 3 Appalachian populations related to income, education, marital status, rurality, perceptions of present income, and body mass index (BMI). Four of 5 cancer beliefs were significantly different across the 3 states. Education, BMI, perceptions of financial security, and Kentucky residence were significantly associated with a lower composite score of cancer beliefs. When comparing the combined Appalachian population to HINTS, 3 of 5 cancer belief measures were significantly different.

CONCLUSIONS

Variations in cancer beliefs were observed across the 3 states' Appalachian populations. Interventions should be tailored to specific communities to improve cancer knowledge and beliefs and, ultimately, prevention and screening behaviors.

HPV Vaccination Coverage Among US Teens Across the Rural-Urban Continuum

BACKGROUND

In this study, we used data from the National Immunization Survey-Teen (NIS-Teen) to examine HPV vaccination uptake by rural and urban residence defined by ZIP code.

METHODS

We used 2012-2013 NIS-Teen data to examine associations of HPV vaccination among teens aged 13-17 years with ZIP code measures of rural/urban (Rural-Urban Commuting Area (RUCA) codes, population density). Multivariable logistic regression was used to estimate the odds of HPV vaccination initiation (≥ 1 dose) and completion (≥ 3 doses).

RESULTS

HPV vaccination was lower among girls from isolated small rural towns (≥1 dose 51.0%; ≥3 doses 30.0%) and small rural towns (≥1 dose 50.2%; ≥3 doses 26.8%) than among urban girls (≥1 dose 56.0%; ≥3 doses 35.9%). Girls from small rural towns had lower odds of completion (0.74, 95% CI: 0.60-0.91) than girls from urban areas. HPV vaccination was lower among boys from isolated small rural towns (≥1 dose 17.3%; ≥3 doses 5.31%) and small rural towns (≥1 dose 18.7%; ≥3 doses 5.50%) than those in urban areas (≥1 dose 28.7%; ≥3 doses 10.7%). Boys in isolated small rural towns had statistically significantly lower odds of initiation (0.68, 95% CI: 0.52-0.88) and completion (0.63, 95% CI: 0.41-0.97) than urban boys. Girls and boys from high-poverty rural areas had lower odds of initiation and completion than did their counterparts from high-poverty urban areas.

CONCLUSION

Rural girls had lower odds of completing the HPV vaccine than their urban counterparts. Rural boys had lower odds than urban boys for HPV vaccination initiation and completion.

Utah pharmacists' knowledge, attitudes, and barriers regarding human papillomavirus vaccine recommendation

OBJECTIVES

To evaluate Utah community pharmacists' knowledge and attitudes toward recommendation of human papillomavirus (HPV) vaccine, to determine whether the knowledge and attitude of pharmacists regarding the HPV vaccine influence their recommendation behaviors, and to capture any self-identified barriers to recommending the HPV vaccine.

DESIGN

A cross-sectional anonymous 73-item survey was developed and administered to community, outpatient, and ambulatory care pharmacists.

SETTING

Utah.

PARTICIPANTS

Utah community pharmacists.

MAIN OUTCOME MEASURES

Recommendation of the HPV vaccine by the pharmacist, knowledge and attitude of pharmacists regarding HPV vaccine, and barriers to vaccine receipt.

RESULTS

The mean HPV vaccine knowledge score was 7.45 ± 2.15 (out of 13), and scores were higher when pharmacists had 4 to 6 technicians per day in the pharmacy and when they were residency trained. The mean attitude score was 24.26 ± 3.16 (out of 30). Positive attitudes were found if they had more than 1 pharmacist and 4 to 6 pharmacy technicians working at any given time in the pharmacy. Those who identified with "other Christianity" had a more positive attitude than Latter Day Saints. Although positive attitude toward the HPV vaccine was a predictor for recommending the vaccine to both boys and girls, higher knowledge was a significant predictor only in recommending the HPV vaccine for boys. Female pharmacists were more likely to recommend the HPV vaccine. The top 3 reported barriers included lack of parental knowledge, parental concerns and opposition, and lack of educational materials to provide parents.

CONCLUSION

Although the majority of respondents perceived HPV vaccination as useful for preventing certain types of cancer, and more than one-half of respondents reported being comfortable in recommending the vaccine, only one-third actually recommended the vaccine for girls and for boys. The results indicate the need for improving knowledge about the HPV vaccine for pharmacists, patients, and parents.

Multilevel Interventions To Address Health Disparities Show Promise In Improving Population Health

Multilevel interventions are those that affect at least two levels of influence-for example, the patient and the health care provider. They can be experimental designs or natural experiments caused by changes in policy, such as the implementation of the Affordable Care Act or local policies. Measuring the effects of multilevel interventions is challenging, because they allow for interaction among levels, and the impact of each intervention must be assessed and translated into practice. We discuss how two projects from the National Institutes of Health's Centers for Population Health and Health Disparities used multilevel interventions to reduce health disparities. The interventions, which focused on the uptake of the human papillomavirus vaccine and community-level dietary change, had mixed results. The design and implementation of multilevel interventions are facilitated by input from the community, and more advanced methods and measures are needed to evaluate the impact of the various levels and components of such interventions.

Belief About Mandatory School Vaccinations and Vaccination Refusal Among Ohio Appalachian Parents: Do Demographic and Religious Factors, General Health, and Political Affiliation Play a Role?

PURPOSE

To examine how demographic, general health, religious, and political characteristics influenced beliefs about mandatory school vaccinations and history of vaccination refusal for children among Ohio Appalachian parents.

METHODS

In 2013 and 2014, baseline data were obtained from parents (n = 337) of girls aged 9-17 from 12 counties in rural Ohio Appalachia enrolled in the Community Awareness, Resources and Education (CARE II) Project. Multivariate logistic regression models were used to identify correlates of parental beliefs about mandatory school vaccinations and history of refusing a doctor-recommended vaccine for their child(ren).

RESULTS

About 47% of parents agreed that parents should have the right to refuse mandatory school vaccinations for their child(ren). Participants who reported their political affiliation as Republican (OR = 2.45, 95% CI: 1.28-4.66) or Independent (OR = 3.31, 95% CI: 1.70-6.44) were more likely to agree that parents should have the right to refuse school-mandated vaccinations than parents who reported their political affiliation as Democrat. Approximately 39% of parents reported ever refusing a vaccine for their child(ren). Participants who were female (OR = 3.90, 95% CI: 1.04-14.58) and believed that parents should have the right to refuse mandatory school vaccinations (OR = 3.27, 95% CI: 1.90-5.62) were more likely to report ever refusing a vaccine for their child(ren).

CONCLUSION

The study findings provide information to better understand factors related to vaccination refusal among parents in Appalachia Ohio that can be used to design interventions to improve vaccination uptake.

Noninitiation and Noncompletion of HPV Vaccine Among English- and Spanish-Speaking Parents of Adolescent Girls: A Qualitative Study

OBJECTIVE

The Advisory Committee on Immunization Practices recommends routine human papillomavirus (HPV) vaccination for female adolescents aged 11 to 12 years, yet vaccination rates remain low. We conducted a qualitative study to understand English- and Spanish-speaking parents' reasons for noninitiation or noncompletion of the HPV vaccine series for their daughters.

METHODS

Parents of female adolescents aged 12 to 15 years who had not initiated or not completed the HPV vaccine series were identified through administrative data in 2 large urban safety net health care systems in Colorado. Focus groups and in-depth interviews were conducted with English-speaking parents and in-depth interviews were conducted with Spanish-speaking parents. All data were recorded, transcribed, and analyzed for thematic content by experienced analysts using established qualitative content analysis techniques.

RESULTS

Forty-one parents participated in the study. Thirty parents participated in individual interviews and 11 parents participated in 1 of 2 focus groups. The most common reasons for noninitiation and noncompletion among English-speaking parents included a low perceived risk of HPV infection, vaccine safety concerns, and distrust of government and/or medicine. In contrast, Spanish-speaking parents most often reported that providers had either not encouraged initiation of the HPV vaccine series or had not explained the necessity of completing the series. Some noninitiating parents, particularly Spanish-speaking ones, also cited concerns that vaccination would encourage sexual activity.

CONCLUSIONS

The reasons for noninitiation and noncompletion of the HPV vaccine series differed substantially between English- and Spanish-speaking parents. To maximize uptake of HPV vaccine, varying approaches might be needed to effectively target specific populations.

Addressing the Barriers to Cervical Cancer Prevention Among Hispanic Women

OBJECTIVE

Cervical cancer in the USA has transformed from a leading cause of cancer death, to a now largely preventable disease. Despite these advances, however, certain segments of the population, including Hispanic women, continue to be at increased risk.

METHODS

A literature review was performed to summarize epidemiologic trends and barriers to care affecting Hispanic women.

RESULTS

Hispanic women suffer a disproportionate burden of cervical cancer in the USA. The reasons why Hispanic women remain at increased risk are multifactorial and include resource limitations within the healthcare system. Language, cultural, and knowledge barriers also play a significant role.

CONCLUSIONS

The greatest modifiable risk factor for the development of cervical carcinoma is non-compliance with recommended preventative care, yet the reasons why women fail to receive this care are varied. A multi-faceted approach to risk reduction is needed, including improved health care access, population-targeted outreach, language-appropriate services, and culturally competent care.

Awareness and acceptance of human papillomavirus vaccination among health sciences students in Malaysia

The major cause of cervical cancer is human papillomavirus (HPV) for which vaccination is available. The success HPV vaccination programme largely depend on the degree of knowledge of the healthcare providers who can recommend to the public. Health sciences students as future healthcare providers play a major role in HPV vaccination initiatives. The objective of this study was to evaluate the knowledge, attitude, practice and to find out the willingness to pay for HPV vaccination among the health sciences students in a private university. The cross-sectional study was conducted among the university students studying health sciences program using a validated questionnaire to measure their awareness and acceptance of HPV vaccination. The students demonstrated moderate knowledge about HPV infection and vaccination with mean knowledge scores of 9.3 out of 17. Students were showing positive attitude towards HPV vaccination with mean scores of 3.80 out of 5. However, low HPV vaccination uptake rate was reported among the students. Most of the students were willing to recommend HPV vaccine. The participants felt that the cost is the major barrier towards HPV vaccination and they felt the government should cover the cost of vaccination for all. The results of this study may be helpful in establishing educational policies on cervical cancer-related topics in the universities.

Quadrivalent human papillomavirus (types 6, 11, 16, 18) recombinant vaccine (gardasil(®)): a review of its use in the prevention of premalignant anogenital lesions, cervical and anal cancers, and genital warts

Quadrivalent human papillomavirus (HPV) [types 6, 11, 16, 18] recombinant vaccine (Gardasil(®); Silgard(®)) is composed of virus-like particles formed by self-assembly of recombinant L1 capsid protein from each of HPV types 6, 11, 16 and 18. It is indicated for use from the age of 9 years as a two- or three-dose vaccination course over 6 months for the prevention of premalignant anogenital lesions, cervical and anal cancers, and genital warts caused by the vaccine HPV types. In placebo-controlled trials, quadrivalent HPV vaccine provided high-level protection against infection or disease caused by the vaccine HPV types over 2-4 years in females aged 15-45 years who were negative for the vaccine HPV types, and provided a degree of cross-protection against certain non-vaccine HPV types. The vaccine also provided high-level protection against persistent infection, anogenital precancerous lesions and genital warts caused by the vaccine HPV types over 3 years in susceptible males aged 16-26 years. Protection has been demonstrated for up to 8 years. In subjects who were negative for the vaccine HPV types, high seroconversion rates and high levels of anti-HPV antibodies were observed in females of all age ranges from 9 to 45 years and in males aged 9-26 years. The vaccine was generally well tolerated and was usually predicted to be cost effective in girls and young women. Therefore, quadrivalent HPV vaccine offers an effective means to substantially reduce the burden of HPV-related anogenital disease in females and males, particularly cervical cancer and genital warts.

Recommendations and administration of the HPV vaccine to 11- to 12-year-old girls and boys: a statewide survey of Georgia vaccines for children provider practices

OBJECTIVE

This study explores the prevalence and provider- and practice-related correlates of physician recommendation and administration of the quadrivalent human papillomavirus (HPV) vaccine, Gardasil, to 11- to 12-year-old girls and the intention to recommend the HPV vaccine to 11- to 12-year-old boys in Georgia. The study also describes physician knowledge about and barriers to HPV vaccination.

MATERIALS AND METHODS

This cross-sectional study was conducted from December 2010 to February 2011. The study sample was drawn using the Georgia Vaccines for Children (VFC) provider list as a sampling frame and probability 1-stage cluster sampling with counties as clusters. The final analytic sample was restricted to 206 provider locations. Weighted percentages and corresponding statistics were calculated accounting for selection probabilities, nonresponse, and the cluster sample design.

RESULTS

Among Georgia VFC providers attending to 11- to 12-year-old girls, 46% had always recommended that their patients get the HPV vaccination and 41% had vaccinated their female patients. Among Georgia VFC providers attending to 11- to 12-year-old boys, 20% would always recommend that their male patients get vaccinated.Physicians most frequently endorsed costs of stocking the vaccine (73%), upfront costs (69%), vaccination (68%), and insurance reimbursements (63%) as barriers to their HPV vaccination practices.

CONCLUSIONS

Despite the Advisory Committee on Immunization Practices' recommendations on HPV vaccination, the prevalence of recommending and administering the HPV vaccine to female and male patients, aged 11 to 12 years, by VFC providers is an ongoing challenge in Georgia.

Effects of a Presidential Candidate's Comments on HPV Vaccine

During and after the 2011 Republican presidential debate, a candidate questioned the safety of HPV vaccine. The authors aimed to determine the effect of these comments on parents. A national sample of 327 parents with adolescent sons ages 11-17 years completed online surveys in fall 2010 (baseline, about 1 year before the debate) and 2011 (follow-up, about 1 month after the debate). The authors used regression models to examine the association of parents' awareness of the candidate's comments with HPV vaccine initiation among their sons, their willingness to get sons free HPV vaccine, and their beliefs about potential harms of HPV vaccine. Overall, 17% of parents reported hearing about the Republican presidential candidate's comments about HPV vaccine. Parents aware of the comments had a larger increase between baseline and follow-up in the belief that HPV vaccine might cause short-term health problems compared with parents who were not aware. Although the candidate's comments may have increased some parents' beliefs about the short-term harms of HPV vaccine, the comments had no effect on other beliefs, willingness to vaccinate, or behavior. Having accurate information about HPV vaccine that is readily available to the public during such controversies may diminish their effect.

Investigating stakeholder attitudes and opinions on school-based human papillomavirus vaccination programs

BACKGROUND

In several countries worldwide, school-based human papillomavirus (HPV) vaccination programs have been successful; however, little research has explored US stakeholders' acceptance toward school-based HPV vaccination programs.

METHODS

A total of 13 focus groups and 12 key informant interviews (N = 117; 85% females; 66% racial/ethnic minority) were conducted with 5 groups of stakeholders: parents of adolescent girls, parents of adolescent boys, adolescent girls, middle school nurses, and middle school administrators throughout the 5 public health regions of New Mexico.

RESULTS

All groups of stakeholders lacked knowledge on HPV and HPV vaccines. Stakeholders were interested in--but apprehensive about--the benefits of HPV vaccination. Despite previous literature showing the benefits of using middle schools as an HPV vaccination site, stakeholders did not deem middle schools as a viable site for vaccination. Nurses reported that using the school as an HPV vaccination site had not occurred to them; parents and adolescents stated they were uncertain about using this type of program. School administrators indicated that they lacked implementation authority.

CONCLUSIONS

Our study uncovered barriers to using middle schools as a site of HPV vaccination. Resources should be directed toward increased support and education for middle school nurses who function as opinion leaders relevant to the uptake of HPV vaccination.

Fatalistic beliefs and completion of the HPV vaccination series among a sample of young Appalachian Kentucky women

PURPOSE

Uptake and completion of the 3-dose human papillomavirus (HPV) vaccine is important for the primary prevention of cervical cancer. However, HPV vaccination rates among adolescent females and young women remain low in certain geographic areas of the United States, including Appalachia. Although greater fatalistic beliefs have been previously associated with lower rates of preventive cancer behaviors among adults, little research exists on the impact of fatalism on HPV vaccination behaviors, especially among younger individuals. Therefore, the purpose of this study was to examine the association between fatalistic beliefs and completion of the full HPV vaccine series among young women, ages 18-26, in Appalachian Kentucky.

RESULTS

Data from this study were from a baseline survey completed by 344 women randomized into a communication intervention trial focused on increasing adherence to the 3-dose HPV vaccine series. Principal components analysis was used to construct 2 fatalism-related subscales from 8 survey questions.

FINDINGS

In a controlled analysis, 1 subscale--"lack of control over cancer"--was significantly associated with not completing the full HPV vaccine series. In a rural area that experiences higher rates of cervical cancer, poverty, limited access to health care, and negative cancer-related attitudes and experiences, fatalism may be common, even among young people.

CONCLUSION

Future educational and interventional research addressing fatalistic beliefs in a culturally sensitive manner may be warranted to improve HPV vaccination behaviors and impact cancer disparities among Appalachian women.

The process of engaging members from two underserved populations in the development of interventions to promote the uptake of the HPV vaccine

We describe a community-engaged research process used to develop multilevel interventions (caregivers, providers, system) to improve the uptake of human papillomavirus vaccine among adolescents by partnering with members from two underserved populations in Ohio. We began by conducting focus groups to better understand the knowledge and attitudes of caregivers and providers about the human papillomavirus vaccine and to develop teams of community members to assist with development of the interventions. The process continued with conducting writing sessions to determine the content and format of the interventions, and initial feedback was obtained during review sessions to refine the interventions prior to implementation. Using this approach, we were able to consider contextual factors that made the interventions more acceptable and relevant to members of the priority populations. Challenges included development and maintenance of a team of community members to participate in the entire intervention development process, rejection of ideas presented by academic researchers, the need to balance community members' suggestions with what was known from evidence-based research, and the time, cost, and effort associated with partnering with community members. The benefits, however, outweigh the challenges associated with using a community-engaged research process to develop interventions aimed at reducing cancer disparities among underserved populations.

Barriers and facilitators to HPV vaccination of young women in high-income countries: a qualitative systematic review and evidence synthesis

BACKGROUND

Vaccination against Human Papillomavirus (HPV) is recommended for adolescent young women prior to sexual debut to reduce cervical cancer related mortality and morbidity. Understanding factors affecting decision-making of HPV vaccination of young women is important so that effective interventions can be developed which address barriers to uptake in population groups less likely to receive the HPV vaccine.

METHODS

We undertook a qualitative systematic review and evidence synthesis to examine decision-making relating to the HPV vaccination of young women in high-income countries. A comprehensive search of databases from inception to March 2012 was undertaken to identify eligible studies reporting the perspectives of key stakeholders including policy makers, professionals involved in programme, parents, and young women. Factors affecting uptake of the vaccine were examined at different levels of the socio-ecological model (policy, community, organisational, interpersonal and intrapersonal).

RESULTS

Forty-one studies were included. Whether young women receive the HPV vaccine is strongly governed by the decisions of policy makers, healthcare professionals, and parents. These decisions are shaped by: financial considerations; social norms and values relating to sexual activity, and; trust in vaccination programmes and healthcare providers. Financial constraints may be overcome through universal healthcare systems offering the HPV vaccine free at the point of delivery. In the healthcare setting, judgements by healthcare professionals about whether to recommend the vaccine may restrict a young woman's access to the vaccine irrespective of her own beliefs and preferences. Parents may decide not to allow their daughters to be vaccinated, based on cultural or religious perceptions about sexual activity.

CONCLUSIONS

Barriers to the uptake of the HPV vaccine have implications for young women's future sexual, physical and reproductive health. Interventions to address barriers to uptake of the vaccine should target appropriate, and multiple, levels of the socio-ecological model. Issues of trust require clear, accessible, and sometimes culturally appropriate, information about the HPV vaccination programme. Although young women are central to the HPV vaccination programme, their views are underrepresented in the qualitative literature. Future research should consider young women's perceptions of, and involvement in, consent and decision-making.

Development and initial feedback about a human papillomavirus (HPV) vaccine comic book for adolescents

Human papillomavirus (HPV) vaccination rates do not meet the Healthy People 2020 objective of 80% coverage among adolescent females. We describe the development and initial feedback about an HPV vaccine comic book for young adolescents. The comic book is one component of a multilevel intervention to improve HPV vaccination rates among adolescents. Parents suggested and provided input into the development of a HPV vaccine comic book. Following the development of the comic book, we conducted a pilot study to obtain initial feedback about the comic book among parents (n = 20) and their adolescents ages 9 to 14 (n = 17) recruited from a community-based organization. Parents completed a pre-post test including items addressing HPV knowledge, HPV vaccine attitudes, and about the content of the comic book. Adolescents completed a brief interview after reading the comic book. After reading the comic book, HPV knowledge improved (2.7 to 4.6 correct answers on a 0-5 scale; p < 0.01) and more positive attitudes toward HPV vaccination (p < 0.05) were reported among parents. Parents confirmed that the comic book's content was acceptable and adolescents liked the story, found it easy to read, and thought the comic book was a good way to learn about being healthy. Parents provided valuable information in the development of a theoretically-based comic book and the comic book appears to be an acceptable format for providing HPV vaccine information to adolescents. Future research will include the comic book in an intervention study to improve HPV vaccination rates.

Young women's constructions of the HPV vaccine: a cross-cultural, qualitative study in Scotland, Spain, Serbia and Bulgaria

BACKGROUND

Following international trends, the HPV (human papilloma virus) vaccine was introduced in Europe for protection against infection from common strands of the HPV virus which can lead to cervical cancer. Young women aged 18-26 years are at greatest risk of infection by the HPV virus yet have been neglected in research, policy, and practice.

PURPOSE

To explore young women's constructions of the HPV vaccine in four European countries with different implementation policies ranging from national school-based programmes, regarded as the gold standard, to regional on-demand and private provision.

METHOD

Qualitative methods comprising 11 focus group discussions with 54 young women aged 18-26, in Scotland (n = 10), Spain (n = 25), Serbia (n = 9) and Bulgaria (n = 10). A discursive analysis was conducted, following an initial thematic analysis.

RESULTS

Two competing discursive constructions were considered: the 'responsible young woman' discourse was constructed as someone with individual rights to health, choice and discretion along with responsibilities to protect health and make rational decisions. In 'the HPV vaccine: a discourse of exclusion', access to the vaccine, wider health promotion and knowledge was controlled by others which had the potential to undermine the young woman's health. We consider how young women managed this tension through recourse to being health vigilant.

CONCLUSION

Qualitative, cross-cultural research highlighted common concerns amongst young European women towards being responsible citizens in the face of their health and highlighted socio-cultural constraints to knowledge and resources. We highlight cross-cultural implications particularly between Western and Eastern European contexts.

The HPV vaccine: a comparison of focus groups conducted in South Africa and Ohio Appalachia

Worldwide, cervical cancer is one of the leading causes of morbidity and mortality among women. Even though women in developing countries account for approximately 85 % of the cervical cancer cases and deaths, disparities in cervical cancer rates are also documented in developed countries like the United States (U.S.). Recently, formative research conducted in the U.S. and developing countries like South Africa have sought to gain a better understanding of the knowledge, beliefs, and attitudes about cervical cancer prevention, HPV, and the acceptance of the HPV vaccine. This study compares findings from two independent focus group studies. One study was conducted in a segregated township in Johannesburg, South Africa (n = 24) and the other study was conducted in Ohio Appalachia (n = 19). The following seven themes emerged during the discussions from both studies: HPV and cervical cancer; health decision making; parent-child communication; healthy children; HPV vaccine costs; sexual abuse; and HPV vaccine education. Findings from both studies indicate the importance of the role of mothers and grandmothers in the health care decision-making process for children and a lack of awareness of HPV and its association with cervical cancer. While there was interest in the HPV vaccine, participants voiced concern about the vaccine's cost and side effects. Some participants expressed concern that receipt of the HPV vaccine may initiate adolescent sexual behavior. However, other participants suggested that the HPV vaccine may protect young women who may experience sexual abuse. The importance of developing culturally appropriate educational materials and programs about cervical cancer prevention and the HPV vaccine were expressed by participants in both countries.

HPV vaccine decision-making and acceptance: does religion play a role?

We conducted a web-based survey among 476 white, Black, and Hispanic parents or caregivers with daughter(s) between the ages of 9-17 to better understand how religion influences HPV vaccine acceptance. Catholic parents were more likely than nonaffiliated parents to have already vaccinated their daughters (vs. being undecided) (OR = 3.26, 95% CI = 1.06, 10.06). Parents with frequent attendance at religious services were more likely than parents who do not attend services to have decided against vaccination (vs. being undecided) (OR = 2.92, 95% CI = 1.25, 6.84). Directions for research and implications for interventions are addressed.

Acceptability of HPV vaccine for males and preferences for future education programs among Appalachian residents

Appalachia is a geographic region with several disparities related to human papillomavirus (HPV) infection, yet little is known about acceptability of HPV vaccine for males among Appalachian residents. HPV vaccine acceptability and preferences for future HPV vaccine education programs were examined among residents of Appalachian Ohio. Focus groups and in-depth interviews were conducted with Appalachian Ohio residents between July and October 2011. Participants (n = 102 from 24 focus groups and 5 in-depth interviews) included four key stakeholder groups: health care providers, community leaders, parents with adolescent sons, and young adult men ages 18 to 26 years. Support for vaccinating males against HPV was high among participants, despite low awareness and knowledge about HPV vaccine for males. Participants reported three categories of potential barriers to vaccinating males against HPV: concerns about vaccine safety and side effects, access to care and vaccination logistics, and gender and cultural issues. Participants reported that HPV vaccine was viewed as being only for females in their communities and that receiving the vaccine may be emasculating or embarrassing to males. Participants suggested that future HPV vaccine education programs mainly target parents, include basic information about HPV-related diseases and HPV vaccine (e.g., number of doses, cost), and present the vaccine as having the potential to prevent cancer (as opposed to preventing genital warts). Acceptability of HPV vaccine for males was high among residents of Appalachian Ohio. Future HPV vaccine education programs in Appalachia should address common potential barriers to vaccination and help destigmatize vaccination among males.

HPV prevalence among women from Appalachia: results from the CARE project

Background

Cervical cancer incidence and mortality rates are high among women from Appalachia, yet data do not exist on human papillomavirus (HPV) prevalence among these women. We examined the prevalence of genital HPV among Appalachian women and identified correlates of HPV detection.

Methods

We report data from a case-control study conducted between January 2006 and December 2008 as part of the Community Awareness, Resources, and Education (CARE) Project. We examined HPV prevalence among 1116 women (278 women with abnormal Pap tests at study entry [cases], 838 women with normal Pap tests [controls]) from Appalachian Ohio. Analyses used multivariable logistic regression to identify correlates of HPV detection.

Results

The prevalence of HPV was 43.1% for any HPV type, 33.5% for high-risk HPV types, 23.4% for low-risk HPV types, and 12.5% for vaccine-preventable HPV types. Detection of any HPV type was more common among women who were ages 18–26 (OR = 2.09, 95% CI: 1.26–3.50), current smokers (OR = 1.86, 95% CI: 1.26–2.73), had at least five male sexual partners during their lifetime (OR = 2.28, 95% CI: 1.56–3.33), or had multiple male sexual partners during the last year (OR = 1.98, 95% CI: 1.25–3.14). Similar correlates were identified for detection of a high-risk HPV type.

Conclusions

HPV was prevalent among Appalachian women, with many women having a high-risk HPV type detected. Results may help explain the high cervical cancer rates observed among Appalachian women and can help inform future cervical cancer prevention efforts in this geographic region.

"HPV? Never heard of it!": a systematic review of girls' and parents' information needs, views and preferences about human papillomavirus vaccination

BACKGROUND AND OBJECTIVE

Two human papillomavirus vaccines were licenced in 2006/2007 for cervical cancer prevention. National vaccination programmes for schoolgirls were subsequently introduced in some European countries, North America and Australia. To understand factors influencing vaccine uptake and to inform the development of appropriate UK educational materials, we aimed to synthesise evidence of girls' and parents' information needs, views and preferences regarding HPV vaccination.

DESIGN

Systematic review and mixed method synthesis of qualitative and survey data.

DATA SOURCES

Twelve electronic databases; bibliographies of included studies 1980 to August 2011.

REVIEW METHODS

Two reviewers independently screened papers and appraised study quality. Studies were synthesised collaboratively using framework methods for qualitative data, and survey results integrated where they supported, contrasted or added to the themes identified.

RESULTS

Twenty-eight qualitative studies and 44 surveys were included. Where vaccination was offered, uptake was high. Intention to decline was related to a preference for vaccinating later to avoid appearing to condone early sexual activity, concerns about vaccine safety and low perception of risk of HPV infection. Knowledge was poor and there were many misconceptions; participants tried to assess the potential benefits and harms of vaccination but struggled to interpret limited information about HPV in the context of existing knowledge about sexually transmitted infections and cancer. Conclusion Many girls and their parents have limited understanding to an extent that impinges on their ability to make informed choices about HPV vaccination and could impact on future uptake of cervical screening. This is a considerable challenge to those who design and provide information, but getting the messages right for this programme could help in developing patient information about other HPV related cancers.

Media coverage of cervical cancer and the HPV vaccine: implications for geographic health inequities

OBJECTIVE

To describe the content of newspaper articles about cervical cancer and the human papillomavirus (HPV) vaccine published in Appalachia and identify potential differences in coverage as compared to the content of newspaper articles published in non-Appalachia Ohio.

BACKGROUND

Individuals rely on media as an important source of health information. Inadequate coverage of health issues may reinforce health inequities such as the elevated cervical cancer incidence and mortality rates in Appalachia Ohio.

METHODS

A content analysis was conducted of all newspaper articles about cervical cancer and the HPV vaccine published in Appalachia and non-Appalachia Ohio during 2006.

FINDINGS

A total of 121 published newspaper articles (42 in Appalachia and 79 in non-Appalachia) about cervical cancer and the HPV vaccine were identified. Articles published in Appalachia Ohio were significantly less likely than articles published in non-Appalachia Ohio to provide information about the threat of cervical cancer and the efficacy of the HPV vaccine. Specifically, few articles published in Appalachia included information about the ability of the vaccine to prevent cervical cancer, the cost of the vaccine and the availability of assistance programmes for the un- and underinsured.

CONCLUSIONS

Newspaper articles printed in the Appalachia region lacked vital information that could help promote uptake of the HPV vaccine. Health educators and healthcare providers should be aware that women from underserved geographic regions like Appalachia may have greater information needs regarding their risk of cervical cancer and the potential benefits of the HPV vaccine as compared to the general patient population.

Health care providers' perspectives on low HPV vaccine uptake and adherence in Appalachian Kentucky

OBJECTIVE

Previous intervention research conducted in Appalachian Kentucky resulted in extremely low uptake and adherence to the human papillomavirus (HPV) vaccine among women ages 18-26, despite provision of free vaccine. Because of these findings, the purpose of this qualitative, follow-up study was to elicit health care providers' perspectives on barriers and facilitators to HPV vaccination and suggested strategies for improving vaccination rates.

DESIGN AND SAMPLE

Researchers conducted semi-structured qualitative interviews with a purposive sample of eight health care providers (seven nursing professionals, one physician) at the health clinic where the original HPV vaccination intervention took place. Interviews were audio-recorded and transcribed and authors used a constant-comparative method to analyze the data.

RESULTS

Significant themes emerged from the interviews, centering around two primary issues: vaccine uptake and vaccine adherence. Related to uptake, health care providers identified perceived patient barriers and inadequate HPV vaccine education. They also identified the vaccine schedule and clinic-centered communication deficiencies as adherence-related barriers.

CONCLUSION

These Appalachian Kentucky health care providers provided important insights into barriers and facilitators to HPV vaccine uptake and adherence that need to be readily addressed in this community. As informed by these providers, several suggestions for improving HPV vaccination, such as more targeted education efforts and patient-centered reminder systems, may be applicable to other nursing professionals working in rural and medically underserved communities.

HPV vaccination among young adult women: a perspective from Appalachian Kentucky

INTRODUCTION

Few studies have assessed barriers to human papillomavirus (HPV) vaccination uptake and adherence, particularly among women of Appalachian Kentucky, a population with higher rates of cervical cancer, lower rates of HPV vaccination, and lower socioeconomic status compared with the rest of the nation. The objective of this study was to address women's reasons for declining the HPV vaccine and, among women who initiated the vaccine series, barriers to completion of the 3-dose regimen.

METHODS

We recruited 17 women aged 18 to 26 from a Federally Qualified Health Center who participated in in-depth, semistructured telephone interviews. All interviews were audio-recorded and transcribed verbatim; analysis of the interview transcripts was an iterative process conducted by all 3 authors.

RESULTS

We identified 3 primary barriers: 1) a knowledge gap wherein women are both uninformed and misinformed about cervical cancer, HPV, and the HPV vaccine, all of which affect vaccination behaviors; 2) environmental and tangible barriers (transportation and prioritizing health over other responsibilities such as child care, work, and school); and 3) ambiguous information sources, which contribute to misinformation and subsequently affect vaccination decisions.

CONCLUSION

Health professionals should use clear and purposeful communication about how cervical cancer develops, the purpose and safety of the HPV vaccine, and the necessity of completing the 3-dose series. Health promotion campaigns and services tailored for young women in Appalachian Kentucky that focus on increasing knowledge and eliminating barriers are needed.

Using the Health Belief Model in Qualitative Focus Groups to Identify HPV Vaccine Acceptability in College Men

This study determines predictors of HPV vaccine acceptability among college-aged male students through the qualitative data collection strategy of focus groups. Over the course of 2 months, six focus groups were conducted with 50 participants, with approximately 10 participants in each focus group. Participants were predominately single, heterosexual, about 20 years old, Caucasian males attending a large Midwestern University. The Health Belief Model (HBM) was used as a guide in developing questions for the focus groups. Each question related to a construct of the HBM. A lack of perceived susceptibility, perceived severity of HPV, and barriers toward taking the HPV vaccine were major themes identified from the focus groups. Overall, the focus group proved to be effective in understanding predictors toward HPV vaccine acceptability. Results enabled the researchers to develop an understanding of content needed for effective interventions. This study indicates a need for more qualitative studies exploring attitudes, beliefs, and behaviors related to HPV vaccine acceptability among at-risk populations.

Correlates of HPV vaccination among adolescent females from Appalachia and reasons why their parents do not intend to vaccinate

Limited research has examined HPV vaccination in Appalachia, a region with cervical cancer disparities. We analyzed 2008-2010 National Immunization Survey-Teen data for adolescent females ages 13-17 from Appalachia (n=1951) to identify correlates of HPV vaccination and reasons why their parents do not intend to vaccinate. HPV vaccine initiation was 40.8%, completion was 27.7%, and follow-through was 67.8%. Vaccination outcomes tended to be higher among females who were older, had visited their healthcare provider in the last year, or whose parents reported receiving a provider recommendation to vaccinate. Only 41.0% of parents with unvaccinated daughters intended to vaccinate in the next year. The most common reasons for not intending to vaccinate were believing vaccination is not needed or not necessary (21.5%) and lack of knowledge (18.5%). Efforts to reduce missed opportunities for vaccination at healthcare visits and address reasons why parents are not vaccinating may help increase HPV vaccination in Appalachia.

Predictors of initial uptake of human papillomavirus vaccine uptake among rural Appalachian young women

Women in Appalachian Kentucky experience a high burden of cervical cancer and have low rates of human papillomavirus (HPV) vaccination. The purpose of this study was to identify normative influences predicting initial HPV vaccine uptake among a sample of young women in southeastern Kentucky. Women (N = 495), ages 18 through 26 years, were recruited from clinics and community colleges. After completing a questionnaire, women received a free voucher for HPV vaccination. Whether women redeemed the voucher for Dose 1 served as the primary outcome variable. Hierarchical logistic regression was used to estimate the influence of healthcare providers, friends, mothers, and fathers on vaccine uptake. One-quarter of the total sample (25.9%) received Dose 1. Uptake was higher in the clinic sample (45.1%) than in the college sample (6.9%). On multivariate analysis, women indicating that their healthcare provider suggested the vaccine, that their friends would "definitely" want them to be vaccinated, and that their fathers would "definitely" want them to receive the vaccine all were 1.6 times more likely to receive Dose 1. Interaction effects occurred between recruitment site (clinic vs. community college) and all three of the normative influences retaining multivariate significance, indicating that the associations only applied to the clinic sample. HPV vaccine interventions may benefit from highlighting paternal endorsement, healthcare provider recommendation, and peer support.

Development and validation of the cervical cancer knowledge and beliefs of Appalachian women questionnaire

BACKGROUND AND PURPOSE

Cervical cancer rates in Appalachia are persistently higher in Appalachia when compared to the rest of the United States. No quantitative instrument exists that examines the cervical cancer knowledge, behavior, and beliefs of Appalachian women. The purpose of this research is to develop, test, and use a new instrument that quantifies the cervical cancer knowledge, behavior, and beliefs of Appalachian women.

METHODS

Constructs from the Health Belief Model, Health Promotion Model, findings from the qualitative literature, and the researcher's clinical background were used to construct an initial 58-item instrument.

INCLUSION CRITERIA

Appalachian residence, intact uterus, age 21-64 year, and English speaking.

RESULTS

Content and construct validity techniques decreased the initial 58-item instrument (5 demographic questions, 9 behavior questions, and 44 cervical cancer knowledge and belief questions) to a 27-item instrument consisting of 5 demographic items, 8 behavior items, and 14 knowledge and belief items. Construct validity was supported with items clustering into 4 factors explaining 53% of the variance. Pilot study testing (20 subjects) and main study testing (217 subjects) composes the sample pool.

CONCLUSIONS

The new instrument demonstrated initial reliability and validity. Revision and retesting in other populations within Appalachia should comprise the next step to confirm reliability and validity.