Increasing HPV Vaccine Uptake in Rural Populations

Transcription

1 Increasing HPV Vaccine Uptake in Rural Populations Electra D. Paskett, PhD 1 The Ohio State University Comprehensive Cancer Center Arthur G. James Cancer Hospital and Richard J. Solove Research Institute

2 2 Rural America: The Role of Coalitions in Health

3 Rural America 72% of the US is classified as rural. 19% of the population of the US or 46.2 million people reside in rural America: Rural, farms, mountains, frontier Black, Hispanic, American Indian, Alaska Native, Appalachian, white Rural populations are understudied due to: Physical location Cost Perceived need 3

4 Appalachia Appalachia consists of 420 counties in 13 states 5 regions: Northern, North Central, Central, South Central and Southern Appalachian Regional Commission defined in 1965 in response to region s deficits 24.8 million residents (about 8% of total U.S. population) (Appalachian Regional Commission, 2009)

5 Appalachian Ohio 32 county area of Ohio Part of federally designated Appalachia Mainly white, low-income Healthcare Professional Shortage Areas Access to care is a major problem: cost, quality, transportation, trust Amish sub-population OSU * US Census,

6 In Appalachia, We don t talk about cancer. re Katz et al, Qualitative Health Research,

7 Appalachia Ohio Coalitions & Councils Women in Action Against Cancer Coalition Noble County Coordinated Council Meigs County Cancer Initiative Partners of Hope Cancer Coalition Fight Cancer Save Lives ACT Now Coalition of Scioto County Pike Healthy Lifestyle Initiative Vinton County Social Service Council Cancer Concern Coalition 7

8 8 Community-Based Participatory Research

9 Gallia County: Problem Identified At Coalition meetings, local health professionals expressed concern over the high rate of cervical cancer and lack of accessible resources In 2007 and 2008, the Gallia County Health District completed 512 Pap tests; 18%-22% were abnormal Abnormal Pap test rate in United States 3%-4% 31%-47% of Gallia County clients with abnormal Pap results were nonadherent in receiving recommended diagnostic follow-up care Plan developed Raise Awareness GYN Committed Enhance Education Trained HCP Colposcopy Procedure Identified Needs Transportation Assistance Colposcopy Equipment Local Facility

10 Colposcopy Clinic Project Project established a clinic to provide colposcopies at no cost for underserved Appalachian women. Goal to improve adherence to follow-up recommendations for women identified with abnormal Pap tests. Project funded by the Governor s Office of Appalachia - Community Investment Fund. Matching grant - coalition had to raise almost $

11 Outcomes Secured local doctor to provide colposcopies 54 clinics since April 7, colposcopies performed to date 6 women have required follow-up All women receive educational brochures and gas vouchers Continuation of Clinic Through the support of ACCN, Coalition has secured 501(c)3 to receive future funding, as needed

12 12 HPV Rates and Vaccine Uptake

13 Human Papillomavirus (HPV) Nearly 80 million people in the U.S., 1 in every 4, are infected with at least one strain of HPV. Persistent infection is associated with multiple cancers & several other diseases. 13 Source: Centers for Disease Control

14 Human Papillomavirus (HPV) Estimated 14 million new HPV infections occur every year among persons aged years. Most common sexually transmitted virus in the United States, but it is preventable. 14 Source: Centers for Disease Control

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17 HPV Prevalence By Type 45.0% 43% 39% 34% 30.0% 27% 26% 23% 15.0% 13% 9% OH Appalachia US (NH White) 0.0% Any Type High-Risk Low-Risk Types 6, 11, 16, 18 (Ruffin et al., unpublished data)

18 HPV-Associated Cervical Cancer Rates by State MMWR 2016;65(26):

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20 Why Don t Parents Get Their Daughter Vaccinated? My doctors said: She was too young Did not need the shot until she started her period My daughter was not sexually active She could get the shot later not needed now Fear of vaccines: Hasn t been out long enough Heard about side effects My daughter doesn t need it: She won t get HPV She won t have sex till she is married She s not going to get a green light for sex 20

21 Survey of Ohio Parents - Results What is the main reason your daughter did not get any HPV shots? Reason African American White, Appalachian White, Non-Appalachian Never heard of the vaccine 42.9% 0% 5.9% Don t know enough about it yet 14.3% 36.4% 11.8% It might be unsafe 0% 18.2% 11.8% My daughter is too young 0% 0% 29.4% Hasn t been to the doctor recently Her doctor didn t recommend the vaccine 28.6% 9.1% 5.9% 14.3% 18.2% 11.8% Too few responses from Hispanic, All Races and Other group to be meaningful 21

22 22 Interventions in Rural America

23 Evidence-based strategies to improve vaccination coverage Women - Completion 8 County Appalachian Kentucky (Vanderpool et al, 2013) Research nurses provided one dose free of charge at various locations to women Randomized to Pap Intervention to receive 2 and 3 dose Intervention included: DVD, sell-efficacy, help to resolve barriers Control: information brochure; reminder calls Intervention vs control: RR=2.44 (p=.03); 43.3% vs 32% for series completion Children/Mothers Rural North Carolina County (Chung et al 2015) Phase 1 educational mtgs with nurses and physicians; reminder postcards Phase 2 - school-based campaign : telephone messages Improvements in yo boys (14.2% to 32.1%) and girls (27.4% to 43.4%) Improvements were greater in Phase 1 and with younger children Four Rural Counties in South Central North Carolina (Cates et al 2011) Social marketing campaign targeting mothers of girls aged and healthcare providers Components: Product, price, promotion, and place Vaccination rates were 2% higher for 9-13 yo girls in 2 of 4 counties vs 96 nonintervention counties

24 Goal To develop and evaluate a multi-level HPV vaccine intervention to increase HPV vaccination rates among young girls and adolescent females (9-17) living in Ohio Appalachia Paskett E, et al., CEBP

25 Multi-Level Intervention Components System-level: Waiting room and examination room posters and brochures Tabletop tent cards for the waiting rooms Quarterly newsletter Vaccine tracking system Invitation to be vaccinated letter to parents from their provider Provider-level: Fact sheet Resource list Article on Cervical Cancer in Ohio Appalachia CME Session Patient-level: Culturally tailored HPV and cervical cancer educational DVD Culturally tailored educational brochures Question & Answer (Q & A) fact sheet Resource list Magnetic appointment reminder card for the 2 nd and 3 rd shot 25

26 HPV Vaccine Uptake: Group Randomized Trial First Shot within Three Months Received Shot Control Arm HPV Arm p-value Yes 4 (3%) 10 (8%) No 120 (97%) 120 (92%) First Shot within Six Months (Ever) Received Shot Control Arm HPV Arm p-value Yes 8 (7%) 17 (13%) No 116 (94%) 113 (87%)

27 Conclusions Educating parents, community members, and providers is key to increasing HPV vaccine uptake Rural populations have different characteristics Messages must be tailored to the unique populations: ALL communities There is a vaccine to prevent cancer Rural The vaccine is safe and effective Provider education benefits of the HPV vaccine; ways to communicate with patients and parents of patients Community members must be part of the solution Multi-level approaches can be used to communicate appropriate messages: Media Community-level Provider/health care Parents/Patients 27

28 28 Thank You