HPV Vaccination Challenges in Rural and Suburban Settings. Deanna Kepka, PhD, MPH College of Nursing Huntsman Cancer Institute University of Utah

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1 HPV Vaccination Challenges in Rural and Suburban Settings Deanna Kepka, PhD, MPH College of Nursing Huntsman Cancer Institute University of Utah

2 Meet Mandy

3 Objectives Present overview of HPV, HPV cancers, and HPV Vaccination Explore social, cultural, and instrumental barriers to HPV vaccination that are unique to rural and suburban settings in the United States Discuss evidence based strategies to improve HPV vaccination in rural and suburban settings in the United States Examine where future research is needed in these areas

4 30,000 cancers are caused by vaccine preventable HPV each year in the U.S.

5 400,000 cases of genital warts are caused by vaccine preventable HPV each year in the U.S. 2x

6 Nearly all abnormal pap tests are caused by vaccine preventable HPV: 1.4 million new cases low-grade + 330,000 new cases high-grade cervical dysplasia (1 in 10 women)

7 HPV-Associated Cancers per Year, United States, WOMEN & MEN Based on Viens et al. MMWR

8 Who has HPV?

9 I DO You DO We DO Nearly ALL of US HAVE HAD or WILL HAVE HPV

10 1 in 4 of Us Today

11 How do I know if I have HPV?

12 HOW can we prevent cancercausing HPV infections? Receive 2 DOSES of the HPV Vaccine at ages years for boys & girls

13 Science Alert Australia (2016) HPV Vaccination Rates: Girls 79% of ages 15 years Boys 73% of ages 15 years

14 How is the U.S. Doing with HPV Vaccination? U.S. Up to Date HPV Vaccination Rates: All 43% of ages years Girls 50% of ages years Boys 38% of ages years HPV Vaccination Up-to-date (%), Girls & Boys, Ages years, NIS-Teen 2016

15 Wait, I thought this was a. Safe and Effective CANCER PREVENTION Vaccine Protection against 9 HPV types 10+ Years Recommended

16 LOCATION MATTERS: Where you live has a huge impact on whether or not you receive the HPV vaccine.

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19 NIS-TEEN DATA Table 1. NIS-Teen 2016 HPV Vaccination Rates by Metropolitan Status, Ages years FEMALES 1-dose 2-dose 3-dose U.S. Average 65.1% 55.0% 43.0% MSA Central City URBAN MSA Noncentral City SUBURBAN Non MSA RURAL MALES 1-dose 2-dose 3-dose U.S. Average 56.0% 43.6% 31.5% MSA Central City URBAN MSA Noncentral City SUBURBAN Non MSA RURAL MSA = Metropolitan Statistical Area Orange color=below national averages

20 Rural Barriers to HPV Vaccination

21 Barriers to HPV vaccination Rural Challenges Strong Provider Recommendation LESS Likely Health Care System Challenges MORE Difficult Lack of Parent/Patient Knowledge Beliefs that it is NOT for ages & NOT for boys Few visits to primary care provider at this age Multiple doses TRAVEL for 2+ DOSES Costs HIGHER COSTS FOR COLD STORAGE Availability of HPV Vaccine (refer to health dept.) Not framed as a Cancer Prevention vaccine

22 Missed Opportunities for HPV Vaccination in Utah

23 Utah Statewide Immunization Information System (USIIS) Records of all persons born in Utah since 1998 Approximately 55,000 girls ages between Healthcare providers track immunization records for patient care by consolidating immunizations from enrolled providers into one centralized record >80% of healthcare providers in Utah report to USIIS Kepka D, Spigarelli MG, Warner EL, Yoneoka Y, McConnell N & Balch A (2016). Statewide analysis of missed opportunities for human papillomavirus vaccination using vaccine registry data. Papillomavirus Research (Amsterdam, Netherlands). Vol. 2, Published, 12/2016.

24 USIIS: Results for All Females MISSED OPPORTUNITY FOR HPV VACCINATION (ANY OR DOSE 2 & 3) No HPV & other vaccine Other vaccine & not HPV dose 2 or % 40.0% Missed Opportunity

25 USIIS: Results by AGE Approximately 65% of preteens (ages 11-12; N=2,593) and 32% of female teens (ages 13-18; N=4,937) had a missed opportunity for the HPV vaccine between years in Utah (p<.001).

26 USIIS: Results by Other Demographics Race and ethnicity related to rates of missed opportunities for the HPV vaccine among all girls ages (Whites=36%, N=2,454; Hispanics=21%, N=254) (p<.001). Rural and urban locations were also associated with rates of missed opportunities for the HPV vaccine (Urban=31%, N=4,448; Large rural town=42%, N=202) (p<.001).

27 USIIS: Limitations/Strengths Limitations: Few variables available Vaccinations may not have been entered correctly or by providers not participating (under-reporting and over-reporting) Strengths: State-wide vaccination records 80% clinician participation 5 year timeframe

28 More research needed on suburban barriers Provider and healthcare system level factors Higher levels of vaccine hesitancy among parents Parent and caregiver/attitudes of adolescent patients about HPV vaccination specifically Bundling practices with other adolescent immunizations Perceptions as a needed or necessary vaccine

29 Evidence Based Strategies to Improve HPV Vaccination

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31 Evidence Based Interventions Standing Orders trained medical staff able to efficiently deliver vaccines to age-eligible patients Provider Prompts Use EHR systems to remind providers to give strong & bundled vaccination recommendations Presumptive recommendations Assume parent will be receiving HPV vaccine at this visit for child Patient reminder and recall systems Texts, postcards, s, phone calls, etc. Plan-do-study-act-cycles: Quality improvement systems

32 HPV Advocate Program Hub & Spoke Project Goal: improve HPV vaccination initiation and completion rates for 11 and 12 year olds at clinics in Utah, Wyoming and Alaska. Share HPV-cancer survivor stories with pediatricians, other primary care providers, and their healthcare teams. Also, include webinar based provider coaching strategies. Partnership with Intermountain West HPV Vaccination Coalition, UPIQ, & the American Academy of Pediatrics (AAP) Utah Chapter. This Project follows the successful completion of a previous one at clinics in Montana, Nevada, Utah, and Wyoming with low HPV vaccination rates.

33 Future Areas of Research Needed Targeted provider and healthcare team training strategies for rural and suburban settings. Characteristics of rural and suburban regions with lowest rates of HPV vaccination for targeted interventions. Aside from a strong provider recommendation, do we need different messages for parents in rural and suburban settings? How can we get rural and suburban practices to own and prioritize HPV vaccination quality improvement initiatives? In rural settings, how can we improve access to the HPV vaccine and reduce costs for small clinics? How do we best monitor and celebrate improved HPV vaccination rates in small practices with challenging HER systems?

34 What questions do you have about location and HPV vaccination? Please type your question in text box.

35 Improving HPV Vaccination Through a Diverse Multi-state Coalition

36 Intermountain West HPV Vaccination Coalition Mission: The Intermountain West HPV Vaccination Coalition brings together immunization program representatives with cancer control, pediatric, and primary care specialists as well as parents and community members who share the common goal of improving human papillomavirus (HPV) vaccination rates in our region.

37 Coalition Reach 2014: Approximately 130 members (3 states) 2018: Approximately 450 members (18 states)

38 Purpose & Vision Goal: To enhance and accelerate HPV vaccination among boys and girls ages Objective: To generate a coordinated plan and propose innovative strategies to address barriers to HPV vaccination Vision: To develop and enrich connections with existing immunization programs, cancer control coalitions, pediatric and primary care organizations, and relevant stakeholder communities

39 What we do: Support HPV vaccination by striving to reach the Healthy People 2020 goal of 80% vaccination Activities: updates and news Monthly calls Presenters include: Researchers, health departments, HPV survivors, American Cancer Society, etc. 2-3 in-person meetings annually HPV Advocate Program HPV Vaccine Education & Provider Training HPV Vaccination Health Services Research

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41 Resource Library 100s of tools available

42 TEDx Talk We have a vaccine that prevents cancer. Yes. Prevents Cancer. Deanna Kepka TEDxRiverton Deanna Kepka from Huntsman Cancer Institute and The University of Utah discusses a vaccine that can prevent cancer. The HPV vaccine can prevent cancers caused by the human papilloma virus in both males and females, including cervical, anal, and throat cancers.

43 Register today June 7-8 at HCI in SLC! Cancer centers will share preliminary findings of their environmental scans with a focus on barriers and facilitators of HPV vaccination in their catchment areas/states. Cancer centers will learn from one another (first round of NCI cancer center P30 grantees and second round of P30 grantees) on strategies to improve HPV vaccination in their region. We will include a focus on HPV vaccination challenges experienced in rural communities. Please contact: Deanna Kepka at deanna.kepka@hci.utah.edu or for more information. All cancer centers and other partners working in population-level HPV vaccination education, training, intervention strategies, and research are invited. Meeting will take place in the afternoon and evening on the 7 th and will end by the early afternoon of the 8 th.

44 Abstract Submissions: Due May 1 st Presentations will be brief presentations (5 minutes) similar to ignite sessions, with automatically advancing slides. The Ignite session will be held the afternoon of June 7 th. In your abstract, highlight 1-2 findings from your environmental scan for HPV vaccination or on one other HPV vaccination related topic. Abstracts should be 300 words or less Submit abstracts as.pdf or.doc to hpvmtg18@hci.utah.edu by May 1, 2018 We will only have enough time for one presentation per cancer center or other organization/institution. All received abstracts that meet guidelines will be published in a conference booklet. Please follow this format below: Title: Authors: Affiliations: Purpose: Methods: Results: Conclusion: Feel free to write Deanna Kepka with questions deanna.kepka@hci.utah.edu

45 Thank you & Questions? Deanna Kepka, PhD, MPH Assistant Professor College of Nursing & Huntsman Cancer Institute Director, Intermountain West HPV Vaccination Coalition University of Utah Office: