Public Health Intervention

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How to Increase HPV Vaccination Uptake in Women of the Bronx Community

Scope of the Problem:

New York has the 4th highest rate for cervical cancer in the country, and communities made up predominantly of minority in N.Y. For example, Bronx has double the incidence rates of mortality from cervical cancer than communities with a predominantly white population such as its neighboring Westchester. According to The National Cancer Institute, the Bronx County, which is the poorest urban county in the U.S. and is composed predominantly of Latino and Black residents, has a cervical cancer rate of that is 35% higher than in the overall rate of the U.S. This increases the importance of spreading awareness in Bronx communities so they make an effort to seek preventative care against cervical cancer. The best approach to decrease the incidence of cervical cancer is being vaccinated against the HPV infection. The CDC encourages clinicians to begin implementing the 2-dose schedule in their practice to protect their preteen ages 11-14 from HPV infection related cancers. For teens ages 15 -26 years, CDC recommends three doses of the HPV vaccine. Many studies have supported the effectiveness of HPV vaccine in reducing the HPV infection. It is crucial to spread awareness about the effectiveness and availability of the vaccine, especially since every year 31,000 women and men in the U.S. are diagnosed with cancers caused by the HPV infection. In the U.S. the HPV vaccine that are available and approved by the FDA are the HPV2, (protects against types 16 and 18) of the virus, and HPV4, (protects against types 6, 11, 16, 18). HPV types 6 and 11 cause genital warts and types 16 and 18 are associated with cervical, vaginal, vulvar, anal, penile, and throat cancers. There can be many reasons as to why women are not getting the HPV vaccine some reasons may include:

  • Have limited knowledge of the effectiveness, risks and benefits of the vaccine.
  • Vaccine may not be offered at the current care facility or their provider has not recommended it.
  • Some parents may be under the impression that getting the HPV vaccine promotes sexual engagement in sexual behavior.
  • Some may be under the misconception that the HPV vaccine causes fertility issue.
  • May have limited knowledge of who can get the vaccine and how it will be covered.

Objective:

 The objective of this program is to promote awareness of the HPV vaccine benefits and availability among the parents, providers and women of Bronx. Through changing the attitudes, educating, and addressing concerns about the HPV vaccine. Also providing information on who, where, and when they can get the vaccine and also how it will be covered (ex. Medicaid and other insurances that may give coverage). The Montefiore Hospital in Bronx has made an effort to spread awareness about the potentially deadly disease. Here is a statement that was made by them “Our goal is to reach the young women who need the vaccine most and let them know that this service is available,” “We want our patients to leave here vaccinated and better educated about HPV and the possible effects of this virus. We need more hospitals and facilities to reach out to potential patients in their communities allowing them to become better informed of what services are available to them.

Planning:

 This can be accomplished a social marketing intervention by targeting parents, potential patients, and providers, which can help increase awareness and in turn help stimulate vaccination among girls ages 11-26.

 Stakeholders include, NYS Cancer Consortium, Rural Health Networks, CDC, New York City Department of Health, The Institute for Family Health Bronx Health Reach, Bronx Healthcare facilities and HPV vaccine developing companies such as Merk the manufacturer of Gardasil.

Studies have proven that counseling provided by clinicians has a positive effect on vaccination outcome, therefore it is important to educate providers on the importance of recommending and administering the HPV vaccine. One way to enhance provider patient communication in the proposed intervention is to invite clinicians who have the ability to offer the vaccine to take an online class. The class would consist of a one hour explaining the steps of counseling a patient on HPV and other important facts about the vaccine. Following the video clinicians would be prompted to take a small quiz to ensure they have participated, and understood the content in the video. An incentive of earning CME credits for participation.

The second focus of the intervention is on improving awareness among parents of children ages 11-17 and patients ages 18-26.  In order to achieve this goal pamphlets will be sent to homes in Bronx with fast facts of HPV vaccination (see list of facts on the last page). The pamphlet will have instructions of how and where the vaccine may be available to them in their neighborhood. Pamphlets will also have a section where myths and concerns of parents and patients will be addressed. Information will be written in English as well as Spanish. The online website is another resource that can help relay important information to potential patients.

What will be on website:

  • Information on facilities and hospitals that offer the vaccine including information on HPV coverage and eligibility and availability of the vaccine at every facility in the bronx. Information on the on the facility’s policies (for ex: insurance plans accepted, availability of appointment, contact info, hours of operation etc.). Facilities can have access to their own information and they can update it as needed.
  • Hyperlinks will help patients navigate directly to the facilities website to make appointments.
  • Informational videos on HPV vaccination statistics and benefits to provide visuals for people who may have trouble reading or have a preference for visuals.
  • All information on the website will be available in Spanish and English.

 

Using qualitative study design participants (n= 20) will be invited to take part in an in -depth interview before the intervention is implemented in their zip code. Members of the Bronx population will be chosen based on eligibility such as:

  • have adolescent female child/children aged 11-17 who has not received HPV vaccine
  • are a legal guardian of a female adolescent aged 11-17 who has not received HPV vaccine
  • females ages 18-26 who has not received HPV vaccine
  • Lives in close proximity to a facility that offers the vaccine

The interview will include questions that will evaluate their perception and knowledge of HPV vaccination’s benefits and effectiveness. Permission will be taken to invite them back for another survey in 6 months. They will be offered an incentive to be part of the study such as 2 tickets to the movies. This can also help prevent participants from dropping out from the study. Prices will be negotiated with individual movie theaters to keep cost down. Questions in the interview will include:

 What do you know about the HPV vaccine?

Do you think it is important for someone to get the vaccine?

Who is eligible for the vaccine?

Is the vaccine safe?

Where is the HPV vaccine offered in your community?

Did you provider offer the vaccine to you or your child?

       

      After 6 months participants will be invited back for another interview (post intervention) . Questions will once again be asked using in depth interviews to access their perception and knowledge of HPV vaccination and to see if there has been any change in perception, or amount of knowledge. As an incentive they will be given $10 American Express gift cards for participation. Question will include similar ones from the last interview but in addition will have questions such as:

Have you changed your mind about the HPV vaccine? if yes why?

Did you or anyone in your family receive the HPV vaccine in the past 6 months?

Can you explain what led you to get the vaccine?

(if they did not get the vaccine then ask) What led you into not getting the vaccine?

Changes in perception and increased knowledge of HPV will show potential for success of the intervention, while no change will indicate no potential for success.

 

Provider will also be interviewed pre and post intervention (n=20).

Providers will be eligible if they work at a primary care facility or hospital in the Bronx that should be offering the vaccine. Through an in -depth interview question that will be asked include:

 Do you counsel patients on the benefits of the HPV vaccine.

Do you have the vaccine available at your facility?

What do you usually say to your patients about the vaccine?

Do you think it is important to give the vaccine?

How many doses should be given patients ages 11-14?

How many doses should be given to patients 15-26?

What are some benefits of the vaccine?

The same questions will be asked in the post interview and positive changes in attitude will indicate a potential for success of the intervention where no change will indicate no potential for success.

Funding:

This intervention should be funded through New York state public health funds, a small investment in this intervention can save the state a large amount of money that would be spent on cancer treatments of patients who fail to get the vaccine. It is proven that prevention of disease cost less than treatment of it. The intervention would need funds to cover cost to design the website, design and print the pamphlets/surveys, carry out the pre and post study, provide incentives to participants, and design and carry out the (1 hour) video and quiz for providers. If the intervention achieves its goal it can be beneficial for the community of Bronx for many years to come as well as it can be replicated in other states to yield similar results.

Evaluation and Maintenance:

If the intervention proves to be successful it is important to continue periodic evaluations to maintain the effectiveness of the program. This can be accomplished through participant feedback via survey evaluations. Surveys should include a section where improvement suggestion is encouraged and can be made by participants. If the intervention shows no potential for success it will be reevaluated to determine what improvements need to be made to it, after improvements are implemented it will again be tested for level of success.

Facts on HPV:

The following are some facts about HPV that can be included in the pamphlet and website. (taken from National Cancer Cervical Cancer Coalition Website)

Fact 1: The vaccine is safe. Years of studying people who have had the HPV vaccine show that it is safe. The HPV vaccine may make some people dizzy and nauseated when it is injected, but it hardly ever causes bad side effects. More than 80 million doses of the HPV vaccine have been given in the US with no serious problems.

 Fact 2: The HPV vaccine causes no bad side effects. The Centers for Disease Control and Prevention (CDC) have found no proof that HPV vaccines cause bad side effects. Like other vaccines, there may be common temporary side effects like pain, redness, and/or swelling where the shot was given. In rare cases, a person may have an allergic reaction to certain vaccines if they’re allergic to yeast or latex.

 

Fact 3: The HPV vaccine does not cause fertility problems.Research has not shown that HPV vaccines cause fertility problems (problems having kids). The vaccine can help protect women from future fertility problems linked to cervical cancer. The HPV vaccine is a safe way to help protect health and the ability to have healthy babies.

 Fact 4: The HPV vaccine does not contain harmful ingredients. Some parents are worried about vaccine ingredients, one being aluminum. There is aluminum in the HPV vaccine, but it’s a safe amount. Aluminum-containing vaccines have been used for years and in more than 1 billion people. In fact – we come in contact with aluminum every day. It’s in foods we eat, water, and even breast milk. Every day, babies, children, and adults come into contact with more aluminum than what’s in the vaccine.

 Fact 5: Getting the HPV vaccine is not opening the door to having sex. Vaccines are used to help prevent diseases. They’re most useful when given before you come in contact with a virus. Young teens build more antibodies against the HPV vaccine (see Fact 8) and are less likely to already have HPV. So it’s better to get vaccinated as a teen than to wait to get it later. Getting the HPV vaccine does not lead to changes in sexual behavior. The age when teens start having sex, the risk of sexually transmitted diseases, and number of pregnancies are much the same when comparing teens who have been vaccinated to those who have not. HPV is so common that almost everyone will come in contact with it at some point in their lives. Even if someone waits until marriage to have sex, they could still get infected with HPV if their partner had previous contact. Vaccinating your child against HPV helps protect them.

 

Fact 6: The HPV vaccine is for both males and females. Both males and females can get infected with HPV. About 8 or 9 out of 10 sexually active adults will have at least one type of HPV in their lifetime. Many people know that cervical cancer is caused by HPV. But there are cancers found in men that are linked to HPV infection. These include cancer of the anus, penis, throat, and tongue. HPV vaccines are strongly recommended for boys and girls to help protect against HPV-linked cancers and genital warts. The HPV vaccine helps reduce the spread of HPV in both males and females.

 

Fact 7: The HPV vaccine works and can help prevent cervical cancer. The HPV vaccine protects against almost all cervix HPV infections and pre-cancers. Studies have shown that HPV vaccines can prevent infections and pre-cancers caused by HPV. Women in the United States, along with women in other countries that give the HPV vaccine, have fewer cervix changes and fewer cases of genital warts.

 Fact 8: The HPV vaccine lasts a long time – maybe forever. If your child gets the HPV vaccine they will make proteins called antibodies that fight the virus. Antibodies give strong and long-lasting protection. While there’s no sign that this protection will go down over time, studies are being done to watch this. Current studies suggest that the vaccine protection lasts a long time. If studies show that protection drops, a booster shot may be needed, just like some other vaccines.

 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4080713/

http://www.montefiore.org/body.cfm?id=1738&action=detail&ref=304

http://einstein.yu.edu/cacbc/page.aspx?id=26360

https://www.health.ny.gov/statistics/cancer/docs/2014_screening_amenable_cancers.pdf

http://einstein.yu.edu/cacbc/page.aspx?id=26360

http://www.sciencedirect.com/science/article/pii/S0090825810001393

https://www.health.ny.gov/statistics/cancer/docs/hpv_related_cancers_and_vaccination_rates_2015.pdf

http://www.nccc-online.org/hpvcervical-cancer/

http://ctb.ku.edu/en/developing-intervention

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5593511/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690341/

https://www.cdc.gov/media/releases/2016/p1020-hpv-shots.html

https://www.cdc.gov/hpv/hcp/hpv-important.html

https://maps.cancer.gov/overview/DCCPSGrants/abstract.jsp?applId=8640117&term=CA169960

http://oro.open.ac.uk/20473/2/Ross_et_al.pdf

https://www.cancer.org/cancer/cancer-causes/infectious-agents/hpv/hpv-vaccine-facts-and-fears.html

https://www.institute.org/bronx-health-reach/about/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1463924/

https://www1.nyc.gov/site/doh/providers/reporting-and-services/citywide-immunization-registry-cir.page