Human Papilloma Virus (HPV) infection is the most common sexually transmitted infection in the United States. Human Papilloma Virus infection can cause cervical, vaginal and vulvar cancers, as well as genital warts in women. Additionally, HPV has been identified as a cause of penile cancer in men, as well as genital warts. It is now know that HPV is a cause of oropharyngeal and anal cancers in both men and women.
The FDA (Food and Drug Administration) in 2007 approved the first vaccine to prevent three of the oncogenic HPV types noted in the United States. At this time, there are two HPV vaccines approved for use in the U.S.—a quadrivalent vaccine (Gardasil, Merck) that protects against HPV types 6,11, 16, and 18; and a bivalent vaccine (Cervarix, Glaxo Smith Kline) which protects against HPV types 16 and 18. Vaccination against HPV infections is recommended for both males and females at age 11 or 12 years (through age 26 years) by the Advisory Committee on Immunization Practices (ACIP) This was recommended for females in 2006 and for males in 2011.
In the United States, there is an estimated 12,000 women diagnosed with cervical cancer on an annual basis. A study that examined the genotype distribution of invasive vaginal cancers from four population based repositories and three residual repositories in the United States prior to the introduction of HPV vaccine—found that three/fourths of vaginal cancers in the U.S. had HPV detected and the authors concluded that 57% of those cancers may be prevented by the current HPV vaccine.
It is important to understand that Human papilloma virus infection (HPV) may clear on its own—without any impact on the person’s health. However, it may result in genital warts, cervical cancer, genital/perianal cancers and cancer of the oral-pharyngeal cavity. The CDC recommends the three-dose series of the HPV vaccine to protect against the types that are responsible for most cases of cervical and other types of genital cancers. However in late 2016 the ACIP came out with a recommended 2-dose series for children 9-14 years; maintaining the 3-dose series for persons 15-26 years for HPV vaccine.
It has been noted as with other cancers, that racial and ethnic disparities have been demonstrated in the numbers of new cases of cervical cancer and deaths. Indiana cervical cancer rates (7.5 per 100,000) are similar to U.S. (7.7 per 100,000). Each of these identified minority groups identified have at least four times great rate of cervical cancer than white women. New cervical cancer cases are observed to be higher among women who are Hispanic (9.3), Asian/Pacific Islander (8.9) and Black (8.8) compared to White women (2.4). Hispanic or Asian/ Pacific Islander death rates are not available for women in Indiana.
Purpose of study
The purpose of this mixed-method study was to:
- Describe study participants’ knowledge of HPV infection and their understanding regarding the prevention of cervical/genital cancers through HPV vaccination.
- Explore participants’ personal and cultural beliefs regarding HPV vaccination in children and young adults, perceptions of wellness and access to care.
This study was intended to reach African American, Hispanic/Latino (English and Spanish speaking) and self-identified Native American/Alaska Native adults living in Indiana. The study was conducted from May 2016 through November 2016.
Methodology
Purposeful sampling was used for participant enrollment of 90 men and women (18 years of age and older) —self-identified as African American, Native American/ Alaska Native or Hispanic/Latino. Participants were recruited from community sites affiliated with the Indiana Minority Health Coalition throughout Indiana as well as four (4) Native American Pow wows held throughout Indiana. Thirty persons from each ethnic population were enrolled. Approximately half (n=14) of the Hispanic/Latino persons interviewed were non-English speaking and a Spanish speaking certified translator was utilized during real-time interviews on-site.
Open-ended interviews were conducted, along with a demographic & knowledge surveys regarding HPV knowledge, understanding and vaccination uptake—with a focus on concepts discussed in the three (3) overarching aims. This study intends to reach adults 18 years and older, who in selected Indiana.
The survey consisted of objective questions which characterized the population by demographics and health history. Group comparisons were only reported as statistically different if the difference was greater or equal to p < .05 by chi square or t-test. The survey covered areas of access to care, HPV knowledge, health perceptions, health insurance coverage and knowledge of cervical cancer.
Upon completion of the survey, participants engaged in semi-structured, open-ended interviews. The interviews were crafted to discern the person’s beliefs and experiences within an individual cultural context. The interview were digitally audio recorded and transcribed verbatim.
The Hispanic/ Latino interviews conducted with non-English speaking participants were translated orally during the interview process, and audio-recorded in real-time with each participant present. This provided an opportunity for researcher/participant dialogue and clarification if questions/ responses were misunderstood or it was felt the response was ‘out-of-context’. Each of these orally translated interviews were transcribed verbatim and analyzed.
Survey and interviews lasted approximately 45 minutes to one hour.
The primary focus of this study is qualitative in nature. The qualitative portion of this study focused on analysis of participant interviews—the verbatim-transcribed narrative text and documented field notes related to verbal and non-verbal cues. The main analyses were related to identification of themes/repeated concepts and interpretation of meaning in the narrative interview content. The verbatim text narrative and field notes were imported into ‘InVivo®11 (software program) to assist in the systematic management and evaluation of text. Narrative content was analyzed for topics, and repeated concepts that were embedded in the text. Important areas explored: identity and cultural influences and health; understanding of HPV and link to genital cancers; HPV vaccination uptake; and access/ confidence in healthcare.
Results
Ninety persons were enrolled in the study and study participants were divided equally: 30 African American; 30 Native American/Alaska Native; and 30 Hispanic/Latino (16 English speaking /14 non-English speaking).
Of the 90 total subjects, the three ethnic groups almost always identified with their African American, Hispanic and Native America (over 90% in each group), while 30% of Native Americans also classified themselves as “White” (female- 70, male- 17, transgender- 1, two spirit -2). Mean age of all participants was 45 years. However, Hispanic respondents were significantly younger than other ethnic groups, by almost 10 years (Mean ages: AA 51; Hispanic 38.3; NA 46 years).
Three key themes have emerged: Trust vs mistrust in healthcare; vaccine beliefs; and access to care. With analysis of interview findings, a majority of participants expressed trust in healthcare providers but some mistrust in messaging regarding vaccination uptake and outcomes. The key theme of vaccine and vaccination beliefs was not consistent throughout the participant population. Some participants related stories of injury, sterilization, increased sexual activity post-vaccination and dire outcomes with vaccination as a ‘mythic’ cause. Other participants were neutral and implied no difficulties with vaccination. Survey findings supported that, vaccines were viewed as valuable offerings at community events (77 % overall), and over 80% would encourage teen participation on HPV immunization and information events.
In the theme regarding ‘access to care’, three-fourths of participants stated they were able to access care regularly and they felt well. These findings were supported by participants reporting overall, nearly one in four (24.7%) reported very poor or fair health status. Hispanics and Native Americans tended to report more frequent fair-poor health (27-30%) than African Americans, and Native Americans reported Very Good-Excellent health status (16.7%) about half as often as other participants (31-36%). Finally, one-in-five participants (21%) reported barriers to accessing care due to cost, and one-third had difficulties paying for prescription medications (31%), but there were no significant differences by ethnic group.
Conclusions
There is still a need for accurate and complete information regarding HPV vaccination—to assure informed vaccination decisions are being made by parents– regarding HPV vaccination.
- Providers should be aware of the possibility of trust and access issues with all diverse cultural groups— and should craft their messaging accordingly.
- Utilizing an approach that demonstrates respect for cultural beliefs as well as understanding regarding possible hesitancy to vaccinate is key to help bridge the knowledge gap and hesitancy issues related to vaccination.
- Finally, it is critical to approach HPV vaccination as a way to prevent genital cancers. This message should be the initial and recurring premise that is communicated to parents who are considering vaccination. Prevention of future infection and possible cancers should be clearly explained to parents, as they consider vaccination.