2021 CANCER & MENTAL WELLBEING EDUCATION TRAINING SERIES
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2021 CANCER & MENTAL WELLBEING
EDUCATION TRAINING SERIES:
A Call to Action – Ending Cancer Inequities
Using an Intersectional Framework
Thursday, August 19, 2021
1:00 – 3:00 pm ET
Closed captioning:
https://www.streamtext.net/player?event=CancerEducationSeriesDay1
Welcome!
Tamanna Patel, MPH Samara Tahmid Hope Rothenberg
Director, Project Manager, Project Coordinator,
Practice Improvement Practice Improvement Practice Improvement
Housekeeping
• This workshop is being recorded. All participants
placed in “listen-only” mode.
• For audio access, participants can either dial into the
conference line or listen through your computer
speakers.
• Submit questions by typing them into the chat box or
using the Q&A panel.
• Access to closed captioning:
• https://www.streamtext.net/player?event=C
ancerEducationSeriesDay1
• Slide handouts and recording will be posted here:
• https://www.bhthechange.org/resources/r
esource-type/archived-webinars/
National Behavioral Health Network for
Tobacco & Cancer Control
• Jointly funded by CDC’s Office on Smoking Visit www.BHtheChange.org and
& Health & Division of Cancer Prevention Join Today!
& Control
Free Access to…
• Provides resources and tools to help Toolkits, training opportunities, virtual
organizations reduce tobacco use and communities and other resources
cancer among individuals experiencing
mental health and substance use Webinars & Presentations
challenged State Strategy Sessions
Communities of Practice
• 1 of 8 CDC National Networks to eliminate
cancer and tobacco disparities in priority
populations
#BHthechange
Networking2Save: A National Network Approach to Promoting Tobacco and Cancer-Related Health Equity in Special Populations A consortium of eight national networks sponsored by the CDC’s Office on Smoking and Health and Division of Cancer Prevention and Control. Our partnership provides leadership on and promotion of evidence-based approaches for preventing commercial tobacco use and cancer for priority populations on a national, state, tribal and territorial level. https://www.cdc.gov/cancer/ncccp/related- programs/Networking2Save.htm
Today’s Featured Sessions & Speakers
• 1 - 2 pm: Sexual and Gender Minority Inclusion in Comprehensive Cancer Care Coffee Chat
• 2 - 3 pm: Enhancing Cancer Care for Rural Communities
Mandi, Pratt-Chapman, MA, PhD Heather Brandt, PhD
Michelle Veras, MPH
Associate Center Director, Patient- Director, HPV Cancer Prevention
Projects Director,
Centered Initiatives and Health Equity Program
National LGBT Cancer Network
GW Cancer Center St. Jude Comprehensive Cancer Center
CDC Welcoming Remarks
Ena Wanliss, M.S.
National Partnership Project Lead
Comprehensive Cancer Control Branch
Division of Cancer Prevention and Control
Centers for Disease Control and Prevention
Determinants of Health
Access to
Care 10%
Social &
Clinical Care
Economic
10%
Factors 40%
Health Physical
Traditional Health
Behaviors Environment
Programming
30-36%*
Outcomes 10%
*Source: https://www.goinvo.com/vision/determinants-of-health/
Cancer and Behavioral Health: What Has Caused the Disparity?
Behavioral and lifestyle factors
(smoking, alcohol use, nutrition access/diet)
Socio-environmental circumstances
Access to and quality of medical care
Bio-chemical factors
(co-morbidities, drug interactions, genetics)
Contextual inequities
(food environments, poverty, discrimination and more)
9
Cancer and Behavioral Health
•1 in 4 adults have some form of mental illness or substance
use condition
•Mental health issues affect patients in all stages of cancer,
whether a pre-existing condition, during treatment, while in
remission, and often throughout the life course.
•While the evidence is still limited some research shows
that:
• Up to 50% of patients with terminal cancer have
been diagnosed with at least one psychiatric
disorder.
• Individuals with a mental illness may develop cancer
at 2.6 times a higher rate on account of late-stage
diagnosis and inadequate treatment and screenings.
Source: McGinty EE, Zhang Y, Guallar E, et al. Cancer incidence in a sample of
Maryland residents with serious mental illness. Psychiatr Serv. 2012; 63:714–717.
[PubMed: 22752037]Cancer and Behavioral Health
• Overall, the total cancer incidence was 2.6 times higher among adults
with serious mental illness vs adults without serious mental illness.
• Both schizophrenia and bipolar disorder are associated with a
significantly increased risk for cancer.
• The risk for lung cancer is 4 times higher among adults with serious
mental illness, and the risk for colorectal cancer was similarly elevated.
• The risk for breast cancer is elevated among women with schizophrenia
and bipolar disorder.
• In the studies conducted to date (very limited research) patients' race did
not statistically affect the higher risk for cancer associated with serious
mental illness.
Source: McGinty, E. E., Zhang, Y., Guallar, E., Ford, D. E., Steinwachs, D., Dixon, L. B., Keating, N. L., & Daumit, G.
L. (2012). Cancer incidence in a sample of Maryland residents with serious mental illness. Psychiatric services
(Washington, D.C.), 63(7), 714–717. https://doi.org/10.1176/appi.ps.201100169Continuum of Cancer Care: Barriers for
Behavioral Health
Lack of
research/data
Co-morbidities
Community
and other
individual risk
Barriers & and systems
Challenges to level barriers
factors
Cancer Care for
BH Populations
Insurance and Prevention,
financial screening,
coverage treatment and
challenges access gapsBut we don’t know the whole story…
The evidence to date from studies regarding mental illness and cancer is varied, complex, and
sometimes conflicting. Reports regarding cancer incidence are particularly inconsistent, with
studies finding the risk of cancer among individuals with mental illness to be higher, lower, or
equivalent to that of the general population.
Cancer is the second leading cause of death among individuals who experience mental health and
substance use disorders.
Source: Kisely S, Crowe E, Lawrence D. Cancer-Related Mortality in People With Mental
Illness. JAMA Psychiatry. 2013;70(2):209–217. doi:10.1001/jamapsychiatry.2013.278
13Reducing Cancer Disparities &
Enhancing Care for LGBTQ+
Communities
August 19, 2021Michelle Veras, MPH Projects Director National LGBT Cancer Network
Agenda ○ Who we are ○ LGBTQ+ Health Disparities ○ Cancer in LGBTQ+ communities ○ LGBTQ+ Cancer Survivors in their own words
LGBTQ+ Cancer Disparities
Disparities across the cancer
continuum
Our knowledge of LGBTQ+ Cancer Disparities is greatly inhibited by the
fact that cancer centers often do not ask sexual orientation or gender
identity on intake forms. But the following information we do know:
LGBTQ+ Communities have:
❖ Increased cancer risks
❖ Lower cancer screening rates
❖ Increased challenges in survivorshipIncreased Cancer Risks ❖ Tobacco Use ❖ Obesity/ Eating Disorders ❖ Alcohol consumption ❖ Sexually Transmitted Infections ❖ HIV Often times we focus on these as an Individual Responsibility. Instead we need to look at the root causes that contribute to health disparities.
Increased Cancer Risks We have increased cancer risks not because LGBTQ+ people are inherently bad at making decisions, or because our bodies are somehow different. Rather, there are systemic inequalities and prejudices that LGBTQ+ have to navigate that cisgender heterosexual communities do not.
The Social Determinants of Health Made up of 5 components of social and environmental factors that impacts health and well being ❖ Economic Stability ❖ Education Access and Quality ❖ Health Care Access and Quality ❖ Neighborhood and Built Environment ❖ Social and Community Context
Economic Stability
Layers of structural discirmination can impact an individual’s
chances of being below the poverty line.
1. Homophobia/ Transphobia
2. Racism
3. Sexism
15.7% of 21.6% of LGBT 30.8% of Black 31.3% of Black
cisgender individuals LGBT lesbians &
heterosexual 29% of individuals; 39.7% of
individuals transgender 38% of Black bisexual women
individuals TransgenderHealth Care Access and Quality A History of Discrimination 80% of 1st year medical students expressed implicit bias against lesbian/gay people. Nearly 50% expressed explicit bias
Healthcare Access and Quality
Putting this in context:
LGBTQ+ communities are more likely to be underinsured and to
have had a negative experience with a health care provider.
Even if we, ourselves have not had a negative experience,
we know someone who has! Fear of discrimination from
healthcare providers is a shared trauma amoung LGBTQ+
communities.Takeaways
LGBTQ+ Communities
More likely to be below the poverty level
+
Heightened experiences of discrimination and rejection
+
More likely to have been mistreated by a doctor
=
Delays in seeking careHow does this impact cancer?
Cancer Screening
In one study at an LGBTQ+ welcoming healthcare center, when
compared to cisgender patients, transgender patients were:
❖ 70 percent less likely to be screened for breast cancer
❖ 60 percent less likely to be screened for cervical cancer
❖ 50 percent less likely to be screened for colorectal cancer
This is likely a result of a higher likelihood of being uninsured and fear
from discrimination.Limited Data Shows
Colorectal Cancer
Breast Cancer
Areas with more LGBTQ people have
Same-sex patnered women have 3.2x
been found to have a higher incidence of
greater risk of dying of breast cancer as
colorectal cancer.
compared to opposite-sex partnered
women. Anal Cancer
Compared with men in the general
Lung Cancer population, Gay and Bisexual who are:
Cancer and respiratory risks from HAPs HIV negative are 20 times more likely to
for same-sex partners are 12.3% (female) be diagnosed with anal cancer
and 23.8% (male) greater, respectively, HIV positive are 80 times more likely to be
than for heterosexual partners. diagnosed with anal cancer.LGBTQ+ Cancer
Survivors
in their own wordsSexual and Gender Minority Inclusion in
Comprehensive Cancer Care Coffee Chat
Tamanna Patel, MPH Michelle Veras, MPH Mandi, Pratt-Chapman, MA, PhD
Director, Projects Director, Associate Center Director, Patient-Centered
Practice Improvement National LGBT Cancer Network Initiatives and Health Equity
GW Cancer CenterEnhancing Cancer Care for Rural Communities Heather M. Brandt, PhD Director, HPV Cancer Prevention Program Co-associate Director for Outreach, St. Jude Comprehensive Cancer Center Member, Department of Epidemiology and Cancer Control St. Jude Children’s Research Hospital stjude.org/hpv August 19, 2021
Disclosures
I have nothing to disclose.
2021 CANCER & MENTAL WELLBEING EDUCATION TRAINING SERIES: A Call to Action – Ending Cancer Inequities Using an Intersectional Framework • August 19, 2021Learning Objectives
• Increase awareness of geographic and rural disparities for
cancer
• Discuss challenges and opportunities for addressing
geographic cancer disparities
• Explore innovative and sustainable solutions to improve
cancer care for rural communities
2021 CANCER & MENTAL WELLBEING EDUCATION TRAINING SERIES: A Call to Action – Ending Cancer Inequities Using an Intersectional Framework • August 19, 2021Cancer in Rural U.S. Communities stjude.org/hpv
Cancer in Rural and Frontier Populations • Rural populations experience the following challenges related to cancer: • Higher poverty rates • Lower educational attainment • Lack of access to heath services • Higher rates of tobacco use, alcohol consumption, and obesity • Less physical activity • Less use of sun safety measures • Lower HPV vaccination rates
Cancer in Rural and Frontier Populations
• Rural populations experience the following challenges related
to cancer:
• Ruralrates
Higher poverty populations have
• Lower educational attainment
• Lack of higher average
access to heath servicesdeath rates
• for all
Higher rates cancer
of tobacco sitesconsumption,
use, alcohol combined and obesity
• Less physical activity
•
compared to urban
Less use of sun safety measures
• counterparts.
Lower HPV vaccination ratesCancer in Rural and Frontier Populations
• Closing the cancer care gap:
• Social, demographic, and personal contributors
• Geographic distribution of services
• Multidisciplinary care needs
• Travel distance and costs
• Financial burdens and health insurance
• Clinical trial infrastructure
Levit LA, Byatt L, Lyss AP, Paskett ED, Levit K, Kirkwood K, Schenkel C, Schilsky RL. Closing the Rural Cancer Care Gap: Three Institutional Approaches. JCO Oncol Pract. 2020 Jul;16(7):422-430. doi:
10.1200/OP.20.00174. Epub 2020 Jun 23. PMID: 32574128.
Charlton M, Schlichting J, Chioreso C, Ward M, Vikas P. Challenges of Rural Cancer Care in the United States. Oncology (Williston Park). 2015 Sep;29(9):633-40. PMID: 26384798.Cancer in Rural and Frontier Populations
• Closing the cancer care gap:
• Social, demographic, and personal contributors
• Geographic distribution of services
• Multidisciplinary care needs
• Travel Local
distance and problems
costs require local
• solutions.
Financial burdens and health insurance
• Clinical trial infrastructure
Levit LA, Byatt L, Lyss AP, Paskett ED, Levit K, Kirkwood K, Schenkel C, Schilsky RL. Closing the Rural Cancer Care Gap: Three Institutional Approaches. JCO Oncol Pract. 2020 Jul;16(7):422-430. doi:
10.1200/OP.20.00174. Epub 2020 Jun 23. PMID: 32574128.
Charlton M, Schlichting J, Chioreso C, Ward M, Vikas P. Challenges of Rural Cancer Care in the United States. Oncology (Williston Park). 2015 Sep;29(9):633-40. PMID: 26384798.Racial and Ethnic Composition Across Rural United
States Counties, 2018
Zahnd WE, Murphy C, Knoll M, Benavidez GA, Day KR, Ranganathan R, Luke P, Zgodic A, Shi K, Merrell MA, Crouch EL, Brandt HM, Eberth JM. The Intersection of Rural Residence and Minority Race/Ethnicity in
Cancer Disparities in the United States. Int J Environ Res Public Health. 2021 Feb 3;18(4):1384. doi: 10.3390/ijerph18041384. PMID: 33546168; PMCID: PMC7913122.A Framework for Improving Rural Cancer
Outcomes
Influences across
the cancer control
continuum
contribute to risk
and outcomes.
Zahnd WE, Murphy C, Knoll M, Benavidez GA, Day KR, Ranganathan R, Luke P, Zgodic A, Shi K, Merrell MA, Crouch EL, Brandt HM, Eberth JM. The Intersection of Rural Residence and Minority Race/Ethnicity in
Cancer Disparities in the United States. Int J Environ Res Public Health. 2021 Feb 3;18(4):1384. doi: 10.3390/ijerph18041384. PMID: 33546168; PMCID: PMC7913122.Cancer in Rural and Frontier Populations
Need for investment in rural cancer control:
• Only 3% of R- and P-mechanism grants were
rural-focused from 2011-2016
• Expanded focus on intersectionality in rural
settings to encompass social determinants of
health in addition to specific correlates of cancer
control
• Clear definitions and application of what
constitutes rural and frontier populations
• Complexity of conditions require equally
complex interventions to address cancer
disparities (as well as other health disparities)
Blake et al., 2017: Making the case for investment in rural cancer control: an analysis of rural cancer incidence, mortality, and funding trends. Cancer Epidemiology Biomarkers and PreventionImproving Cancer Prevention and Control
with Rural Populations
• Promote healthy behaviors that reduce cancer risk
• Increase cancer screenings and vaccinations that prevent
cancer or detect it early
• Participate in state-level and local efforts
• Establish policy, systems, and environmental supports in rural
communitiesImproving Cancer Prevention and Control
with Rural Populations
Partner with faith-based organizations to provide programs and
resources, such as for smoking cessation
Offer HPV vaccinations in non-traditional settings, such as using
mobile clinics
Promote the option of stool-based colorectal cancer screening
tests in traditional and non-traditional settings
Expand patient transportation options
CDC. Preventing and treating cancer in rural America. Available at: https://www.cdc.gov/ruralhealth/cancer/policybrief.htmlHPV Cancers in Rural U.S. Communities stjude.org/hpv
HPV-Associated Cancer Incidence Rates by State,
United States, 2013-2017
CDC. https://gis.cdc.gov/Cancer/USCS/DataViz.htmlEstimated Up-to-Date HPV Vaccination Coverage
among Adolescents, 2019
National Coverage = 54%
Elam-Evans LD, Yankey D, Singleton JA, Sterrett N, Markowitz LE, Williams CL, Fredua B, McNamara L, Stokley S. National, Regional, State, and Selected Local Area Vaccination Coverage Among Adolescents
Aged 13-17 Years - United States, 2019. MMWR Morb Mortal Wkly Rep. 2020 Aug 21;69(33):1109-1116. doi: 10.15585/mmwr.mm6933a1. PMID: 32817598; PMCID: PMC7439984. (Map: TeenVaxView)NIS-TEEN HPV Vaccination Uptake, 2018 and 2019
2018 2019
>1 HPV HPV UTD >1 HPV HPV UTD
United States Overall 68.1 (66.8-69.3) 51.1 (49.8-52.5) 71.5 (70.1-72.8) 54.2 (52.7-55.8)
Alabama 64.7 (58.1-70.7) 50.2 (43.4-56.9) 65.6 (58.6-71.9) 47.3 (40.4-54.3)
Arkansas 60.8 (54.1-67.1) 42.6 (36.0-49.5) 67.9 (61.5-73.6) 50.5 (43.9-57.2)
Florida 64.1 (57.3-70.4) 46.5 (39.7-53.5) 67.9 (59.6-75.2) 56.0 (47.4-64.2)
Georgia 68.1 (61.8-73.8) 49.6 (43.1-56.1) 65.9 (59.0-72.3) 49.7 (42.7-56.8)
Kentucky 56.9 (50.0-63.5) 42.6 (35.9-49.5) 74.4 (68.2-79.8) 54.9 (48.2-61.4)
Louisiana 67.2 (60.3-73.4) 46.7 (39.5-54.1) 73.9 (66.9-80.0) 59.5 (51.7-66.8)
Mississippi 51.7 (44.9-58.5) 32.6 (26.4-39.5) 49.5 (42.0-57.1) 30.5 (23.7-38.3)
Missouri 61.6 (55.0-67.8) 42.1 (35.7-48.8) 69.0 (61.9-75.4) 54.3 (46.8-61.7)
North Carolina 68.6 (62.2-74.5) 52.1 (45.4-58.7) 71.3 (64.4-77.3) 49.5 (42.6-56.5)
South Carolina 63.7 (57.0-69.8) 41.2 (34.7-47.9) 71.8 (65.4-77.4) 53.0 (46.0-59.9)
Tennessee 62.3 (55.4-68.8) 44.4 (37.4-51.6) 61.9 (54.6-68.8) 43.0 (35.9-50.4)
2019 NIS-TEEN MMWR: https://www.cdc.gov/mmwr/volumes/69/wr/mm6933a1.htm?s_cid=mm6933a1_w
2019 NIS-TEEN, jurisdiction: https://stacks.cdc.gov/view/cdc/91797Estimated vaccination coverage among adolescents aged 13-17 years by year: National Immunization Survey-Teen, United States, 2006-2019
>1 HPV Vaccination Coverage in Rural Areas is
Consistently Lower
80
71.9
70
60
59.5
Percent Vaccinated
50
40
30
20
10
0
2013 2014 2015 2016 2017 2018
Mostly Urban Mostly Rural
Walker TY, Elam-Evans LD, Williams CL, Fredua B, Yankey D, Markowitz LE, Stokley S. Trends in human papillomavirus (HPV) vaccination initiation among adolescents aged 13-17 by metropolitan statistical area
(MSA) status, National Immunization Survey - Teen, 2013 - 2017. Hum Vaccin Immunother. 2020 Mar 3;16(3):554-561. doi: 10.1080/21645515.2019.1671765. Epub 2019 Oct 29. PMID: 31662024; PMCID:
PMC7227639.HPV Cancers in Rural United States
HPV-associated Cervical Vulvar
12.3 overall 7.2 females only 2.1 females only
13.8 females
10.9 males
Zahnd WE, Rodriguez C, Jenkins WD. Rural-Urban Differences in Human Papillomavirus-associated Cancer Trends and Rates. J Rural Health. 2019 Mar;35(2):208-215. doi: 10.1111/jrh.12305. Epub 2018 May 28.
PMID: 29808500.HPV Cancers in Rural United States
Oropharyngeal
5.1 overall
1.7 females
8.7 males
Zahnd WE, Rodriguez C, Jenkins WD. Rural-Urban Differences in Human Papillomavirus-associated Cancer Trends and Rates. J Rural Health. 2019 Mar;35(2):208-215. doi: 10.1111/jrh.12305. Epub 2018 May 28.
PMID: 29808500.HPV Cancers in Rural United States
Rural populations
have an increased
incidence of HPV-
associated cancers
compared to urban
Oropharyngeal populations.
5.1 overall
1.7 females
8.7 males
Zahnd WE, Rodriguez C, Jenkins WD. Rural-Urban Differences in Human Papillomavirus-associated Cancer Trends and Rates. J Rural Health. 2019 Mar;35(2):208-215. doi: 10.1111/jrh.12305. Epub 2018 May 28.
PMID: 29808500.Opportunity for Impact
Up-to-date (UTD) HPV Vaccination, both HPV-associated Cancers, both males
males and females, 13-17 years (2019) and females (2017)
U.S. = 54.2% UTD (>1 71.5%) U.S. = 12.3 cases per 100,000
Arkansas = 50.5% UTD (>1 67.9%) Arkansas = 14.2 cases per 100,000
Mississippi = 30.5% UTD (>1 49.5%) Mississippi = 15.5 cases per 100,000
Missouri = 54.3% UTD (>1 69.0%) Missouri = 13.9 cases per 100,000
Tennessee = 43.0% UTD (>1 61.9%) Tennessee = 14.3 cases per 100,000
HPV Cancer: 2017 U.S. Cancer Statistics data; darkest colors = 13.7-17.1 cases
HPV UTD: 2019 NIS-TEEN data; lightest colors = 30.5-47.4%; darkest colors = per 100,000; lightest colors = 8.9-11.4 cases per 100,000
62.7-78.9%Opportunity for Impact
HPV vaccination is safe, effective, and durable,
yet uptake is less than optimal. Low HPV
vaccination uptake
Up-to-date (UTD) HPV Vaccination, both
exists in areas where HPV-
HPV-associated Cancers, both males
males andassociated disease
females, 13-17 years (2019) burden is greatest.
and females (2017) There is
tremendous opportunity U.S.
U.S. = 54.2% UTD (>1 71.5%)
for= 12.3
impact.
cases per 100,000
Arkansas = 50.5% UTD (>1 67.9%) Arkansas = 14.2 cases per 100,000
Mississippi = 30.5% UTD (>1 49.5%) Mississippi = 15.5 cases per 100,000
Missouri = 54.3% UTD (>1 69.0%) Missouri = 13.9 cases per 100,000
Tennessee = 43.0% UTD (>1 61.9%) Tennessee = 14.3 cases per 100,000
HPV Cancer: 2017 U.S. Cancer Statistics data; darkest colors = 13.7-17.1 cases
HPV UTD: 2019 NIS-TEEN data; lightest colors = 30.5-47.4%; darkest colors = per 100,000; lightest colors = 8.9-11.4 cases per 100,000
62.7-78.9%Preventing HPV Cancers with Rural U.S. Communities stjude.org/hpv
Barriers and Facilitators to HPV Vaccination in
Rural U.S. Communities
People living in rural areas were less likely to be aware of HPV and HPV
vaccine and less likely to believe HPV can cause cervical cancer as
compared to people living in urban areas.
Prevalence (%)
HINTS Item Rural Urban
Heard of HPV 55.8 67.2
Heard of HPV vaccine 58.6 65.8
HPV can cause cervical cancer 64.4 75.4
Can get HPV through sexual contact 55.4 65.9
Mohammed KA, Subramaniam DS, Geneus CJ, Henderson ER, Dean CA, Subramaniam DP, Burroughs TE. Rural-urban differences in human papillomavirus knowledge and awareness among US adults. Prev Med.
2018 Apr;109:39-43. doi: 10.1016/j.ypmed.2018.01.016. Epub 2018 Jan 31. PMID: 29378268.Barriers and Facilitators to HPV Vaccination in
Rural U.S. Communities: Initiation
Level Barriers Facilitators
Individual •
•
Older age of caregiver
Ever had a Pap/abnormal Pap
•
•
Older age of vaccine recipient
Female and transfemale gender identity
• Caregivers’ perceptions about harm or pain • Receipt of other vaccines
• Parents’ perception of daughter’s risk • Current hormonal contraceptive use
• Parents’ perception of age (too young) • Caregivers’ awareness of HPV and cervical cancer
• Sexual behavior concerns • Heard about vaccine on radio/television
• Knowledge and awareness facilitators: vaccine
recommendations, cost covered, benefit
Interpersonal None found/reported •
•
Parent/patient/provider relationships
Provider discussion with parent/patient and making
recommendation
• Positive influence of parents and peers
Organizational None found/reported •
•
School-based programs
School-generated patient reminders
• County-wide provider and health practice training
Community/societal None found/reported • County-wide social marketing campaign
Peterson CE, Silva A, Holt HK, Balanean A, Goben AH, Dykens JA. Barriers and facilitators to HPV vaccine uptake among US rural populations: a scoping review. Cancer Causes Control. 2020 Sep;31(9):801-814.
doi: 10.1007/s10552-020-01323-y. Epub 2020 Jun 14. PMID: 32537702.Barriers and Facilitators to HPV Vaccination in
Rural U.S. Communities: Completion
Level Barriers Facilitators
Individual •
•
Older age of caregiver
Transportation concerns
•
•
Older age of vaccine recipient
Receipt of other vaccines
• Intention to complete vaccine series
• Perceived lack of control over cancer
• Receipt of an intervention DVD on importance of HPV
vaccine
Interpersonal None found/reported • Accompanied to vaccination by a friend
Organizational None found/reported •
•
School-based programs
School-generated patient reminders
• County-wide provider and health practice training
Community/societal None found/reported None found/reported
Peterson CE, Silva A, Holt HK, Balanean A, Goben AH, Dykens JA. Barriers and facilitators to HPV vaccine uptake among US rural populations: a scoping review. Cancer Causes Control. 2020 Sep;31(9):801-814.
doi: 10.1007/s10552-020-01323-y. Epub 2020 Jun 14. PMID: 32537702.Multi-level and
Multi-component Interventions
Health care system-based interventions Community-based interventions
implemented in combination implemented in combination
• At least one intervention to increase client • One or more interventions to increase
demand community demand
• e.g., client reminder and recall, client-
• e.g., manual outreach and tracking,
based clinic education
client or community-wide education,
client incentives
• One or more interventions that address
either, or both, of the following strategies: • One or more interventions to enhance
• Interventions to enhance access to access to vaccination services
vaccinations (e.g., expanded access) • e.g., expanded access in healthcare
• Interventions directed at vaccination settings, home visits, reduced client out-
providers or systems (e.g., provider of-pocket costs
reminders, standing orders, provider
assessment and feedback)
The Guide to Community Preventive Services: https://www.thecommunityguide.org/Multi-level and
Multi-component Interventions
Health care system-based interventions Community-based interventions
implemented in combination implemented in combination
• At least one intervention to increase client • One or more interventions to increase
demand community demand
What do successful interventions
• e.g., client reminder and recall, client-
based clinic education
• e.g., manual outreach and tracking,
client or community-wide education,
•
look like in rural U.S. communities?
One or more interventions that address
client incentives
either, or both, of the following strategies: • One or more interventions to enhance
• Interventions to enhance access to access to vaccination services
vaccinations (e.g., expanded access) • e.g., expanded access in healthcare
• Interventions directed at vaccination settings, home visits, reduced client out-
providers or systems (e.g., provider of-pocket costs
reminders, standing orders, provider
assessment and feedback)
The Guide to Community Preventive Services: https://www.thecommunityguide.org/Improving HPV Vaccination in
Rural U.S. Communities
Multi-level approaches:
• Patient / parent
• Healthcare providers, settings, and systems
• Communities, including schools
Educational strategies, e.g., training and instruction, print materials
Provider recommendation
Social marketing and health communication campaigns
*Free* HPV vaccination
Varying types and levels of engagement
Brandt HM, Vanderpool RC, Pilar M, Zubizarreta M, Stradtman LR. A narrative review of HPV vaccination interventions in rural U.S. communities. Prev Med. 2021 Apr;145:106407. doi:
10.1016/j.ypmed.2020.106407. Epub 2021 Jan 1. PMID: 33388323.Improving HPV Vaccination in
Rural U.S. Communities: Opportunities
Multi-level? YES!
Multi-component? ALSO, YES!
Multi-level and multi-component interventions allow for
implementation of myriad strategies to overcome barriers and
enhance facilitators to HPV vaccination in rural settings.
Brandt HM, Vanderpool RC, Pilar M, Zubizarreta M, Stradtman LR. A narrative review of HPV vaccination interventions in rural U.S. communities. Prev Med. 2021 Apr;145:106407. doi:
10.1016/j.ypmed.2020.106407. Epub 2021 Jan 1. PMID: 33388323.Improving HPV Vaccination in
Rural U.S. Communities: Opportunities
Greater consistency in measurement and reporting:
• Ages
• One or both sexes
• Data sources
• Time points
• Values
Consistent measurement and reporting across multiple levels and
for multiple components aids in understanding the most effective
approaches to increase HPV vaccination in rural settings.
Brandt HM, Vanderpool RC, Pilar M, Zubizarreta M, Stradtman LR. A narrative review of HPV vaccination interventions in rural U.S. communities. Prev Med. 2021 Apr;145:106407. doi:
10.1016/j.ypmed.2020.106407. Epub 2021 Jan 1. PMID: 33388323.Improving HPV Vaccination in
Rural U.S. Communities: Opportunities
Rural U.S. communities:
• Available data, such as IIS
• Defining rural
• Provide contextual information
A clear basis for how and why a target population and setting is
‘rural’ allows for future research to understand how a proposed rural
setting may or may not align with previous research in rural
communities.
Brandt HM, Vanderpool RC, Pilar M, Zubizarreta M, Stradtman LR. A narrative review of HPV vaccination interventions in rural U.S. communities. Prev Med. 2021 Apr;145:106407. doi:
10.1016/j.ypmed.2020.106407. Epub 2021 Jan 1. PMID: 33388323.Improving HPV Vaccination in
Rural U.S. Communities: Opportunities
Community Clinical
• Cancer coalitions • Health department
• HPV coalitions • Pediatric practices
• Immunization coalitions • Federally-qualified health centers
• Faith-based organizations • Rural health clinics
• Non-profit organizations • Safety net clinics
• American Cancer Society • Professional societies and
organizations
Limited focus on community-clinical linkages to address supply and
demand challenges.
Brandt HM, Vanderpool RC, Curry SJ, Farris P, Daniel-Ulloa J, Seegmiller L, Stradtman LR, Vu T, Taylor V, Zubizarreta M. A multi-site case study of community-clinical linkages for promoting HPV vaccination. Hum
Vaccin Immunother. 2019;15(7-8):1599-1606. doi: 10.1080/21645515.2019.1616501. Epub 2019 Jun 3. PMID: 31158042; PMCID: PMC6746520.Improving HPV Vaccination in
Rural U.S. Communities: Opportunities
Outside the medical home, e.g.,:
• Schools
• Pharmacies
• Dental clinics
• Mobile vaccination clinics
Within and beyond the medical home, reduce missed opportunities.
Create access points for vaccination.
e.g.,
Calo et al., 2019: Implementing pharmacy-located HPV vaccination: findings from pilot projects in five U.S. states. Hum Vaccin Immunother
Harris et al., 2020: The perspectives, barriers, and willingness of Utah dentists to engage in human papillomavirus vaccine practices. Hum Vaccin Immunother
Kaul et al., 2019: School-based human papillomavirus vaccination program for increasing vaccine uptake in an underserved area in Texas. Papillomavirus Res
Ryan et al., 2020: Exploring opportunities to leverage pharmacists in rural areas to promote administration of human papillomavirus vaccine. Prev Chronic Dis
Vanderpool et al., 2015: Implementation and evaluation of a school-based human papillomavirus vaccination program in rural Kentucky. Am J Prev MedImproving HPV Vaccination in
Rural U.S. Communities: Opportunities
Big “P” /
Policy Opportunity Description Level
Little “p”
Healthcare provider HPV vaccination recommendation to patients at each visit, particularly when other vaccines are being administered; decreases missed Provider Little “p”
recommendation opportunities.
Reminder and recall systems Reminders within the electronic medical record, prompting providers to initiate HPV vaccination recommendation; patient reminders to Clinic Little “p”
initiate and/or complete the HPV vaccine series.
State immunization registries Statewide registries in which all immunization records are entered and maintained. State Big “P”
Standing orders Official clinic protocols that give clinical staff authorization to complete immunizations for patients meeting recommended guidelines. Clinic Little “p”
Provider assessment and Routine feedback to providers on patients’ HPV vaccination series initiation and completion rates. Clinic Little “p”
feedback evaluations
Participation in VFC Program Clinic approval and implementation of processes that allow for participation in the VFC Program. Clinic Little “p”
Vaccination in alternative settings Providing HPV vaccination programs in schools, pharmacies, mobile clinics, dental practices, and other community-based, non-medical Clinic, Community Little “p”
settings.
Pharmacy-related requirements State-enacted laws allowing pharmacists to provide the HPV vaccine series to youth and young adults. State Big “P”
School-entry requirements State-enacted laws that require students to initiate and complete the HPV vaccine series to maintain eligibility to attend school. State Big “P”
Communication campaigns Leveraging rural community partnerships and voices of local residents to deliver positive HPV vaccination messaging. Community Little “p”
Rural HPV vaccination research Increased funding for interventional rural HPV vaccination research (e.g., randomized controlled trials, quasi-experimental studies, and National Big “P”
pragmatic trials).
Vanderpool RC, Stradtman LR, Brandt HM. Policy opportunities to increase HPV vaccination in rural communities. Hum Vaccin Immunother. 2019;15(7-8):1527-1532. doi: 10.1080/21645515.2018.1553475. Epub
2019 Jan 4. PMID: 30608894; PMCID: PMC6746481. Brandt HM, Pierce JY, Crary A. Increasing HPV vaccination through policy for public health benefit. Hum Vaccin Immunother. 2016 Jun 2;12(6):1623-5. doi:
10.1080/21645515.2015.1122145. Epub 2015 Dec 15. PMID: 26669416; PMCID: PMC4964717.Improving HPV Vaccination in
Rural U.S. Communities: Opportunities
• Healthcare provider, setting, and system
• Build HPV vaccination confidence
• Multi-level and multi-component interventions
• Consistent HPV vaccination measurement and reporting
• Definitions and descriptions of rural settings
• Community-clinical linkages
• Access points outside the medical home
• Reduce missed opportunities
• Big “P” and Little “p” policiesHeather M. Brandt, PhD Director, HPV Cancer Prevention Program Co-associate Director for Outreach, St. Jude Comprehensive Cancer Center Member, Department of Epidemiology and Cancer Control St. Jude Children’s Research Hospital 262 Danny Thomas Place MS 762 Memphis, Tennessee 38105 email: PreventHPV@stjude.org stjude.org/hpv
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