frances hsieh
TRANSCRIPT
A comprehensive intervention to promote HPV
vaccination of adolescent girls in the United States to prevent
cervical cancer
Capstone Project by
Frances HsiehCandidate for Master of Public Health
Johns Hopkins University Bloomberg School of Public Health
May 11, 2010
Background: cervical cancer and human papillomavirus (HPV) Cervical cancer affects about 10,800 new
women a year, about a third of whom will not survive
Cervical cancer is caused by persistent infection with HPV, a common sexually transmitted virus
High-risk HPV are oncogenic HPV-16 and HPV-18 are the most prevalent, accounting
for ~70% of cervical cancer Low-risk HPV are not oncogenic but may cause
benign problems such as genital warts HPV-6 and HPV-11 account for ~90% of cases of genital
warts
There are ways to help prevent cervical cancer Papanicolaou test (Pap smears)
Examine cervical cells for precancerous changes
The introduction of Pap smears in 1949 allowed for 75% drop in incidence of cervical cancer and 74% drop in mortality rate
Treatment of abnormal findings can prevent progression to cancer
Also two new HPV vaccines: Gardasil and Cervarix
Comparing the two vaccinesQuadrivalent (Merck) Bivalent (GSK)
Licensed in US 2006 2009
HPV types covered HPV 6/11/16/18 HPV 16/18
Protection against HPV 16/18 related
precancerous lesions>98% >93%
Protection against HPV 6/11 related genital
lesions>98% --
Schedule 0, 2, 6 months 0, 1, 6 months
Approvals
Males and females 9 to 26 years old
Protection against cervical, vaginal and
vulvar cancer and precancerous lesions
Protection against genital warts
Females 10 to 25 years
Protection against cervical cancer and
precancerous lesions
CDC’s Advisory Committee on Immunization Practices (ACIP) recommends:
Routine vaccination of females ages 11-12 May be started as young as 9 years old Vaccine also recommended for females 13
to 26 years old, the “catch-up” group
Recommendations are supported by American College of Obstetrics and Gynecology
(ACOG) American Academy of Pediatrics (AAP) American College of Physicians (ACP) American Academy of Family Physicians (AAFP)
Recommendations are targeted at adolescents because: Highest prevalence rates found in girls
following sexual debut Important to have been vaccinated prior to
exposure to HPV Antibody development triggered by the
vaccine is higher when given to girls 12-16 than at older ages
Both bigger health impact and more cost-effective to target girls up to 18 years old for rather than up to 26 years old
Current levels of HPV vaccine coverage are low and vary across the country
There is also a problem with girls returning for follow-up doses
Barriers to HPV vaccination Knowledge and awareness of HPV, the link to
cervical cancer, and the vaccine Parents and adolescents may not fully understand risk
and severity or the efficacy of the vaccine Providers may be reluctant to bring up vaccination if
unfamiliar with HPV Attitude toward HPV as STI
Parents may be reluctant to vaccinate daughters due to concern it may condone sexual activity
Logistical barriers for adolescents No regular schedule for physician visits Busy with school and extracurricular activities Remembering two other follow-up appointments Cost of vaccine
Enabling factors
Insurance coverage for vaccine
VCF program Time and means of
getting to appointments
Reinforcing factors
• Subjective norm based on:
• Physician recommendation
• Perceived expectation of peers
Quality of Life
Healthy adolescent girls and young women
Health
• Lower rates of HPV infection
• Lower rates of cervical cancer
Behavior
HPV vaccination:• Making and
keeping appointments
Environment
Access to and availability of:
• HPV vaccine• Health care team
to administer vaccine
Genetics
Health Program
Phase I: Social Assessment
Phase II: Epidemiological, Behavioral, & Environmental
Assessments
Phase III: Education & Ecological Assessments
Phase IV: Administration & Policy Assessments
Educational Strategies
• Educational campaign /social marketing targeted to parents about HPV infection risk and severity
• Train physicians in related specialties (pediatrics, family and internal medicine) on HPV and the vaccine, recommendations, and counseling points
• Offer CME for training
PRECEDE Framework Including the Health
Intervention Program
Policy, Regulation and Organization
• Include HPV vaccination in school curriculum on STI prevention
• Allow adolescent consent for vaccination
• Vaccine administration through family planning clinics, community health centers, school clinics
• Reminders about further doses through e-mail or text messages
Predisposing factors
Awareness and knowledge of HPV
Perceived risk and severity of HPV infection
Perceived effectiveness and safety of vaccine
Perceived barriers
Health Belief Model
Enabling factors
Insurance coverage for vaccine
VCF program Time and means of
getting to appointments
Reinforcing factors
• Physician recommendation
• Subjective norm: peer’s expectations of vaccination
Educational Strategies
• Educational campaign /social marketing targeted to parents about HPV infection risk and severity
• Train physicians in related specialties (pediatrics, family and internal medicine) on HPV vaccine effectiveness and safety, vaccination recommendations, counseling talking points
• Offer CME for training
Policy, Regulation and Organization
• Include HPV vaccination in school curriculum on STI prevention
• Allow adolescent consent for vaccination
• Vaccine administration through family planning clinics, community health centers, school clinics
• Reminders about further doses through e-mail or text messages
Predisposing factors
Awareness and knowledge of HPV
Perceived risk and severity of HPV infection
Perceived effectiveness and safety of vaccine
Perceived barriers
Ecological Model
Models used in the intervention
Enabling factors
Insurance coverage for vaccine
VCF program Time and means of
getting to appointments
Reinforcing factors
• Physician recommendation
• Subjective norm: peer’s expectations of vaccination
Educational Strategies
• Educational campaign /social marketing targeted to parents about HPV infection risk and severity
• Train physicians in related specialties (pediatrics, family and internal medicine) on HPV vaccine effectiveness and safety, vaccination recommendations, counseling talking points
• Offer CME for training
Policy, Regulation and Organization
• Include HPV vaccination in school curriculum on STI prevention
• Allow adolescent consent for vaccination
• Vaccine administration through family planning clinics, community health centers, school clinics
• Reminders about further doses through e-mail or text messages
Predisposing factors
Awareness and knowledge of HPV
Perceived risk and severity of HPV infection
Perceived effectiveness and safety of vaccine
Perceived barriers
Integrative Behavior Model
Behavior
HPV vaccination:• Making and
keeping appointments
Environment
Access to and availability of:
• HPV vaccine• Health care team
to administer vaccine
Norms
Attitude
Personal Agency
Summary Human papillomavirus is a sexually transmitted virus that
can cause cervical cancer if infection persists Recently developed vaccines have been shown to be
effective in preventing persistent HPV infection and precancerous lesions
It is best to vaccinate at an early age, before sexual debut. For this reason, adolescent girls are targeted for coverage
However, current vaccination rates are low and vary widely from state to state
Low awareness and knowledge of HPV and its natural history, attitudes towards STIs, and logistical barriers are obstacles to overcome to increase vaccination
A comprehensive, theory-based, intervention of education, policy changes, and programmatic changes may help increase rates of vaccination
Implementation and ways to tailor the intervention to specific groups should also be addressed
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