Chastity L. Walker: Attitudes, Practices, and Beliefs About. Human ... committee members, Dr. Sandra Greene, Dr. Michel Landry, Dr. Elizabeth Randall-David.
Attitudes, Practices, and Beliefs About Human Papillomavirus Vaccine Among Young Adult African-American Women: Implications for Effective Implementation
By Chastity L. Walker
A dissertation submitted to the faculty of the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctor of Public Health (DrPH) in the Department of Health Policy and Management in the School of Public Health.
Chapel Hill August 2009
Approved by: Chair: Suzanne Havala Hobbs, DrPH Sandra Greene, DrPH Michel D. Landry, PhD Elizabeth Randall-David, PhD Mona Saraiya, MD
© 2009 Chastity L. Walker ALL RIGHTS RESERVED
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ABSTRACT Chastity L. Walker: Attitudes, Practices, and Beliefs About Human Papillomavirus Vaccine Among Young Adult African-American Women: Implications for Effective Implementation (Under the direction of Suzanne Havala Hobbs, DrPH) Cervical cancer is both a preventable and treatable disease. Racial and ethnic minorities and those of low-socioeconomic status tend to experience the greatest morbidity and mortality due to cervical cancer. Vaccination against the human papillomavirus (HPV) has been shown to prevent cervical cancer and genital warts, and subsequently reduce the number of women requiring follow-up and treatment of abnormal Pap Tests. There is relatively little published evidence to assess acceptance and utilization of the HPV vaccine among minority and low socioeconomic groups. The purpose of this study was to generate knowledge and inform policy considerations to reduce cervical cancer incidence and mortality by use of the HPV vaccine among African-American women, aged 18-26. A qualitative descriptive study design sought to characterize the barriers to, and potential facilitators of HPV vaccine introduction to young adult African-American women, aged 18-26, while recommending strategies for implementation. The study comprised a mix of both primary and secondary data collection and analysis methods. Interviews were conducted with stakeholders demonstrating expertise in cervical cancer prevention and an assessment of the literature on vaccines, diffusion of innovation, and policy adoption was conducted to inform policy alternatives to promote receipt of the
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vaccine among the target group. Several overarching themes emerged to suggest factors that might deter or promote use of the vaccine including: mistrust of government, access to vaccination, attitudes about health, varying opinions regarding HPV vaccine guidelines, social determinants contributing to cervical cancer disparities, and a comprehensive strategy for introducing vaccination among others. Strategic recommendations to support implementation of HPV vaccination catch-up programs, specifically designed for African-American women, aged 18-26, include addressing gaps in knowledge thru expansion of a cervical cancer prevention social marketing educational campaign to Historically Black Colleges and Universities (HBCU’s) and enhancing access by evaluating how best to integrate HPV immunization and cervical cancer screening delivery. These findings confirm that introduction of HPV vaccination to African-American women will require an incremental and targeted approach, and can be used by public health officials and policy-makers as they strive to improve the overall quality and delivery of cervical cancer prevention services.
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Dedication
In memory of my beloved Grandmother, Maeola Harriet HooksA woman whose spirit exemplified faith, strength, and compassion. Thank you for inspiring me and giving me the wings to soar!
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Acknowledgements The completion of this work would not have been possible without the guidance and support of many people, to whom I am eternally grateful. First and foremost, my sincere gratitude and thanks to my family- for your encouragement, confidence in me, and most importantly prayers on my behalf- throughout this journey. You all believed in me when I had doubts and your love sustained me. I am thankful for my ‘sister circle’ [Bonita, Debra, Felicia, Janelle, Joycelyn, Mattie, Nicole, Nikki, Phaeydra, Rachel, and Teri] as I could not have been more fortunate to have an ensemble of champions standing beside me, cheering me on, and motivating me to excel; you have been that and so much more. Our friendship is a sacred sisterhood, a blessing not to be taken for granted. I am indebted to my committee chair, Dr. Suzanne Havala Hobbs, for her steady guidance, direction and encouragement at all the right moments. To my other committee members, Dr. Sandra Greene, Dr. Michel Landry, Dr. Elizabeth Randall-David and Dr. Mona Saraiya, I am appreciative of the support, insight and helpful critique offered by all of you on many occasions; your counsel and contributions helped me accomplish a great work that I am proud of. I am priveleged and honored to have had a committee that provided their expertise, wisdom, and belief in the importance of this work. My sincere thanks to the interview subjects for their participation- the knowledge and insight shared was fundamental to this dissertation. I also wish to acknowledge the numerous individuals who offered encouragement, a kind word, or contributed to this effort in some way. Finally, I wish to acknowlege my cohort of fellow DrPH travelers who’ve been a part of this journey.
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Thank you for your friendship, camaraderie and good humor over our years in the program; the experience of learning from and alongside you can only be described as priceless.
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TABLE OF CONTENTS
ABSTRACT --------------------------------------------------------------------------------------------- ii LIST OF TABLES ------------------------------------------------------------------------------------- x LIST OF FIGURES -----------------------------------------------------------------------------------xi LIST OF ABBREVIATIONS-----------------------------------------------------------------------xii CHAPTER I: INTRODUCTION ------------------------------------------------------------------- 1 A. Statement of the Issue ---------------------------------------------------------------------------------------1 B. Background ---------------------------------------------------------------------------------------------------2 C. Significance of Issue -----------------------------------------------------------------------------------------5 D. Purpose & Specific Aims -----------------------------------------------------------------------------------6
CHAPTER II: REVIEW OF THE LITERATURE --------------------------------------------- 8 A. Part One: Knowledge of HPV and cervical cancer ------------------------------------------------------9 Knowledge of Human Papillomavirus---------------------------------------------------------------------9 B. Part Two: Attitudes Toward/ Perception of Human Papillomavirus -------------------------------- 11 Attitudes Towards Human Papillomavirus-------------------------------------------------------------- 11 Acceptance of Human Papillomavirus Vaccine -------------------------------------------------------- 12 C. Part Three: Policy Analysis and Interpretation--------------------------------------------------------- 14 D. Discussion--------------------------------------------------------------------------------------------------- 20 E. Limitations of Literature Review------------------------------------------------------------------------- 24
CHAPTER III: METHODOLOGY --------------------------------------------------------------- 26 A. Conceptual Framework------------------------------------------------------------------------------------ 27 B. Study Design ------------------------------------------------------------------------------------------------ 29 C. Phase One: Review of Literature February 2007 to July 2008--------------------------------------- 30 D. Phase Two: Key Informant Interviews December 2008 to January 2009 -------------------------- 30 E. Phase Three: Policy Analysis & Interpretation --------------------------------------------------------- 35 F. Ethics & Confidentiality ----------------------------------------------------------------------------------- 35
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CHAPTER IV: RESULTS -------------------------------------------------------------------------- 37 A. Descriptive Analysis --------------------------------------------------------------------------------------- 38 B. Emergent Themes ------------------------------------------------------------------------------------------ 39 C. Key Findings ------------------------------------------------------------------------------------------------ 40
CHAPTER V: POLICY ANALYSIS ------------------------------------------------------------- 84 A. Diffusion of Innovations ---------------------------------------------------------------------------------- 94 B. Analysis of Options ---------------------------------------------------------------------------------------110
CHAPTER VI: IMPLEMENTATION PLAN ------------------------------------------------ 115 CHAPTER VII: DISCUSSION ------------------------------------------------------------------ 129 A. Conclusion -------------------------------------------------------------------------------------------------141 B. Limitations of the Research Study ----------------------------------------------------------------------144 C. Final Word -------------------------------------------------------------------------------------------------147
APPENDIX A---------------------------------------------------------------------------------------- 148 APPENDIX B ---------------------------------------------------------------------------------------- 150 APPENDIX C---------------------------------------------------------------------------------------- 152 APPENDIX D---------------------------------------------------------------------------------------- 153 APPENDIX E ---------------------------------------------------------------------------------------- 157 APPENDIX F ---------------------------------------------------------------------------------------- 160 APPENDIX G---------------------------------------------------------------------------------------- 164 APPENDIX H---------------------------------------------------------------------------------------- 168 APPENDIX I----------------------------------------------------------------------------------------- 173 REFERENCES--------------------------------------------------------------------------------------------------175
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LIST OF TABLES Table 2.1. Results of Literature Review….……………………………………………..17 Table 3.1. Social Ecological Model …………………………………………………….29 Table 3.2. Phase Two-Informant Interviews ……………………………………………33 Table 4.1. Key Informant Interview Participants by Stakeholder Group ………………39 Table 4.2. Emergent Themes ……………………………………………………………40 Table 4.3. Barriers that Hinder Acceptance/Use of HPV Vaccine……………………....47 Table 4.4. Facilitators that Support Acceptance/Use of HPV Vaccine ...……………….50 Table 4.5. Communication Channels of Young Adult African-American Women ………62 Table 4.6. Factors to Consider for HPV Vaccine Policy Recommendations …………...78 Table 4.7. Strategies for Effective HPV Vaccine Implementation ………………………81 Table 5.1. Recommendations Regarding Interventions to Improve Vaccination ……….87 Table 5.2. Vaccine Policy Issues ………………………………………………………..89 Table 5.3. Comparison of Adult Vaccine Costs per Dose ……………………………….92 Table 5.4. State HPV-Related Legislation Over Time (1997-2008) …………………...101 Table 5.5. Proposed/Enacted HPV Related Legislation by Type ……………………...102 Table 5.6. Education and Awareness Legislation by Type …………………………….106 Table 5.7. Evaluation of Policy Options for Improving Cervical Cancer Prevention ……………………………………………………………………. 116 Table 6.1. Women ROCC! Core Elements ……………………………………………..118 Table 6.2. Integration of NBCCEDP Cervical Screening and HPV Vaccination Evaluation Questions…………………………………………..……128 Table 7.1. Advantages/Drawbacks to HPV Vaccination of African-American Females, aged 18-26 ……………………………………………… 144
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LIST OF FIGURES Figure 2.1. A Basic Policy Analysis Process ……………………………………….……15 Figure 3.1. Socio Ecological Model-Determinants of HPV Vaccine Acceptance & Use …………………………………………………………………..….. 30 Figure 5.1. Functions of a National Immunization System ……………………………...88 Figure 6.1. Age-Eligibility Requirements for NBCCEDP, VFC and 2006 ACIP HPV Vaccine Recommendations …………………………………………..126
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LIST OF ABBREVIATIONS
AA
African-American
ACIP
Advisory Committee on Immunization Practices
ACS
American Cancer Society
AED
Academy for Educational Development
CCC
Comprehensive Cancer Control
CDC
Centers for Disease Control and Prevention
DCPC
Division of Cancer Prevention and Control
FDA
Food and Drug Administration
HBCU
Historically Black Colleges and Universities
HIV
Human Immunodeficiency Virus
HPV
Human Papillomavirus
HSI
Hispanic-Serving Institution
IRB
Institutional Review Board
MERCK
MERCK Pharmaceuticals, Inc.
NBCCEDP
National Breast and Cervical Cancer Early Detection Program
NCCCP
National Comprehensive Cancer Control Program
OB/GYN
Obstetrician/ Gynecologist
REACH
Racial and Ethnic Approaches to Community Health
ROCC!
Reaching Out Against Cervical Cancer
STD
Sexually Transmitted Disease
STI
Sexually Transmitted Infection
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Abbreviations continued S-CHIP
State Children’s Health Insurance Program
UNC
University of North Carolina
VFC
Vaccine for Children Program
VPAP
Vaccine Patient Assistance Program (MERCK, Inc)
WIG
Women in Government
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CHAPTER I: INTRODUCTION
A. Statement of the Issue
Cervical cancer incidence rates in developed countries such as the United States (US) are much lower than those in developing countries. Eighty percent of global cervical cancer cases and deaths occur in less developed nations, 1-3 and most of these deaths occur in SubSaharan Africa, South Asia and Latin America 4, 5. In the United States, approximately 11,000 women are diagnosed with invasive cervical cancer, and 4,120 die from it annually.6, 7 At one time, cervical cancer was the leading cause of cancer death among US women. However, regular use of the Papanicoalaou Test (Pap Test), beginning in the 1970s, moved cervical cancer to the seventh most common cancer in the United States. Nonetheless, not all populations and geographic regions of the US have experienced equal declines in morbidity and mortality. In the US, groups with the highest mortality include African-American women in the South, Hispanics along the Texas-Mexico border, Whites in Appalachia, American Indians of the Northern Plains, Vietnamese-American, and Alaskan natives. 8 The statistics related to African-American women are alarming considering cervical cancer can be detected through Pap screenings and treated when caught early. Recent data from the 2005 United States Cancer Statistics Report show significantly higher age-adjusted incidence rates of cervical cancer among African-American women- at 10.3 per 100,000 ( 7.7 per 100,000 for Whites).7 African-American women are twice as likely to be diagnosed at
later stages as compared to white women, particularly in the Southern region of the United States. 9, 10 Similarly, the mortality rate for African-American women was 4.4 per 100,000, twice that of non-Hispanic White (2.2 per 100,000) women. 9, 11 While some studies show that African-American women have similar rates of cervical cancer screening as their white counterparts, more recent data suggest disparities in cervical cancer screening, morbidity and mortality remain. 11, 12 African-American women over the age of forty have higher incidence rates of invasive cancer than white women but lower or equivalent rates to those
