Human Papillomavirus Vaccine Uptake, Knowledge, and Acceptance for Youth: A Systematic Review of Appalachia

"Despite high rates of HPV-related cancer in Appalachia, the lack of public discussion about HPV and cervical cancer and misunderstandings about the need for the vaccine before sexual debut keep knowledge and approval of HPV vaccination low for the intended vaccine group and their parents."

Disparities in human papillomavirus (HPV) vaccine initiation and completion rates are even greater in the Appalachian regions of the United States (US) than elsewhere in that country. Forty-two percent of this 205,000-square-mile region on the east coast of the US is considered rural, with high rates of family poverty. This article examines how knowledge of the HPV vaccine and diseases caused by HPV, such as cervical cancer, and communication with healthcare professionals influence vaccine uptake among young females ages 9-17 in Appalachia compared to the rest of the US. The goal is to form the evidence base for culturally effective interventions to improve the uptake of HPV vaccination in this underserved region.

A literature review revealed 15 articles, whose findings were grouped into the following categories:

• Vaccine uptake: Six of the articles discussed HPV vaccine uptake, finding that Appalachian regions have lower vaccine initiation and completion rates than other areas in the US. Furthermore, lower uptake and higher cervical cancer rates were found when comparing Appalachian and non-Appalachian counties within a single state. It is notable that no distinct pattern of vaccine uptake is seen in Appalachia, so the region should not be viewed homogeneously when analysing vaccine initiation or completion: "interventions and campaigns should be tailored to the culture and contributing factors by subregions rather than the region as a whole."
• Vaccine acceptance for early adolescent girls: Multiple articles found that parents living in Appalachia presumed that younger girls (9-12 years old) were not at risk for HPV infection due to assumptions about their daughters' lack of sexual activity. This suggests that concerns about age and parental perceived sexual debut of their child may be the contributing factor for low uptake in the region rather than vaccine acceptance.
• HPV knowledge: A lack of knowledge and understanding of HPV, the vaccine, and cervical cancer by participants living in Appalachia was common and is potentially a barrier to vaccination.
• HPV communication: Multiple articles found that provider communication about HPV-related topics was consistently low. However, when a provider recommendation was received, it was one of the strongest predictors of initiation of vaccination and vaccine acceptance. Communication among family members also played a role; two of the studies discussed the close-knit nature of nuclear and extended families in Appalachia and how non-nuclear relatives such as grandmothers had a significant influence on decisions to vaccinate. Negative discussion among this population of females could contribute to the commonly cited fears of safety and side effects that prevented many participants from vaccinating themselves and young girls.

Among the challenges in Appalachia that may complicate vaccine promotion for the recommended immunisation ages is the fact that many Appalachian communities have been described as church-centred and highly conservative. (According to one study cited in the review, church-centred societies are less likely to discuss HPV-related topics.) Abstinence is the primary form of birth control taught in schools and in churches within these communities. Thus, the assumed certainty of abstinence in youth undermines the perceived need for the vaccine in early adolescence. In addition, participants in several studies reported fears of promoting sexual promiscuity among adolescents if they encouraged vaccination.

Another factor related to lack of HPV-related knowledge in Appalachian communities is reflected in studies about the way HPV in covered in the media. For example, one study cited here found that Appalachian newspapers were significantly less likely to publish articles covering HPV, the vaccine, and cervical cancer, but when they did, they less frequently discussed HPV vaccine efficacy or protocols, prevalence and severity of cervical cancer and HPV, risk factors for the conditions, and vaccine financial assistance programmes. Furthermore, staff from these Appalachian newspapers stated that the newspapers avoided publishing HPV-related information due to lack of reader interest and concerns about encouraging sexual promiscuity in youth and sparking rumours about those who received the vaccine.

Relatedly, a study discovered that people in Appalachia are 4.5 times more likely to have poor functional health literacy than those in non-Appalachia and, on average, scored 3.9 points lower on health literacy tests. Thus, the low overall health literacy of the population due to less access to health education sources contributes to illiteracy surrounding the vaccine and HPV.

In light of this analysis, the researchers call for increased education about HPV in Appalachian communities, suggesting that it may need to involve more generations than just those of the vaccine age range because of the importance of family in these regions. Lack of parental approval may deter some children from wanting to be immunised, even if they were able to receive it without their parents' consent. This may also be why a school-based approach might not be effective. Instead, a family-centred communication approach, engaging matriarchal figures, may be more effective in Appalachia.

Specifically, they propose a multi-pronged approach to tackling vaccine promotion on 3 fronts:

1. In healthcare facilities: Healthcare professionals in Appalachia need additional training - e.g., about how to raise and discuss health matters related to sex with youth and parents. Making HPV and its vaccine part of routine medical information about cancer prevention (e.g., include with smoking cessation education, which is very high in Appalachia) might alleviate the stigma surrounding HPV in these areas and improve communication in healthcare settings.
2. At churches: A review of HPV vaccine promotion in rural churches in the US state of Georgia found that church members said they would appreciate vaccine-related educational sessions through church-related functions because they considered church a safe space to express thoughts and opinions. HPV vaccine promotion programmes could also be incorporated into women's conventions held by larger community churches in which respected, local medical professionals participate.
3. Through the local media: Some of the articles in this review mentioned a distrust in the national advertisements due to their relation to pharmaceutical companies, so tailoring messages towards communities using local physicians and testimonials from trusted community members may be more effective.

In conclusion: "More research must be done to develop and test educational programs appropriate for providers, parents, and youth living in Appalachia and gain understanding of this complex region in order to prevent the spread of HPV and HPV related cancers."