Barriers to the HPV Vaccination and Cervical Cancer Screening for BAME Women

What are the Barriers of Human Papillomavirus (HPV) Vaccination and Cervical Cancer Screening amongst Minority Women age 12-26?

Abstract

Background: Minority women systematically experience socio-economic disadvantages, which put them in the face of greater obstacles in attaining optimal health. Approximately 44 million women in the United States, nearly one third of all women in America, self-identify as women of a minority racial or ethnic group. Yet, minority women fare worse than non-Hispanic white women across a broad range of measures, with some of the largest disparities being that of HPV-related cervical cancer mortality. Objective: The objective is to emphasize the barriers of care in relation to cervical cancer screening and HPV vaccination, as well as examine patterns in barriers like demographic, cultural, and health belief factors amongst minority women.Methods: The data collection review and process was based on article review factors that were associated with HPV vaccine acceptability, initiation, and series completion among adolescent and young adult women of different racial, ethnic, and socioeconomic groups in the United States. Results: Selected characteristics of the included studies contended that an estimated 12,000 women are diagnosed with cervical cancer annually in the United States, and 4500,000 women worldwide develop cervical cancer each year. Higher rates of cervical cancer are found in US regions with large minority and impoverished populations. Conclusion: It is imperative for clinicians to progress minority women screening and early detection. Further intervention models need to reflect multifactorial determinants of screening utilization.

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Introduction

Background

While there have been strides in HPV and cervical cancer prevention efforts, many minority women across the board still experience significant barriers to care. For example, women from rural and poor communities tend to have health illiteracy in regard to their own self-care, which also includes their mistrust for the healthcare system. Additionally, many minority women simply lack financial access to care. Socio-economic disadvantages (i.e. race, class, gender, education, occupation, etc.) are the underlying issues. Though many health efforts are made by health professionals, and health ramifications like informative technologies and preventative care strategies have been achieved, there is a continual socio-economic and racial imbalance with both the diagnosis and treatment of cervical cancer, especially the strains directly influenced by HPV.

Specific Aims

Our specific aims are to first identify Health care barriers and challenges to cervical cancer screening and HPV vaccination within the population of minority women. We also want to uncover minority women, health care provider & health care system risk factors for cervical cancer screening & HPV vaccination, as well as, health care challenges and opportunities in improving cervical cancer screening rates amongst minority women. Lastly, we want to pinpoint the nurses’ roles in preventing cervical cancer in underserved racial and or ethnic populations.

Methods

Search Strategy

In June 2017,we searched four electronic bibliographic databases (Google scholar, Medline, Pubmed and Cinahl) using the search terms ‘HPV’ ‘cervical cancer’ ‘pap smear’ ‘minority women’ ‘ethnic women’ and ‘health disparities’. All of the studies identified during the database search were assessed for relevance to the review based on the information provided in the title, abstract, and description of key words and terms. A full report was retrieved for all studies that met the inclusion criteria.

Inclusion Criteria

The data collection review and process was based on article review factors that were associated with HPV vaccine acceptability, initiation, and series completion among adolescent and young adult women of different racial, ethnic, and socioeconomic groups in the United States.

We reviewed relevant peer-reviewed and evidence-based qualitative literature in order to identify current vaccination trends, rates and factors associated with HPV and cervical cancer. Study findings a related to race (black, Latina, Asian), and socio-economic disadvantages were summarized.

Eligibility Criteria

Understanding current vaccination trends and the barriers to series initiation and completion, the Centers for Disease Control and Prevention (CDC) recommends that 11 to 12 year old adolescents receive two doses of the HPV vaccine in order to protect against themselves against cancers that are caused by HPV. The HPV vaccine series can be given to girls beginning at age 9 years old, but many parents believe this age is too immature for a sexually transmitted disease vaccination. Additionally, it is recommended by the CDC that girls and women age 13 through 26 years of age who have not yet been vaccinated or completed the vaccine series to be given the HPV vaccination immediately to provide HPV-cancer related protection.

In understanding HPV vaccination parameters, it is essential that we too recognize gaps in knowledge and all the misconceptions surrounding HPV vaccination and cervical cancer. When the vaccine is given prior to HPV exposure, it is highly effective in preventing infection from two high-risk genotypes (HPV-16/HPV-18) of HPV, which causes approximately 70 percent of cervical cancers, and two low-risk (HPV-6/HPV-11) genotypes that are responsible for over 90 percent of all genital warts.

As we assessed the appropriateness of our criteria interests, we focused on Black/African-American, Latina and non-white adolescent women age 12-26, minority teen women reported having sexual intercourse, adolescent women who have completed puberty, and low income and health care illiterate young women, who are too uninsured or have limited access.

Quality Assessment

The methodological quality is significant to our study. It was organized and detailed oriented. It presented evidence that there is a need for increasing HPV vaccination among young minority women. The failure to achieve equitable vaccination has exacerbated health disparities in HPV and cervical cancer incidence and mortality. Research suggests that low- income and minority women are disadvantaged due to the difference in cervical cancer screening, practices and beliefs, as well as healthcare access barriers and systemic risk factors.

We used the ‘Research and Quality Scoring Method’ by Sackett and Haynes, the Jadad scale, and the items published by Cho and Bero to rate the quality of each study (Table 1). The range of total quality scores was from 0 to 9. Studies that ranged from 0 to 5 were considered low quality, whereas studies that ranged from 6-9 were considered high quality. Two raters independently coded variables using Microsoft Excel. Discrepancies were identified and resolved amongst our team members.

Statistical Analysis

Race/ethnicity and low socio-economic status are known predictors of late-stage diagnosis of cervical cancer and are important predictors of cancer mortality.

In the United States, approximately 12,000 women develop cervical cancer and 44000 die of the disease each year, with higher incidence and mortality rates reported in low-income minority populations.

HPV vaccination has been shown to reduce the prevalence of high-risk HPV infection among teen women and thus, has the potential to decrease the risks of cervical cancer among vaccinated young women.

According to preceding surveillance and qualitative studies, it is indicated that a decline in the annual rate of high-grade cervical cancer, from 834 per 100,000 in 2008 to 688 per 100,000 in 2014, among women aged 21 to 24 years, which reflects the impact of HPV vaccination. However, declines were not significant in areas with high proportions of minority women (i.e blacks, Latinas) and/or people living in low-income areas.

Results

Included Studies

The search yielded nearly 500 potential article titles for review, yet less than 70 were relevant to our interests. And of that 70, about 20 were dated within the last 10 years. Accordingly, less than 20 seemed more characteristic of our research interests and provided adequate information to our research question.

Description of Studies

Selected characteristics of the included studies contended that an estimated 12,000 women are diagnosed with cervical cancer annually in the United States, and 4500,000 women worldwide develop cervical cancer each year. In the United States, cervical cancer incidence is nearly twice as high in counties with poverty levels > 20% compared with those with poverty levels <10%, and cervical cancer incidence and mortality are 25% and 95% higher, respectively, among black women and 53% and 41% higher for Latina women compared with that of white women. Rates of cervical cancer are inversely proportional to screening and treatment access, and poor and minority women face more barriers to health care access. Therefore, higher rates of cervical cancer are found in US regions with large minority and impoverished populations.

Quality Assessment

It is crucial to understand current vaccination trends and barriers to the HPV vaccination series initiation, in order to influence effective strategies to improve HPV vaccine completion and to reduce disparities in cervical cancer.

All studies assessed literature review aims to identify barriers and facilitators of equitable uptake of HPV vaccination and cervical cancer prevention among low-income and ethnic minority young women. Outcome measures revealed that approximately 44 million women in the United States, nearly one third of all women in America, self-identify as women of a minority racial or ethnic group. Consequently, it is imperative that we not only improve HPV vaccination rates overall, but also focus on high-risk populations to prevent an increase in HPV and cervical cancer disparities.

Assessment methods and deductions varied between studies. For example, according to Race, Ethnicity, and Income Factors Impacting Human Papillomavirus Vaccination rates, current trends in the United States indicate HPV rates stagnated between 2011 and 2012 amongst adolescent women. They believe that provider recommendation is a key factor in HPV vaccination, and minorities are less likely to report receiving recommendations for HPV vaccination.

Fittingly, Challenges and Opportunities to Improve Cervical Cancer Screening Rates in US Health Centers through Patient-Centered Medical Home Transformation states that HPV vaccination improvement and cervical cancer screening processes amongst young minority women can be divided into four sections based upon health center and patient characteristics, patient-level, provider-level and system-level barriers, patient-targeted solutions, provider-targeted solutions and system-level changes, and lastly, the patterns across health center characteristics.

Addressing the Barriers to Cervical Cancer Prevention Among Hispanic Women identifies the reasons why Hispanic women fare an increased risk to HPV related cervical cancer, which is multifactorial. This includes resource limitations within the healthcare system, as well as language, cultural, and knowledge difficulties.

Similarly, Individual, Provider, and System Risk Factors for Breast and Cervical Cancer Screening Among Underserved Black, Latina, and Arab Women, distinguishes between race, culture and pap test between three different minority women. Black women have more health literacy risks associated with reduced odds of a Papanicolaou (Pap) test. For Latina women, the lack of doctor recommendations were significantly associated with decreased odds a Pap test. And, for Arab women, the lack of doctor recommendations was considerably associated with the decreased odds of a Pap test.

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In Barriers to cervical cancer screening among ethnic minority women: a qualitative study, the analysis reveals that fifteen women had delayed screening and/or had never been screened for cervical cancer. These ethnic minority women felt that there was a lack of awareness about cervical cancer in their community, and some did not recognize or understand the terms cervical screening or pap smear test. However, negative healthcare experiences were identified by all women, and are the biggest barrier to preventative and screening efforts.

Correspondingly, Differences in cervical cancer screening knowledge, practices, and beliefs: An examination of survey responses, interviews respondents aged 21 to 35 and of minority ethnicities. Within the interview participants were asked “What is the purpose of a Pap smear or Pap test?” 49% stated that a Pap test checks for cancer, although not all participants knew it tested specifically for cervical cancer. 20% stated that it checked for abnormal or precancerous cells. 41% knew that a Pap test checked the cervix. 29% were vague in their answers, which suggest that they did not fully understand the purpose. 9% indicated that a Pap test checked for STIs. Some participants thought a Pap test evaluated other body parts including the ovaries, uterus, breasts, and used nonspecific terms like “down there.” About 26% answered correctly, while 36% did in fact answer incorrectly. The correct and the incorrect answers were then analyzed by race. Those who answered incorrectly had more than four times the odds of being non-Hispanic black women.

Cervical Cancer Prevention: New Tools and Old Barriers, shares many ethnic minority (African-American and Hispanic) women’s cervical cancer prevention experiences in the face of high cervical cancer burden. The outcome of the study is to enlighten future research and outreach efforts in order to positively reduce the burden of cervical cancer in underserved populations.

 Disparities in HPV and Cervical Cancer Screening Between Highly Educated White and Minority Young Women, acknowledged that education effects health awareness, which in turn makes cervical cancer screening unequal across the racial/ethnic lines of young women. The study results indicate that women of color have greater time lapses since their last cervical cancer screening. However, research also accentuates that race and awareness are not fully capable of explaining the variation of preventative screening practices among highly educated women.

Lastly, The Nurse’s Role in the Prevention of Cervical Cancer Among Underserved and Minority Populations, identified disparities in the incidence of cervical cancer and barriers that may be contributed to underserved populations. The study calls for nurses to play many roles in the prevention of cervical cancer, with a prominent one being a patient educator. There is a need to educate nurses about the risks and impact of HPV and cervical cancer, which includes education and increasing awareness.  

Discussion

Implications for More Research

The studies analyzed found that cervical cancer screening practices between vaccinated and unvaccinated participants is an area for future research using stronger study designs in order to make stronger, causal arguments about the relationship of HPV vaccination to cervical cancer screening. Overall findings from the studies could enlighten future interventions with stronger study designs aimed at tailoring messages for patients, standardizing education for providers, or both.

Implications for Practice

The prevention of health disparities and disease is, in part, contingent upon preventative medical practices and techniques. Extra efforts need to be made to educate all young women, and particularly young women of color, about HPV and cervical cancer. This may be accomplished by stressing the efficacy of screening and addressing concerns and misunderstandings of HPV vaccination and cervical cancer screening.

Limitations

The women in the sample studies may not be illustrative of the general population. There is a possibility of selection bias, whether it is with greater participation of pro-health attitudes or that of illiterate and disproportionate health knowledge. The measures for receipt and understanding of HPV vaccination and Pap screening of the studies are self-reported, and thus are subject to recall bias and reporting errors.

Conclusion

Health professionals have the competence and capacity to prevent, detect, and treat HPV and cervical cancer. Thus, chasm between the quality and quantity of medical care being delivered should no longer be a healthcare question. A paradigm shift is needed; with a multi-faceted approach including improved health care access, population-targeted outreach, language-appropriate services, and culturally competent care.

We call health professionals to work together to identify possible solutions and opportunities, as well as socio-economic patterns in healthcare barriers, which includes demographic, cultural, and health belief and behavior factors. Furthermore, intervention models need to reflect multifactorial determinants of screening utilization.

References

Alligood-Percoco, N. and J. P. Kesterson (2016). “Addressing the Barriers to Cervical Cancer Prevention Among Hispanic Women.” J Racial Ethn Health Disparities 3(3): 489-495.

Bennefield, Z. C. (2015). “Disparities in HPV and Cervical Cancer Screening Between Highly Educated White and Minority Young Women.” American Journal of Health Education 46(2): 90-98.

Jeudin, P., E. Liveright, M. G. Del Carmen and R. B. Perkins (2014). “Race, ethnicity, and income factors impacting human papillomavirus vaccination rates.” Clin Ther 36(1): 24-37.

Kasting, M. L., S. Wilson, T. W. Zollinger, B. E. Dixon, N. W. Stupiansky and G. D. Zimet (2017). “Differences in cervical cancer screening knowledge, practices, and beliefs: An examination of survey responses.” Prev Med Rep 5: 169-174.

Marlow, L. A., J. Waller and J. Wardle (2015). “Barriers to cervical cancer screening among ethnic minority women: a qualitative study.” J Fam Plann Reprod Health Care 41(4): 248-254.

Moshkovich, O., L. Lebrun-Harris, L. Makaroff, P. Chidambaran, M. Chung, A. Sripipatana and S. C. Lin (2015). “Challenges and Opportunities to Improve Cervical Cancer Screening Rates in US Health Centers through Patient-Centered Medical Home Transformation.” Adv Prev Med 2015: 182073.

Rogers, N. M. and A. G. Cantu (2009). “The nurse’s role in the prevention of cervical cancer among underserved and minority populations.” J Community Health 34(2): 135-143.

Roman, L., C. Meghea, S. Ford, L. Penner, H. Hamade, T. Estes and K. P. Williams (2014). “Individual, provider, and system risk factors for breast and cervical cancer screening among underserved Black, Latina, and Arab women.” J Womens Health (Larchmt) 23(1): 57-64.

Scarinci, I. C., F. A. Garcia, E. Kobetz, E. E. Partridge, H. M. Brandt, M. C. Bell, M. Dignan, G. X. Ma, J. L. Daye and P. E. Castle (2010). “Cervical cancer prevention: new tools and old barriers.” Cancer 116(11): 2531-2542