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.
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.
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.
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