Low HPV Vaccination Rates in Rural Missouri Prompts YSPH Student Response
When Mary Katherine “MK” Montgomery’s work in child development was featured in a Yale School of Public Health social media post last year, a neonatologist in her Missouri hometown took notice.
After reading the story, Dr. Alan Barnette, a friend of MK’s mother, Dr. Claudia Preuschoff, who is also a pediatrician, who works in the St. Francis Healthcare System wondered if MK might use her training to help address a stubborn and serious public health dilemma.
Barnette and colleagues had identified childhood HPV vaccinations as an opportunity to improve population health after expanding St. Francis’ outpatient pediatric services. Missouri has the seventh highest HPV incidence rate in the country, yet data on vaccination rates was unavailable. So, Barnette and Preuschoff asked other pediatricians to help them survey how many eligible children had office visits, how many parents accepted the HPV vaccine and, if not, why.
The results were sobering: in a two-week survey period 90 in 194 children (about 46 percent) did not receive the vaccination. The same survey also demonstrated that while one practice has 81 percent HPV vaccination coverage, another only had 28 percent.
Armed with this data, Barnette reached out to MK and asked for help as she was beginning a class, “Developing Health a Promotion and Disease Prevention Intervention,” taught by Professor Trace Kershaw at the Yale School of Public Health.
MK pitched the project in class and was quickly joined by four other students: Sally Alsup (Social and Behavioral Sciences), Devan Carr (Social and Behavioral Sciences), Hazel Lan (Social and Behavioral Sciences) and Savanah Russ (Epidemiology of Microbial Diseases and Public Health Modeling). Savanah and Devan had worked on HPV vaccination uptake projects before and Sally is passionate about women’s reproductive rights and medically accurate sex education in schools. Hazel brought a wealth of epidemiological and statistical savvy to the team. Kershaw’s curriculum provided a framework and timeline for the project.
“Our interests converged around this project,” said MK “It was a perfect fit.”
The initial data collected by the two physicians allowed the YSPH group to look at vaccinations rates within the St. Francis Healthcare System, including four recently acquired pediatric practices in the state’s southeastern region—encompassing 6,250 square miles, 10 counties and a population of about 57,500 people under the age of 18.
The YSPH student team began by defining the problem and developing a conceptual model particular to the region to address its low vaccination rate. After administering anonymous surveys to healthcare providers and parents, two findings in particular struck the group as targets for their intervention:
- When children aged 11 to 13 get their TDAP and Meningococcal vaccines, the HPV vaccine was not being administered at comparable rates.
- There is stigma and misinformation around HPV and the vaccine which create hesitancy among some parents who, meanwhile, are comfortable having their children vaccinated for polio, chickenpox or measles.
The misinformation collected by the students included beliefs by some that there are aborted fetal cells in vaccines and suspicions that the vaccine could kill.
“These wild responses reflect what some people are believing and thinking,” MK said. “We realized our intervention and our scope was going to be so much larger than intended. We were not just tackling physician education. We’re tackling a huge amount of misinformation and knowledge gap for folks on what the disease is, what it causes — which is cancer — and what the vaccine does.”
After analyzing data and refining the conceptual model through literature reviews and community focus groups, the YSPH students narrowed the scope of their intervention to five behaviors and outcomes over which they had the greatest influence.
The team discovered that the hesitancy to vaccinate against HPV is due, in part, to sexual stigma associated with the vaccine process. “There is a fear among some parents that giving the HPV vaccine to an adolescent either implies that they are already sexually active or implicitly condones sexual activity,” said Sally, who was drawn to the project because it complements her passions for reproductive health and advocacy for comprehensive sexual education.
The intervention in Missouri aims to engage parents by emphasizing that the purpose of the HPV vaccine is to protect against cancer, in both males and females.
On the practice level, this means creating vaccine-friendly environments where everyone from the receptionist to the clinical practitioner is trained to answer questions and provide information on the vaccine’s benefits. An information postcard is also handed to all parents with kids in the 11 to 13 age group, and exam rooms also have fliers posted with QR codes to informational videos are available. Physicians are now teeing up the vaccine to be given concurrently with other vaccines given at this age and required for school enrollment.
On the community level, the group is partnering to develop social media information campaigns that target misinformation. They are also building on the very successful Pink campaign for breast cancer awareness month that the hospital runs and developing a marketing campaign that emphasizes the HPV vaccine as a cancer prevention measure rather than play into fears that the HPV vaccine will encourage sexually risky behavior by their children.
To reach kids in the community directly, the YSPH students partnered with the principal of a large Catholic high school that many teens in the region attend. He welcomed MK, an alumna of the high school, back to pitch the idea of a focus group with the kids in two advanced biology classes. Spending her recent spring break there, she gathered valuable input on materials that young people found interesting and would pay attention to. In turn, the local high school students will, hopefully, create a social media campaign tailored to other kids their age. There’s some evidence to suggest that young people are promoting HPV vaccination amongst themselves. “Those conversations are helping parents, friends and younger siblings in a way we want to capture,” MK said.
Devan, meanwhile, is particularly passionate about addressing low HPV vaccine rates because it demonstrates a failure to communicate effectively. “I feel very lucky to have been vaccinated for HPV as a child. However, many of my friends and peers are now suffering from preventable conditions due to parental vaccine hesitancy. These misconceptions will continue to impact our communities, and our cancer rates, until we learn how to better navigate our relationship with vaccines and sexual health.”
As the spring semester comes to an end, the five-woman team of MPH candidates is finalizing its implementation plan and presenting it to their various partners. Because the project was initiated by the community itself, they are confident that this foundational work will sustain HPV vaccination education and improve vaccine coverage in the region.
“Our pediatric providers and administrators have welcomed the collaboration with the Yale students,” said Barnette. “The magnitude of the public fear concerning the safety of the HPV vaccine was greater than we initially suspected. The Yale group’s design, collection and analysis of community attitudes toward the HPV vaccine is vital to success of our interventions.”
This class project balanced the needs of both community partners and the educational competencies requirements of the course, said Kershaw. “These students did something really special and unique. They tackled a complex public health issue and made a discernible improvement. This is what the Yale School of Public Health is all about.”