A Fresh Perspective:
Improving Indiana’s HPV Vaccination Rates
Indiana Rural Health Association
Annual Conference
June 15, 2012
Today’s Panel
Moderator
Deborah Stiffler, PhD, RN, CNM
Associate Professor of Nursing, IU School of Nursing
IRHA Board Member
Indiana Immunization Coalition, Inc.
Sarah Strawbridge, MSM, CHES, Executive Director
Kristopher Kirby, BS, Operations Coordinator
ISDH Breast & Cervical Cancer Program
Erin Triplett, MPH, Director, Early Detection Programs/Chronic Disease Division
IU National Center of Excellence in Women’s Health
Tina Darling, BS, former Associate Director
Lynn Baldwin, MSN, RN, WHNP-BC, former WOW Bus Coordinator
Goal: Eradicate Cervical Cancer in Indiana
• Overview/explanation of how improving
Indiana’s HPV vaccination rates directly relates
to cervical cancer prevention.
• Efforts of IIC and ISDH BCCP
• Efforts of IU CoE
Goals for Clay County Project
• To improve the health of all Indiana women, starting with a targeted
cervical cancer education/awareness intervention pilot project for the
women of Clay County.
• To show that such an intervention in Clay County will increase the number
of women utilizing preventive health care services, such as Pap smear
screening, thereby improving their morbidity and mortality risk.
• If successful, take the model used in Clay County and replicate it
elsewhere in the state , for cervical cancer or other disease states, either
in individual counties or by region, depending on the community in need.
• By including health professions students in this outreach, increase the
number of new graduates who decide to practice in rural Indiana.
What is HPV?
• HPV = Human Papillomavirus
– Group of more than 150 related viruses
– “papillomavirus” refers to the fact that certain
types of HPV may cause papillomas, or warts,
which are benign tumors
• There are more than 100 types of HPV
– More than 30 types can be transmitted through
sexual contact
HPV and Cervical Cancer
• According to the National Cancer Institute, there
are more than 6 million new genital HPV
infections each year. HPV is the most commonly
transmitted STI.
• Almost all women will have an HPV infection at
some point, but very few will develop cervical
cancer
• Virtually all cervical cancers are caused by HPV
infections, with just two HPV types (16, 18)
responsible for about 70% of all cases.
Vaccination Guidelines
• 47th
• 3 doses over 6 months
• Cervarix and Gardasil
– Two brands of HPV vaccine
– Best to receive all 3 doses from the same brand
• Most effective when given before young
adolescents and young adults become touchy
feely or have sexual contact with his or her
first partner
Vaccination Guidelines cont.
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Cervarix only for girls
– 11 or 12 years of age - may be given starting at age 9
Gardasil for both males and females
– 11 or 12 years of age - may be given starting at age 9
Catch-Up Schedule (for those who have not completed the 3-dose series)
– Cervarix
• Girls and women 13 through 26 years of age who did not get all 3 doses
when they were younger
– Gardasil
• Females 13 through 26 years of age
• Males 13 through 21 years of age
• May be given to men 22 through 26 years of age who have not completed
the 3-dose series
3 Dose Series*
– 1st Dose - 11 or 12 years of age
– 2nd Dose – 1 to 2 months after Dose 1
– 3rd Dose - 6 months after Dose 1
– *Additional (booster) doses are not recommended.
HPV vaccine may be given at the same time as other vaccines
Centers for Disease Control and Prevention, http://www.cdc.gov/vaccines/pubs/vis/default.htm
Referrals
• 3 Doses of the HPV vaccine AND regular
screenings can prevent cervical cancer
• No symptoms and can pass without even
knowing it
• Where to go?
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Health Care Provider
CHC/FQHC or Rural Health Clinic
Local Health Department
Little Red Door and Planned Parenthood
Indiana Family Health Council, Inc.
Economic Impact of HPV on Hoosiers
• $3,400,000,000 is spent annually on diagnosis and
treatment of HPV infection and its associated cervical
diseases.
• Women 20-29 years of age incur annual cost of
$51, 863 per 1000 women.
• Estimated lifetime total medical cost of HPV infection
for men and women aged 15-24 is $2,900,000,000
(Source: Reducing the Health Burden of HPV Infection Through Vaccination, David Soper, Department of Obstetrics and Gynecology, Medical University of
South Carolina, Charleston, SC 29425)
Economic Impact of HPV on Hoosiers
• Kristen Forbes’ Family Experience
– Kristen’s Story
– $380,000 in just one year of cervical cancer
treatment
• HPV is the second most expensive STI after
HIV
Contact Info
ISDH Breast & Cervical Cancer Program
Erin Triplett, MPH, Director
Early Detection Programs/Chronic Disease Division
etriplett@isdh.in.gov
317-233-7901
Indiana Immunization Coalition, Inc.
Sarah Strawbridge, MSM, CHES, Executive Director
director@vaccinateindiana.org
317-628-7116
Kristopher Kirby, BS, Operations Coordinator
kkirby@vaccinateindiana.org
765-586-0249
Why Clay County?
• In 2008, BRFSS showed only 57% of county’s
estimated 15,595 women had received a Pap
smear in the previous three years.
Source: 2008 Behavioral Risk Factor Surveillance System sponsored by the Centers for Disease Control and Prevention.
• Falls within the state’s Health Professions
Shortage Area (HPSA).
Source: Bureau of Health Professions, HHS, 2007.
• Close proximity to regional health services and
health professions students (IUSM, ISU) in Terre
Haute.
• St. Vincent health system presence in Brazil.
Focus Groups and
Key Informant Interviews
• Engage in “friend-making” in the county
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James Buechler, MD, Lugar Center for Rural Health
Peggy Davis, Purdue Extension
Deb Plummer, YMCA of Clay County
Mary Yelton, Clay County schools
Clay City Center for Family Medicine
Andrea Baysinger, St. Vincent Clay
• Identified key gathering places for women
• Identified county leaders for KII’s
• Hired independent consultant to conduct
Results
• Major Health Problems?
– Cancer (“Everyone seems to have cancer.”), fibromyalgia,
heart disease, diabetes, osteoporosis, depression,
obesity.
• Barriers to Care & Screening?
– Time, cost, access, denial and “family first.”
“When in poverty, there is no prevention as people live day by day.
Prevention is off their radar. They deal with other issues and don’t deal
with what they don’t see. “
“Women put themselves last in relation to health. They take care of
others first, it’s their natural instinct.”
Results
• Organization of Services?
– Lack of specialists, especially Ob/Gyn (must leave
county for specialty services)
– Limited hours
– “They [services] have limited hours and you have to go early or you
may not get seen.”
– Trust and Fear
“…being afraid of finding out something bad.”
“You can’t rely on providers. They don’t give all give feedback after tests.
If it’s bad they tell you, but maybe not if it’s okay. They tend not to give
specific values on the tests.”
Results
• Community and Policy Issues?
– Low income = low expectations for health care
– Lack of insurance
“ [Employers] schedule workers so that they don’t work enough hours
to qualify for health insurance.”
– Limited social services to meet need
– Illegal drug culture = isolation, interferes with
accessing care
– Smoking ban – tried without success
“It’s removing personal rights. We need it, but there’s lots of resistance.”
– Limited, if any, public transportation
Conclusions
1) Even though cervical cancer not specifically
identified as a problem by leaders and focus
groups, we “followed the data” that said
otherwise.
2) EDUCATE!
3) EDUCATE!
4) EDUCATE!
“Need education. The community needs to be inundated with
information through various avenues.”
Quotes
“There needs to be more education on it. . . some women just
don’t know about those things.”
“Education about the [program] needs to get out into the
community. Mobile unit is good for this community, especially
one from an outside entity – a positive.”
“Women like to be part of a group that reaches out.”
“It depends on how you are brought up. My mom did it, so I do
too. “
Take our show on the road!
• WOW Bus = Women’s Wellness on Wheels
• Formerly the MOM Mobile/IU School of
Nursing
The WOW Bus!
How the WOW Bus Works
• Classroom with large screen TV & DVD player
• 2 private assessment rooms for consultation
• 2 private desks
WoW Bus Education & Screening
• Women would first watch a 10 minute DVD about
Cervical Cancer and HPV
• Private consultation with health professional student
– Biometric screening including blood pressure, blood
glucose, height, weight, BMI
– Complete health assessment with student. Questions
included:
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Demographics – age, BMI, health care coverage
Health Prevention – current on screenings?
Health Behaviors – diet, exercise, smoking, drug use
Risk Factors – domestic violence, depression, sexual behaviors
Education
• DVD
– Primarily used “Genital Warts and Cervical Cancer:
The Woman’s Side”
http://www.creativehealthcommunications.com
– Also used web-based, interactive tutorial: “Pap
Smear” by MedlinePlus
http://www.nlm.nih.gov/medlineplus/tutorials/papsmear/htm/index.htm
Education
• Individualized education based on answers to
assessment questions on iPads (data collected)
• Gift bag included educational handouts:
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Cervical Cancer & HPV
Breast Cancer
Smoking Cessation
Diet & Exercise
Diabetes
Heart Health
Mental Health
Osteoporosis
Colon Cancer
Education
– Centers for Disease Control and Prevention,
http://www.cdc.gov
– Central Indiana Affiliate – Susan G. Komen for the
Cure, http://www.komenindy.org
– Merck – produces the Gardasil vaccine
– National Cancer Institute, http://www.cancer.gov
– Office of Women’s Health, DHHS
http://www.womenshealth.gov
– U.S. Preventive Services Task Force
Resources
• Goal was to connect women to resources &
services within their own community:
– Breast & Cervical Cancer Program (BCCP)
– Clay County Health Department
– Crisis Pregnancy Center
– Health care providers in Clay County
– Planned Parenthood of Terre Haute
– Weight Watchers
Barriers
• The screening took 20-30 minutes to complete
• Childcare – limited space and personnel on
the bus to watch children & keep them
occupied
• Up to date on health screenings or desired
other screenings
• Unsure of purpose of bus when driving or
walking by
Schedule the WoW Bus
Tisha Reid, Associate Director
IU National Center of Excellence in Women’s Health
Phone: 317-948-3315
Email: iucoe@iupui.edu
Results from iPad Surveys
• A total of 101 women seen/surveyed
• Ages 18-60+ (18 was minimum age to
participate in screenings)
What age range best represents your age?
What was your BMI today?
Averages
• Average weight was 171.73
– Lowest 97.6
– Highest 290.4
• Average BMI was 28.9
– Lowest 16.9
– Highest 46.6
– BMI
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< 25 normal
25-29.9 overweight
>30 obese
>40 is morbidly obese
Other Screenings
• Random Blood Sugar
– Average blood sugar was 98.76 ( normal is 70-140
mg/dl)
• Lowest was 62
• Highest 184
• Blood Pressure
– Average 127/76
• Highest systolic 163
• Highest diastolic 106
Depression Screen
• Used the PHQ-9 screen
– 5 women answered positively on our survey and
were asked to complete the PHQ-9
• Scores 9, 12, 14, 20, 21
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5-9 minimal symptoms
10-14 minor depression, dysthymia, or mild major depression
15-19 major depression, moderately severe
>20 major depression, severe
Thinking about your mental health, such as stress, depression,
and problems with emotions, during the past 30 days was there
a time when your mental health was not good?
How many days was your mental
health not good?
If you have been unable to see your healthcare
provider, what was the reason?
How long has it been since you have
seen your healthcare provider?
A mammogram is an x-ray of your breast. Have
you ever had a mammogram?
When was the last time that you had a
mammogram?
A Pap test is a test for cancer of the cervix. Have
you ever had a Pap test?
When was the last time that you had a Pap test?
Strategies to Improve HPV Vaccination
• As a provider, make a strong recommendation for the HPV vaccine
– If a parent declines a vaccine, ask why and document in the chart. This
can reinforce offering again at follow-up visits.
– Make adolescent vaccination a priority
• 2012 HEDIS measures
– Adolescents 13 years of age should have received 1 dose of Tdap, 1
dose of meningococcal conjugate, and 3 doses of HPV (females only)
by their 13th birthday
• Create a SOP to check the vaccination status of your adolescent patients at
every visit, even acute care visits
• Encourage parents/guardians to schedule the next (two) dose(s) of HPV
before leaving the office
• Send reminder/recall notices to parents
• Report vaccines that are administered within CHIRP (Indiana’s
immunization registry)
Strategies to Improve HPV Vaccination
cont.
• Work with local schools to promote
adolescent immunization
– Provide educational materials that can be
disseminated to parents
– Conducting ‘back-to-school’ vaccination clinics, all
recommended vaccines should be offered, not
just the vaccines that are required for school entry
– Identify school-based heath centers in your area
• Connect with public health system partners
Thank You!
Questions?