Women perceiving 1-2-3 Pap intervention as
personally relevant and effective follow the HPV
vaccination regimen
141st APHA Annual Meeting ∙ November 2013
Elisia L. Cohen, Robin C. Vanderpool, Katharine Head,
Tom Collins, Wallace Bates, Grace Jones, Nebraska
Jones, Pamela Stamper, Richard Crosby*
This presentation is supported by Cooperative Agreement Number 1U48DP001932-01 from the Centers for
Disease Control and Prevention (CDC). The findings and conclusions in this presentation are those of the
authors and do not necessarily represent the official position of the CDC.
Presenter Disclosures
Richard A. Crosby
(1) The following personal financial relationships with
commercial interests relevant to this presentation
existed during the past 12 months:
Drs. Crosby and Cohen have received support from the Merck
Investigator Initiated Sponsored Program.
UK Rural Cancer Prevention Center
UK Rural Cancer Prevention Center
The Rural Cancer Prevention Center (RCPC) is a planned
collaboration of community members, public health
professionals, and researchers designed to reduce health
disparities associated with cervical, breast, and colorectal cancer
among residents of the Kentucky River Health District in
Appalachian Kentucky.
HPV Vaccination Rates for 2010
(Time of Intervention)
• Two available HPV vaccines: Gardasil and Cervarix
• Adolescents ages 13-171
• ≥1 dose 48.7% nationally, 40.1% in Kentucky
• ≥3 doses 32% nationally, 27.3% in Kentucky
• Adult women ages 19-26
• ≥ 1 dose 20.7% nationally2
1Dorell,
C., Stokley, S., Yankey, D., & Markowitz, L. (2011). National and State Vaccination Coverage Among Adolescents
Aged 13 Through 17 Years- United States, 2010. Morbidity and Mortality Weekly Report, 60(33), 1117-1123.
2CDC. (2012). Adult Vaccination Coverage-United States, 2010. Morbidity and Mortality Weekly Report, 61(4), 66-72.
Message Development and Testing
• 87 in-depth interviews with college students aged 18-26 who were
HPV vaccine early adopters and non-adopters
• 5 small-group focus group discussions drew participants who had
resided within our Appalachian Kentucky catchment areas within the
past year; these young adult women were eligible if they reported
having one dose of the HPV vaccine, were 18-26, and from clinical,
community college, and university settings.
• “engaged elicitation” approach to message testing
Message Development and Testing
• Findings: Problem of non-adopters
•
•
•
•
•
•
Don’t know a lot about HPV/HPV vaccine
Suspicious of drug companies
Suspicious of vaccine novelty
Vaccine pain fears/worry
Privacy concerns (for both vaccine and Pap)
Belief that they’d have to “start over” if they missed 1 dose
• Findings: Problem of adherence
•
•
•
•
Not knowing benefits of all 3 doses
Lack of vaccine/HPV knowledge
Myths about “starting over”/not being able to get the next dose after missed dosage
Obstacles: significant others (why do you need an STD vaccine?), transportation, time, $
• Promising message development areas:
•
•
•
•
Positive value in “staying on top of” reproductive health
Disparity frame for EKY risk: “important statistics”
18 years old+: the vaccine/pap is no one’s business but their own… “I gotta look out for myself”
Survivor knowledge: “New opportunity” for my generation
1-2-3 Pap Intervention
In order to promote doses 2 and 3, community advisory board
members suggested a visual- and audio-based educational program
with local “actors” to increase the salience of the health messages.
Based on message testing with young adult women from eastern
Kentucky, the RCPC partnered with the UK Department of
Communication to develop a 12 minute DVD.
1-2-3 Pap
The Rural Cancer Prevention Center (RCPC) initiated a two-stage HPV
vaccine promotion program for young women residing in rural
Appalachia.
Stage 1 = social marketing and diffusion study
Stage 2 = DVD-based intervention (randomized control trial)
1-2-3 Pap DVD
The DVD features 3 young women from eastern Kentucky, 2 local female healthcare providers
(a nurse practitioner and a physician), and a female television reporter from the regional
news station.
The primary messages of the DVD include efforts to increase self-efficacy for follow-up
vaccination through modeling (& scripts), understanding the value of the HPV vaccine,
emphasize the importance of all 3 doses, and understanding the importance of Pap testing.
After receiving dose 1, women are randomized to watch the DVD or receive standard of care
and subsequently followed to monitor uptake of doses 2 and 3.
Ultimate Goal = HPV Vaccination!
Table 1. 1-2-3 Pap Segment Outline
Theme
Script exemplar
Local TV anchor and KY Cancer Control Specialist indicates “Women in Eastern KY are 40% more likely to die from
cervical cancer than elsewhere in the United States.”
1
1-2-3 Pap is a special project designed to reduce
cancer disparities among young adult women from
Eastern Kentucky.
HPV is a common disease
2
The HPV vaccine is effective
3
Granddaughter/grandmother narrative about cervical
cancer
The benefits of vaccination and Pap testing
overwhelm the short-term consequences of each
Graphics and Nurse explaining: The HPV vaccine can protect women against the types of HPV that cause 70% of
cervical cancers.
Tommi, a young women from E. KY who lost her grandmother to cervical cancer, explains that the vaccine is a novel
opportunity for her generation.
Nurse describes how the pain of a vaccine or the slight discomfort from a Pap test can prevent a lot of pain later, and
even save women’s lives
Opening
4
5
1-2-3 Pap; reminder of vaccine and Pap schedule
6
Overcoming stigma associated with HPV vaccination
7
1-2-3 Pap; remember to schedule your Pap test
8
9
A Pap test is private and routinely conducted by
medical professionals
1-2-3 Pap; overcoming obstacles to vaccination
10
1-2-3 Pap; scheduling efficacy
Closing
RCPC information and cues to action
Nurse explains “many women who get cervical cancer when they are older, likely got HPV in their teens or 20s.”
Nurse narrates over graphics and pictures of a young adult receiving a vaccine that 3 shots in addition to regular Pap
testing provides fullest protection against cervical cancer.
Young adult women from EKY explain how to talk to others who may question the need for a vaccine; women can
remind their partners that all three doses of the vaccine compared with regular pap-tests will help women take care of
their body and reproductive health for the long term.
Graphics showing schedule and Nurse suggests after women get their three doses of the HPV vaccine, “if you have not
scheduled a pelvic exam and Pap tests that you should!”
The segment explains a Pap test and shows the tools used by medical professionals in the process.
Young women from EKY describe the hurdles that women may face in getting all three doses of the vaccine. These
segments describe how women may keep their decision (to vaccinate/get a Pap test) private, how they can talk openly
with their loved ones about how HPV can be spread through skin-to-skin contact; how the safe and effective vaccine
can protect against this common virus; and how the benefits of the HPV vaccine outweigh the pain.
Young women from EKY remind the viewer that they should think through how, where and when they can follow up
by scheduling their next vaccination today.
Local TV anchor and KY Cancer Control Specialist thanks participants and reminds them to schedule their next HPV
vaccines and Pap tests by calling the 1-888 (toll-free) number listed on the screen.
Study Enrollment
• From July 2010 until December 2011, 344 young women, ages 18-26,
received dose 1 of the HPV vaccine as a result of outreach and social
marketing efforts in the KY River District.
• Of these women 155 completed pre- and post-test surveys, and
women’s completion of the HPV vaccine schedule was evaluated
Preliminary Findings
Percent of Sample
Lived in southeastern Kentucky more than 5 years
90%
Age
Mean = 21.99 (SD 2.4)
Caucasian
96%
Some college
48%
Married
30%
Children at home
39%
Ever abnormal Pap test result
47.9%
Not using birth control
49.3%
Never had a Pap test
10.8%
Sexually experienced
93.9%
Lifetime partners
Mean = 4.7 (SD 7.2)
Evaluation of the DVD’s perceived message
effectiveness was evaluated with an additive scale
demonstrating high reliability (.94).
•
•
•
•
•
•
•
•
•
•
•
Video kept attention
Video was believable
Liked the video
Identified with women*
Video was credible
Relevant to my own life*
Gave me info or ideas
Skills I can use
Info that fits needs
Made for women like me*
Convince other women
Principle Component Analysis Revealed a
Single Solution
Component Matrixa
Video Kept Attention
Video was believable
Liked the video
Identified with women
Video was credible
Relevant to my own life
Gave me info or ideas
Skills I can use
Info that fits needs
Made for women like me
.829
.867
.847
.671
.845
.744
.865
.879
.849
.846
Convince other women
.725
Extraction Method: Principal Component Analysis.
a.
b.
1 components extracted.
* = components of a personal relevance
Perceived Message Effectiveness was Correlated with
Intentions to Receive 3 Doses of HPV Vaccination
Correlations
Women who perceived the video as more
effective (and personally relevant) are
significantly more likely to intend to complete
the HPV vaccine series (receive dose 3) (p
<.05).
How likely 3rd dose
Video Kept Attention
Pearson Correlation
.435**
Sig. (2-tailed)
0
N
Video was believable
Pearson Correlation
153
.519**
Sig. (2-tailed)
0
N
Liked the video
Pearson Correlation
154
.374**
Sig. (2-tailed)
0
N
Identified with women
Pearson Correlation
153
.213**
Sig. (2-tailed)
0.008
N
Video was credible
Pearson Correlation
153
.569**
Sig. (2-tailed)
0
N
Relevant to my own life
Pearson Correlation
155
.273**
Sig. (2-tailed)
0.001
N
Gave me info or ideas
Pearson Correlation
154
.480**
Sig. (2-tailed)
0
N
Skills I can use
Pearson Correlation
154
.346**
Sig. (2-tailed)
0
N
Info that fits needs
Pearson Correlation
155
.352**
Sig. (2-tailed)
0
N
Made for women like me
Pearson Correlation
Sig. (2-tailed)
N
** Correlation is significant at the 0.01 level (2-tailed).
154
.339**
0
155
Findings
•
Women who perceived the video as effective were also
significantly more likely to complete the vaccination series (p <.05) .
•
This finding is consistent with data previously reported by
Vanderpool et al (2013), the DVD intervention may have created a
significantly (P = .003) greater return rate for series completion
(43.3%) compared to the rate observed for women randomized to the
control condition (31.9%) (Relative difference 35.7%). Women
aassigned to the intervention were 2.44 times more likely than
women in the usual care group to complete the series.
Future research
• The 1-2-3 Pap intervention demonstrates that a locally-tailored, highfidelity video intervention can be effectively developed and culturallytailored to improve HPV vaccine series completion.
• We are now testing the dissemination and implementation of this
video in other populations (e.g., KY statewide, WV, and NC)
Questions?
Thank you!
Rick.crosby@uky.edu