Objective-Previous intervention research conducted in Appalachian Kentucky resulted in extremely low uptake and adherence to the human papillomavirus (HPV) vaccine among women ages 18 -26, despite provision of free vaccine. Because of these findings, the purpose of this qualitative, follow-up study was to elicit health care providers' perspectives on barriers and facilitators to HPV vaccination and suggested strategies for improving vaccination rates.Design and Sample-Researchers conducted semi-structured qualitative interviews with a purposive sample of eight health care providers (seven nursing professionals, one physician) at the health clinic where the original HPV vaccination intervention took place. Interviews were audiorecorded and transcribed and authors used a constant-comparative method to analyze the data.Results-Significant themes emerged from the interviews, centering around two primary issues: vaccine uptake and vaccine adherence. Related to uptake, health care providers identified perceived patient barriers and inadequate HPV vaccine education. They also identified the vaccine schedule and clinic-centered communication deficiencies as adherence-related barriers. Conclusion-TheseAppalachian Kentucky health care providers provided important insights into barriers and facilitators to HPV vaccine uptake and adherence that need to be readily addressed in this community. As informed by these providers, several suggestions for improving HPV vaccination, such as more targeted education efforts and patient-centered reminder systems, may be applicable to other nursing professionals working in rural and medically underserved communities. HHS Public Access Author Manuscript Author ManuscriptAuthor Manuscript Author ManuscriptUptake and adherence to the three-dose human papillomavirus (HPV) vaccine remains low, which is particularly concerning for communities that shoulder an excessive burden of cervical cancer and have limited access to health care, such as Appalachian Kentucky. A previous intervention study conducted in this geographic region revealed low HPV vaccination rates among young women ages 18-26, despite waiving the cost of the vaccine series. The current study serves as a qualitative follow-up to this previous intervention research, seeking to understand health care providers' perspectives on actual barriers and facilitators to HPV vaccination and garnering strategies for improving vaccination rates in this region.

IntroductionFew studies have assessed barriers to human papillomavirus (HPV) vaccination uptake and adherence, particularly among women of Appalachian Kentucky, a population with higher rates of cervical cancer, lower rates of HPV vaccination, and lower socioeconomic status compared with the rest of the nation. The objective of this study was to address women’s reasons for declining the HPV vaccine and, among women who initiated the vaccine series, barriers to completion of the 3-dose regimen.MethodsWe recruited 17 women aged 18 to 26 from a Federally Qualified Health Center who participated in in-depth, semistructured telephone interviews. All interviews were audio-recorded and transcribed verbatim; analysis of the interview transcripts was an iterative process conducted by all 3 authors.ResultsWe identified 3 primary barriers: 1) a knowledge gap wherein women are both uninformed and misinformed about cervical cancer, HPV, and the HPV vaccine, all of which affect vaccination behaviors; 2) environmental and tangible barriers (transportation and prioritizing health over other responsibilities such as child care, work, and school); and 3) ambiguous information sources, which contribute to misinformation and subsequently affect vaccination decisions.ConclusionHealth professionals should use clear and purposeful communication about how cervical cancer develops, the purpose and safety of the HPV vaccine, and the necessity of completing the 3-dose series. Health promotion campaigns and services tailored for young women in Appalachian Kentucky that focus on increasing knowledge and eliminating barriers are needed.

Objective Compare the characteristics of rural and urban callers to NCI’s Cancer Information Service (CIS), and explore the association of geographic location and discussion of cancer clinical trials. Methods Using CIS call data from 2006–2008, we assigned a rural or urban designation to caller ZIP codes using Rural-Urban Commuting Area Codes. Calls which discussed clinical trials were analyzed using univariate and multivariate analyses. Results The CIS received 227,579 calls from 2006–2008 where geographic location could be determined. Overall, 10.3% of calls included a discussion of clinical trials; there were significantly more discussions among urban dwellers than rural individuals (10.5% vs. 9.4%, respectively). Multivariate regression analyses supported the univariate findings. In addition, compared to other callers, patients (OR 5.58 [95% CI: 4.88,6.39]) and family and friends (6.26 [5.48,71.5]) were significantly more likely to discuss clinical trials. Conclusion Urban callers were more likely than their rural counterparts to discuss cancer treatment trials, placing individuals living in rural areas at a disadvantage in learning about and communicating with their providers about possible participation in clinical trials. Practice implications Through its multiple access points, the CIS can serve as an important source of clinical trials information for rural cancer patients, family members, and providers.

Purpose-To explore whether sexually related behaviors predict refusal of the human papillomavirus (HPV) vaccine among a sample of women aged 18-26 in Appalachian Kentucky.Methods-Using a convenience sample, young women attending health clinics and a community college in southeastern Kentucky were recruited to participate in a Women's Health Study. After completing a questionnaire, women received a free voucher for the three-dose HPV vaccine series. Completion of dose one served as the outcome variable.Results-Women with a history of an abnormal Pap test were almost two times more likely to decline the HPV vaccine (adjusted odds ratio [AOR] 1.91, 95% confidence interval [CI] 1.14-3.20, p = 0.015), and women who reported they had never had a Pap test were four times more likely to decline the vaccine (AOR 4.02, 95% CI 1.13-14.32, p = 0.032). Women engaging in mutual masturbation were nearly two times more likely to decline the free vaccine (AOR 1.91, 95% CI 1.17-3.10, p = 0.009). Use of hormonal birth control showed a protective effect against refusal of the free HPV vaccine (AOR 0.593, 95% CI 0.44-0.80, p = 0.001).Conclusions-Among this sample of Appalachian women, those engaging in behaviors that increase their risk for HPV infection were more likely to refuse the vaccine. Conversely, those women engaging in protective health behaviors were more likely to accept the vaccine. These findings suggest that those women not being vaccinated may be the very group most likely to benefit from vaccination. Cervical cancer prevention programs need to be creative in efforts to reach young women most in need of the vaccine based on a higher profile of sexually related behaviors and the proxy measure of this risk (having an abnormal Pap test result).