Pediatricians in Appalachia are less likely than doctors in other areas to encourage parents to have their children receive the human papillomavirus (HPV) vaccine, according to a new study. The results are alarming because HPV infection is the most important risk factor for cervical cancer -- and studies show that Appalachian women are more likely to get cervical cancer and to die from it than women living elsewhere.
"We found that pediatricians in Appalachia were less likely than others to think their patients were even susceptible to HPV," said Janice Krieger, lead author of the study and assistant professor of communication at Ohio State University.
"That's a huge problem. If pediatricians in Appalachia don't think HPV infection is an issue for their patients -- when we know that it is -- it is going to be difficult to convince women to get the HPV vaccine for themselves or their children."
HPV is the most common sexually transmitted infection and will infect about half of sexually active people in the United States during their lifetimes. HPV causes about 70 percent of cervical cancer cases, which can be deadly, especially in Appalachia. The cervical cancer mortality rates for women living in Appalachia Ohio were 41.7 percent greater than non-Appalachia Ohio from 2000 to 2004.
If Appalachian women are not getting the information they need about HPV from pediatricians, they aren't getting it from their local newspapers either. In a separate study, Krieger and her colleagues found that newspapers published in Appalachia contained fewer articles than papers outside the region about the threat of cervical cancer and the efficacy of the HPV vaccine.
"The results of these two studies suggest that women in Appalachia, who are at higher risk for cervical cancer, are less likely than others to have the information they need to make informed decisions about the HPV vaccine," Krieger said.
The study of pediatricians appears online in the journal Women's Health Issues and will be published in a future print edition.
In this study, Krieger and her colleagues surveyed 334 pediatricians in Appalachian and non-Appalachian areas of Kentucky and West Virginia.
The results showed that those pediatricians serving Appalachian areas were less likely to say they encouraged their patients to receive the vaccine, and were less likely to say their patients were susceptible to HPV.
One key reason may be the pediatricians in Appalachia were less likely than others to say that they would be comfortable talking to the parents of their patients about the importance of the HPV vaccine, Krieger said.
"The fact that HPV is sexually transmitted makes it a difficult subject to bring up. Other studies have shown that is especially true in small towns and rural areas where parents may be concerned about community gossip," she said.
"Pediatricians may be recommending the vaccine less often because they are worried about offending parents of their patients."
These results suggest that more needs to be done to provide training and encouragement to pediatricians working in Appalachia, she said.
"We don't do enough to help physicians understand the risks their patients face from cervical cancer. And we need to help them develop strategies for discussing the vaccine, especially if they think a parent might be resistant," she said.
The second study, about media coverage of cervical cancer and the HPV vaccine, appears online in the journal Health Expectations, and will be published in a future print edition.
Krieger said she and her colleagues conducted this study because people rely on the media as an important source of health information, and the researchers wanted to know what Appalachian residents were learning about the HPV vaccine.
The researchers did a content analysis of all 121 articles about cervical cancer and the HPV vaccine published in Ohio newspapers during 2006. They compared the 42 articles published in Appalachia areas of Ohio with the 79 articles in non-Appalachian regions of the state.
"We found that the articles published in the Appalachia region tended to lack vital information that could help promote use of the HPV vaccine," Krieger said.
For example, 46 percent of the articles in non-Appalachian newspapers mentioned that the HPV vaccine can prevent cervical cancer, compared to only 17 percent of the articles in Appalachian papers.
While the cost of the HPV vaccine is a major concern in poor areas of Appalachia, only 2 percent of the articles in the region mentioned that financial assistance was available to pay for the vaccine, compared to 22 percent of the articles outside the area.
Krieger said the Appalachian newspapers in this study were smaller papers with significantly lower circulation rates than papers in other areas.
"These newspapers may not have the resources of their larger counterparts to conduct in-depth health reporting or purchase wire stories," she said.
But other reasons for the lack of coverage probably centered on local cultural norms. Because of the link between HPV and sexual activity, many newspapers may have been reluctant to bring up the issue.
"We contacted staff from several newspapers in Appalachia and we were told that their readers didn't want this type of information," Krieger said.
Overall, the two studies show that women in Appalachia may be less likely than others to learn about the HPV vaccine and its link to cervical cancer from either the local media or their pediatricians, she said.
The pediatrician study received funding from the National Cancer Institute, and the Ohio State Comprehensive Cancer Center. Co-authors were Mira Katz, associate professor of health behavior and health promotion at Ohio State; Jennifer Kam, assistant professor at the University of Illinois; and Anthony Roberto, associate professor at Arizona State University.
Co-authors of the media coverage study were Katz; Dana Eisenberg, Sarah Heaner, Melanie Sarge and Parul Jain, all current or former graduate students at Ohio State.
- Janice L. Krieger, Mira L. Katz, Jennifer A. Kam, Anthony Roberto. Appalachian and Non-Appalachian Pediatricians’ Encouragement of the Human Papillomavirus Vaccine: Implications for Health Disparities. Women's Health Issues, 2011; DOI: 10.1016/j.whi.2011.07.005
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