Barriers to Health Equity in Human Papillomavirus Vaccination and Cervical Cancer Prevention

Abstract

Introduction Despite the availability of an effective human papillomavirus (HPV) vaccine and early screening, detection, and treatment, cervical cancer remains one of the leading causes of cancer death among women around the world. Previous research concerning barriers to primary and secondary prevention of cervical cancer have emphasized geographic region as a primary determinant of access to prevention services, with divisions by country income level as the dominant determinant. Much of the research focusing on access and utilization of HPV vaccination has been largely centered in high income countries (HIC) like the United States (US), where research examining barriers to cervical cancer screening have been focused in low-and-middle-income countries (LMICs). Universal healthcare and established healthcare institutions are common in HICs, and so access to HPV vaccinations and cervical cancer screenings are available, minimizing the burden of cervical cancer in those settings. LMICs, on the other hand, often lack resources required for routine organized cervical cancer screening and HPV vaccination is often unavailable or inaccessible. These differences in the availability of healthcare and human resources also serve to strengthen the divide observed in the literature for cervical cancer by country income. This division has led to a skewed perception concerning the progress that has been made toward minimizing the significant cervical cancer burden carried by women living in many LMICs. The overall aim of this dissertation is to broadly describe the context of cervical cancer prevention and control globally, with a focus on the US, sub-Saharan Africa, and Nigeria, while highlighting successes in maximizing access to primary and secondary prevention of the disease and identifying areas needing additional research. MethodsAim 1. A secondary database analysis examining the association between nativity status and HPV vaccination in the United States was conducted to provide further insight into the determinants of vaccine uptake within an underserved population living within the US. Aim 2. A systematic scoping review was conducted to describe the use of community engaged practices that have been used for cervical cancer prevention and control in sub-Saharan Africa. Aim 3. A longitudinal analysis of cervical cancer screening trends in Nigeria was carried out to describe changes in patient characteristics, screening uptake, and screening outcomes over time for women screened for cervical cancer at a tertiary healthcare facility in Nigeria. ResultsAim 1. The findings of our analysis of a nationally representative dataset demonstrate that foreign-born US residents do not differ from native-born US residents in rates of HPV vaccine initiation or completion, though Black immigrants who were age-eligible for vaccination did have higher odds of vaccine initiation than non-Hispanic White natives. Aim 2. We identified that community engagement has been used to improve knowledge about cervical cancer and prevention in several countries in sub-Saharan Africa. Researchers who intentionally leveraged existing trusted community organizations and community leaders in the conduct of research and the dissemination of research findings found success in increasing knowledge about the impact of cervical cancer on those communities and identified effective methods for prevention efforts in the future. Aim 3. We determined that most of the women screened for cervical cancer at Jos University Teaching Hospital (JUTH) were predominantly Christian, and their average age at first screening was 38-years. Most women had a normal first pap smear, but we found that the likelihood of repeated screening after a normal screening decreased annually. Discussion Aim 1. The conclusions we draw from this study are different from those of previous research conducted using different databases, highlighting the need for further research into the specific aspects of nativity status that influence vaccine uptake. Efforts to ensure vaccination among foreign-born US residents should continue. Aim 2. The reported successful use of community-engaged research practices illustrates that this approach to cervical cancer prevention and control can be effective in increasing the sustainability of cancer prevention efforts in sub-Saharan African communities. Aim 3. The findings of this study provide insight into population and health system barriers to cervical cancer control in Nigeria, and areas for advocacy and policy changes to address these barriers. These conclusions summarize the progress of the field of cancer epidemiology in the effort to minimize inequities in cervical cancer, highlighting that more intentional efforts are needed to support underserved populations in the US and globally.