On the Path to Prevention from the St. Jude HPV Cancer Prevention Program November 2022

Rural life is a choice made by 1 in 5 people in the United States, but by living in a rural area, they don’t choose to be at higher risk of cancers, including HPV cancers. We must do more to make sure those living in rural America are protected. For several years, HPV vaccination coverage has been lower for children in rural areas than children in urban areas.

We can do something to change this.

Gil Friedell, MD, famously believed and lived by the idea that “if the problems are in the community, the solutions are in the community.” It is in this spirit that local solutions are likely needed to address local problems. In this case, this means working with rural communities to address low HPV vaccination coverage and high HPV cancer rates. They will lead us to the solutions.

Now is the time to act to ensure that people in rural areas get protected against HPV cancers. This is personal for me. I grew up in rural Iowa. Most of my family members still live in that area. I have worked with rural communities throughout my career. There is a strong sense of community and resiliency in these areas. People come together to support each other. They also rely on each other. I want them to be protected against HPV cancers, too.

In this month’s e-newsletter, we highlight the St. Jude HPV Cancer Prevention Program’s commitment to improving HPV vaccination coverage with rural communities. If you are interested in joining this effort, please reach out.

HPV vaccination is cancer prevention.

National Rural Health Day celebrates the selfless, community-minded, and determined spirit of rural America. This day showcases the efforts of health care providers, rural health cooperatives, and other allies and partners to build on collective strengths and address challenges affecting rural health.

Rural communities have a strong sense of resiliency and belonging in which people living in these areas are deeply invested. Continuity of care and personal relationships between health care providers and patients are unique advantages of living in a rural community.

Despite these strengths, rural communities face barriers to care, such as health care provider shortages and lower levels of vaccination awareness. These barriers mean that rural children and adolescents are less likely than their urban counterparts to get preventive care from a health care provider. Also, HPV vaccination coverage among rural youth lags behind that of urban youth by about 10%.

Health care providers and public health practitioners in rural areas work diligently to close gaps in health care experienced by those who live in rural communities. They do this by educating people on the importance of preventive care and by improving access to it. They use innovative means to ensure that all children can access preventive care and vaccinations, including HPV vaccination.

On November 17, as we honor efforts to improve health within rural communities, let’s do our part to improve HPV vaccination coverage for all children, especially those in rural areas. We can:

Join HPV vaccination efforts in our communities
Serve as trusted sources for HPV vaccination information
Use social media to educate online communities about the importance of on-time HPV vaccination
Ask parents and caregivers in our networks to pledge to protect children against HPV cancers

We know that HPV vaccination is cancer prevention. Let’s work together to protect the futures of all children and prevent 6 types of cancer through on-time HPV vaccination. The St. Jude HPV Cancer Prevention Program is committed to improving HPV vaccination by working with rural communities and those who serve them. Learn more about preventing HPV cancers with rural communities here.

Access social media resources (like the image below) celebrating National Rural Health Day on the stjude.org/bright-future website.

This year’s theme for National Rural Health Day is Driving Change: Going the Extra Mile. It is clear that we must identify ways to improve HPV cancer prevention with rural communities who have lower HPV vaccination coverage and higher rates of HPV cancers compared to those living in more metropolitan areas. This means we have to take on those extra miles to find and implement solutions – literally and figuratively. We have to address misinformation and build confidence in HPV vaccination as cancer prevention.

The St. Jude HPV Cancer Prevention Program team reached out to experts to ask how we can improve HPV vaccination coverage with rural communities and go the extra mile to drive change in HPV cancer prevention. Here is what they had to say is needed.

Holistic Approach and Commitment

“The South Carolina Office of Rural Health is committed to reducing the disparities that lead to unequal health outcomes for our rural communities. We provide support to local healthcare providers as they address the full scope of acute and chronic health conditions that are more prevalent in our rural communities. In addition, we've given increased attention to the underlying social determinants of health over the past decade. In 2017, we published the Rural Health Action Plan, a broad roadmap of 15 recommendations and 50+ action steps to guide collaborations between the health, housing, educational and employment sectors. In 2019, SCORH launched RuralForwardSC to put the Rural Health Action Plan into motion. The COVID-19 pandemic broadened the scope of this initiative to address digital equity and digital literacy, telehealth utilization, vaccine hesitancy, and access to behavioral health. We are confident that this work has laid a foundation for increased rates of HPV vaccination among rural people. We look forward to supporting any efforts to make our younger generations healthier and more resilient." – Graham Adams, PhD, South Carolina Office of Rural Health

Rural Communities Are Not Monolithic

"Developing an understanding of what works, under what conditions is essential to leverage the limited resources available to rural communities. Rural communities are not homogeneous, and it is important to understand the diverse nature of such communities and the challenges they face at multiple socioecological levels. Indeed, it is imperative that we coordinate and collaborate across health care organizations, providers, and their teams, given the limited resources available. It's all hands-on deck when working towards improving the health of rural communities, which in turn provide crucial resources for the U.S. population at large." – Prajakta Adsul, MBBS, MPH, PhD, University of New Mexico Comprehensive Cancer Center

Local Solutions for Local Problems

“It is important to assist rural health clinics to identify their local barriers to uptake (in patients, parents, providers, and health systems) and work to address those individual barriers. This effort will result in long-lasting changes. This is the approach we are taking in 39 clinics in 10 health systems in Appalachian areas of 4 states.” – Electra D. Paskett, PhD, Ohio State University

Over the past four years, I have been working with an amazing team at the University of South Carolina and Duke University to better understand why HPV vaccination rates are lower in rural communities. We have learned some important lessons. First, providers matter. Just like urban or suburban parents, rural parents are most likely to get their child vaccinated against HPV if they have received a strong recommendation from a trusted healthcare provider. Second, school nurses matter. School nurses are embedded in rural communities. They are trusted sources of information and have intimate connections to families within their local communities. We began to see the power of school nurses in promoting not only required vaccinations but also recommended vaccinations in rural communities. – Sayward Harrison, PhD, University of South Carolina

“Before starting a project in a rural setting, I seek to understand why people in these communities decline HPV vaccination because, sometimes, their reasons are rooted in sociocultural contexts outside our usual biomedical way of thinking. That information helps me select interventions and corresponding implementation strategies that are responsive to those contexts. By doing this initial engagement, I also show these community members that I really listen to them and value their opinions. I cannot convince a rural family to get the HPV vaccine if they don’t trust their provider or me. That's what I like about working in these rural communities and why it’s so important. It allows me to stay connected with people, learn from them, and use that knowledge to prevent HPV-related cancers.” – William A. Calo, PhD, JD, Penn State College of Medicine

More Access Points, More Opportunities

“In rural areas, we need to be more innovative and think outside the box. Many health professional in rural communities can give parents a strong recommendation for the HPV vaccination – including pharmacists, dentists, and dental hygienists.” – Natoshia M. Askelson, MPH, PhD, University of Iowa

“Finding a provider for a vaccination in a rural community is increasingly difficult as many family medicine clinics are no longer providing vaccinations. For uninsured children, finding a Vaccines for Children (VFC) enrolled provider is extremely challenging. Pharmacies can provide childhood and adult vaccinations and enroll in the VFC program to increase access. Approximately 90% of the U.S. population lives within 5 miles of a pharmacy and rural patients visit the pharmacy an average of 14 times a year. Our work suggests pharmacists, physicians, and parents are interested in pharmacies for HPV vaccination.” – Benjamin S. Teeter, PhD, University of Arkansas for Medical Sciences

“The disparities between urban and rural populations have persisted for far too long, and we have a responsibility to go where the need is greatest. Ultimately, facing more barriers means that rural communities need and deserve more efforts and assistance in overcoming them; and it is our role to do just that. When increasing access to vaccination providers, thoughtfulness and creativity should abound. We are not limited to pediatricians and family physicians (though we treasure and appreciate them). To increase rural HPV vaccination, we must explore multiple options such as pharmacists (particularly community pharmacists who have established trust and relationships with community members), mobile vaccination units, vaccine clinics, sports physical clinics, and school-based vaccination programs.” – Casey L. Daniel, PhD, MPH, University of South Alabama Mitchell Cancer Institute

“Pharmacies are often as equally accessible in rural as in urban communities, and therefore, would be important venues for HPV vaccination. Designated primary care centers like federally qualified health centers and rural health clinics can also serve as important settings for the Vaccine for Children program in rural communities, allowing low-income adolescents no-cost access to HPV and other vaccinations.” – Whitney Zahnd, PhD, University of Iowa

“Rural U.S. populations face unique challenges accessing the HPV vaccine, including long distances to healthcare facilities and a shortage of providers. The Federal Retail Pharmacy Program for COVID-19 vaccination has been successful in expanding access to COVID-19 vaccines. Adopting this approach for HPV vaccines can increase uptake while addressing some of the current barriers to pharmacy-based programs such as vaccine supply and reimbursement.” – Caryn E. Peterson, MS, PhD, University of Illinois at Chicago

“Partnering with schools and supporting school nurses with on-campus vaccination events
has tremendous potential for reaching families with limited access to healthcare services. We have found in rural south Texas that offering vaccination events at schools, in partnership with school nurses, significantly increases school- and grade-level HPV vaccination rates. This was particularly true during the pandemic.” – Jane R. Montealegre, PhD, Baylor College of Medicine

Health care providers across Tennessee are working to catch up on HPV vaccinations missed during the COVID-19 pandemic. This effort is especially important for children in rural areas. Rural communities are uniquely self-sufficient. Raising awareness of HPV vaccination is important to address misinformation and teach people how HPV vaccination preserves health.

Christian Family Medicine and Pediatrics is a network of 11 rural health clinics that cover 12 rural counties in West Tennessee. These clinics provide walk-in acute care and primary care, including HPV vaccination. They also distribute St. Jude HPV Cancer Prevention Program education materials to parents and caregivers. Other health care allies serving Tennessee's rural communities are taking innovative steps to administer HPV vaccinations. ShotRX901 is a Vaccines for Children mobile vaccination provider owned by Ted Lyons, PharmD, and Merica Lyons, PharmD. Starting in Tipton County this spring, ShotRX901 will provide vaccinations, including HPV vaccination, in rural Tennessee counties.

These are just two examples of health care providers serving rural Tennesseans for improved HPV vaccination coverage.

Native American Heritage Month celebrates the significant contributions Native Americans have made to the United States throughout history.

How are we doing with HPV cancer prevention for this population? In a February seminar leading up to International HPV Awareness Day, Ronny A. Bell, PhD, MS (Lumbee) of the Wake Forest School of Medicine spoke about the importance of HPV cancer prevention for American Indian and Alaska Native populations. American Indians and Alaska Natives are at higher risk of HPV cancers, particularly cervical cancer. Data show that this population has relatively high rates of HPV vaccination compared to other racial and ethnic groups; however, coverage remains suboptimal. Few published studies exist on effective, culturally appropriate messaging and interventions to improve HPV vaccination coverage among these groups. Work is underway to plan and implement culturally respectful strategies to assess HPV vaccination among the American Indian and Alaska Native populations.

The American Indian Cancer Foundation offers culturally appropriate resources to aid in education and intervention efforts.

The St. Jude HPV Cancer Prevention Program with Cervivor, Inc. hosted an HPV Cancer Survivors School last month in Memphis. HPV Cancer Survivors School was based on the highly successful Cervivor School model developed and implemented by Cervivor Inc. The program teaches HPV cancer survivors how to become more involved in HPV cancer prevention efforts and advocacy. A diverse group of survivors from across the U.S. and from countries including St. Lucia and Honduras participated. Attendees heard from experts in HPV cancer prevention including Tamika Felder, founder and chief visionary, Cervivor Inc.; Heather Banks, lead advocacy educator, Cervivor Inc.; Vetta Sanders Thompson, PhD, associate dean for Equity, Diversity, and Inclusion, Washington University in St. Louis; and St. Jude HPV Cancer Prevention Program staff.

Attendees received training on how to tell their story from visibility coach Roshanda Pratt. They learned advocacy tips from a panel of HPV cancer survivor peers. They also developed advocacy action plans. Sessions were facilitated by Kathryn Gentner.

We look forward to supporting HPV cancer survivors as they apply what they learned in HPV Cancer Survivors School to their HPV cancer prevention advocacy. The voices of HPV cancer survivors are powerful. These voices echo as we see the impact of HPV cancers and share the importance of HPV cancer prevention.

As we enter the holiday season, take time to perform an act of kindness by encouraging loved ones to stay up-to-date with vaccinations. The CDC recommends timely vaccines to protect against contagious and preventable viruses and diseases based on age, exposure, and the immune system.

The CDC Child and Adolescent Immunization Schedule gives an age-based overview of all recommended vaccines, including HPV vaccination starting at age 9. As you have holiday discussions with family members and friends, encourage parents and caregivers to make community immunity a reality. This holiday season, let’s communicate the benefits of vaccination.

Keys to Improving HPV Vaccination Coverage is a fall seminar series that launched in September. It was organized by the American Cancer Society, National HPV Vaccination Roundtable, Indiana Immunization Coalition, and St. Jude. The three-part virtual series aims to increase the capacity of state teams to improve HPV vaccination coverage.

The second seminar, Implementing Best Practices to Improve HPV Vaccination Coverage, featured HPV vaccination best practices experts including Sherri Zorn, MD, Washington HPV Free Taskforce; Samantha Olds Frey, chief executive officer, Illinois Association of Medicaid Health Plans (IAMHP); and Katie Crawford, senior payor and state engagement manager, American Cancer Society. Jennifer Nkonga of the American Cancer Society moderated the seminar. It focused on starting HPV vaccination at age 9, engaging with health plans and healthy systems, and using learning collaboratives to improve HPV vaccination coverage.

Register to attend the final seminar, Monitoring Process and Impact of Efforts to Improve HPV Vaccination Coverage, November 15. Recordings of previous seminars are available. Email PreventHPV@stjude.org for more information.

Thanksgiving Day is a U.S. holiday that takes place this year on November 24. Thanksgiving is about celebrating the harvest and its bounty, tracing back hundreds of years. In modern times, Thanksgiving has become a time to share a bountiful meal (made or purchased) with family and friends and a time to express gratitude. In this spirit, the St. Jude HPV Cancer Prevention team shared what they are thankful for – and also their favorite Thanksgiving dish.

“I am thankful for my dog, Otis, and the joy that he brings me every day. My favorite Thanksgiving dishes are all things potato! Sweet potato casserole with pecans and toasted marshmallows. Mashed potatoes with lots of butter and herbs.” – Alison Footman, postdoctoral fellow

“I am thankful for having a caring, supportive, and motivating partner, my dear husband (Suresh). He always encourages me to pursue my dreams, no matter what comes in life. I am so thankful that I have him in my life. My favorite Thanksgiving dishes are sweet potatoes and mashed potatoes.” – Pragya Gautam Poudel, postdoctoral fellow

“I am thankful for the opportunity to relax and spend time with my family. My favorite Thanksgiving dishes are dressing and turnip greens.“– Portia Knowlton, program coordinator

“Quality time with my family is what I’m thankful for. My favorite Thanksgiving dishes are greens and smoked turkey tails.”– Ursula Leflore, administrative specialist

“I could never give enough thanks for family, friends, and good health. My favorite Thanksgiving dish is sweet potato casserole with marshmallows.” – Duha Magzoub, graduate student assistant

“I am thankful for being so close to my family. My favorite Thanksgiving dish is duck dressing.” – Carol Minor, program coordinator

“I’m thankful for a new addition being added to our family. My favorite Thanksgiving dishes are macaroni and cheese and sweet potato casserole.” – Brooke Morgan, program coordinator

“I am so grateful for all that this year has come with. First, my family is happy and healthy. I also started my Doctor of Public Health program at Johns Hopkins, have traveled across the eastern part of the U.S. to educate communities about HPV cancer prevention, and will soon start a new role as program manager in the St. Jude HPV Cancer Prevention Program. My favorite Thanksgiving dish is definitely dressing. I could have a whole plate of that and usually do.“– Julia Neely, program coordinator

“I am most thankful that I get to make new memories with family and friends with each new day. My favorite Thanksgiving dish is pecan pie.” – Andrea Stubbs, administrative director

“I am thankful for a wonderful life partner, supportive and caring family members and friends, and our beloved pup, Elvis. I also am thankful for the opportunity to continue to grow and thrive with this incredible team at St. Jude. My favorite Thanksgiving dish is the bird – the turkey. I always cook a feast for Thanksgiving, and the turkey is the star of the show.” – Heather Brandt, director

The St. Jude HPV Cancer Prevention Program’s Path to a Bright Future campaign spotlights the benefits of on-time HPV vaccination to prevent cancer in children ages 9–12. The campaign also raises awareness of the dangers of HPV pre-cancers and cancers.

Join us:

Get your child vaccinated against HPV by their 13th birthday: If you or your child is in the recommended age range (ages 9–26 and possibly until age 45), get vaccinated.
Encourage others to get their children vaccinated: Normalize HPV vaccination as cancer prevention.
Share the facts: HPV vaccination is safe, effective, and durable. It prevents 6 types of cancer.

Learn more and join the campaign.