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Abstract
Human papillomavirus (HPV) is the most common sexually transmitted infection (STI) in the United States. Each year, over 46,000 cancers are attributable to HPV types that can be prevented by the current vaccine, and almost 56% of these cancers are diagnosed among women. Additionally, adolescent HPV vaccine coverage remains below 60 percent in the U.S. The study purpose was to better understand the impact of rurality on HPV-associated cancers among women and men and the impact of state immunization policies on adolescent HPV vaccine uptake. CDC National Program of Cancer Registries and NCI Surveillance, Epidemiology, and End Results 2008-2018 program data was used to calculate mean age-adjusted incidence rates and incidence rate ratios for all HPV-associated and six site-specific cancers. Bivariate and multivariate regression analyses were performed using negative binomial models. The qualitative study explored the policy environment and process in states that passed HPV vaccine school mandate legislation and assessed HPV and cancer risk knowledge, attitudes, beliefs, and perceptions among state stakeholders.Quantitative study findings demonstrated an association between rurality and elevated penile and vulvar cancer incidence after adjustment for confounders. Economic status was independently associated with increased all HPV-associated, cervical, vulvar, oropharyngeal, and anal cancer. A lower county PCP rate was associated with increased cervical cancer incidence. Policy stakeholders described parent, healthcare professional, and state as intersecting at three roles essential to adolescent vaccine uptake: as educator, public health advocate, and vaccine champion. Stakeholders cited Department of Health (DOH) leadership and changing existing DOH rules or regulations as major facilitators to HPV vaccine policy introduction. Participants identified opposition from anti-vaccine groups and a lengthy regulatory review and approval process as barriers to policy introduction. Quantitative findings illustrate the independent association between socioeconomic status and increased HPV-associated and site-specific cancers. Additional behavioral studies are warranted to examine the root causes of sexual risk behavior, poor access to health care, and vaccine and cancer screening hesitancy in rural and urban populations. Parents, healthcare professionals, and the state can collectively use their influence and shared responsibilities as vaccine advocate, educator, and champion to improve state vaccination rates post-COVID-19.