October 15, 2018
5 min read

Q&A: HPV vaccine coverage lacking among rural teens

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Photo of Robin Vanderpool
Robin C. Vanderpool

More teenagers aged between 13 and 17 years received the HPV vaccine in 2017 than 2016, with 65.5% administered at least one dose and 48.6% completing the three-dose series, according to the CDC. However, many barriers to HPV vaccination exist in rural areas, where HPV-related cancers are more prevalent.

In fact, a national study published this year in Preventive Medicine found that 58.6% of rural residents had heard about HPV vaccination, and only 55.8% had heard of the virus itself (compared with 67.2% and 65.8% in urban areas, respectively). An estimate provided by the Kaiser Family Foundation suggests that only 42.4% of rural teenagers had completed the series.

Infectious Diseases in Children spoke with Robin C. Vanderpool, DrPH, associate professor in the department of health, behavior and society at the University of Kentucky College of Public Health and the University of Kentucky Markey Cancer Center, about some of the barriers to HPV vaccination among rural teenagers and what is needed to prevent future infections. – by Katherine Bortz

How do HPV infections and associated cancers compare in rural vs. urban populations ?

Unfortunately, we have seen in an increase in HPV-associated cancers in rural areas compared with urban areas. For example, since the mid-1990s, rates of HPV-related cancers in males residing in rural areas have increased by roughly 90%. Rural women also have significantly higher incidence rates of cervical, vaginal, vulvar, head and neck and anal cancer compared with their female urban counterparts.

Teen getting vaccinated 
Source: CDC

Why are these infections and cancers be more prevalent in rural residents?

There is obviously something going on to cause these higher rates of HPV-related cancer among rural populations. There may be two circumstances going on: there may be a higher prevalence of the virus, a higher number of cases where the virus is not clearing itself, or both.

What does vaccination coverage look like among rural adolescents?

The CDC has really focused on a variety of rural health issues. Even for other vaccinations, such as meningococcal, the rates are lower in rural communities compared with those in urban communities. In essence, the HPV vaccination is following the trend of having lower adolescent vaccine coverage in general, even for some of the ones that are required [for school admission].


What are some of the physical barriers to adolescent vaccination in rural communities ?

There are several barriers related to access of care, such as fewer pediatricians, family medicine doctors and specialty providers. We know that many of our rural communities have shortages of primary care physicians, and there may be limited places to get vaccinated. There are also issues related to distance and travel. Many people may have an hour-long drive into the main town where providers or the health department might be located.

Even something like weather can be a barrier. When we look at areas like Appalachian Kentucky, snow, ice, flooding and really bad weather cause schools to close and buses to stop service. County school systems may be closed for days at a time in some instances. This can impact the ability to go into town for groceries, let alone health care services.

Are there any logistical barriers to vaccination?

Health insurance can be a problem for many rural residents. We know that in rural areas, there are often lower rates of health insurance coverage. That can be problematic when it comes to getting preventive care. It is so important that families have access to rural health clinics, community health centers and local health departments that participate in the federally sponsored Vaccines for Children program, which provides immunizations at no cost to Medicaid-eligible children.

There may also be cultural beliefs or resistance to thinking about a vaccine, which in this case prevents an STD infection. There are difficult but important conversations that need to be had about sexual health among adolescents, and that can sometimes be a hard conversation to initiate between parents and health care providers. I think that because the vaccine is not a mandated, highly recommended vaccine, it does not have that same support that we might have for some other vaccines.

In what areas do patients and parents need to be educated regarding HPV and vaccination?

There is still a lack of knowledge on this topic across the United States, not just in rural areas. Many people do not understand what HPV is as a virus, the implications of persistent infection, the understanding that there are low- and high-risk types of the virus and how the body can either clear the infection itself or how it can persist and lead to a cancer diagnosis in the future.

There is also a lack of understanding regarding what parts of the body HPV affects. It is not just about cervical cancer, although that is a very important concern and it is where some of the first work around HPV was done in the scientific community. HPV is also a causal factor for anal, vaginal, vulvar, penile and head and neck cancers.


What can pediatricians and physicians do to better educate rural patients and parents about the vaccine and why they need it?

A lot of the science and research, particularly from our colleagues at the University of North Carolina, shows that providers need to make this a consistent, strong and regular part of their communication about adolescent vaccines. When a family is there to get vaccines that are required for school entry, physicians need to provide a very straightforward announcement that you are offering the HPV vaccine for their child and that it is one of the recommended adolescent vaccines. We also know that across many health behaviors, including vaccination, a physician’s recommendation is the strongest rationale for why people engage in a behavior.

What other areas can pediatricians and health care providers target to make the vaccine more accessible?

We need to think outside of the box and outside of the traditional medical home. We do want our kids and youth being seen by their primary care provider or their pediatrician, but kids are being seen in other locations where the vaccine could be delivered. In this case, I think school health clinics, pharmacies and dental clinics are an important partnership.

You need the will of the community to do this, and you need champions to help take that on. If you have an active local health department, they could employ school nurses that go into the schools to deliver health care-related work with families and children; this could be an area for HPV vaccine promotion. We know pharmacies are prevalent and available in rural communities. We have had pharmacies in several states across the U.S. who take this on. Recent guidelines from the American Dental Association encourage provider and patient education about HPV and HPV vaccination. Additionally, many pharmacies deliver flu, hepatitis, pneumonia, shingles and other vaccines, so why not make this part of their portfolio of services that they are able to offer?


Mohammed KA, et al. Prev Med. 2018;doi:10.1016/j.ypmed.2018.01.016.

Vanderpool RC. Closing the gap between urban and rural HPV vaccination rates. Presented at: RHIhub Webinar. Sept. 18, 2018.

Walker T. Vaccination coverage among U.S. adolescents: Results from the 2017 National Immunization Survey-Teen (NIS-Teen). Presented at RHIhub Webinar. Sept. 18, 2018.

Disclosure: Vanderpool reports no relevant financial disclosures.