Addressing Knowledge Gaps: The Key Role of Community Health Workers and Healthcare Providers in Human Papillomavirus Prevention and Vaccine Uptake in a Border Community

"Although all CHWs and HCPs stated they would recommend HPV vaccination for increasing vaccine uptake, they will need to be thoroughly versed in HPV health, including an effective, community-tailored method for responding to misconceptions and myths about HPV and the vaccine."

The United States (US)-Mexico border region, where human papillomavirus (HPV) prevalence for any subtype has been found to be 53.2%, is reported to have the highest cervical cancer rates in the US. Health literacy is essential in lowering rates of sexually transmitted infections (STIs), including HPV. Yet sexual health education in the US state of Texas is focused on abstinence-only education. The public health care system, through community health workers (CHWs), or "promotors/as de salud", and other healthcare providers (HCPs), therefore, may be left the task of increasing health literacy, promoting healthy behaviours, and providing resources. Drawing on data gathered through focus groups with CHWs and HCPs, the goals of this study were to: (i) assess HPV-related knowledge, attitudes, and practices among Hispanics in El Paso, Texas; (ii) identify barriers and facilitators of vaccine uptake; and (3) assess the practices and behaviours of CHWs and HCPs.

El Paso, Texas is one of the largest metropolitan cities on the US-Mexico border, with 82% of its inhabitants of Hispanic origin. Adolescents in El Paso have the highest rate of first-dose HPV vaccine uptake in Texas and one of the highest in the US. This fact suggests the presence of facilitators for first-dose HPV vaccine uptake in the population of predominantly Mexican origin in El Paso and indicates that this specific location may provide information in the study of first-dose vaccine uptake in children and young adults.

Led by trained facilitators, 3 focus groups with CHWs (n = 17) and HCPs (n = 7) were conducted on Zoom between April and June 2020. In addition, CHWs and HCPs completed a brief questionnaire.

CHWs displayed a range of awareness and knowledge about HPV, some evidencing strong knowledge of HPV-associated risks, such as cervical, uterine, and oral cancers, and others having only basic or very little knowledge of HPV. CHWs gained their knowledge of HPV in different ways, the majority learning of it through HPV-affected family, friends, or clients; some gained awareness through school or work-related trainings or courses, and one learned about HPV through a gynaecologist. HCPs displayed clinical knowledge of HPV, stressing its association with cancer and genital warts.

The roles CHWs and HCPs saw for themselves in HPV cancer prevention shared similarities but were distinct in some of their approaches (see Table 2 in the paper). Regarding the HPV vaccine, all CHWs and HCPs stated they would recommend that patients receive it. Both CHWs and HCPs identified the need to be more proactive and intentional in their role in HPV health promotion. HCPs are viewed as authority figures by the community and recognised they need to take an active role; they mentioned community partnerships and educational campaigns as good avenues.

CHWs and HCPs identified many similar perceived obstacles in their efforts to prevent HPV cancer in the Hispanic community of El Paso. Financial, knowledge, patriarchy (e.g., "machismo"), behaviours, attitudes, and fears were identified as the perceived patient-related barriers to promoting HPV cancer prevention. Both CHWs and HCPs explained that their female patients are often discouraged by their husbands from seeking out sexual-health-related health care. Non-patient-related obstacles mentioned by HCPs were high cost of HPV vaccines, vaccine accessibility, and inconsistency in practices and information provided by HCPs, which causes distrust in patients and results in patients not seeking out medical care, including HPV-related care.

Overall, the study points to a lack of knowledge and education surrounding HPV and preventative measures among Hispanic communities. This lack of knowledge is often replaced by erroneous information and myths about HPV, both of which are exacerbated by stigma and cultural factors that further prevent individuals from adopting preventive practices. Another important barrier is the lack of access to health care. There is limited knowledge about the community resources available due to a lack of health insurance and finances.

The researchers suggest that using routine health care visits to educate parents, youth, and children about HPV, sexual health, and the HPV vaccine can further close the gaps of HPV vaccine uptake. However, these opportunities are being missed due to self-reported lack of knowledge on the part of CHWs and HCPs, as well as not being fully comfortable initiating these conversations. Education is important both for the health professionals and the community, and it must be culturally tailored to meet the needs of the communities.

As proposed here, the health messaging and recommendations given by CHWs and HCPs should use different methods to reach different age groups, including but not limited to social media, media outlets, and health fairs. "Talking about HPV and sexual health in a Hispanic community needs to be normalized to invite members of the community to take preventive practices and remove the myths that surround the virus. CHWs and HCPs need to continue to spread information and resources as well as to encourage individuals to seek health care....Closing the HPV vaccine uptake gaps will require the health care system to work together with the community."

As part of the 5-year behavioural research project of which this study is a part, the results of the focus groups will inform the design of a randomised controlled trial (RCT), expected to be launched late in 2023, to attempt to vaccinate 400 Hispanic adults. Participants will go from being unvaccinated or having an incomplete vaccination series, to be fully vaccinated during a 9-month time period, where they will be followed-up by the researchers to understand how their knowledge, attitudes, and practices change over the time of the study. With Hispanic adults being the audience, the RCT intervention will be culturally tailored. The perspectives of CHWs and HCPs will be essential in the development of these interventions.