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Week 11 Assignment
PUBH 6030/PUBH 8030/PUBH 8030H/HLTH 6030/HLTH 8030:
Socio-Ecological Perspectives on Health
Megan Bledsoe
Fall Quarter, 2016
Dr. Jirina Foltysova
Walden University
11/08/2016

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1. Target Population
The specifically targeted population discrepancies are primarily female and male adolescents
who should receive and complete their human papilloma virus (HPV) vaccine series, secondarily
followed by an examination of the racial discrepancies in completion of the HPV vaccine series.
2. Health Issues
Compliance with the HPV vaccine series is at an all-time low. Females are traditionally
recommended the vaccine more often than males (92% recommend the vaccine to females
compared to 31% to males), with recommendations occurring more often in later adolescences
(13-17 years of age) than younger (Allison, et al., 2013; McCave, 2010).
3. Indicators
3.1. Definition
Approximately 75 million Americans are infected with HPV, with nearly 14 million new cases
occurring each year (CDC, 2015). Every year, over 17,000 women and nearly 10,000 men are
affected by HPV related cancers (CDC, 2015). Women are able to be screened for cervical
cancer with yearly pap smears, but for those with throat cancer (primarily men) it often goes
undetected until a lump is noticed on the side of their neck, calling for a biopsy to determine the
cause.
3.2. Influence
Recently, it has been discovered that nearly 70% of oropharynx cancer in men and 91% of all
cervix (over 11,000 new cases each year) and anal cancers (over 5,000 new cases each year) is
caused by HPV (CDC, 2016). Unfortunately, the strains of HPV which cause the majority of the
HPV related cancers are protected against by receiving the nonavalent HPV vaccination series
(CDC, 2016).

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4. Social Determinants of Health
4.1. Description
The primary barrier to HPV vaccination compliance are parents and primary physicians. The
parents come to appointments with their own beliefs about the HPV vaccine (“They don’t need it
this early.”, concerns that the vaccine gives their daughter license to have sex, and feeling
uncomfortable discussing sexually transmitted diseases (STDs) (Holman, et al., 2014; McCave,
2010; Zimet, et al., 2010). Effective physician communication can alleviate parental concerns
and offer support in the decision.
Insurance companies also provide a barrier to completing the vaccination series. Some
private insurance companies will not cover the 3 shot series (or only cover it for females),
causing families to choose to pay out of pocket (approximately $120 per vaccine), wait to
vaccinate in hopes of coverage at a later date, or find a public program to complete the series
(Dempsey & Davis, 2006). This creates either a strain financially for the families, an opportunity
to either delay or not receive vaccine, or stress on the family to find another avenue for
vaccinating.
4.2. Impact
Children with parents supportive of the HPV vaccination have a higher rate of completing the
series, thus protecting them from contracting and developing HPV related cancers later in life
(Allison, et al., 2013; Holman, et al., 2014; McCave, 2010; Zimet, et al., 2010). Parents who are
uneducated about HPV are more likely to refuse the vaccine (Holman, et al., 2014; McCave,
2010; Zimet, et al., 2010). Additionally, parents who do not worry about whether their insurance
will cover the vaccinations for their children are more likely to push for vaccination (Dempsey &
Davis, 2006).

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5. Socio-Ecological Theory
5.1. Significance
By applying the Socio-Ecological Theory, we can create a better understanding of how to correct
societal issues at all applicable levels, thus fixing the problem from the root up. HPV vaccination
compliance is affected at each level of the Socio-Ecological Model (SEM). Each level offers its
own obstacles and influences to overcome. Encouraging the government to step in for assistance
will not address parental beliefs; each level must be addressed for their own influences in order
to achieve higher compliance in vaccination rate completion.
5.2. Application
Within the SEM, there are different categories to be analyzed – Individual, Interpersonal,
Organizational, Community, and Public Policy. In regards to HPV vaccination compliance, the
levels with the most influence on the issue are Interpersonal, Community, and Public Policy. At
the Interpersonal level, parents have the ultimate say-so in whether their adolescent children
receive the vaccine. The Community level introduces further discrepancies, such as those
between the completion rates among different races. The Public Policy level is where change can
be most felt, as it can allow for schools to offer vaccination programs.
Through use of the SEM, it was identified that the education system might be the most
appropriate target for many of the levels; the targeted population (adolescents) spend the
majority of their time in school, parents trust and rely on the school system, the community
bands together to support the school, and the school itself thrives on government assistance in
order to stay open. By targeting strategies to take place at the school, several issues with HPV
vaccination compliance can be relieved, removing the burden from parents as well as increasing
compliance rates.

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6. Intervention
6.1. Individual Level
The primary factor at this level is the perceived need for the vaccine by the individual. At a
young age (9 years old, when it is now offered), children are rarely introduced to sexual
education and having to receive a shot to protect against a sexually transmitted disease is
unheard of (Burdette, et al., 2014; Holman, et al., 2014). The individual is most likely more
afraid of the shot than the risk of getting HPV related cancer down the road.
The most beneficial intervention at this point is to begin introducing appropriate level
sexual education. This can be done either within the school or at home (based on parental level
of comfort). Puberty onset occurs, on average, around the age of 10 for females and 12 for males
(Burdette, et al., 2014; Ferrer, et al., 2015). At a minimum, the changes that come with puberty
can and should be discussed; this could segue into the HPV vaccine and why it is important for
adolescents to receive.
6.2. Interpersonal Level
The primary factor at this level are the individual’s parents. Parents who are uneducated about
the vaccine are more likely to refuse or delay the vaccination series, putting the responsibility
onto their child to receive at a later age (most likely after coming into contact with HPV)
(Burdette, et al., 2014; Holman, et al., 2014; McCave, 2010; Orenstein, et al., 2016).
Additionally, conversations with the physician increase the likelihood of completing the
vaccination series (Orenstein, et al., 2016; Remes, et al., 2014; Ylitalo, et al., 2013). A
physician’s attitudes and beliefs towards the vaccine can determine if the children will receive
the shots at all. Intervention for this level includes educational seminars and face to face training
with physicians to begin having the discussion of sex and STDs with their patients and parents.

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6.3. Organizational Level
Historically speaking, women of low socioeconomic status were less likely to start and complete
the vaccine series (Beavis & Levinson, 2016). Low socioeconomic status and having insurance
are directly correlated (Beavis & Levinson, 2016). Additionally, some private insurance
companies do not cover the cost of completing the vaccine series, leaving the expense to be paid
out of pocket by parents (Dempsey & Davis, 2006).
Interventions at this level would be to appeal to the private insurance companies through
the government to ensure that all vaccinations are covered without any cost sharing (Bevis &
Levinson, 2016; Dempsey & Davis, 2006; Orenstein, et al., 2016). The Affordable Care Act has
assisted in ensuring the population has insurance, regardless of pre-existing conditions or
financial status (Bevis & Levinson, 2016; Orenstein, et al., 2016).
6.4. Community Level
Cultural and community norms are evidenced by the lowered vaccination rates found among
non-White women. African Americans, Hispanic, and Asian women have a lower knowledge of
HPV, resulting in lower vaccination rates (Ferrer, et al., 2015; Ylitalo, et al., 2013). Cultural
norms need to be addressed in order to remove this as a barrier to vaccine compliance.
Within the community, the school system is a place for everyone. In order to educate the
community on HPV, it is recommended that the school host education nights for families to
attend or have parents be included in homework assignments about HPV (and sexual education
in general). Offering education and vaccination programs through the school encourages
involvement from the community and removed burdens from the parents (i.e. financial, time
commitments, etc.) for completion of the vaccine series (Allison, et al., 2013; Burdette, et al.,
201; Dempsey & Davis, 2006; Holman, et al., 2014; McCave, 2010; Remes, et al., 2014).

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6.5. Public Policy Level
The government needs to become involved in the HPV vaccination completion rates and realize
that the states are performing poorly. By ensuring that insurance companies cover the cost of the
series, it releases the burden of cost off of parents (Holman, et al., 2014; McCave, 2010;
Dempsey & David, 2006; Burdette, et al., 2014). By encouraging the public to have free health
clinics where the vaccine series can be offered, it brings about a sense of community that can
encourage the completion of the vaccinations (Allison, et al., 2013; Remes, et al., 2014).
Government interventions are vital to the success of the completion of the HPV
vaccination series in adolescents. While the above strategies can assist in removing vaccine
denial, the primary strategy is to target the schools, where adolescents spend the majority of their
time. Through government stipends, schools could offer free HPV vaccinations to individuals
who meet the age requirement, with parental permission (Allison, et al., 2013; Holman, et al.
2014; Remes, et al., 2014).
6.6. Explanation of How Applying Intervention across All Levels of the SEM Will
Contribute To Positive Health Outcomes
By applying interventions across the board, all obstacles can be addressed and removed. Relying
solely on the policy level to encourage vaccination series are completed is useless, when parents
still do not understand why their adolescent needs to have the HPV vaccine to begin with. All
levels need to be addressed so as to provide complete transparency to the individuals receiving
the vaccine and the parents supporting/making the decision to do so. Once the innermost levels
(Individual and Interpersonal) are addressed and educated, the remaining levels are merely
strategies to allow for better compliance.

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6.7. Socio-Ecological Model Table
Level Factors for Population and
Health Issue
Activities
Individual Perceived need for vaccination series Age appropriate sexual education and health class offered within the school
system (i.e. explanation about puberty; introduction of STD’s and the HPV
vaccine).
Interpersonal Parental beliefs and
attitudes/comfortability and knowledge
of physicians
Education of physicians on how to conduct difficult/uncomfortable
discussions (i.e. sex) with adolescent patient and their parents in order to
ensure a parental education on the topic of HPV.
Organizational Insurance companies Governmental incentives to insurance companies to cover the entire cost of
all vaccines (specifically HPV series) and remove any cost-sharing from the
patients. Additionally, ensuring all patients have some form of insurance to
assist in covering the cost of the vaccine.
Community/
Environment
School vaccination programs Offering vaccination programs through the school to allow adolescents,
with parental permission, to receive and complete the HPV vaccine series.
Society/
Public Policy
Government assistance Enforcing insurance companies to comply with activities listed at
Organizational level; offer incentives and materials to schools offering
vaccination programs.

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7. Stakeholders and Organizations
In order to identify the barriers and get recommendations on overcoming them, a committee was
set up to hear from a wide variety of experts on HPV vaccinations – the American Academy of
Pediatrics, the Centers for Disease Control and Prevention, the U.S. Department of Health and
Human Services, and local health departments (Orenstein, et al., 2016). Since the government
recognizes already that HPV vaccination compliance is an issue, it would be best to focus efforts
on implementing a school based program with both the national government and state
governments. Having government backing for school system implementation will help
encourage states to adopt the plan for vaccination completion.
8. Application of the Principles of Community-Based Participatory Research
Applicable Community-Based Participatory Research (CBPR) principles for a school based HPV
vaccination intervention include recognizing the community as an identity, integrating
knowledge and action for mutual benefit of all partners, and promoting a co-learning and
empowering process attending to social inequalities. These principles are chosen because they
directly relate to issues identified earlier in this proposal.
Recognizing the community as an identity will enable the program to reach out to the
African American and Hispanic community in order to address the disparity in their lowered
immunization compared to the Caucasian community (see section 6.4 Community Level). By
creating a school based program to better educate students and their parents about sexual
education (see section 6.2 Interpersonal Level), we can address the principle of integrating
knowledge and action. Lastly, the school program would promote co-learning, by offering facts
about sexual education, specifically HPV statistics (both about the disease and the vaccine) (see
sections 6.4 Community Level and 6.5 Public Policy Level).

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9. Likelihood of Favorable Health Outcomes
Implementation of a school based program for providing the HPV vaccine has two distinct
advantages: the ability to reach a large group of eligible individuals and increased access to the
vaccine (Ferrer, et al., 2015; Walling, et al., 2016). Unfortunately, many adolescents miss their
doctor appointments due to transportation issues, forgetting the appointment, or financial
concerns (Bevis & Levinson, 2016; Dempsey & Davis, 2006; Ferrer, et al., 2015; Orenstein, et
al., 2016; Walling, et al., 2016). Implementation of school based vaccination programs has
shown to have an increase of success in other countries. There are several states in the United
States whose overall vaccination rate is less than 40% for boys and less than 60% for females
(CDC, 2016).
Schools in other countries (the United Kingdom, Australia, Canada, etc.) have had a
reported success when incorporating school based vaccination programs, not just for HPV, but
for a wide variety of vaccinations required for school-age children. The United Kingdom has
implemented a school based HPV vaccination program for its students. In the 2014/2015 school
year, 89.4% of eligible students received their first HPV vaccine shot, while an estimated 79.9%
completed the vaccination series (Public Health England, 2015). Australian schools provide the
entire vaccine series free to girls and boys aged 12-13 years through their schools (Cancer
Council Australia, 2016). As a result, Australia has shown a 77% reduction in types of HPV that
cause nearly 75% of cervical cancer (Cancer Council Australia, 2016). Canada’s province
Alberta included boys in the free school based HPV vaccination program in 2013. This program
has had a female vaccination completion rate of 85%, with males completing the series at 79%
participation (Walling, et al., 2016). Additionally, Canada has seen a 90% completion rate for
meningitis, hepatitis and MMR since implementing a school program for vaccines (Walling, et
al., 2016).

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10. Relationship to the Essential Public Health Services
Essential Public Health services incorporated in this proposal will be monitoring health statuses
to identify and solve community health problems and informing, educating and empowering
people and the community about health issues.
The primary incorporated service is to monitor HPV vaccination status within the United
States, focusing primarily on states with a very low series completion status. The states with the
lowest compliance are Wyoming (47.7%), Utah (47.8%), Kansas (50.9%) and Mississippi
(52.4%); while the highest completion rates are found in Rhode Island (87.9%) and Philadelphia
(79.3%) (CDC, 2015; CDC, 2016). While we have identified target states to focus on
implantation of the school based program, each state should be encouraged by the government
through stipends and incentives to incorporate a program in order to get the national HPV
compliance rate above 85% (currently at 63% for girls and 50% for boys) (CDC, 2016). Through
government grants, progress of completion rates can be monitored and researched – best practice
implementations can be reviewed and perfected, to ultimately get a >90% completion rate.
A second service this proposal provides for is the education of the community about
HPV. The aim is to provide a better sexual education program that is age appropriate, such as
introducing the concept of puberty at a younger age and providing a comprehensive sexual
education that builds upon prior lessons taught through the school (Burdette, et al., 2014). In the
United States, curriculums are based on prior years’ knowledge, growing more complex as the
student progresses through the system. Currently, where sexual education is allowed to be taught,
it is a comprehensive, semester long course that is not brought up again once completed. By
beginning in 4th or 5th grade, initially just discussing puberty, and then gradually building upon
that knowledge as the student grows, full comprehension can be achieved, better preparing the
student for healthy sexual relationships and the knowledge of better sex practices.

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11. References
Allison, M. A., Dunne, E. F., Markowitz, L. E., O'leary, S. T., Crane, L. A., Hurley, L. P., . . .
Kempe, A. (2013). HPV Vaccination of Boys in Primary Care Practices. Academic Pediatrics,
13(5), 466-474. doi:10.1016/j.acap.2013.03.006
Beavis, A. L., & Levinson, K. L. (2016). Preventing Cervical Cancer in the United States:
Barriers and Resolutions for HPV Vaccination. Front. Oncol. Frontiers in Oncology, 6.
doi:10.3389/fonc.2016.00019
Burdette, A. M., Gordon-Jokinen, H., & Hill, T. D. (2014). Social determinants of HPV
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Cancer Council Australia (Ed.). (2016). Has the program been successful? Retrieved November
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Dempsey, A., & Davis, M. (2006, December 15). Overcoming Barriers to Adherence to HPV
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Ferrer, H. B., Trotter, C. L., Hickman, M., & Audrey, S. (2015). Barriers and facilitators to
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States. Journal of Community Health, 35(6), 645-652. doi:10.1007/s10900-010-9255-4

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References (Continued)
Orenstein, W. A., Gellin, B. G., Beigi, R. H., Despres, S., Lynfield, R., Maldonado, Y., . . .
Zettle, M. (2016). Overcoming Barriers to Low HPV Vaccine Uptake in the United States:
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Vaccine Advisory Committee on June 9, 2015. Public Health Reports, 131(1), 17-25.
doi:10.1177/003335491613100106
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coverage in ... Retrieved November 8, 2016, from
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4_15_ReportFinal181215_v1.1.pdf
Remes, O., Smith, L. M., Alvarado-Llano, B. E., Colley, L., & Lévesque, L. E. (2014, October
08). Individual- and Regional-level determinants of Human Papillomavirus (HPV) vaccine
refusal: The Ontario Grade 8 HPV vaccine cohort study. BMC Public Health, 14(1).
doi:10.1186/1471-2458-14-1047
Walling, E. B., Benzoni, N., Dornfeld, J., Bhandari, R., Sisk, B. A., Garbutt, J., & Colditz, G.
(2016, July 13). Interventions to Improve HPV Vaccine Uptake: A Systematic Review.
Pediatrics, 138(1). doi:10.1542/peds.2015-3863
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Zimet, G. D., Weiss, T. W., Rosenthal, S. L., Good, M. B., & Vichnin, M. D. (2010). Reasons
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women. BMC Women's Health, 10(1). doi:10.1186/1472-6874-10-27