ReMARk: A multi-level strategy to address disparities in rural HPV-related cancer prevention

A substantial missed opportunity to prevent cancers in rural areas of the United States is the low rates of human papillomavirus (HPV) immunization. Among the 50 states, Florida is a particular concern with the second highest number of HPV-related cancers and a rank of 44th in HPV immunization initiation (≥ 1 dose). Even higher cancer risk is present within the rural northern Florida counties that are the focus of this proposal. Due to multiple factors presenting challenges for parents living in rural areas to access timely information and resources about their cancer prevention options a multilevel approach is needed. Guided by the Integrated Behavior Model, the overall objective of this proposal is to ensure all families have access to cancer prevention information to make the best choices for their children’s health. We will use a three-arm cluster randomized trial to assess the added clinical- and associated cost-effectiveness on increasing uptake of proven cancer prevention protocols with three nested evidence-based implementation strategies: (1) clinician-targeted communication training, (2) parent-targeted educational resources designed to support parents - messages and structured phone conversations, (3) community-targeted healthcare access to transportation assistance, mobile clinics, and navigation to healthcare insurance. Community-focused organizations with longstanding relationships within rural communities will support implementation: University of Florida (UF) Institute of Food and Agricultural Sciences Extension, UF Clinical and Translational Science Institute Community Engagement Program, UF Cancer Center Community Advisory Board, UF OneFlorida Clinical Research Consortium, Suwannee River Area Health Education Center, and a federally designated Rural Health Network. The specific aims are: (1) Estimate the added clinical- and associated cost-effectiveness of parent-targeted educational resources alone and when combined with community-targeted healthcare access assistance beyond the effects of clinician-targeted training; (2) Estimate the differential effectiveness of the implementation strategies by patient-level factors; and (3) Measure moderation of implementation strategy effectiveness by clinic-level factors. The proposed research is significant for its potential to increase parents’ informed decision-making about cancer prevention. The project is innovative through its evaluation of the clinical- and cost-effectiveness of layered evidence-based strategies. The proposed project will build evidence on how to support parents and prevent cancers in rural areas.