Human Papillomavirus Vaccination History Among Women With Precancerous Cervical Lesions: Disparities and Barriers

Human Papillomavirus Vaccination History Among Women With Precancerous Cervical Lesions: Disparities and Barriers

Mehta, Niti R. MPH; Julian, Pamela J. MPH; Meek, James I. MPH; Sosa, Lynn E. MD; Bilinski, Alyssa; Hariri, Susan PhD; Markowitz, Lauri E. MD; Hadler, James L. MD, MPH; Niccolai, Linda M. PhD

Abstract

OBJECTIVE: To estimate racial, ethnic, and socioeconomic differences in human papillomavirus (HPV) vaccination history among women aged 18–27 years with precancerous cervical lesions diagnosed, barriers to vaccination, and timing of vaccination in relation to the abnormal cytology result that preceded the diagnosis of the cervical lesion.

METHODS: High-grade cervical lesions are reportable conditions in Connecticut for public health surveillance. Telephone interviews and medical record reviews were conducted during 2008–2010 for women (n=269) identified through the surveillance registry.

RESULTS: Overall, 43% of women reported history of one or more doses of HPV vaccine. The mean age at vaccination was 22 years. Publicly insured (77%) and uninsured (85%) women were more likely than privately insured women (48%) to report no history of vaccination (P<.05). Among unvaccinated women, being unaware of HPV vaccine was reported significantly more often among Hispanics than non-Hispanics (31% compared with 13%,P=.02) and among those with public or no insurance compared with those with private insurance (26% and 36% compared with 6%, P<.05 for both). The most commonly reported barrier was lack of provider recommendation (25%). Not having talked to a provider about vaccine was reported significantly more often among those with public compared with private insurance (41% compared with 18%, P<.001). Approximately 35% of women received vaccine after an abnormal cytology result; this occurred more frequently among African American women compared with white women (80% compared with 30%, P<.01).

CONCLUSION: Catch-up vaccination strategies should focus on provider efforts to increase timely coverage among low-income and minority women.

LEVEL OF EVIDENCE: III

Obstetrics & Gynecology:

March 2012 - Volume 119 - Issue 3 - p 575–581

doi: 10.1097/AOG.0b013e3182460d9f

Original Research

Diet Rich in Antioxidants May Cut Stroke Risk

December 2, 2011 — Women who eat an antioxidant-rich diet may significantly cut their stroke risk, particularly those without a history of cardiovascular disease (CVD), new research suggests.

The prospective study found that women with no history of CVD who consumed the highest amount of antioxidants in foods such as fruit, vegetables, tea, whole grains, and chocolate had a 17% lower risk for strokes than those who ate the least amount. Among women with a history of CVD, those who consumed the most antioxidants had a 45% lower risk for hemorrhagic strokes.

"This study suggests that eating a diet rich in antioxidants, especially from fruits and vegetables, may be of importance for stroke prevention," lead author Susanne Rautiainen, MSc, a PhD student at Karolinska Institutet, Sweden, told Medscape Medical News.

The study was published online December 1 in Stroke: Journal of the American Heart Association.

Antioxidant Capacity

Researchers used the Swedish Mammography Cohort, a database that includes women born from 1914 to 1948 in the counties of Uppsala and Västmanland, Sweden. The cohort contained 36,715 women who were followed up from September 15, 1997, to December 31, 2009. A 1997 questionnaire on diet, education, weight, height, and potential risk factors for stroke served as a baseline for the analysis.

Investigators calculated the total antioxidant capacity (TAC) in the diet, using a database of the most common foods. "The TAC does not identify specific antioxidants, but rather, it measures the entire antioxidant network, including all present antioxidants, and takes into account the synergistic effects between compounds," explained Ms. Rautiainen.

The researchers analyzed the 31,035 women who were free of CVD at baseline separately from the 5680 women with a history of CVD. Members of the CVD-free cohort were categorized into quintiles, and those with a CVD history into quartiles, of dietary TAC.

From the Swedish Hospital Discharge Registry, researchers identified 1322 strokes among CVD-free women and 1007 strokes among those with a history of CVD. Risk was adjusted for age; education; smoking; body mass index; physical activity; hypertension; hypercholesterolemia; diabetes; family history of myocardial infarction; aspirin use; dietary supplement use; and intakes of total energy, alcohol, and coffee.

The researchers report that among the CVD-free women, those in the highest quintile of dietary TAC had a statistically significant 17% lower risk for total stroke compared with women in the lowest quintile (hazard ratio, 0.83; 95% confidence interval, 0.70 - 0.99; P = .04).

Dietary TAC was inversely associated with both cerebral infarction and hemorrhagic stroke, although these results were not statistically significant.

Fruits and vegetables contributed about 50% of TAC. Other contributors included whole grains (18%), tea (16%), and chocolate (5%).

CVD Subgroup

In the CVD subgroup, women in the highest quartile of dietary TAC had a significant 45% lower risk for hemorrhagic stroke compared with those in the lowest quartile (adjusted hazard ratio, 0.55; 95% confidence interval, 0.32 - 0.95; P = .03). However, there was no association with total stroke.

In this subgroup, women in the lowest TAC quartile might have been more likely to have a history of stroke, and therefore be more likely to get a hemorrhagic stroke, although the inverse association remained after adjusting for history of stroke, said Ms. Rautiainen.

"Women with a CVD history may control their blood pressure or change their lifestyles because of knowledge of their disease," she speculated. "This might have produced a spurious inverse association between TAC of diet and risk of hemorrhagic stroke."

The findings of this study seem to conflict with those of previous research that failed to show beneficial effects of antioxidant supplements on stroke risk. "The contradiction may be explained by the fact [that] these studies looked at high doses of single antioxidants, whereas we aimed to examine antioxidant intake by taking into account all antioxidants present in the diet, including thousands of compounds, in doses obtained from a usual diet," said Ms. Rautiainen.

Oxidative stress may be at the root of some strokes, as the body may be unable to neutralize cell-damaging free radicals, which can lead to inflammation and vascular damage, said Ms. Rautiainen.

How might antioxidant-rich foods reduce this stroke risk? According to Ms. Rautiainen, vitamins C and E, carotenoids, flavonoids, and other such compounds scavenge free radicals, thereby inhibiting oxidative stress. "Antioxidants, especially flavonoids, may also help improve endothelial function and reduce blood clotting, blood pressure, and inflammation," she said.

The next step for the research team is to see whether TAC intake is associated with CVDs other than stroke, she concluded.

Overall Strengths

Approached for comment, Louise D. McCullough, MD, PhD, from the Department of Neurology and the Department of Neuroscience, University of Connecticut Health Center, and the Stroke Center at Hartford Hospital, said the study's overall strengths were its size and the fact that the cohort was followed up for such a long time.

"This is by far the biggest and most complete trial that's been done," she said.

The results confirm what has been long suspected: "People have known from retrospective trials and correlative studies that antioxidants in fruits and vegetables, etc, reduce stroke risk," said Dr. McCullough. "This confirms it in a prospective trial."

She pointed out that eating a healthy, antioxidant-rich diet is associated with other healthy behaviors. "People who tend to eat healthier tend to also have healthier lifestyles as a whole, but even controlling for that, in this large population it does seem that the diet had an independent beneficial effect on stroke incidence."

Dr. McCullough noted that the reduced risk among healthy women "wasn't a huge change in risk" in terms of absolute numbers, but she emphasized that reducing stroke risk by incorporating more antioxidant-rich foods in the diet is relatively easy to do.

The study was supported by the Swedish Research Council for Infrastructure and the Swedish Council for Working Life and Social Research. The authors have disclosed no relevant financial relationships.http://www.medscape.com/viewarticle/754618