Rural Americans lack adequate health care access and quality.1 More than 10% of Americans live in federally designated health professional shortage areas where they have limited or nonexistent health care services. The shortages apply to physicians, nurses, nurse practitioners, physician assistants, dentists, pharmacists, and many allied health professionals. Generally, the smaller, more isolated, and poorer the community, the worse the shortage problem becomes. 2To make matters worse, rural populations are older and poorer than their urban counterparts and often have more limited insurance coverage.3,4 People in rural communities often have high rates of chronic conditions, accompanied by increased prevalence of problem health behaviors including smoking, obesity, and lack of exercise.2 The need for core health services (eg, primary care, medical and hospital services, long-term care, oral health care, and public health services) is enormous.Rural

There is a need for culturally appropriate mental health treatments and preventive services.

PURPOSE Primary care clinicians will continue to play an important role in cervical cancer prevention, particularly with regard to administration of the newly licensed human papillomavirus (HPV) vaccine and continued administration of Papanicolaou tests. Little is known about the factors that infl uence cervical cancer prevention counseling, particularly in the adolescent encounter. We conducted a qualitative study to better understand the implications for counseling about cervical cancer prevention by primary care clinicians who care for adolescents. METHODSWe conducted in-depth interviews with 37 primary care clinicians in New Mexico to understand the context in which they provide anticipatory guidance about sexual health risks as well as their attitudes about counseling for the forthcoming HPV vaccine. RESULTSClinicians identifi ed 4 categories of factors related to their counseling experiences with adolescents about HPV: (1) the need to build rapport with adolescent patients, (2) the presumption that adolescent patients engage in high-risk behaviors, (3) the situational delivery and complexity of HPV counseling, and (4) perceptions of clinician and community receptivity to the HPV vaccine.CONCLUSION Our fi ndings show that conditions of the preadolescent and young adolescent visit pose a challenge to the successful integration of counseling about cervical cancer prevention in primary care. Counseling strategies that are designed to emphasize a preventive focus while including parents in the discussion at the time of vaccination and that are appropriate to populations with different cultural values and beliefs will help to enhance communication about cervical cancer prevention and the particular role of the HPV vaccine. 2007;5:298-304. DOI: 10.1370/afm.723. Ann Fam Med INTRODUCTIONH uman papillomavirus (HPV) ranks as the most commonly acquired sexually transmitted infection in the United States, and infection with HPV is linked to cervical cancer and genital warts.1,2 In June 2006, the fi rst HPV vaccine (Merck) was approved for females aged 9 to 26 years. 3 Shortly after its approval, the National Advisory Committee on Immunization Practices recommended that the vaccine be given to girls aged 11 to 12 years. 4 The approval of the HPV vaccine marks the beginning of a new stage in preventing sexually transmitted diseases (STDs) and their sequelae, in this case cervical cancer. Currently, the hepatitis B vaccine, administered during infancy, is the only existing vaccine that prevents a sexually transmitted disease, although several other STD vaccines are in various stages of development. 3,[5][6] Collectively, these vaccines have the potential to serve as powerful disease prevention weapons against chronic illnesses, including cancer. The availability of these vaccines will have important implicaAndrew L. Sussman, PhD 299CERVIC A L C A NCER PR EVENT ION COUNSELING tions for adolescents who, because they are at higher risk for contracting these diseases, will likely be the targeted recipients for these...

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To better understand how community-based long-term care providers define advance care planning and their role in the process, we conducted 8 focus groups with 62 care managers (social workers and registered nurses) providing care for Ohio's Medicaid waiver program. Care managers shared that most consumers had little understanding of advance care planning. The care managers defined it broadly, including legal documentation, social aspects, medical considerations, ongoing communication, and consumer education. Care managers saw their roles as information providers, healthcare team members, and educators/coaches. Better education, resources, and coordination are needed to ensure that consumer preferences are realized.