A Bundled, Practice-Based Intervention to Increase HPV Vaccination.

Missed opportunities for human papillomavirus (HPV) vaccination during pediatric health care visits are common. To evaluate the effect of online communication training for clinicians on missed opportunities for HPV vaccination rates overall and at well-child care (WCC) visits and visits for acute or chronic illness (hereafter referred to as acute or chronic visits) and on adolescent HPV vaccination rates. From December 26, 2018, to July 30, 2019, a longitudinal cluster randomized clinical trial allocated practices to communication training vs standard of care in staggered 6-month periods. A total of 48 primary care pediatric practices in 19 states were recruited from the American Academy of Pediatrics Pediatric Research in Office Settings network. Participants were clinicians in intervention practices. Outcomes were evaluated for all 11- to 17-year-old adolescents attending 24 intervention practices (188 clinicians) and 24 control practices (177 clinicians). Analyses were as randomized and performed on an intent-to-treat basis, accounting for clustering by practice. Three sequential online educational modules were developed to help participating clinicians communicate with parents about the HPV vaccine. Weekly text messages were sent to participating clinicians to reinforce learning. Statisticians were blinded to group assignment. Main outcomes were missed opportunities for HPV vaccination overall and for HPV vaccine initiation and subsequent doses at WCC and acute or chronic visits (visit-level outcome). Secondary outcomes were HPV vaccination rates (person-level outcome). Outcomes were compared during the intervention vs baseline. Altogether, 122 of 188 clinicians in intervention practices participated; of these, 120, 119, and 116 clinicians completed training modules 1, 2, and 3, respectively. During the intervention period, 29 206 adolescents (14 664 girls [50.2%]; mean [SD] age, 14.2 [2.0] years) made 15 888 WCC and 28 123 acute or chronic visits to intervention practices; 33 914 adolescents (17 069 girls [50.3%]; mean [SD] age, 14.2 [2.0] years) made 17 910 WCC and 35 281 acute or chronic visits to control practices. Intervention practices reduced missed opportunities overall by 2.4 percentage points (-2.4%; 95% CI, -3.5% to -1.2%) more than controls. Intervention practices reduced missed opportunities for vaccine initiation during WCC visits by 6.8 percentage points (-6.8%; 95% CI, -9.7% to -3.9%) more than controls. The intervention had no effect on missed opportunities for subsequent doses of the HPV vaccine or at acute or chronic visits. Adolescents in intervention practices had a 3.4-percentage point (95% CI, 0.6%-6.2%) greater improvement in HPV vaccine initiation compared with adolescents in control practices. This scalable, online communication training increased HPV vaccination, particularly HPV vaccine initiation at WCC visits. Results support dissemination of this intervention. ClinicalTrials.gov Identifier: NCT03599557.

Human papillomavirus (HPV) vaccination rates lag behind vaccination rates for other adolescent vaccines; a bundled intervention may improve HPV vaccination rates. Our objective is to evaluate the impact of quality improvement (QI) training plus a bundled practice-based intervention (provider prompts plus communication skills training plus performance feedback) on improving HPV vaccinations in pediatric resident continuity clinics. Staff and providers in 8 resident clinics participated in a 12-month QI study. The intervention included training to strengthen provider communication about the HPV vaccine. Clinics also implemented provider prompts, received monthly performance feedback, and participated in learning collaborative calls. The primary outcome measure was eligible visits with vaccination divided by vaccine-eligible visits (captured HPV vaccination opportunities). Practices performed chart audits that were fed into monthly performance feedback on captured HPV vaccination opportunities. We used conditional logistic regression (conditioning on practice) to assess captured vaccination opportunities, with the time period of the study (before and after the QI intervention) as the independent variable. Overall, captured opportunities for HPV vaccination increased by 16.4 percentage points, from 46.9% to 63.3%. Special cause was demonstrated by centerline shift, with 8 consecutive points above the preintervention mean. On adjusted analyses, patients were more likely to receive a vaccine during, versus before, the intervention (odds ratio: 1.87; 95% confidence interval: 1.54-2.28). Captured HPV vaccination rates improved at both well-child and other visits (by 11.7 and 13.0 percentage points, respectively). A bundled intervention of provider prompts and training in communication skills plus performance feedback increased captured opportunities for HPV vaccination.

BackgroundSuboptimal human papillomavirus (HPV) vaccination rates persist among adolescents in the United States (U.S.). New Jersey (NJ), among the top, most racially/ethnically diverse states in the U.S., had among the lowest HPV vaccine initiation rates, prior to 2018. This study examined parental HPV vaccine knowledge and adolescent HPV vaccine initiation among multiethnic parents in NJ, where access to language concordant HPV vaccine information and vaccination services may differ, for immigrant parents.MethodsWe surveyed parents of adolescents (ages 11–18) at community events in NJ to examine parental HPV vaccine knowledge and adolescent HPV vaccine uptake. Vaccine knowledge was assessed using an 11-item question stem that covered vaccine efficacy, gender recommendation, vaccine protection, and myths. Multivariable models assessed the association of parent nativity on HPV vaccine knowledge scores and adolescent HPV vaccine initiation, controlling for sociodemographic factors.ResultsOf the 77 parents, most parents (84%) were aware of the HPV vaccine. However, knowledge scores were low and differed by parent nativity. Non-U.S. born parents had significantly lower knowledge scores − 1.7 [− 3.1, − 0.4] and lower odds of adolescent children initiating the HPV vaccine 0.3 [0.1, 0.9] compared to U.S.-born parents after adjusting demographic characteristics.ConclusionsOur findings reveal that parental HPV vaccine knowledge remains low among suburban dwelling, immigrant parents, even though they have higher education and access to health care. Multilevel strategies to reduce missed opportunities for HPV vaccine education among parents and HPV vaccination for adolescents are needed, including for suburban, immigrant communities.

Background: the distribution of human papillomavirus (HPV) infection, vaccination rates, and awareness levels varies across China. Methods: this study examined HPV infection prevalence, vaccine uptake, and barriers among 2440 women aged 30–64 in Shenzhen, China, using partial least squares structural equation modeling (PLS-SEM) to analyze associated factors. Results: The overall HPV prevalence was 14.2% (347/2440), with HPV52 being the most common type, followed by HPV58 and HPV53. Factors significantly associated with HPV infection included more sexual partners, genital tract infections, manual labor, and single marital status (p < 0.05), whereas higher education demonstrated a protective association (p < 0.05). The HPV vaccination rate was 41.8% in ages 30–45. There were direct effect indicators of younger age, fewer pregnancies, and premenopausal status (p < 0.05) on HPV vaccine uptake, whereas inversely associated factors included divorce/widowed, lower household income, irregular menstruation, more deliveries, no contraception, and lack of HPV knowledge. Among 828 unvaccinated individuals, 47.9% of those aged 46–64 were willing if the age restrictions were expanded, with the main barrier being a lack of vaccine knowledge (40.7%). Willingness was significantly associated with younger age and healthcare occupation (p < 0.05), but negatively with eastern Shenzhen residence, lower household income, no HPV disease awareness, abnormal leucorrhea, lack of HPV knowledge, and belief against post-vaccination screening (p < 0.05). Conclusions: Socioeconomic disparities in HPV infection and vaccination rates in Shenzhen highlight intervention priorities. The impact of HPV knowledge underscores the need for effective health communication. The vaccination willingness and infection status among women aged 45+ provide supporting evidence for expanding HPV vaccination to older age groups.

Far too few adults getting recommended vaccines

For a previous longitudinal cluster randomized controlled trial (2018-2019), we randomized 48 primary care pediatric practices to online communication training vs usual care. Online communication training reduced missed opportunities (MOs) for initial human papillomavirus (HPV) vaccination at well-child care (WCC) visits by 6.8 percentage points among children aged 11-17years. The current study estimated implementation costs of the communication training intervention at WCC visits. We analyzed monthly surveys completed by intervention practice lead clinicians to track clinician plus office staff personnel hours devoted to implementing the intervention. We converted personnel time into 2019 US dollars using national median hourly wages for physicians and other health care workers; we tracked nonpersonnel costs. We calculated costs per practice (overall and by practice size) and estimated costs per averted MO for HPV vaccine initiation using an effectiveness estimate determined by grouped logistic regression at the practice level. Practices varied from 1 to 24 clinicians (mean = 7.5) and from 241 to 8866 visits (mean = 2353) during the 6-month intervention. Total intervention costs varied substantially across the 24 intervention practices from $370 to $6653, with a mean of $2003 (95% CI, $1377-$2762) and median of $1305. The incremental cost per averted MO for HPV vaccine initiation at WCC visits averaged $110 ($212 in practices with 1 or 2 physicians and $94 in practices with 3 or more physicians). The implementation cost per averted MO for HPV vaccine initiation at WCC visits of this online communication training intervention was modest, particularly among larger pediatric practices.

Lessons Learned From Human Papillomavirus Vaccination to Increase Uptake of Adolescent COVID-19 Vaccination

The purpose of this DNP project was to establish baseline human papillomavirus (HPV) vaccination rates, improve baseline knowledge of HPV and HPV vaccines, reduce barriers to HPV vaccination, and increase intention of HPV vaccine uptake among college students. A precaution adoption process model-based survey, in-person education session, and posteducation survey were administered to college students in a Midwestern university to measure perceptions of HPV and HPV vaccination as well as to identify barriers to HPV vaccination. From the preeducation survey to the posteducation survey, correct answers to questions increased, and barriers and misconceptions about HPV and the HPV vaccine decreased, indicating successful education. HPV vaccination intent, defined as indication of "likely" or "very likely" to receive the vaccine on the surveys, rose from 28.0% to 90.7% among participating college students. This study showed that implementing engaging, in-person HPV prevention education is an effective method for decreasing barriers related to vaccination and increasing vaccination intention.

Implementation and Evaluation of a School-Based Human Papillomavirus Vaccination Program in Rural Kentucky.

In the United States, uptake of human papillomavirus (HPV) vaccination has been exceptionally low as compared with other vaccines. During the coronavirus disease (COVID-19) pandemic, routine vaccinations were deferred or delayed, further exacerbating HPV vaccine hesitancy. The specific effect of the pandemic on HPV vaccination rates in the United States has not been yet described. We aimed to determine the percentage of children achieving full HPV vaccination (2 doses) by age 15 years and to compare prepandemic to pandemic rates of HPV vaccination at pediatric practices across our institution. A retrospective chart review was performed to compare HPV vaccination rates in the "prepandemic" and "pandemic" periods for all children 9 through 14 years of age. Additionally, peaks in COVID-19 positivity were compared with HPV vaccination rates. Of children aged 9-14 years, 49.3% received at least 1 dose of HPV vaccine in the prepandemic period, compared with 33.5% during the pandemic (P < 0.0001). Only 33.5% of patients received the full 2-dose series of HPV prepandemic, compared with 19.0% of patients during the pandemic (P < 0.0001). When COVID-19 positivity rates peaked, HPV vaccination also declined. The issue of low HPV vaccination rates was amplified due to the COVID-19 pandemic, as illustrated by the correlation between peaks in COVID-19 positivity and low rates of HPV vaccination.

Human papillomavirus (HPV) infection and vaccination: A cross-sectional study of college students’ knowledge, awareness, and attitudes in Villanova, PA

Purpose: New strategies to improve human papillomavirus (HPV) vaccine uptake among minority and underserved adolescents are needed. The purpose of this study is to describe the development of a multi-level HPV vaccine intervention to increase adolescent HPV vaccination rates. Methods: A community-engaged process was used over a one year period. Caregivers (n=18) and providers (n=27) from a Federally Qualified Health Center participated in: 1) focus groups to better understand knowledge and acceptability of the HPV vaccine, and to generate ideas for the intervention content and format; 2) writing sessions to develop the content and intervention components; and 3) review sessions to obtain initial feedback and make revisions prior to pilot testing the intervention. Results: Intervention components developed were based on the Protection Motivation Theory and the PACE (Present the issue, Ask questions, Check understanding, and Express concerns) communication system. The intervention components developed (English and Spanish) focus on three levels: 1) Caregivers: a) an interactive computer program tailored for the adolescent's gender, age, race/ethnicity, b) a brochure with information about additional resources, and c) a HPV vaccine comic book to assist caregivers with explaining the HPV vaccine to younger adolescents; 2) Providers: a) an automated PowerPoint presentations including current HPV vaccine initiation and completion rates, suggestions to address common barriers, and video clips demonstrating the teach-back methodology, b) current HPV vaccine scientific literature, and c) “Ask me about the HPV vaccine!” pins; and 3) Health Centers: a) posters, and b) refrigerator magnets that serve as reminders for the second and third dose of the HPV vaccine. Conclusions: Community members provided valuable input into the development of a multi-level HPV vaccine intervention. The input will make the intervention relatable and more acceptable to the priority population. Using this community-engaged approach is more complex, increases costs, and involves additional time and effort from community members and academic researchers. The value of the partnership is critical and the additional time and energy expended is important to successfully address cancer disparities among minority and underserved populations. Citation Format: Mira Lynn Katz, Paul L. Reiter, Mack T. Ruffin, IV, Electra D. Paskett. Development of a multilevel human papillomavirus (HPV) vaccine intervention. [abstract]. In: Proceedings of the Seventh AACR Conference on The Science of Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; Nov 9-12, 2014; San Antonio, TX. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2015;24(10 Suppl):Abstract nr A15.

Toward a Deeper Understanding of the Spectrum of Parental Human Papillomavirus Vaccine Hesitancy

Since mid-2006, a licensed human papillomavirus (HPV) vaccine has been available and recommended by the Advisory Committee on Immunization Practices (ACIP) for routine vaccination of adolescent girls at ages 11 or 12 years. Two vaccines that protect against HPV infection are currently available in the United States. Both the quadrivalent (HPV4) and bivalent (HPV2) vaccines protect against HPV types 16 and 18, which cause 70% of cervical cancers; HPV4 also protects against HPV types 6 and 11, which cause 90% of genital warts. In 2011, the ACIP also recommended HPV4 for the routine vaccination of adolescent boys at ages 11 or 12 years. HPV vaccines can be safely co-administered with other routinely recommended vaccines, and ACIP recommends administration of all age-appropriate vaccines during a single visit. To assess progress with HPV vaccination coverage among adolescents aged 13-17 years, characterize adherence with recommendations for HPV vaccination by the 13th birthday, and describe HPV vaccine adverse reports received postlicensure, CDC analyzed data from the 2007-2013 National Immunization Survey-Teen (NIS-Teen) and national postlicensure vaccine safety data among females and males. Vaccination coverage with ≥1 dose of any HPV vaccine increased significantly from 53.8% (2012) to 57.3% (2013) among adolescent girls and from 20.8% (2012) to 34.6% (2013) among adolescent boys. Receipt of ≥1 dose of HPV among girls by age 13 years increased with each birth cohort; however, missed vaccination opportunities were common. Had HPV vaccine been administered to adolescent girls born in 2000 during health care visits when they received another vaccine, vaccination coverage for ≥1 dose by age 13 years for this cohort could have reached 91.3%. Postlicensure monitoring data continue to indicate that HPV4 is safe. Improving practice patterns so that clinicians use every opportunity to recommend HPV vaccines and address questions from parents can help realize reductions in vaccine-preventable infections and cancers caused by HPV.

Background: Rates of human papillomavirus (HPV) vaccine uptake in Hmong-Americans, an Asian American and Pacific Islander (AAPI) minority group, are substantially lower than the majority of Americans. In 2015, a community health center (CHC) in Minnesota found that HPV vaccine rates for Hmong children ages 9-17 were 32% in girls and 20% in boys, much lower than nationally published HPV coverage rates in 2017 (47% and 53%, respectively). This qualitative study identified barriers, facilitators, and decision-making processes about HPV vaccinations among Hmong adolescents and parents. Methods: Hmong adolescents (14-17 years old) and their parents were recruited from a local CHC to participate in focus group sessions. Using a community-based participatory action research approach, bilingual community researchers conducted eight focus groups with adolescents and parents. Prior to focus groups, participants provided demographic information and completed a survey about HPV and HPV vaccination. Focus group transcripts were analyzed using participatory thematic analysis. Themes were codified using a socioecological model (multilevel) framework combined with an assets lens. Results: A total of 12 adolescents and 13 parents participated in the focus groups (N = 25). Both survey and focus group results showed that Hmong adolescents and parents had low levels of awareness regarding HPV or the HPV vaccine. At the individual-level, both adolescents and parents reported concerns about side effects and costs as potential reasons for not getting vaccinated. Whereas, an individual-level facilitator for both adolescents and parents included personal agency (i.e., individual desire to want to learn more about HPV and the HPV vaccine). At the community-level, barriers included community narratives around traumatic experiences with vaccine, and facilitators included strong community connections and communications. At the institutional-level, barriers included lack of a school policy requiring HPV vaccinations and structural constraints in health care settings, while facilitators included ease of obtaining vaccines at school-based clinics and provider authoritative decision making. Finally, there was a range of decision-making processes between parents and adolescents and parents and providers. Conclusion: A culturally-appropriate HPV educational program for Hmong adolescents and parents could address barriers and build on facilitators and assets to promote HPV vaccine uptake. These findings have been used in the development of an eHealth application to increase HPV vaccinations in Hmong adolescents. Future research studies that test the feasibility, acceptability, and efficacy of culturally-tailored, multilevel HPV vaccination interventions may provide evidence about the efficacy of culturally-appropriate education in comprehensive vaccine strategies. Citation Format: Serena Xiong, Maiyia Y Kashouaher, Bai Vue, Kathleen A Culhane-Pera, Shannon L Pergament, Jay Desai, Hee Yun Lee. HPV vaccination in Hmong-American adolescents: A multilevel and assets-based qualitative study [abstract]. In: Proceedings of the Twelfth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2019 Sep 20-23; San Francisco, CA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl_2):Abstract nr B048.