A Multilevel Intervention to Increase HPV Vaccination among Asian American Adolescents

Community Engagement in Vaccination Promotion: Systematic Review and Meta-Analysis

BACKGROUND

Community engagement plays a vital role in global immunization strategies, offering the potential to overcome vaccination hesitancy and enhance vaccination confidence. Although there is significant backing for community engagement in health promotion, the evidence supporting its effectiveness in vaccination promotion is fragmented and of uncertain quality.

OBJECTIVE

This review aims to systematically examine the effectiveness of different contents and extent of community engagement for promoting vaccination rates.

METHODS

This study was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. A comprehensive and exhaustive literature search was performed in 4 English databases (PubMed, Embase, Web of Science, and Cochrane Library) and 2 Chinese databases (CNKI and Wan Fang) to identify all possible articles. Original research articles applying an experimental study design that investigated the effectiveness of community engagement in vaccination promotion were eligible for inclusion. Two reviewers independently performed the literature search, study selection, quality assessment, and data extraction. Discrepancies were resolved through discussion, with the arbitration of a third reviewer where necessary.

RESULTS

A total of 20 articles out of 11,404 records from 2006 to 2021 were retrieved. The studies used various designs: 12 applied single-group pre-post study designs, 5 were cluster randomized controlled trials (RCTs), and 3 were non-RCTs. These studies targeted multiple vaccines, with 8 focusing on children's immunization, 8 on human papillomavirus vaccine, 3 on hepatitis B virus vaccine, and 1 on COVID-19 vaccine. The meta-analysis revealed significant increases in vaccination rates both in pre-post comparison (rate difference [RD] 0.34, 95% CI 0.21-0.47, I2=99.9%, P<.001) and between-group comparison (RD 0.18, 95% CI 0.07-0.29, I2=98.4%, P<.001). The meta-analysis revealed that participant recruitment had the largest effect size (RD 0.51, 95% CI 0.36-0.67, I2=99.9%, P<.001), followed by intervention development (RD 0.36, 95% CI 0.23-0.50, I2=100.0%, P<.001), intervention implementation (RD 0.35, 95% CI 0.22-0.47, I2=99.8%, P<.001), and data collection (RD 0.34, 95% CI 0.19-0.50, I2=99.8%, P<.001). The meta-analysis indicated that high community engagement extent yielded the largest effect size (RD 0.49, 95% CI 0.17-0.82, I2=100.0%, P<.001), followed by moderate community engagement extent (RD 0.45, 95% CI 0.33-0.58, I2=99.6%, P<.001) and low community engagement extent (RD 0.15, 95% CI 0.05-0.25, I2=99.2%, P<.001). The meta-analysis revealed that "health service support" demonstrated the largest effect sizes (RD 0.45, 95% CI 0.25-0.65, I2=99.9%, P<.001), followed by "health education and discussion" (RD 0.39, 95% CI 0.20-0.58, I2=99.7%, P<.001), "follow-up and reminder" (RD 0.33, 95% CI 0.23-0.42, I2=99.3%, P<.001), and "social marketing campaigns and community mobilization" (RD 0.24, 95% CI 0.06-0.41, I2=99.9%, P<.001).

CONCLUSIONS

The results of this meta-analysis supported the effectiveness of community engagement in vaccination promotion with variations in terms of engagement contents and extent. Community engagement required a "fit-for-purpose" approach rather than a "one-size-fits-all" approach to maximize the effectiveness of vaccine promotion.

TRIAL REGISTRATION

PROSPERO CRD42022339081; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=339081.

Human papillomavirus vaccination: a quantitative cross-sectional study of perceived barriers, influential advisors, and acculturation among Chinese college students aged 18-26 in the USA

HPV vaccines are highly effective in preventing HPV-associated cancers; however, HPV vaccination uptake is low among Chinese students studying at U.S. colleges. The purposes of this study were to evaluate (a) perceived barriers and influential others trusted for advice regarding HPV vaccination and (b) factors (i.e. HPV vaccination, acculturation) related to barriers and influential advisors among 18- to 26-year-old Chinese students attending U.S. colleges. We used a cross-sectional design to obtain self-reported data in 2019 from a chain-referral sample of 213 Chinese students. Among 125 respondents who were unvaccinated or partially vaccinated, the reported barriers to receiving the HPV vaccine included: (a) lack of recommendations from a healthcare provider, (b) lack of risk perception for HPV infection, and (c) limited knowledge about HPV vaccination locations. The influential advisors for receiving HPV vaccination were doctors, parents, self, nurses, and same-sex friends. Multivariate analysis revealed that unvaccinated respondents were more likely to report the following barriers to HPV vaccination: (a) lack of recommendations from a healthcare provider, (b) lack of risk perception for HPV infection, (c) limited knowledge about vaccination locations, and (d) uncertainty about effectiveness. High Asian identified respondents were more likely to perceive barriers related to limited knowledge about vaccination locations and uncertainty about effectiveness, while they were less likely to state nurses as influential advisors. Individuals who received one or more HPV vaccine doses were more inclined to view same-sex friends and nurses as influential advisors for HPV vaccination. The influence of culture on preferences for information sources, such as specific providers and provider gender, needs to be addressed. Programs designed to decrease barriers and improve HPV vaccination among Chinese students should also focus on acculturation status.

Increasing COVID-19 Immunization Awareness in Rural Communities Through a Multimedia Campaign

PURPOSE/OBJECTIVES

The purpose of this project was to implement a multimedia campaign to increase COVID-19 vaccine awareness and acceptance in rural communities.

DESCRIPTION OF PROJECT

This project was created and implemented in partnership with a public university in Michigan and targeted to rural Michigan communities. The campaign consisted of digital advertisements and video interviews with nurses from rural areas. Interview questions were developed using knowledge of the health belief model and allowed the nurses to share their COVID-19 stories. Video interviews were published to social media, and digital advertisements were targeted to rural areas via geofencing. A viewer response survey was provided to measure likelihood of behavior change after viewing.

OUTCOME

The campaign advertisements and videos reached 602 980 people during the implementation period, and 239 surveys were completed. Of the 53 unvaccinated respondents, 87% stated an increased likelihood to vaccinate.

CONCLUSION

This project supports the ability of the clinical nurse specialist to lead a multimedia campaign partnership that can reach thousands of people and increase the likelihood of vaccination. As the popularity of digital media continues to rise, clinical nurse specialists can embrace these channels to disseminate critical health information.

Creating and Activating an Implementation Community to Drive HPV Vaccine Uptake in Texas: The Role of an NCI-Designated Cancer Center

The University of Texas MD Anderson Cancer Center, a comprehensive cancer center designated by the National Cancer Institute (NCI), defines its service population area as the State of Texas (29.1 M), the second most populous state in the country and the state with the greatest number of uninsured residents in the United States. Consistent with a novel and formal commitment to prevention as part of its core mission, alongside clear opportunities in Texas to drive vaccine uptake, MD Anderson assembled a transdisciplinary team to develop an institutional Framework to increase adolescent HPV vaccination and reduce HPV-related cancer burden. The Framework was developed and activated through a four-phase approach aligned with the NCI Cancer Center Support Grant Community Outreach and Engagement component. MD Anderson identified collaborators through data-driven outreach and constructed a portfolio of collaborative multi-sector initiatives through review processes designed to assess readiness, impact and sustainability. The result is an implementation community of 78 institutions collaboratively implementing 12 initiatives within a shared measurement framework impacting 18 counties. This paper describes a structured and rigorous process to set up the implementation of a multi-year investment in evidence-based strategies to increase HPV vaccination that solves challenges preventing implementation of recommended strategies and to encourage similar initiative replication.

Developing a Culturally and Linguistically Congruent Digital Storytelling Intervention in Vietnamese and Korean American Mothers of Human Papillomavirus-Vaccinated Children: Feasibility and Acceptability Study

BACKGROUND

The high morbidity, mortality, and economic burden attributed to cancer-causing human papillomavirus (HPV) call for researchers to address this public health concern through HPV vaccination. Disparities of HPV-associated cancers in Vietnamese and Korean Americans exist, yet their vaccination rates remain low. Evidence points to the importance of developing culturally and linguistically congruent interventions to improve their HPV vaccination rates. We adopted digital storytelling (DST) that combines oral storytelling with computer-based technology (digital images, audio recording, and music) as a promising approach for facilitating the communication of culturally relevant health messages.

OBJECTIVE

This study aimed to (1) assess the feasibility and acceptability of intervention development through DST workshops, (2) conduct an in-depth analysis of the cultural experience that shapes HPV attitudes, and (3) explore aspects of the DST workshop experience that could inform future formative and intervention work.

METHODS

Through community partners, social media, and snowball sampling, we recruited 2 Vietnamese American and 6 Korean American mothers (mean age 41.4, SD 5.8 years) who had children vaccinated against HPV. Three virtual DST workshops were conducted between July 2021 and January 2022. Our team supported mothers to develop their own stories. Mothers completed web-based surveys before and after the workshop and provided feedback on each other's story ideas and the workshop experience. We used descriptive statistics to summarize quantitative data and constant comparative analysis to analyze qualitative data collected in the workshop and field notes.

RESULTS

Eight digital stories were developed in the DST workshops. They were well accepted, and the mothers showed overall satisfaction and relevant indicators (eg, would recommend it to others, would attend a similar workshop, it was worth their time; mean 4.2-5, range 1-5). Mothers found the process rewarding and appreciated the opportunity to share their stories in group settings and learn from each other. The 6 major themes that emerged from the data reflect the mothers' rich personal experiences, attitudes, and perceptions about their child's HPV vaccination, which included (1) showing parents' love and responsibility; (2) HPV and related knowledge, awareness, and attitudes; (3) factors influencing vaccine decision-making; (4) source of information and information sharing; (5) response to children's being vaccinated; and (6) cultural perspectives on health care and HPV vaccination.

CONCLUSIONS

Our findings suggest that a virtual DST workshop is a highly feasible and acceptable approach to engaging Vietnamese American and Korean American immigrant mothers in developing culturally and linguistically congruent DST interventions. Further research is needed to test the efficacy and effectiveness of digital stories as an intervention for Vietnamese American and Korean American mothers of unvaccinated children. This process of developing an easy-to-deliver, culturally and linguistically aligned, and holistic web-based DST intervention can be implemented with other populations in other languages.

Patient-Provider Health Communication Strategies: Enhancing HPV Vaccine Uptake among Adolescents of Color

Cervical cancer remains a public health issue in the United States, particularly among stigmatized racial and ethnic populations. The human papillomavirus (HPV) vaccine has been clinically proven to prevent cervical cancers, and other HPV-associated cancers, among men and women. However, HPV vaccine uptake is suboptimal; only 55% of adolescents complete the two-dose series by age 15. Past research has shown that provider HPV vaccine communication for people of marginalized races/ethnicities is subpar. This article focuses on provider communication strategies to promote HPV vaccine uptake effectively and equitably. The authors reviewed the literature on evidence-based patient-provider HPV vaccine communication techniques to create a set of communication language providers could use and avoid using to enhance HPV vaccine acceptance and uptake among adolescents of marginalized racial and ethnic groups. Evidence has shown that information and the manner of dissemination are critical for influencing HPV vaccine uptake. These communication strategies must be suited to the context of the targeted population, and the message content can be broadly categorized into source, content, and modality. Strategies to improve patient-provider communication among adolescents of color using source, modality, and content include the following: (1) Source: increase provider self-efficacy to provide the recommendation, building rapport between providers and parents; (2) Content: persistent, forceful language with minimal acquiescence should be employed, reframing the conversation focus from sex to cancer; and (3) Modality: use multiple vaccine reminder modalities, and work with the community to culturally adapt the vaccination language. Utilizing effective behavior-change communication adapted for adolescents of color can reduce missed opportunities for HPV prevention, potentially decreasing racial and ethnic disparities in HPV-related morbidity and mortality.

Knowledge about HPV Infection and the HPV Vaccine among Parents in Southeastern Serbia

Background and Objectives: The vaccine against human papilloma virus (HPV) infection is recommended, according to the Serbian National Immunization Program, for children and adolescents aged 9−19 years. Three doses are given keeping in mind the recommendation that the second dose should be administered at least one month after the first dose, and the third at least three months after the second dose. No children who participated in this first study received the third dose because they did not meet these criteria. The study explored parents’ knowledge about HPV infection and their awareness of the HPV vaccine. Materials and Methods: A cross-sectional questionnaire-based study was carried out in the city of Nis, in southeastern Serbia. According to the 2011 population census, the sample of children aged 9 to 19 was 850, and during the observed period, 631 children received the vaccine. A total of 615 fully completed questionnaires filled out by parents were included in the study. The study was carried out from 6 June 2022 to 7 October 2022. Multivariable logistic regression analysis was used. The odds ratio (OR) and 95% confidence intervals (CI) were calculated. The statistical significance was p < 0.05. Results: A total of 615 children were included in the study (499 were vaccinated with the first dose and 116 with the second). Out of 499 children vaccinated with the first dose, 398 (79.6%) were girls, which is significantly higher than the rate for boys (101). The independent variable sex was statistically significant at the level of p = 0.84, OR = 2.664 (95% CI from 0.879 to 7.954). Boys are 164% less likely to be vaccinated with the HPV vaccine than girls. We determined that the independent variable place of residence was significant at the level of p = 0.041, (OR = 3.809, 95% CI from 1.702 to 8.525). Based on these findings, we determined that parents who came from rural areas were 82% less likely to know about HPV infection and HPV vaccination. Children under 15 years of age were significantly more vaccinated than those ≥15 years (OR = 3.698, 95% CI from 1.354 to 12.598). The independent variable parental education was significant at the level of OR = 0.494, 95% CI from 0.301 to 0.791. Parents who had medical education showed significantly higher awareness about the infection caused by HPV and about the HPV vaccine (p = 0.004) than parents with no medical education. The possibility that a parent would decide to vaccinate a child significantly increased upon a pediatrician’s recommendation, p = 0.000 with OR = 0.250 (95% CI from 0.127 to 0.707). Health insurance coverage of HPV vaccination for children aged 9−19 years significantly increased the probability of a positive parental decision to vaccinate a child, p = 0.001 with OR = 3.034 (95% CI from 1.063 to 8.662). Conclusion: We identified several significant factors that were important for HPV vaccination such as: children under 15 years, female sex, urban place of residence, medical education of parents, pediatrician’s recommendation of the HPV vaccination, and HPV vaccination free of charge. Health education and the promotion of HPV vaccination as well as healthy sexual behavior are important factors in the preservation and improvement of the health of the whole population.

Sources of Information and Communication About HPV Among Chinese Students Attending U.S. Colleges: Implications for Culturally Appropriate Strategies

INTRODUCTION

Little is known about human papillomavirus (HPV) information sources and communication among Chinese students attending U.S. colleges. We assessed information sources and communication about HPV and HPV vaccines among this population.

METHODOLOGY

A cross-sectional design with 449 participants was conducted by using a questionnaire and snowball sampling. Summary statistics and multiple logistic regression were used.

RESULTS

The most common sources of HPV information included the internet and friends. Communication about HPV occurred most frequently among friends, family, and health professionals. Those who had better HPV knowledge and attitudes and were vaccinated against HPV were more likely to use internet, friends, family, and health professionals as their information sources.

DISCUSSION

Because the internet, friends, and families are likely sources for HPV information and communication, future internet-based culturally appropriate education should offer information not only to Chinese students but also to their social circles. Cultural beliefs may affect HPV prevention and should be examined.

Factors associated with intention of human papillomavirus vaccination among Chinese college students: implications for health promotion

Human papilloma virus (HPV) is the most common reproductive tract virus. Most HPV infections occur during adolescence or young adulthood, and thus college students are one of the main target populations of HPV vaccination. However, data on knowledge of HPV and HPV vaccine as well as the intention to be vaccinated among Chinese college students were limited. The purpose of this study was to address this gap by investigating a sample of college students from four universities and analyzing the factors influencing their intention. College students (N = 343) filled in a survey comprised of demographic information, HPV and vaccine knowledge, and vaccination intention between September 2018 and January 2019. A descriptive statistical analysis was conducted to describe students' HPV-related knowledge and vaccination intention. Logistic regression analysis was used to determine the predictors of HPV vaccination intention. The participants had low levels of HPV and HPV vaccine-related knowledge, as well as modest intention to be vaccinated. Significant differences were identified in gender, years of study, and perceived susceptibility of HPV infection. Students who perceived higher risk of HPV infection (OR = 6.659, p = .001), had higher level knowledge of HPV vaccine (OR = 2.697, p < .001), in junior (OR = 0.186, p = .006) and senior year (OR = 0.276, p = .015) had greater intention to get HPV vaccinated. The findings suggest that multiple-level efforts are continuously needed to target Chinese college students to increase their HPV vaccine knowledge and vaccination awareness to reduce HPV-related disease burden among this population.