Implementation of a Postpartum HPV Vaccination Program in a Southeast Texas Hospital: A Qualitative Study Evaluating Health Care Provider Acceptance

Human Papillomavirus Vaccination in the Postpartum Period: A Systematic Review

OBJECTIVE

To assess whether routine postpartum human papillomavirus (HPV) vaccination is acceptable and feasible and to identify key themes and strategies that can be used to increase postpartum HPV vaccination rates.

DATA SOURCES

PubMed and ClinicalTrials.gov were queried from inception to July 2024 for postpartum and HPV vaccination. Studies were limited to human subjects and the English language.

METHODS OF STUDY SELECTION

Screening was performed for studies of any method that evaluated HPV vaccination in the postpartum period (N=60). Only original research that reported either uptake or acceptability of the HPV vaccine was included. Thirty-nine studies were eliminated after abstract review because they did not meet the inclusion criteria.

TABULATION, INTEGRATION, AND RESULTS

Nine studies were categorized according to the primary aim of the study (defining the problem, assessing patient perspectives, or testing interventions to increase vaccination) and demonstrated that postpartum HPV vaccination programs can significantly increase HPV vaccination rates and are feasible and acceptable to patients.

CONCLUSION

Incorporating HPV vaccination into standard postpartum care provides an opportunity to reach vulnerable patient populations, reduces cost for patients, and has the ability to prevent HPV-related cancers.

Evaluation of an HPV vaccine toolkit to improve OB/GYN discussion of HPV vaccination

Background

HPV (Human Papillomavirus) vaccination is a safe, effective method to prevent HPV-associated disease. Racial-ethnic disparities in HPV vaccination exist, which could lead to widening gaps in cervical cancer mortality. Provider discussion of HPV vaccination has been shown to be a primary factor for increasing vaccination rates. The objective of this study is to assess provider discussion of HPV vaccination pre and post implementation of an intervention, named the HPV Vaccine Toolkit, in an Obstetrics and Gynecology (OB/GYN) clinic in Boyle Heights, Los Angeles.

Study design and methods

This quality improvement study occurred over four cycles of development. Its design was guided by the Theory of Planned Behavior. The toolkit components included dot phrases (pre-written phrases to speed documentation), educational posters, electronic health record prompts, HPV vaccine referral guides, and educational sessions. Chart audits and pre- and post-providers surveys were performed between 2019 and 2021 to assess for an increase in provider discussion of the HPV vaccine, as well as to evaluate the various components of the toolkit.

Results

Provider discussion increased over the four cycles of this intervention, with HPV vaccination discussion documented in 15 % of patients in 2019, 19 % of patients in 2020 and 47 % of patients in 2021. Gaps identified included limited discussion of vaccination at postpartum visits. Provider uncertainty of where to refer patients for the HPV vaccine decreased following the intervention.

Conclusion

Discussion of HPV vaccination is an important preventative strategy that can be overlooked in OB/GYN clinics. Implementation of multicomponent strategies can increase provider discussion of HPV vaccination status, although barriers to discussion remain. Improved counseling on HPV vaccination could have significant impacts on reducing HPV-related disease.

Quantitative and qualitative assessment of an all-inclusive postpartum human papillomavirus vaccination program

BACKGROUND

A postpartum human papillomavirus vaccination program was locally implemented to address low initiation rates among young adults. Within 20 months, the program achieved high vaccine initiation and series completion rates. Based on the program's success, it was expanded to all 36 counties served by a public hospital.

OBJECTIVE

This study aimed to conduct a quantitative and qualitative evaluation to examine the success and limitations of the program when expanded from 1 county to 36 counties, many of which are home to rural and medically underserved communities.

STUDY DESIGN

Patient navigators reviewed the electronic medical records and immunization registry records of women aged ≤26 years, who delivered an infant at the public hospital, to determine whether they needed to initiate or complete the human papillomavirus vaccine series. Eligible women were counseled and offered the human papillomavirus vaccine during their hospital stay. Patient navigators scheduled follow-up injections in addition to the mother's postpartum or her infant's well-child visits, made reminder phone calls, and rescheduled missed appointments. Descriptive statistics, including frequencies and proportions, were used for patients approached in the initial and expansion programs. Frequencies from the initial and expansion programs were examined separately. Qualitative interviews were conducted with the clinic staff to evaluate the program. The qualitative analyses were conducted using NVivo (QSR International, Melbourne, Australia, version 10).

RESULTS

Both initial and expanded programs achieved vaccine completion rates above 70%. Of the 2631 eligible postpartum women enrolled in the initial program, 785 (30%) had already been fully vaccinated. Of the remaining 1846 women, 1265 (69%) women received their first dose, and 196 (11%) women received their second or third dose on the postpartum unit. Of the 1461 women who received at least 1 dose through the initial program, 1124 (77%) completed all 3 doses. Of the 4330 eligible postpartum women enrolled in the expanded program, 886 (21%) had already been fully vaccinated. Of the remaining 3444 women, 2284 (66%) received their first dose, and 343 (10%) received their second or third dose on the postpartum unit. Of the 2627 women receiving at least 1 dose through the expanded program, 1932 (74%) completed all 3 doses. Clinic staff interviewed felt the program benefited the postpartum unit and clinics, because it increased patient knowledge of the vaccine, increased patient volume for vaccination, and gave healthcare providers more time to focus on other tasks.

CONCLUSION

Human papillomavirus vaccination on the postpartum unit is an effective way to increase catchup rates and is well accepted by healthcare providers. High completion rates can be achieved if adequate support is provided, even among patients residing in rural or underserved areas who need extensive support to access primary healthcare services. Although this particular program may be considered costly, it is overall effective because the vaccine prevents 5 different types of cancer in women. The inclusion of human papillomavirus vaccination in routine postpartum care is a relatively easy way to reach many adults not vaccinated at a younger age and could help address low vaccination rates among young women in the United States, including hard-to-reach populations.

Inpatient Immunization With HPV Vaccine: A Qualitative Study With Postpartum Women

INTRODUCTION

Rates of immunization with human papillomavirus (HPV) vaccine among adolescent and young adult females remain suboptimal. There is a continued need to focus on catch-up immunization. Some hospitals in the United States have implemented inpatient postpartum HPV immunization programs (IPP-HPV) as part of a strategy to improve rates of catch-up immunization. Patients' perspectives are critical to facilitating broad adoption of IPP-HPV. The objectives of this study were to understand the experiences and perspectives of postpartum women recommended to receive HPV vaccine before hospital discharge and to identify facilitators of and barriers to program implementation.

METHODS

We conducted in-depth semistructured interviews with postpartum women eligible for IPP-HPV. We used purposive sampling to ensure representation across race, ethnicity, and language. Interviews were analyzed using an iterative thematic approach.

RESULTS

The median age of participants (n = 24) was 22 years (range, 15-26 years), and six had declined the inpatient dose of HPV vaccine. Overall, women viewed IPP-HPV favorably. Facilitators of program implementation included viewing HPV vaccine as prevention, normalization of the vaccine, convenience of IPP-HPV, and the experience of a patient-centered approach. Barriers included the peripartum environment and associated stress, vaccine hesitancy, and a lack of both awareness of and knowledge about HPV vaccine.

CONCLUSIONS

IPP-HPV immunization is a strategy well-received by women for improving rates of catch-up immunization. The implementation of such programs may be optimized by increasing awareness that the vaccine is available and recommended for postpartum women, and by using a patient-centered approach that is sensitive to the needs of postpartum patients.

A National Survey of Obstetrician/Gynecologists' Knowledge, Attitudes, and Beliefs Regarding Adult Human Papillomavirus Vaccination

Background: Many women see an obstetrician/gynecologist (OB/GYN) annually and receive their primary care from an OB/GYN. Understanding OB/GYNs' human papillomavirus (HPV) vaccination practices, including knowledge of and barriers to vaccination, is essential to design effective interventions to increase vaccination. This study evaluated OB/GYN knowledge, attitudes, and beliefs regarding vaccinating both younger (18-26 years) and mid-adult (27-45 years) women. Materials and Methods: Data were collected from OB/GYN providers in October 2019 through a nationwide web-based survey. Items included the following: HPV-related vaccination practices, recommendation strength, knowledge (seven items), benefits (four items), and barriers (eight items). Results: The sample (n = 224) was majority were White (69%), men (56%), and practice in suburban clinics (55%). Most (84%) reported they usually or always recommend HPV vaccine to eligible patients, but estimated only about half (51%) of other OB/GYNs did the same. Recommendation strength varied by patient age with 84% strongly recommending it to patients ≤18 years, compared with 79% and 25% strongly recommending to younger and mid-adult patients, respectively (p < 0.01). Participants reported lower benefits (p = 0.007) and higher barriers (p < 0.001) for 27- to 45-year-old patients compared with younger patients. Cost was the most frequently reported barrier, regardless of patient age. Overall knowledge was high (m = 5.2/7) but 33% of participants did not know the vaccine was safe while breastfeeding. Conclusions: Although providers reported strongly and consistently recommending the HPV vaccination to their adult patients, there were gaps in knowledge and attitudinal barriers that need to be addressed. Provider performance feedback may be important in improving HPV vaccination awareness among providers.

Success of an EMR-Driven Postpartum Intervention to Improve HPV Vaccination Rates

Human papillomavirus vaccination (HPV) remains low in the United States. The inpatient postpartum setting provides an innovative opportunity to vaccinate eligible patients. This study evaluated two different interventions to improve HPV vaccination rates in hospitalized postpartum patients: a nurse based protocol and an electronic medical record (EMR) postpartum order prompt. This was a comparative intervention study performed in a prospective cohort of postpartum patients at two affiliated County Hospitals. The intervention was conducted over a 6-month period aimed at increasing HPV vaccination rates through a nurse based protocol at one hospital (H-NBP) and an EMR postpartum order prompt at the second hospital (H-EMR). Outcomes measures included vaccine administration, patient refusal, and vaccine wastage. A multiple logistic regression model was used to compare outcomes. At H-NBP, 143 vaccine-eligible patients (74%) were identified of which 44 (32%) received the HPV vaccine, 66 (46%) refused, and 33 (21%) had missed opportunities. At H-EMR, 169 patients (87%) were identified as vaccine-eligible of which 111 (66%) received the HPV4 vaccine, 24 (14%) refused and 34 (20%) had missed opportunities. After adjusting for sociodemographic variables, patients at H-EMR were nearly 6 times more likely than patients at H-NBP to undergo postpartum HPV vaccination (OR 5.865, CI 3.358-10.245, p value < 0.0001). An EMR prompt offers a greater impact on HPV vaccination rates than a nursing protocol. The feasibility and success of inpatient postpartum HPV vaccination interventions as demonstrated in this study provides insights on how to approach vaccination strategies in nontraditional clinical settings.

Postpartum Health and Wellness: A Call for Quality Woman-Centered Care

Introduction The first 3 months after giving birth can be a challenging time for many women. The Postpartum Health and Wellness special issue explores this period, one that is often overlooked and under-researched. Methods This issue is designed to bring greater focus to the need for woman-centered care during the postpartum period. Articles in this issue focus on four key areas: (1) the postpartum visit and access to care, (2) the content of postpartum care and postpartum health concerns, (3) interconception care including contraception, and (4) policy, systems, and measurement. Results The submissions highlight deficits in the provision of comprehensive care and services during a critical period in women's lives. The research highlighted in this issue supports the recommendation that Maternal and Child Health leaders collaborate to create woman-centered postpartum services that are part of a coordinated system of care. Conclusion In order to achieve optimal health care in the postpartum period it is becoming more apparent that increased flexibility of services, cross-training of providers, a "no wrong door" approach, new insurance and work-place policy strategies, improved communication, and effective coordinated support within a system that values all women and families is required.