Advancing Human Papillomavirus Vaccine Delivery: 12 Priority Research Gaps

Impact of the COVID-19 pandemic on social media utilization, influences related to parental vaccine decision making, and opinions on trustworthy social media vaccination campaigns: A qualitative analysis

There is a continued need for research to better understand the influence social media has on parental vaccination attitudes and behaviors, especially research capturing the effects of the COVID-19 pandemic. The goal of this study was to explore parents' perspectives related to the impact the pandemic had on 1) social media engagement, 2) vaccine messaging on social media, and 3) factors to guide future intervention development. Between February and March 2022, 6 online, synchronous, text-based focus groups were conducted with parents of adolescents aged 11 to 17 years. Participants who all utilized social media were recruited from across the United States. Qualitative data were analyzed using content analysis. A total of 64 parents participated. Average age was 47 years, and participants were predominantly White (71.9%), female (84.3%), and engaged with social media multiple times per day (51.6%). Participants (95.3%) viewed obtaining all recommended vaccines as important or very important; however, overall vaccination rates for their adolescents were varied (50% ≥1 dose HPV; 59.4% MenACWY; 78.1% Tdap; 65.6% Flu; 81.3% COVID-19). Three themes emerged highlighting the pandemic's impact on parent's (1) general patterns of social media use, (2) engagement about vaccines on social media and off-line behaviors related to vaccination, and (3) perspectives for developing a credible and trustworthy social media intervention about vaccination. Participants reported fatigue from contentious vaccine-related content on social media and desired future messaging to be from recognizable health institutions/associations with links to reputable resources. Plus, providers should continue to provide strong vaccine recommendations in clinic.

Evidence-Based Storytelling for a Strategic Roadmap to Promote Cancer Prevention via Adolescent HPV Vaccination in Northern New England

Vaccination rates for the human papillomavirus (HPV) among rural youth in northern New England lag those of more urbanized areas. Reasons include a lack of available medical offices, time constraints, perceptions of vaccines and HPV, and, to a smaller degree, delays caused by the COVID-19 pandemic. We have a responsibility to increase vaccinations in these communities. To do so, vaccination experts recommend addressing the three C's of vaccination hesitation: confidence, complacency, and convenience. With this framework as our foundation, in this article we detail a plan to address these important elements, and we add several more C's: clinics, communication, collaboration, community, capacity, and commitment to the list as we discuss the essential pieces-human, infrastructural, and perceptual-needed to create and promote successful, community-supported, school-based HPV vaccination clinics to serve youths aged nine to 18. We then integrate research and storytelling science into an innovative Persuasion Playbook, a guide for local opinion leaders to use in creating evidence-based, pro-vaccine messages on the community level to promote the clinics via evidence-based, pro-vaccination messages.

Engaging health plans to prioritize HPV vaccination and initiate at age 9

Health plans can influence pediatric and primary care providers and patients to understand HPV vaccination coverage and increase HPV vaccination uptake. By initiating vaccination at age nine, health plans can lay the groundwork for on-time HPV cancer prevention by age 13. In 2022, the American Cancer Society engaged 28 health plans in a 12-month HPV vaccination learning collaborative in which plans set their own quality improvement targets, implemented multi-pronged interventions, and joined quarterly best-practice sharing calls. Twenty-five of the 28 plans reported including a focus on ages 9 to 10. Preliminary pre-intervention data illustrate that vaccination rates from participating plans follow national trends and reaffirm existing gaps for HPV vaccination. Health plan interventions to address HPV vaccination are consistent with best practices but could be maximized to target initiation at ages 9-10 by using provider and patient reminders, targeted provider education, and dose-specific provider pay for performance and patient incentive programs. Health plans should explore future capacity to analyze non-HEDIS required data, including HPV initiation and HPV vaccination data for adolescents below age 13.

An Evaluation of Knowledge and Comfort in Discussing the Human Papillomavirus (HPV) Vaccine Among a Sample of Physicians Practicing in South Carolina

Objective To determine knowledge and comfort in discussing the human papillomavirus (HPV) vaccine among a sample of physicians practicing in South Carolina. Methods This descriptive cross-sectional study utilized a 33-question survey assessing knowledge of HPV, the HPV vaccine, and comfort in discussing associated topics with patients among a sample of physicians across the state of South Carolina. Descriptive and correlational analyses were performed. Results Of the total 66 participants, most self-reported having sufficient knowledge about HPV, yet responses to fact-based questions yielded an average score of only 7.03/13. Most felt comfortable discussing HPV, while some reported discomfort discussing sex-related topics (3.6%). A positive significant correlation was determined between having sufficient knowledge of HPV and comfort levels discussing both HPV and sex-related topics ((p-value < 0.001), (p = .0028)), comfort levels discussing HPV and comfort levels discussing sex (p = .0030), and comfort level discussing sex and previous communication training (Mantel-Haenszel chi-square = 0.0447). Conclusions The results of this study support the role of future interventions aimed at increasing the HPV knowledge base and training in discussions of sex for providers to help increase HPV vaccination rates in South Carolina.

Human papillomavirus vaccination uptake among childhood cancer survivors in Western New York

INTRODUCTION

The risk of human papillomavirus (HPV)-associated cancers is significantly higher among survivors of a childhood cancer compared to the general population. Despite this, their HPV vaccine uptake rates are lower. We examined factors related to HPV vaccine uptake among childhood cancer survivors from Western New York over 13 years following the introduction of HPV vaccines.

METHODS

Retrospective review of patients diagnosed with invasive or noninvasive cancerous conditions at age 9 or younger treated at Roswell Park Oishei Children's Cancer and Blood Disorder Program. We matched vaccine date information for patients aged 9-26 years between 2006 and 2020 from the New York State Immunization Information System. Demographic and cancer-related information was abstracted from electronic medical records. Cumulative vaccine uptake was assessed by Kaplan-Meier and Cox proportional hazards regression models.

RESULTS

A total of 284 patients were included in the analyses. Most were non-Hispanic/White (80.3%) and resided in a metropolitan area (81.7%). Approximately half had leukemia or lymphoma (54.9%), and most received chemotherapy. Females were more likely to initiate the HPV vaccine and did so sooner (median = 5.5 years) than males (median = 5.7 years; log-rank p = .301). Patients who were older at vaccine eligibility and males who received blood product transfusions were significantly less likely to initiate the HPV vaccine.

CONCLUSION

While rates of HPV vaccine initiation have been increasing with time among childhood cancer survivors, they remain low overall, with differences seen by treatment and diagnosis. Our findings support the need for further research to optimize HPV vaccine delivery in cancer care.

Social Media Perceptions and Internet Verification Skills Associated With Human Papillomavirus Vaccine Decision-Making Among Parents of Children and Adolescents: Cross-sectional Survey

BACKGROUND

Human Papillomavirus (HPV) vaccination is recommended for children aged 11-12 years in the United States. One factor that may contribute to low national HPV vaccine uptake is parental exposure to misinformation on social media.

OBJECTIVE

This study aimed to examine the association between parents' perceptions of the HPV vaccine information on social media and internet verification strategies used with the HPV vaccine decision-making stage for their child.

METHODS

Parents of children and adolescents aged 9-17 years were recruited for a cross-sectional survey in North Texas (n=1192) and classified into 3 groups: children and adolescents who (1) were vaccinated, (2) unvaccinated and did not want the vaccine, and (3) unvaccinated and wanted the vaccine. Multinomial logistic regression models were estimated to identify factors associated with the HPV vaccine decision-making stage with children and adolescents who were vaccinated as the referent group.

RESULTS

Of the 1192 respondents, 44.7% (n=533) had an HPV-vaccinated child, 38.8% (n=463) had an unvaccinated child and did not want the vaccine, and 16.4% (n=196) had an unvaccinated child and wanted the vaccine. Respondents were less likely to be "undecided/not wanting the vaccine" if they agreed that HPV information on social media is credible (adjusted odds ratio [aOR] 0.40, 95% CI 0.26-0.60; P=.001), disagreed that social media makes them question the HPV vaccine (aOR 0.22, 95% CI 0.15-0.33; P<.001), or had a higher internet verification score (aOR 0.74, 95% CI 0.62-0.88; P<.001).

CONCLUSIONS

Interventions that promote web-based health literacy skills are needed so parents can protect their families from misinformation and make informed health care decisions.

Adaptation and Dissemination of a National Cancer Institute HPV Vaccine Evidence-Based Cancer Control Program to the Social Media Messaging Environment

Social media offers a unique opportunity to widely disseminate HPV vaccine messaging to reach youth and parents, given the information channel has become mainstream with 330 million monthly users in the United States and 4.2 billion users worldwide. Yet, a gap remains on how to adapt evidence-based vaccine interventions for the in vivo competitive social media messaging environment and what strategies to employ to make vaccine messages go viral. Push-pull and RE-AIM dissemination frameworks guided our adaptation of a National Cancer Institute video-based HPV vaccine cancer control program, the HPV Vaccine Decision Narratives, for the social media environment. We also aimed to understand how dissemination might differ across three platforms, namely Instagram, TikTok, and Twitter, to increase reach and engagement. Centering theory and a question-answer framework guided the adaptation process of segmenting vaccine decision story videos into shorter coherent segments for social media. Twelve strategies were implemented over 4 months to build a following and disseminate the intervention. The evaluation showed that all platforms increased following, but Instagram and TikTok outperformed Twitter on impressions, followers, engagement, and reach metrics. Although TikTok increased reach the most (unique accounts that viewed content), Instagram increased followers, engagement, and impressions the most. For Instagram, the top performer, six of 12 strategies contributed to increasing reach, including the use of videos, more than 11 hashtags, COVID-19 hashtags, mentions, and follow-for-follow strategies. This observational social media study identified dissemination strategies that significantly increased the reach of vaccine messages in a real-world competitive social media messaging environment. Engagement presented greater challenges. Results inform the planning and adaptation considerations necessary for transforming public health HPV vaccine interventions for social media environments, with unique considerations depending on the platform.

Scaling up the discovery of hesitancy profiles by identifying the framing of beliefs towards vaccine confidence in Twitter discourse

Our study focused on the discovery of how vaccine hesitancy is framed in Twitter discourse, allowing us to recognize at-scale all tweets that evoke any of the hesitancy framings as well as the stance of the tweet authors towards the frame. By categorizing the hesitancy framings that propagate misinformation, address issues of trust in vaccines, or highlight moral issues or civil rights, we were able to empirically recognize their ontological commitments. Ontological commitments of vaccine hesitancy framings couples with the stance of tweet authors allowed us to identify hesitancy profiles for two most controversial yet effective and underutilized vaccines for which there remains substantial reluctance among the public: the Human Papillomavirus and the COVID-19 vaccines. The discovered hesitancy profiles inform public health messaging approaches to effectively reach Twitter users with promise to shift or bolster vaccine attitudes.

Effect of a web-based cervical cancer survivor story on the willingness and behavioral change for Human Papillomavirus Vaccination among Japanese parents with at least one daughter aged 11 to 18 years old: Randomized Controlled Trial

Background

Providing adequate information to parents who have children eligible for human papillomavirus (HPV) vaccination is essential to overcoming vaccine hesitancy in Japan, where the government recommendation has been suspended. However, prior trials assessing the effect of brief educational tools have shown only limited effects on increasing the willingness of parents to vaccinate their daughters.

Objective

The aim of this trial is to assess the effect of a cervical cancer survivor’s story on the willingness of parents to get HPV vaccination for their daughters.

Methods

In this double-blinded, randomized controlled trial (RCT) implemented online, we enrolled 2175 participants aged 30-59 years in March 2020 via a webpage and provided them with a questionnaire related to the following aspects: awareness regarding HPV infection and HPV vaccination, and willingness for HPV vaccination. Participants were randomly assigned (1:1) to see a short film on a cervical cancer survivor or nothing, stratified by sex (male vs female) and willingness for HPV vaccination prior to randomization (yes vs no). The primary endpoint was the rate of parents who agreed for HPV vaccination for their daughters. The secondary endpoint was the rate of parents who agreed for HPV vaccination for their daughters and the HPV vaccination rate at 3 months. The risk ratio (RR) was used to assess the interventional effect.

Results

Of 2175 participants, 1266 (58.2%) were men and 909 (41.8%) were women. A total of 191 (8.8%) participants were willing to consider HPV vaccination prior to randomization. Only 339 (15.6%) participants were aware of the benefits of HPV vaccination. In contrast, 562 (25.8%) participants were aware of the adverse events of HPV vaccination. Although only 476 (21.9%) of the respondents displayed a willingness to vaccinate their daughters for HPV, there were 7.5% more respondents in the intervention group with this willingness immediately after watching the short film (RR 1.41, 95% CI 1.20-1.66). In a subanalysis, the willingness in males to vaccinate daughters was significantly higher in the intervention group (RR 1.50, 95% CI 1.25-1.81); however, such a difference was not observed among females (RR 1.21, 95% CI 0.88-1.66). In the follow-up survey at 3 months, 1807 (83.1%) participants responded. Of these, 149 (8.2%) responded that they had had their daughters receive vaccination during the 3 months, even though we could not see the effect of the intervention: 77 (7.9%) in the intervention group and 72 (8.7%) in the control group.

Conclusions

A cervical cancer survivor’s story increases immediate willingness to consider HPV vaccination, but the effect does not last for 3 months. Furthermore, this narrative approach to parents does not increase vaccination rates in children eligible for HPV vaccination.

Trial Registration

UMIN Clinical Trials Registry UMIN000039273; https://tinyurl.com/bdzjp4yf

Missed opportunities for human papillomavirus vaccine series initiation in a large, rural U.S. state

Human papillomavirus (HPV) vaccination rates are lower in rural versus urban areas of the United States. Our objective was to identify the types of vaccination clinic settings where missed opportunities for HPV vaccine series initiation most frequently occurred in Montana, a large, primary rural U.S. state. We analyzed a limited dataset from Montana’s immunization information system for adolescents who turned 11 years old in 2014–2017. Vaccination visits where the HPV vaccine was due but not administered were missed opportunities. We compared missed opportunities across six types of clinic settings, and calculated adjusted relative risks (RR) using a generalized estimating equation model. Among n = 47,622 adolescents, 53.9% of 71,447 vaccination visits were missed opportunities. After adjusting for sex, age, and rurality of clinic location, receiving vaccines in public health departments was significantly associated with higher risk of missed opportunities (aRR = 1.25, 95% confidence interval = 1.22–1.27, vs. private clinics). Receipt of vaccines in Indian Health Services and Tribal clinics was associated with fewer missed opportunities (aRR = 0.72, 95% CI: 0.69–0.75, vs. private clinics). Our results indicate the need for interventions to promote HPV vaccine uptake in public health departments, which are a critical source of immunization services in rural and medically underserved areas of the U.S.

Using concept mapping to identify opportunities for HPV vaccination efforts: Perspectives from the Midwest and West Coast

Human papillomavirus (HPV) infection significantly contributes to the burden of cancer in the United States, despite the existence of a highly effective vaccine. While numerous interventions to address vaccination uptake exist, vaccination rates remain low. We conducted a concept mapping exercise to solicit perspectives on barriers and facilitators to HPV vaccination from state-level stakeholders in five states in the Midwest and West Coast of the U.S. We identified 10 clusters of barriers and facilitators based on participants' statements. For rural areas specifically, clusters rated as most important included education and provider influence; those rated as most feasible were education and coordinated/consistent messaging. Our results suggest that a combination of important (but potentially more difficult to implement) strategies, combined with those rated as most feasible (but potentially less impactful) may be beneficial. Our findings highlight similarities across diverse states, suggesting that states can learn from each other and work together to improve HPV vaccination rates. Using concept mapping proved to be an efficient way to collect information from diverse, stakeholders in different locations, and is a methodology that could be used for program planning in areas beyond HPV vaccination.

Exploring novel strategies for social media HPV vaccine information

To respond to potential public health impacts of social media influencing vaccine confidence, Facebook proposed that prior to proceeding to any link about Human Papillomavirus (HPV) vaccination, a pop-up will prompt the user to visit a reputable website on vaccine information. This study explored the acceptability of a pop-up Facebook message for HPV vaccine information. A national sample of U.S. adults (n = 579) was surveyed online. Most participants rated the pop-up messages as acceptable, useful, and factual. Regression results indicated that being male, seeing HPV content on social media in the past month, believing that information on social media is credible, holding positive HPV vaccination attitudes, and having shared HPV content on their own social media were associated with greater likelihood of clicking on a pop-up. While the pop-up approach may be acceptable, there are many factors that may be associated with being less likely to click on the pop-up.

HPV Vaccination Champions: Evaluating a Technology-Mediated Intervention for Parents

Human papillomavirus (HPV) vaccination prevents 6 HPV-related cancers in men and women. Yet, rates of HPV vaccination among adolescents in the United States lag behind other developed nations, revealing a significant public health issue. This feasibility study tested a collaborative online learning environment to cultivate HPV vaccination champions. A 3-month training program recruited parents to serve as proponents and social media influencers to identify solutions to overcome barriers to HPV vaccination. A mixed methods study design included a pretest survey, three online asynchronous focus groups, a posttest survey, as well as a longitudinal follow-up survey at 6 months. Participants included 22 parents who self-identified as female (95.4%) and white (90.9%). Overall, there was a statistically significant difference in knowledge of HPV and HPV vaccination between pretest and posttest (p = 0.0042). This technology-mediated intervention increased parents' confidence and motivated them to speak more freely about HPV vaccination in-person and online with others in their social networks. Participants identified prevalent misinformation about HPV vaccination and learned how to effectively craft messages to address concerns related to safety and side effects, gender, understanding of risk, and sexual activity. Objective measures and qualitative open-ended assessment showed high intervention engagement and treatment satisfaction. All participants (100%) indicated that they enjoyed participating in the intervention. The effectiveness of this feasibility study suggests that social media is an appropriate platform to empower parents to counter vaccine hesitancy and misinformation through HPV vaccination information that is simple and shareable in-person and online.

Effect of Training Pediatric Clinicians in Human Papillomavirus Communication Strategies on Human Papillomavirus Vaccination Rates: A Cluster Randomized Clinical Trial

IMPORTANCE

Missed opportunities for human papillomavirus (HPV) vaccination during pediatric health care visits are common.

OBJECTIVES

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.

DESIGN, SETTING, AND PARTICIPANTS

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.

INTERVENTIONS

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 AND MEASURES

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.

RESULTS

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.

CONCLUSIONS AND RELEVANCE

This scalable, online communication training increased HPV vaccination, particularly HPV vaccine initiation at WCC visits. Results support dissemination of this intervention.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03599557.

Incomplete Records as a Leading Cause of Missed Opportunity for Human Papillomavirus Vaccine Initiation in a Safety Net Health System

OBJECTIVE

The goal of this study was to categorize reasons behind missed opportunities for human papillomavirus (HPV) vaccine initiation in an under-resourced population and to identify associated patient and clinic characteristics.

METHODS

Manual chart review was performed for patients aged 11 to 18 years who visited a primary care clinic in a health system in Texas, USA between 06/01/18 and 08/31/18 and were due for an initial HPV vaccine dose but did not receive it. Reasons for HPV vaccine noninitiation were categorized as follows: incomplete immunization record, no documentation of discussion (no documentation that the HPV vaccine was offered or ordered), refusal, staff/provider error, and medical. Multinomial logistic regression was used to examine factors associated with each category.

RESULTS

Of 4467 adolescents seen in the study period, 575 (12.9%) were due for the first dose of HPV vaccine but did not receive it. The most common reason for noninitiation was incomplete immunization record (37%), followed by no documentation of discussion (24%), refusal (20%), staff/provider error (15%), and medical (4%). The highest odds of incomplete immunization were among older adolescents. The highest odds of no documentation of discussion were during sick visits. The highest odds of staff/provider error were among patients with commercial insurance. The lowest odds of refusal were in patients with county/indigent insurance.

CONCLUSIONS

The most common reason for missed opportunity visits for HPV vaccine initiation was lack of adequate immunization records. Our study highlights the importance of immunization record access and bidirectional reporting as important targets for future interventions.

Identifying HPV vaccine narrative communication needs among parents on social media

Sharing personal experiences is an important communication strategy in public health, including vaccination. This study sought to understand if parents would be receptive to learning about the HPV vaccine from other parent experiences, and what format this information should take on social media. In May 2020, we conducted a qualitative study of six online focus groups across the U.S. with parents (n = 48) of children ages 9–14. Using a text-based discussion format, we discussed their experiences getting information about the HPV vaccine and using Twitter to learn about health topics. Four coders structured qualitative findings by themes including content, delivery, and source of information. An accompanying survey was used to describe participant Twitter use and HPV vaccine knowledge and attitudes. The average participant age was 44.6 years old, 63% were mothers, and the majority had high HPV vaccine knowledge. Parents indicated that they want to hear from other parents about their experiences with the HPV vaccine. However, it was hard to know where to find this information. When experiences are shared on social media, the negative ones are more memorable and more personal. Parents thought Twitter could be an important space to communicate about the HPV vaccine if it was done in a credible, verifiable, and authentic way. Parents want to learn about the HPV vaccine through other parent experiences, especially when this aligns with science supporting the vaccine. Public health and medical communities must embrace this mix of evidence and lived experiences to deliver and discuss health information.

Quality over quantity: human papillomavirus vaccine information on social media and associations with adult and child vaccination

Human Papillomavirus (HPV) vaccination is recommended for adults aged 27-45 as a shared clinical decision with their healthcare provider. With the rise of social media as a vaccine information source, this study examined the extent of exposure to HPV vaccine content by social media platform and evaluated associations between HPV vaccine content on social media and HPV vaccine intent among both 27-45 year olds and their eligible children. U.S. participants (51% women, 9% Black, 8% Hispanic/Latinx), aged 27-45, were cross-sectionally surveyed online from April to May 2020 (n = 691). Outcomes included HPV vaccination intention (intend/do not intend) for themselves and, among participants with unvaccinated children aged 9-17 (n = 223), their eligible children. Adjusted odds ratios for HPV vaccine content and both outcomes were calculated. Extent of HPV vaccination exposure on social media was not associated with intention to vaccinate for HPV. Seeing mostly negative/mixed information about the HPV vaccine on social media was associated with lower odds of vaccination intention for adults (aOR = 0.34, 95% CI 0.15, 0.79) and adolescents (aOR = 0.34, 95% CI 0.21, 0.53). Viewing HPV vaccine information from social media as not credible was associated with lower odds of vaccine intent for adults (aOR = 0.17, 95% CI 0.07, 0.41) and adolescents (aOR = 0.16, 95% CI 0.10, 0.29). Although extent of HPV vaccine exposure on social media was not associated with vaccination outcomes, findings support developing quality social media strategies that increase the dissemination of positive and credible information in favor of HPV vaccination.

Correcting HPV Vaccination Misinformation Online: Evaluating the HPV Vaccination NOW Social Media Campaign

The human papillomavirus (HPV) vaccine provides protection from six HPV-related cancers. Approximately half of South Carolina adolescents have not completed the vaccination series, representing a missed opportunity to prevent cancer. The HPV Vaccination NOW: This is Our Moment social media campaign is an initiative of the South Carolina Cancer Alliance (SCCA) and Hollings Cancer Center at the Medical University of South Carolina (MUSC). This statewide social media campaign aimed to increase parental awareness of and build vaccine confidence around HPV vaccination in S.C. The ten-week campaign was strategically implemented between June and August 2019 to encourage HPV vaccination at back-to-school medical appointments. A process evaluation showed that the campaign resulted in over 370,000 total impressions, reached over 33,000 individuals, and culminated with over 1122 followers. There were over 2700 engagements on Facebook and Twitter. A qualitative content analysis indicated that pro-vaccine and anti-vaccine comments were dominated by personal stories. Comments promoting misinformation about the HPV vaccine were often countered through peer-to-peer dialogue. Findings suggest that creating opportunities for the target audience to engage with campaign messages effectively corrected misinformation.

Influences on HPV vaccination across levels of the social ecological model: perspectives from state level stakeholders

Nationally, human papillomavirus (HPV) vaccination rates fall short of the Healthy People 2020 goal of 80% completion. Although strategies to increase these rates exist, low rates persist. We used concept mapping with state-level stakeholders to better understand barriers and facilitators to HPV vaccination. Concept mapping is a participatory research process in which respondents brainstorm ideas to a prompt and then sort ideas into piles. We present results of the brainstorming phase. We recruited participants identified by researchers' professional connections (n = 134) via e-mail invitations from five states (Iowa, South Dakota, Minnesota, Oregon, and Washington) working in adolescent health, sexual health, cancer prevention and control, or immunization. Using Concept Systems' online software we solicited participants' beliefs about what factors have the greatest influence on HPV vaccination rates in their states. From the original sample 58.2% (n = 78) of participants completed the brainstorming activity and generated 372 statements, our team removed duplicates and edited statements for clarity, which resulted in 172 statements. We coded statements using the Social Ecological Model (SEM) to understand at what level factors affecting HPV vaccination are occurring. There were 53 statements at the individual level, 22 at the interpersonal level, 21 in community, 51 in organizational, and 25 in policy. Our results suggest that a tiered approach, utilizing multi-level interventions instead of focusing on only one level may have the most benefit. Moreover, the policy-level influences identified by participants may be difficult to modify, thus efforts should focus on implementing evidence-based interventions to have the most meaningful impact.

Dimensions of Misinformation About the HPV Vaccine on Instagram: Content and Network Analysis of Social Media Characteristics

BACKGROUND

The human papillomavirus (HPV) vaccine is a major advancement in cancer prevention and this primary prevention tool has the potential to reduce and eliminate HPV-associated cancers; however, the safety and efficacy of vaccines in general and the HPV vaccine specifically have come under attack, particularly through the spread of misinformation on social media. The popular social media platform Instagram represents a significant source of exposure to health (mis)information; 1 in 3 US adults use Instagram.

OBJECTIVE

The objective of this analysis was to characterize pro- and anti-HPV vaccine networks on Instagram, and to describe misinformation within the anti-HPV vaccine network.

METHODS

From April 2018 to December 2018, we collected publicly available English-language Instagram posts containing hashtags #HPV, #HPVVaccine, or #Gardasil using Netlytic software (n=16,607). We randomly selected 10% of the sample and content analyzed relevant posts (n=580) for text, image, and social media features as well as holistic attributes (eg, sentiments, personal stories). Among antivaccine posts, we organized elements of misinformation within four broad dimensions: 1) misinformation theoretical domains, 2) vaccine debate topics, 3) evidence base, and 4) health beliefs. We conducted univariate, bivariate, and network analyses on the subsample of posts to quantify the role and position of individual posts in the network.

RESULTS

Compared to provaccine posts (324/580, 55.9%), antivaccine posts (256/580, 44.1%) were more likely to originate from individuals (64.1% antivaccine vs 25.0% provaccine; P<.001) and include personal narratives (37.1% vs 25.6%; P=.003). In the antivaccine network, core misinformation characteristics included mentioning #Gardasil, purporting to reveal a lie (ie, concealment), conspiracy theories, unsubstantiated claims, and risk of vaccine injury. Information/resource posts clustered around misinformation domains including falsification, nanopublications, and vaccine-preventable disease, whereas personal narrative posts clustered around different domains of misinformation, including concealment, injury, and conspiracy theories. The most liked post (6634 likes) in our full subsample was a positive personal narrative post, created by a non-health individual; the most liked post (5604 likes) in our antivaccine subsample was an informational post created by a health individual.

CONCLUSIONS

Identifying characteristics of misinformation related to HPV vaccine on social media will inform targeted interventions (eg, network opinion leaders) and help sow corrective information and stories tailored to different falsehoods.

Preparing for A COVID-19 Vaccine: A Mixed Methods Study of Vaccine Hesitant Parents

This study investigated vaccine acceptance of putative COVID-19 vaccines among a national sample of vaccine hesitant parents. Vaccine hesitancy and politicization of vaccine development has led to a pronounced distrust of COVID-19 vaccines in the U.S. A total of 1,381 vaccine-hesitant parents participated in this study. Participants indicated a general unwillingness to vaccinate their children (M = 3.55, SD = 2.13) and themselves (M = 3.58, SD = 2.16) when a COVID-19 vaccine becomes available. More educated parents were more likely to plan to vaccinate themselves [F(5, 533) = 9.93, p < .05] and their children [F(5, 533) = 10.278, p < .05]. Understanding vaccine hesitant parents offers crucial insights as a COVID-19 vaccine becomes available for the general public and as we wait for a vaccine to be approved for pediatric use.

Identifying Strategies to Reduce Missed Opportunities for HPV Vaccination in Primary Care: A Qualitative Study of Positive Deviants

The objectives of this study were to assess the contextual factors, practice strategies, and sustainability of interventions implemented during a national quality improvement (QI) project to raise human papillomavirus (HPV) vaccination rates. We conducted semistructured interviews with positive deviant practices that successfully reduced missed opportunities by ≥20% for HPV vaccination in the prior year. We assessed leadership support, motivators, interventions used, and sustainability. Key themes related to QI teams included strong leadership support, multidisciplinary teams, having a practice champion, and a collaborative environment. Themes related to the interventions included using a presumptive bundled recommendation for all appropriate vaccines at age 11, previsit planning, and reminders for preventive visits, which were sustainable for most practices 1-year postintervention. Both internal practice-level factors (multidisciplinary teams, collaboration, and previsit planning) and organizational factors (institutional support and health system-level reminders for preventive visits) were key to a successful QI intervention to improve HPV vaccination.

A Mixed-Methods Analysis of Barriers to and Facilitators of Human Papillomavirus Vaccination Among Adolescents in Montana

OBJECTIVES

Human papillomavirus (HPV) vaccination rates among adolescents are lower in rural areas than in urban areas of the United States. The objective of this study was to identify barriers to and facilitators of adolescent HPV vaccination in Montana, a large, primarily rural state.

METHODS

Using a mixed-methods design, we integrated quantitative analyses of Montana's National Immunization Survey-Teen (NIS-Teen) data from 2013-2017 with qualitative data collected at a statewide meeting in October 2018 and from stakeholder interviews conducted from October 2018 through June 2019. Using NIS-Teen data, we identified trends and estimated adjusted prevalence ratios (aPRs) to identify factors associated with vaccine uptake. Using directed content analysis of qualitative data, we identified themes related to vaccine uptake.

RESULTS

In Montana, initiation of the HPV vaccine series among adolescents aged 13-17 increased from 34.4% in 2013 to 65.5% in 2017. We identified 6 themes related to HPV vaccination from qualitative analyses, including medical providers' recommendation style as a facilitator of vaccination and parental vaccine hesitancy as a barrier to vaccination. In NIS-Teen 2017 data (n = 326 adolescents), receiving a medical provider recommendation was significantly associated with series initiation (aPR = 2.3; 95% CI, 1.5-3.6). Among parents who did not intend to initiate the vaccine series for their adolescent within 12 months (n = 71), vaccine safety was the top concern (aPR = 24.5%; 95% CI, 12.1%-36.9%).

CONCLUSIONS

HPV vaccination rates have increased in Montana but remain lower than rates for other adolescent vaccines. Future work should focus on reducing missed opportunities, increasing parents' knowledge of and confidence in vaccination, and training medical providers on addressing common vaccine concerns.

Social media engagement association with human papillomavirus and vaccine awareness and perceptions: Results from the 2017 US Health Information National Trends Survey

Due to social media's ability to publicize misinformation about vaccines, there is a need to study associations between social media engagement (SME) with human papillomavirus (HPV) and vaccine-related awareness and beliefs. Therefore, the study objectives were to (1) describe the SME of a nationally representative sample of US adults, and (2) determine the associations between SME and HPV-related awareness, HPV-related knowledge, HPV vaccine-related awareness, and perceived HPV vaccine efficacy. In 2019, we completed a secondary analysis of the 2017 Health Information National Trends Survey (Cycle 5.1). We created the SME index from 5 social media items. For each outcome variable, 3 models using binary and multinomial logistic regression were estimated. SME in the sample (n = 3171) was low (M = 0.9; range: 0-2). Respondents with higher SME had higher odds of HPV awareness (AOR = 1.56; 95% CI = 1.23, 1.99). Higher SME was associated with awareness of the HPV vaccine (AOR = 1.46; 95% CI = 1.16, 1.85). Respondents with higher SME had higher odds of perceiving HPV vaccine to be "not at all successful" (AOR = 2.22; 95% CI = 1.16, 4.24), "a little successful" (AOR = 1.99; 95% CI = 1.35, 2.94), "pretty successful" (AOR = 1.40; 95% CI = 1.04, 1.89), and "very successful" (AOR = 1.40; 95% CI = 1.02, 1.92) compared to those who selected "don't know" after adjusting for demographics and internet use. Our study highlights novel findings using a comprehensive SME index with a national sample providing insight to leverage existing consumer behaviors to better connect and disseminate accurate HPV information in a more strategic manner.

Prevalence and characteristics of HPV vaccine hesitancy among parents of adolescents across the US

BACKGROUND

While many clinicians encounter parents or adolescents who refuse HPV vaccine, little is known about the prevalence of hesitancy for HPV vaccine nationally or its association with vaccination.

METHODS

In April 2019, we surveyed families with adolescents 11-17 years using a national online panel (Knowledge Panel®) as the sampling frame. We assessed the prevalence of HPV vaccine hesitancy with the validated 9-item Vaccine Hesitancy Scale (VHS). We used multivariate analyses to assess demographic factors associated with HPV vaccine hesitancy. We also assessed practical barriers to receipt of HPV vaccine and the relationship between barriers and hesitancy. Finally, we evaluated the association between both HPV vaccine hesitancy and practical barriers on HPV vaccine receipt or refusal.

RESULTS

2,177 parents out of 4,185 sampled (52%) completed the survey, 2,020 qualified (lived with adolescent). Using a VHS cut-off score > 3 out of 5 points, 23% of US parents were hesitant about HPV vaccine. Hesitancy was lower among those with Hispanic ethnicity. At least one out of five parents disagreed that the HPV vaccine is beneficial for their adolescent, that the vaccine is effective, protects against HPV-related cancers, or that they followed their adolescent's health-care provider's recommendation about the vaccine. Many were concerned about vaccine side effects and the novelty of the vaccine. Adolescents living with vaccine-hesitant parents were less than one-third as likely to have received the vaccine (RR = 0.29, 95% CI 0.24, 0.35) or completed the vaccine series (RR = 0.29, 95% CI 0.23, 0.36), and were 6-fold more likely to have refused the vaccine because of parental vaccine-related concerns (RR = 6.09, 95% CI = 5.26, 7.04). Most practical barriers were independently associated with vaccine receipt but not with vaccine refusal.

CONCLUSIONS

HPV vaccine hesitancy is common nationally and strongly related to both under-vaccination and vaccine refusal.

Intersectoral cooperation to increase HPV vaccine coverage: an innovative collaboration between Managed Care Organizations and state-level stakeholders

In order to reduce disparities in human papillomavirus (HPV) vaccine coverage, intersectoral approaches are needed to reach vulnerable populations, including Medicaid enrollees. This manuscript describes a collaboration between Medicaid Managed Care Organizations (MCOs), the American Cancer Society, and a state health department in a Midwestern state to address HPV vaccination. Qualitative interviews (n = 11) were conducted via telephone with key stakeholders from the three participating organizations using an interview guide designed to capture the process of developing the partnership and implementing the HPV-focused project. Interviews were transcribed and coded using thematic analysis. Interviewees described motivation to participate, including shared goals, and facilitators, like pooled resources. They cited barriers, such as time and legal challenges. Overall, interviewees reported that they believed this project is replicable. Conducting this project revealed the importance of shared vision, effective communication, and the complementary resources and experiences contributed by each organization. Valuable lessons were learned about reaching the Medicaid population and groundwork was laid for future efforts to serve vulnerable populations and reduce health disparities. This work has significant implications for other organizations seeking to partner with large nonprofits, state health departments, MCOs, or others, and the lessons learned from this project could be translated to other groups working to improve vaccination rates in their communities.

Effect of State Immunization Information System Centralized Reminder and Recall on HPV Vaccination Rates

BACKGROUND

Although autodialer centralized reminder and recall (C-R/R) from state immunization information systems (IISs) has been shown to raise childhood vaccination rates, its impact on human papillomavirus (HPV) vaccination rates is unclear.

METHODS

In a 4-arm pragmatic randomized controlled trial across 2 states, we randomly selected practices representative of the specialty (pediatrics, family medicine, and health center) where children received care. Within each practice, patients 11 to 17.9 years old who had not completed their HPV vaccine series (NY: N = 30 616 in 123 practices; CO: N = 31 502 in 80 practices) were randomly assigned to receive 0, 1, 2, or 3 IIS C-R/R autodialer messages per vaccine dose. We assessed HPV vaccine receipt via the IIS, calculated intervention costs, and compared HPV vaccine series initiation and completion rates across study arms.

RESULTS

In New York, HPV vaccine initiation rates ranged from 37.0% to 37.4%, and completion rates were between 29.1% and 30.1%, with no significant differences across study arms. In Colorado, HPV vaccine initiation rates ranged from 31.2% to 33.5% and were slightly higher for 1 reminder compared with none, but vaccine completion rates, ranging from 27.0% to 27.8%, were similar. On adjusted analyses in Colorado, vaccine initiation rates were slightly higher for 1 and 3 C-R/R messages (adjusted risk ratios 1.07 and 1.04, respectively); completion rates were slightly higher for 1 and 3 C-R/R messages (adjusted risk ratios 1.02 and 1.03, respectively).

CONCLUSIONS

IIS-based C-R/R for HPV vaccination did not improve HPV vaccination rates in New York and increased vaccination rates slightly in Colorado.

School-based human papillomavirus vaccination program for increasing vaccine uptake in an underserved area in Texas

OBJECTIVE

Compare the effectiveness of community-based HPV-related education and onsite school-based vaccination versus community-based education only for increasing HPV vaccine uptake in a rural, medically underserved area.

METHODS

Our cohort included 2307 Rio Grande City Consolidated Independent School District (RGCISD) middle school students from 3 schools enrolled in August 2016 and followed until April 2018. Using a quasi-experimental design, this study implemented an onsite school-based vaccination program and physician-led education on HPV and HPV vaccines for parents/guardians, school nurses/staff, and pediatric/family providers in the surrounding community (15-mile radius of RGCCISD) at 1 middle school ("intervention school"), and education-only for the remaining 2 schools ("comparison schools"). The Centers for Disease Control and Prevention's HPV-related educational materials supplemented the education. HPV vaccine status was obtained from school immunization records and the project's contracted vaccine vendor. HPV vaccine initiation and completion rates were compared pre and post intervention and between the intervention and comparison schools. Logistic regression was used to compare the odds of newly initiating/completing vaccination between the intervention and comparison schools.

RESULTS

At baseline, the intervention school had lower HPV vaccine initiation and completion rates than the comparison schools (20.00% and 8.70% vs 28.97% and 14.56%). Post intervention, the intervention school had higher initiation and completion rates than the comparison schools (53.67% and 28.36% vs 41.56% and 20.53%). Students from the intervention school were over 3.6-times more likely to newly initiate/complete the HPV vaccinations than students from the comparison schools.

CONCLUSION

The school with on-site vaccination events and community-based education had a higher adolescent HPV vaccination rate compared to schools that received community-based education only.

Implementing Evidence-Based Strategies to Improve HPV Vaccine Delivery

BACKGROUND

High-quality evidence indicates that intervening with health care providers improves human papillomavirus (HPV) vaccine delivery. However, scaling up evidence-based strategies in real-world clinical practice remains challenging. We sought to improve the reach and impact of strategies for HPV vaccination quality improvement (QI) through local adaptation and implementation in a large, not-for-profit health care system.

METHODS

We conducted an HPV vaccination QI program using existing materials to support physician training coupled with assessment and feedback. Local physicians with high HPV vaccination rates facilitated training, which included didactic instruction and video vignettes modeling effective communication. We randomly assigned 25 clinics with 77 physicians to the QI arm or the wait-list control arm. We used hierarchical linear models to assess HPV vaccination coverage (≥1 dose) over 6 months among patients aged 12 to 14.

RESULTS

Of 45 physicians in the QI arm, the program reached 43 (95%) with training plus assessment and feedback. In the overall sample, HPV vaccination coverage increased in both the QI and control arms (8.6 vs 6.4 percentage points, respectively), although the 2.2-percentage point difference did not reach statistical significance. Sensitivity analyses that excluded physicians with poor data quality indicated a statistically significant advantage of 3.3 percentage points for QI versus control (b = 0.034; SE = 0.015; P < .05).

CONCLUSIONS

Our locally adapted QI program achieved excellent reach, with small improvements in HPV vaccination coverage. Future implementation research is needed to bolster program impact and support health systems in leveraging local resources to conduct these programs efficiently.

Parental knowledge gaps and barriers for children receiving human papillomavirus vaccine in the Rio Grande Valley of Texas

Purpose: Despite its availability for more than a decade, the human papillomavirus (HPV) vaccine has low uptake in Texas (49%). The objective of this study was to understand parental knowledge and attitudes about HPV and the HPV vaccine as well as child experience with the HPV vaccine among a medically underserved, economically disadvantaged population.

Methods: As part of a Cancer Prevention Research Institute of Texas-funded project to improve HPV vaccination rates, we surveyed parents / guardians of 4^th–12^th graders (ages 9–17) in the Rio Grande City Consolidated Independent School District (RGCCISD). Descriptive statistics were used to describe parents’ knowledge and attitude and children’s vaccine experience.

Results: Of the 7,055 surveys distributed, 622 (8.8%) were returned. About 84% of the respondents were female. About 57.1% of the parents /guardians had female RGCCISD students with a mean age of 11.7 ± 1.8 years. Overall, 43.9% reported receiving a healthcare provider recommendation and 32.5% had their child vaccinated. Higher percentages were reported if the respondent was female and had a female child aged ≥15 years old. Among survey respondents, 28.2% reported their child initiated the HPV vaccine and 18.8% completed the series. Barriers of uptake included work / school schedule conflicts and no healthcare provider recommendation.

Conclusions: There are still prominent gaps in parents’ and students’ complete understanding of HPV vaccination, gender preferences for vaccination, and provider recommendations. Future interventions must target men and minority populations in order to increase knowledge and awareness about HPV, the HPV vaccine, and HPV-associated cancers.

HPV vaccination knowledge, intentions, and practices among caregivers of childhood cancer survivors

The HPV vaccine is an important vaccine for childhood cancer survivors because of their risks of second cancers, yet few survivors receive it. We examined HPV vaccine knowledge among caregivers of childhood cancer survivors, whether their child had received the vaccine, and their intentions to vaccinate. Eligible participants were caregivers (mostly parents) whose child finished cancer treatment at Primary Children’s Hospital in Salt Lake City, Utah 3 to 36 months prior to the start of the study (N = 145). Additional analyses were done among caregivers whose child was age-eligible for the HPV vaccine (ages 11 and up; N = 61). We ran descriptive statistics and fit multivariable generalized linear models to identify factors associated with intention to vaccinate and HPV vaccination uptake. Among caregivers whose child had not yet gotten the HPV vaccine, approximately 30% stated they were not likely to get the vaccine for their child and the most commonly cited reason was not enough information (25.2%). Provider discussion about vaccines and side effects (relative risk (RR) = 1.85, 95% CI 1.16–2.94), along with recommendations regarding vaccines after cancer treatment (RR = 1.35, 95% CI 1.06–1.72), led to greater caregiver intention to get the HPV vaccine for their child with cancer. Approximately 40% of age-eligible survivors had gotten at least one dose of the HPV vaccine. Our findings demonstrate a need for oncology-focused interventions to educate families of childhood cancer survivors about the importance of the HPV vaccine after cancer therapy.

Relative contributions of parental intention and provider recommendation style to HPV and meningococcal vaccine receipt

We described the relative contributions of parental intention and provider recommendation style to HPV and meningococcal vaccine receipt. Parent-child dyads that were eligible for both meningococcal and HPV vaccines participated in pre-visit surveys and consented to audio recording of their clinical interactions with healthcare providers related to vaccination. Surveys were analyzed for parent and child demographics and parental intention to vaccinate children with HPV and/or meningococcal vaccines. Audio recordings were analyzed for provider recommendation style, defined as indicated (provider stated vaccine was due at that visit) or not, and for child receipt of vaccines. Linear and logistic regression models were used to determine the relative contributions of parental intention and provider recommendation style to vaccine receipt. 56 parents/child dyads participated. 79% of children received HPV vaccines, and 93% received meningococcal vaccines. After controlling for demographic variables, parental intention did not differ by vaccine type. However, providers were less likely to use an indicated recommendation for HPV than for meningococcal vaccine. After controlling for demographic factors, parental intention, and provider recommendation style, vaccine type (HPV or meningococcal) was no longer associated with vaccine receipt Differences that were previously attributed to vaccine-specific factors may be explained by parents' and providers' roles in vaccine receipt. These findings suggest that interventions and policy recommendations regarding adolescent vaccination should focus on increasing parental demand for vaccines and ensuring that providers present all vaccines as the medical standard of care.

Provider-level rates of HEDIS-consistent HPV vaccination in a regional health plan

Background. Health insurers are well-positioned to address low HPV vaccination coverage in the US through initiatives such as provider assessment and feedback. However, little is known about the feasibility of using administrative claims data to assess provider performance on vaccine delivery. Methods. We used administrative claims data from a regional health plan to estimate provider performance on the 2013-2015 Healthcare Effectiveness Data and Information Set (HEDIS) measure for HPV vaccine. This measure required that a girl receive three doses of HPV vaccine by age 13. Providers who administered ≥1 dose in a HEDIS-consistent series received credit for meeting the goal. Results. From January 2008-April 2015, 1,975 (8.5%) of 11-12 year-old girls in our sample received a HEDIS-consistent HPV vaccine series. Our sample of providers consisted of 1,236 who had ≥10 well-visits with different female patients, and 94% of these were pediatricians. A substantial minority of providers (39.4%) did not administer any HEDIS-consistent HPV vaccine doses. Only 5.5% of providers administered HPV vaccine doses that were part of a HEDIS-consistent series to at least one-quarter of their patients. These estimates did not vary by provider sex or age. Doses in a HEDIS-consistent vaccine series were often attributed to multiple providers. Conclusions. In a regional health plan, only 5.5% of providers in our sample administered doses that were part of a complete, three-dose HPV vaccine series to at least one-quarter of their 11-12 year-old female patients.

Strengthening the Effectiveness of National, State, and Local Efforts to Improve HPV Vaccination Coverage in the United States: Recommendations From the National Vaccine Advisory Committee

In February 2018, recognizing the suboptimal rates of human papillomavirus (HPV) vaccination in the United States, the assistant secretary for health of the US Department of Health and Human Services charged the National Vaccine Advisory Committee (NVAC) with providing recommendations on how to strengthen the effectiveness of national, state, and local efforts to improve HPV vaccination coverage rates. In the same month, the NVAC established the HPV Vaccination Implementation Working Group and assigned it to develop these recommendations. The working group sought advice from federal and nonfederal partners. This NVAC report recommends ways to improve HPV vaccination coverage rates by focusing on 4 areas of activity: (1) identifying additional national partners, (2) guiding coalition building for states, (3) engaging integrated health care delivery networks, and (4) addressing provider needs in rural areas.

A retrospective and prospective look at strategies to increase adolescent HPV vaccine uptake in the United States

The HPV vaccine debuted more than ten years ago in the United States and many strategies have been evaluated to increase HPV vaccination rates, which include not only improving current vaccination behaviors but also sustaining these behaviors. Researchers and practitioners from a variety of backgrounds have engaged in this work, which has included efforts directed at public health and government policies, health education and health promotion programs, and clinical and patient-provider approaches, as well as work aimed to respond to and combat anti-HPV vaccination movements in society. Using a previously developed conceptual model to organize and summarize each of these areas, this paper also highlights the need for future HPV vaccine promotion work to adopt a multi-level and, when possible, integrated approach in order to maximize impact on vaccination rates.