Parental views of school-located delivery of adolescent vaccines

Improving adolescent human papillomavirus (HPV) immunization uptake in school-based health centers through awareness campaigns

PURPOSE

The aim of this study was to measure the effect of a multicomponent human papillomavirus (HPV) vaccine promotion campaign on adolescent HPV vaccine uptake at school-based health centers (SBHCs) in Seattle, WA.

METHODS

Youth-led HPV vaccine promotion campaigns were introduced in 2016 in 13 schools with SBHCs in Seattle. Five other schools with SBHCs served as controls. Vaccination records for students were obtained from the Washington Immunization Information System from September 2012 to August 2018. We compared increase in HPV vaccine uptake in SBHCs between 1) intervention and control schools, and 2) pre- and post-intervention periods in intervention schools using generalized estimating equations.

RESULTS

HPV vaccine uptake was high at baseline among students that use SBHCs for vaccines and has steadily increased between 2012 and 2018. Implementing the promotion campaign resulted in 14% higher (95% Confidence Interval (CI): 1%, 30%) HPV vaccine uptake in intervention SBHCs compared to control SBHCs, adjusting for time and confounders. Comparing pre-and post-intervention periods in intervention SBHCs, HPV vaccine uptake was 14% higher (95% CI: -4%, 35%) in the post-intervention period. SBHCs that received more active intervention activities saw 9% higher (95% CI: 1%, 21%) vaccine uptake compared to those that received passive intervention.

CONCLUSION

The vaccination promotion program implemented in a school-based setting resulted in higher HPV vaccine uptake in the post-intervention period compared to pre-intervention period, but this increase was not statistically significant. Even so, schools that received more intervention activities for longer periods of time had higher HPV vaccine uptake.

School-Located Influenza Vaccination: Do Vaccine Clinics at School Raise Vaccination Rates?

BACKGROUND

Only half of US schoolchildren receive influenza vaccine. School-located influenza vaccination (SLIV) might raise vaccination rates but conducting flu vaccine clinics at schools is challenging to implement. We compared 2 school-based programs designed to raise influenza vaccination rates: parent reminder/educational messages sent to parents from schools which is a low-intensity intervention vs the combination of reminder/educational messages plus SLIV clinics which is a high-intensity intervention.

METHODS

We assigned 36 schools (6 school districts, 2 per group) to 3 groups: (1) control, ie, no SLIV and no parent reminder/education, (2) parent reminder/education emailed by schools, and (3) parent reminder/education plus SLIV clinics. Some schools had SLIV clinics in prior years. Health department nurses conducted SLIV clinics.

RESULTS

Among 24,832 children at 36 schools, vaccination rates were control (51.3%), parent reminder/education-only (41.2%), and reminder/education + SLIV (58.7%). On multivariate analyses which controlled for vaccination in prior seasons, children in reminder/education + SLIV schools had higher vaccination rates (OR 1.27, 95% CI 1.10-1.47), but children in reminder/education-only schools had lower rates (OR 0.87, 95% CI 0.75-1.00) than children in control schools.

CONCLUSIONS

Parent reminder/education combined with SLIV clinics raise vaccination rates, but parent reminder/education alone does not.

Improving HPV vaccine delivery at school-based health centers

OBJECTIVE

To identify characteristics associated with human papillomavirus (HPV) vaccination rates, describe barriers and facilitators to vaccine uptake and the potential role for clinician-to-clinician Assessment, Feedback, Incentives, and eXchange (AFIX) visits in school-based health centers (SBHCs). Methods: We conducted clinician-to-clinician AFIX visits at 24 New York City (NYC) high-school and middle-school SBHCs with up-to-date adolescent vaccination rates below 40%. Using NYC's immunization information system, we assessed HPV initiation and series completion rates at the time of AFIX visit and follow-up three to five months later. We analyzed responses to a questionnaire and summarized interviews to identify barriers and facilitators to HPV immunization practices and quality improvement (QI) implementation. Results: Baseline initiation and completion rates were 76% and 43% for high schools, and 81% and 45% for middle schools. SBHCs that allowed adolescent self-consent or did not require separate vaccine consent had higher baseline rates, but was not statistically significant. Barriers to series completion included challenges with scheduling and appointment compliance. At follow-up, high school SBHCs increased HPV vaccine initiation by 2.9 percentage points (p < 0.01) and series completion by 2.7 percentage points (p < 0.05). There was no statistically significant increase at middle school SBHCs. Most SBHCs (88%) chose reminder/recall systems as a QI strategy. Fewer than half (42%) implemented their QI strategy. Conclusions: We identified barriers to HPV vaccine series completion at our sample of SBHCs. Clinician-to-clinician AFIX visits may help improve vaccination rates and encourage providers to address barriers, including streamlining consent processes for HPV vaccination. Abbreviations: School-based health (SBH); quality improvement (QI).

African-American parents' and daughters' beliefs about HPV infection and the HPV vaccine

OBJECTIVE

To increase our understanding about the health beliefs of African-American parents and their daughters toward HPV infection and HPV vaccine acceptance.

METHODS

The Health Belief Model was used as a guiding framework. Principles of grounded theory, theoretical sampling, and constant comparison analysis were used to qualitatively analyze data generated from personal interviews of African-American parents (n = 30) and their 12- to 17-year-old daughters (n = 34).

RESULTS

Mothers and daughters perceived low susceptibility to HPV infection and perceived the HPV vaccine as beneficial in protecting against genital warts and cervical cancer. Compared to daughters, parents placed particular emphasis on the vaccine's protection against genital warts. A major HPV vaccine acceptance barrier among parents and daughters was the politicization of the HPV vaccine by government figures. In addition, concerns about unknown side effects, safety, and effectiveness of HPV vaccination emerged. Cues to action varied among parents and daughters, and self-efficacy was higher among parents than daughters.

CONCLUSION

Understanding the health beliefs that promote HPV vaccine acceptance, while identifying and addressing beliefs that are barriers among parents and daughters, will assist in the development of appropriate HPV vaccine promotion initiatives for African-American parents and daughters.

Can School-Located Vaccination Have a Major Impact on Human Papillomavirus Vaccination Rates in the United States?

School-local vaccination (SLV) has been a highly effective method of increasing rates of human papillomavirus (HPV) vaccination in many countries internationally in which vaccines are purchased by national, regional, or local public health authorities and offered free of charge within schools. However, the effectiveness of SLV for increasing HPV vaccination rates in the United States is likely to be substantially limited due to a number of identified barriers, the most significant of which is with the need to bill for vaccines among adolescents not covered under the Vaccines for Children Program. HPV vaccination within school-based health centers (SBHCs) has been much more effective than SLV, but SBHCs exist in only 2% of schools in the United States. The opportunity gap between the United States and other countries will remain unless reimbursement issues related to HPV delivery in schools can be addressed in a sustainable manner or SBHCs become much more common.

School-located Influenza Vaccinations for Adolescents: A Randomized Controlled Trial

PURPOSE

We aimed to evaluate the effect of school-located influenza vaccination (SLIV) on adolescents' influenza vaccination rates.

METHODS

In 2015-2016, we performed a cluster-randomized trial of adolescent SLIV in middle/high schools. We selected 10 pairs of schools (identical grades within pairs) and randomly allocated schools within pairs to SLIV or usual care control. At eight suburban SLIV schools, we sent parents e-mail notifications about upcoming SLIV clinics and promoted online immunization consent. At two urban SLIV schools, we sent parents (via student backpack fliers) paper immunization consent forms and information about SLIV. E-mails were unavailable at these schools. Local health department nurses administered nasal or injectable influenza vaccine at dedicated SLIV clinics and billed insurers. We compared influenza vaccination rates at SLIV versus control schools using school directories to identify the student sample in each school. We used the state immunization registry to determine receipt of influenza vaccination.

RESULTS

The final sample comprised 17,650 students enrolled in the 20 schools. Adolescents at suburban SLIV schools had higher overall influenza vaccination rates than did adolescents at control schools (51% vs. 46%, p < .001; adjusted odds ratio = 1.27, 95% confidence interval 1.18-1.38, controlling for vaccination during the prior two seasons). No effect of SLIV was noted among urbanschools on multivariate analysis. SLIV did not substitute for vaccinations in primary care or other settings; in suburban settings, SLIV was associated with increased vaccinations in primary care or other settings (adjusted odds ratio = 1.10, 95% confidence interval 1.02-1.19).

CONCLUSIONS

SLIV in this community increased influenza vaccination rates among adolescents attending suburban schools.

Condom Availability in Schools: A Practical Approach to the Prevention of Sexually Transmitted Infection/HIV and Unintended Pregnancy

Adolescents and young adults are highly impacted by sexually transmitted infections (STIs) and unplanned pregnancy in the United States and globally. Consistent and correct use of male latex condoms is associated with protection against both STIs and pregnancy. Providing adolescents and young adults with access to free condoms in schools may increase the use of condoms by improving condom availability, eliminating cost, and decreasing embarrassment associated with purchasing condoms. Studies demonstrate that condom availability in schools is associated with the increased use of condoms and improved overall sexual health. The Society for Adolescent Health and Medicine encourages schools to make condoms available to students as part of efforts to decrease rates of STIs and unplanned pregnancy in adolescents and young adults. The Society for Adolescent Health and Medicine also encourages health care providers to advocate for and support the availability of condoms in local schools.

Facilitators and barriers of parental attitudes and beliefs toward school-located influenza vaccination in the United States: Systematic review

The study objective was to identify facilitators and barriers of parental attitudes and beliefs toward school-located influenza vaccination in the United States. In 2009, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention expanded their recommendations for influenza vaccination to include school-aged children. We conducted a systematic review of studies focused on facilitators and barriers of parental attitudes toward school-located influenza vaccination in the United States from 1990 to 2016. We reviewed 11 articles by use of the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) framework. Facilitators were free/low cost vaccination; having belief in vaccine efficacy, influenza severity, and susceptibility; belief that vaccination is beneficial, important, and a social norm; perception of school setting advantages; trust; and parental presence. Barriers were cost; concerns regarding vaccine safety, efficacy, equipment sterility, and adverse effects; perception of school setting barriers; negative physician advice of contraindications; distrust in vaccines and school-located vaccination programs; and health information privacy concerns. We identified the facilitators and barriers of parental attitudes and beliefs toward school-located influenza vaccination to assist in the evidence-based design and implementation of influenza vaccination programs targeted for children in the United States and to improve influenza vaccination coverage for population-wide health benefits.

School-Located Influenza Vaccinations: A Randomized Trial

OBJECTIVE

Assess impact of offering school-located influenza vaccination (SLIV) clinics using both Web-based and paper consent upon overall influenza vaccination rates among elementary school children.

METHODS

We conducted a cluster-randomized trial (stratified by suburban/urban districts) in upstate New York in 2014-2015. We randomized 44 elementary schools, selected similar pairs of schools within districts, and allocated schools to SLIV versus usual care (control). Parents of children at SLIV schools were sent information and vaccination consent forms via e-mail, backpack fliers, or both (depending on school preferences) regarding school vaccine clinics. Health department nurses conducted vaccine clinics and billed insurers. For all children registered at SLIV/control schools, we compared receipt of influenza vaccination anywhere (primary outcome).

RESULTS

The 44 schools served 19 776 eligible children in 2014-2015. Children in SLIV schools had higher influenza vaccination rates than children in control schools county-wide (54.1% vs 47.4%, P < .001) and in suburban (61.9% vs 53.6%, P < .001) and urban schools (43.9% vs 39.2%; P < .001). Multivariate analyses (controlling for age, grade, vaccination in previous season) confirmed bivariate findings. Among parents who consented for SLIV, nearly half of those notified by backpack fliers and four-fifths of those notified by e-mail consented online. In suburban districts, SLIV did not substitute for primary care influenza vaccination. In urban schools, some substitution occurred.

CONCLUSIONS

SLIV raised seasonal influenza vaccination rates county-wide and in both suburban and urban settings. SLIV did not substitute for primary care vaccinations in suburban settings where pediatricians often preorder influenza vaccine but did substitute somewhat in urban settings.

HPV vaccine uptake in a school-located vaccination program

Previous research has implied that while parents may be willing to have their adolescents receive some recommended vaccines via school-located vaccination program (SLVP), they were less likely to agree to the HPV vaccine being administered via SLVP. During an SLVP in a large urban area, 86% of those participating in the program received an HPV vaccine.

Social mobilisation, consent and acceptability: a review of human papillomavirus vaccination procedures in low and middle-income countries

BACKGROUND

Social mobilisation during new vaccine introductions encourages acceptance, uptake and adherence to multi-dose schedules. Effective communication is considered especially important for human papillomavirus (HPV) vaccine, which targets girls of an often-novel age group. This study synthesised experiences and lessons learnt around social mobilisation, consent, and acceptability during 55 HPV vaccine demonstration projects and 8 national programmes in 37 low and middle-income countries (LMICs) between January 2007 and January 2015.

METHODS

A qualitative study design included: (i) a systematic review, in which 1,301 abstracts from five databases were screened and 41 publications included; (ii) soliciting 124 unpublished documents from governments and partner institutions; and (iii) conducting 27 key informant interviews. Data were extracted and analysed thematically. Additionally, first-dose coverage rates were categorised as above 90 %, 90-70 %, and below 70 %, and cross-tabulated with mobilisation timing, message content, materials and methods of delivery, and consent procedures.

RESULTS

All but one delivery experience achieved over 70 % first-dose coverage; 60 % achieved over 90 %. Key informants emphasized the benefits of starting social mobilisation early and actively addressing rumours as they emerged. Interactive communication with parents appeared to achieve higher first-dose coverage than non-interactive messaging. Written parental consent (i.e., opt-in), though frequently used, resulted in lower reported coverage than implied consent (i.e., opt-out). Protection against cervical cancer was the primary reason for vaccine acceptability, whereas fear of adverse effects, exposure to rumours, lack of project/programme awareness, and schoolgirl absenteeism were major reasons for non-vaccination.

CONCLUSIONS

Despite some challenges in obtaining parental consent and addressing rumours, experiences indicated effective social mobilisation and high HPV vaccine acceptability in LMICs. Social mobilisation, consent, and acceptability lessons were consistent across world regions and HPV vaccination projects/programmes. These can be used to guide HPV vaccination communication strategies without additional formative research.

School-located vaccination for adolescents: Past, present, and future and implications for HPV vaccine delivery

Adolescents were first specifically targeted for school-located vaccination (SLV) in the 1990s when hepatitis B catch-up vaccination was recommended for all adolescents. SLV affords the opportunity to access adolescents at a time when their activities have developmental import and the patients have the capacity to decline repeatedly missing school and extracurricular events to get vaccinated. As noted above, SLV has been primarily reserved for brief catch-up interventions among youth, with routine vaccination recommendations quickly defaulting to the primary care provider. Now in 2016, with relatively disappointing adolescent immunization rates for the routinely recommended human papillomavirus (HPV) vaccine, the SLV option is one that could potentially help increase vaccination rates for a particularly effective, life-saving, 3-dose vaccination series. This article will serve as a brief review of the successful use of SLV in other countries, lessons learned when SLV was employed to immunize adolescents against hepatitis B in the United States in the late 1990s and early 2000s, and the current hopes and challenges for the future of adolescent SLV programming in the United States. Overall, the shift to the use of SLV to administer routinely recommend vaccine for adolescents will require careful planning to implement known strategies for accessing youth and in addition to new strategies designed to assure appropriate reimbursement for cost-effect SLV services. While not the best option for all adolescents, SLV provides an important opportunity to immunize youth with limited access to healthcare services in the community at large.

School-Located Vaccination Clinics for Adolescents: Correlates of Acceptance Among Parents

Four vaccines are recommended by The Advisory Committee for Immunization Practices for adolescents: tetanus, diphtheria, acellular pertussis vaccine (Tdap), meningococcal conjugate vaccine (MCV4), human papillomavirus vaccine (HPV), and annual seasonal influenza vaccine. However, coverage among adolescents is suboptimal. School-located vaccination clinics (SLVCs) offer vaccines to students at school, increasing access. This study seeks to determine the relationship between attitudes of parents of middle- and high-school students and acceptance of SLVCs for all four adolescent recommended vaccines. We conducted a telephone and web-based survey among parents of students enrolled in six middle and five high schools in Georgia. Analyses were conducted to examine associations between parental attitudes and willingness to allow their child to be vaccinated at school. Tdap and influenza vaccine had the highest rates of parental SLVC acceptance while HPV vaccine had the lowest. Parents who accepted SLVCs had higher perceived severity of influenza, meningococcal, and HPV illnesses compared to parents who did not accept SLVC. Intention to vaccinate was associated with SLVC acceptance for Tdap [Adjusted OR (AOR) 7.38; 95% confidence interval (CI) 2.44-22.31], MCV4 (AOR 2.97; 95% CI 1.67-5.28), and HPV vaccines (AOR 7.61; 95% CI 3.43-16.89). Social norms were associated with acceptance of SLVCs for influenza vaccine (AOR 1.44; 95% CI 1.12-1.84). These findings suggest parents of adolescents are generally supportive of SLVCs for recommended adolescent vaccines. Perceived severity of illness and intention to get their adolescent vaccinated were the most consistent correlates of parental SLVC acceptance for all vaccines. Future SLVC planning should focus on perceptions of disease severity and benefits of vaccination.

Parents' and providers' attitudes toward school-located provision and school-entry requirements for HPV vaccines

OBJECTIVE

To determine parents' and providers' attitudes toward school-located provision and school-entry requirements for HPV vaccination.

METHODS

Parents/guardians of 11-17 y old girls and pediatric healthcare providers at one inner-city public clinic and three private practices completed semi-structured interviews in 2012-2013. Participants were asked open-ended questions regarding their attitudes toward school-located provision and school-entry requirements for HPV vaccination. Parents' answers were analyzed with relationship to whether their daughters had not initiated, initiated but not completed, or completed the HPV vaccine series. Qualitative analysis was used to identify themes related to shared views.

RESULTS

129 parents/guardians and 34 providers participated. 61% of parents supported providing HPV vaccinations in schools, citing reasons of convenience, improved access, and positive peer pressure. Those who opposed school-located provision raised concerns related to privacy and the capacity of school nurses to manage vaccine-related reactions. Parents whose daughters had not completed the series were more likely to intend to vaccinate their daughters in schools (70%) and support requirements (64%) than parents who had not initiated vaccination (42% would vaccinate at school, 46% support requirements) or completed the series (42% would vaccinate at school, 32% support requirements; p < 0 .05 for all comparisons). 81% of providers supported offering vaccination in schools, wanting to take advantage of the captive audience, improve vaccine completion rates, and decrease the administrative burden on medical office staff, but were concerned about adequate information transfer between schools and medical offices. Only 32% of providers supported school-entry requirements, largely because they felt that a requirement might provoke a public backlash that could further hinder vaccination efforts.

CONCLUSIONS

School-located provision of HPV vaccination was widely accepted by healthcare providers and parents whose children have not completed the series, indicating that this venue might be a valuable addition to improve completion rates. Support for school-entry requirements was limited among both parents and healthcare providers.

Sauver JL, Finney Rutten LJ. The most effective and promising population health strategies to advance human papillomavirus vaccination

The US is failing to make substantive progress toward improving rates of human papillomavirus vaccine uptake. While the Healthy People 2020 goal for human papillomavirus (HPV) vaccination is 80%, the three-dose completion rate in the US in 2014 for 13- to 17-year-old females is less than 40%, and the rate for males is just above 20%. Experts point to a number of reasons for the poor HPV vaccination rates including parental concerns about safety, necessity, and timing. However, the evidence refuting these concerns is substantial. Efforts focusing on education and communication have not shown promise, but several population health strategies have reminder/recall systems; practice-focused strategies targeting staff, clinicians, and parents; assessment and feedback activities; and school-based HPV vaccination programs.

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

INTRODUCTION

Human papillomavirus (HPV) vaccination rates remain marginal across the U.S., including Kentucky, a state recognized for increased HPV-related cancer burden. School-based HPV immunization programs may be a viable approach to improving vaccination initiation and completion rates among youth. Therefore, the purpose of this study was to design, implement, and evaluate a school-based HPV vaccination program conducted in rural south-central Kentucky.

METHODS

Guided by evidence-based approaches to increasing immunization rates, the practical expertise of school nursing staff, and a detailed study protocol, academic and health department-based investigators implemented an HPV vaccination project in two high schools during the 2012-2013 academic year; data were analyzed in 2013-2014. Rates of returned parental consent forms, parental consent/declination, and HPV vaccination rates were documented.

RESULTS

At the beginning of the school year, all 935 students at the two schools were given HPV vaccination parental consent forms. Five hundred eleven students returned consent forms (55% return rate), and 447 of these students were HPV vaccine naïve (87%). Of these students, 315 (70%) initiated the vaccine series, with 276 (62%) completing the entire three-dose series, so that 88% of students initiating the vaccine series successfully completed the series. In estimating rates for the entire school body, 45% of students had received all three doses by the end of the project.

CONCLUSIONS

Despite study design limitations, results of this project provide further evidence about school-based immunization programs as an effective strategy for improving HPV vaccination rates among Kentucky and U.S. adolescents.

Catching Up With the HPV Vaccine: Challenges and Opportunities in Primary Care

PURPOSE

Data confirm that high rates of human papillomavirus (HPV) vaccination have not been achieved despite strong clinician endorsement of the vaccine. We conducted a study of primary care clinicians to assess the broad range of health care delivery, health policy, and attitudinal factors influencing vaccination uptake and opportunities for informed decision making.

METHODS

We implemented a mixed methods study in RIOS Net, a primary care practice-based research network in New Mexico. We first conducted qualitative, in-depth interviews with primary care clinicians, health policy makers, and immunization experts, and followed up with a confirmatory survey distributed to RIOS Net clinician members.

RESULTS

Health service delivery challenges emerged as the greatest barrier to HPV vaccination, specifically the lack of capacity to track and distribute reminders to eligible patients. Clinicians also reported variations in counseling approaches attributable to both age and emphasis on the cancer prevention benefits of the vaccine. There was no evidence of sociocultural influences on vaccine decision making, nor did concerns about perceived overprotection emerge.

CONCLUSIONS

Our findings, based on a long-term program of research, suggest that both patients' attributes and health system delivery are most influential in HPV vaccination coverage challenges. Interventions targeting innovative communication techniques, as well as health system changes that build on efforts toward coordinated care and utilization of other venues to promote vaccination, will be necessary to address these challenges.

Opportunities for increasing human papillomavirus vaccine provision in school health centers

BACKGROUND

Uptake of human papillomavirus (HPV) vaccine remains low among adolescents in the United States. We sought to assess barriers to HPV vaccine provision in school health centers to inform subsequent interventions.

METHODS

We conducted structured interviews in the fall of 2010 with staff from all 33 school health centers in North Carolina that stocked HPV vaccine.

RESULTS

Centers had heterogeneous policies and procedures. Out-of-pocket costs for children and youth to receive privately purchased HPV vaccine were a key barrier to providing HPV vaccine within school health centers. Other barriers included students not returning consent forms, costs to clinics of ordering and stocking privately purchased HPV vaccine, and difficulty using the statewide immunization registry. Most (82%) school health centers were interested in hosting interventions to increase HPV vaccine uptake, especially those that the centers could implement themselves, but many had limited staff to support such efforts. Activities rated as more likely to raise HPV vaccine uptake were student incentives, parent reminders, and obtaining consent from parents while they are at school (all ps < .05).

CONCLUSIONS

Although school health centers reported facing several key barriers to providing HPV vaccine, many were interested in partnering with outside organizations on low-cost interventions to increase HPV vaccine uptake among adolescents.

School-located influenza vaccination with third-party billing: outcomes, cost, and reimbursement

OBJECTIVE

To assess rates of immunization; costs of conducting clinics; and reimbursements for a school-located influenza vaccination (SLIV) program that billed third-party payers.

METHODS

SLIV clinics were conducted in 19 elementary schools in the Denver Public School district (September 2010 to February 2011). School personnel obtained parental consent, and a community vaccinator conducted clinics and performed billing. Vaccines For Children vaccine was available for eligible students. Parents were not billed for any fees. Data were collected regarding implementation costs and vaccine cost was calculated using published private sector prices. Reimbursement amounts were compared to costs.

RESULTS

Overall, 30% of students (2784 of 9295) received ≥1 influenza vaccine; 39% (1079 of 2784) needed 2 doses and 80% received both. Excluding vaccine costs, implementation costs were $24.69 per vaccination. The percentage of vaccine costs reimbursed was 62% overall (82% from State Child Health Insurance Program (SCHIP), 50% from private insurance). The percentage of implementation costs reimbursed was 19% overall (23% from private, 27% from Medicaid, 29% from SCHIP and 0% among uninsured). Overall, 25% of total costs (implementation plus vaccine) were reimbursed.

CONCLUSIONS

A SLIV program resulted in vaccination of nearly one third of elementary students. Reimbursement rates were limited by 1) school restrictions on charging parents fees, 2) low payments for vaccine administration from public payers and 3) high rates of denials from private insurers. Some of these problems might be reduced by provisions in the Affordable Care Act.

School-located influenza vaccination with third-party billing: what do parents think?

OBJECTIVE

School-located influenza vaccination (SLIV) may be instrumental in achieving high vaccination rates among children. Sustainability of SLIV programs may require third-party billing. This study assessed, among parents of elementary school students, the attitudes about SLIV and billing at school, as well as factors associated with being supportive of SLIV.

METHODS

We conducted a survey (April 2010 to June 2010) of parents of 1000 randomly selected primarily low-income children at 20 elementary schools at which SLIV with billing had occurred.

RESULTS

Response rate was 70% (n = 699). Eighty-one percent agreed (61% strongly) they "would be okay" with SLIV for their child. Many agreed it was better to get vaccinated at their child's doctor's office because they could take care of other health issues (72%) and the doctor knows the child's medical history (65%). However, an equal percentage (47%) thought the best place for influenza vaccination was the child's doctor's office and the child's school. Twenty-five percent did not want to give health insurance information necessary for billing at school. Factors independently associated with strongly supporting SLIV included parental education of high school or less (relative risk 1.30; 95% confidence interval 1.09-1.58), Hispanic ethnicity (1.25; 1.08-1.45); believing the vaccine is efficacious (1.49; 1.23-1.84); and finding school delivery more convenient (2.37; 1.82-3.45). Having concerns about the safety of influenza vaccine (0.80; 0.72-0.88) and not wanting their child to be vaccinated without a parent (0.74; 0.64-0.83) were negatively associated.

CONCLUSIONS

The majority of parents were supportive of SLIV, although parental concerns about not being present for vaccination and about the safety and efficacy of the vaccine will need to be addressed.

What parents and adolescent boys want in school vaccination programs in the United States

PURPOSE

Schools are increasingly a part of vaccine provision, because of laws mandating provision of information by schools about vaccination, school entry requirements, and mass vaccination campaigns. We examined preferences for programmatic aspects of voluntary school mass vaccination programs (i.e., "vaccination days").

METHODS

We analyzed data from a national sample of United States parents of adolescent males ages 11-19 years (n = 308) and their sons (n = 216), who completed an online survey in November 2011.

RESULTS

Sons believed that adolescents should be able to get vaccinated without parental consent at a younger age than parents did (p < .001) and were more willing to participate in vaccination days without a parent present (p = .04). Parents perceived school vaccination days to be a more convenient way to get their sons recommended vaccines if they were younger parents, had older adolescent sons, supported laws letting schools share vaccination records with health care providers, or had sons who were previously immunized at school (all p < .05). Parents of older sons were less likely to want their sons' vaccination records sent home (odds ratio [OR] = .47; 95% confidence interval [CI], .29-.77) or to their sons' physicians (OR = .61; 95% CI, .37-.98) compared with parents of younger sons, but more likely to prefer their sons' records be entered in an immunization registry (OR = 1.66; 95% CI, 1.05-2.63).

CONCLUSIONS

Sons' age had an important role in support for vaccination days and preferences for sharing vaccination information with health care professionals. Parents and sons had similar beliefs about vaccination in schools, but the sons' responses suggested an interest in greater autonomy.

School-located vaccination of adolescents with insurance billing: cost, reimbursement, and vaccination outcomes

PURPOSE

To assess, in a school-located adolescent vaccination program that billed health insurance, the program costs, the proportion of costs reimbursed, and the likelihood of vaccination.

METHODS

During the 2010-2011 school year, vaccination clinics were held for sixth- to eighth-grade students at seven Denver public schools. Vaccine administration and purchase costs were compared with reimbursement by insurers. Multivariate analyses were used to compare the likelihood of vaccination among students in intervention schools with students in control schools who did not participate in the program, with analyses stratified by grade (sixth grade vs. seventh-eighth grades).

RESULTS

Fifteen percent (466 of 3,144) of students attending intervention schools were vaccinated at school-located vaccination clinics. Among students vaccinated at school, 41% were uninsured, 37% publicly insured, and 22% privately insured. Estimated vaccine administration costs were $23.98 per vaccine dose. Seventy-eight percent of vaccine purchase costs and 14% of vaccine administration costs were reimbursed by insurers; 41% of total program costs were reimbursed. Sixth-grade students in intervention schools were more likely than those in control schools to receive tetanus-diphtheria-acellular pertussis (risk ratio [RR], 1.30; 95% confidence interval [CI], 1.08, 1.57), meningococcal conjugate (RR, 1.42; CI, 1.18, 1.70), and human papillomavirus (for females only, RR, 1.69; CI, 1.21, 2.36) vaccines during the 2010-2011 school year, with similar results for seventh- to eighth-grade students.

CONCLUSIONS

Although school-located adolescent vaccination with billing appears feasible and likely to improve vaccination rates, improvements in insurance coverage and reimbursement rates may be needed for the long-term financial sustainability of such programs.

HPV vaccination: are we initiating too late?

BACKGROUND

Human papillomavirus (HPV) vaccination is recommended in early adolescence. While limited data suggest that patients frequently delay initiation of the three-dose series, age-based variability in initiation of HPV vaccination and its clinical relevance are not well described. Thus, this study aims to characterize HPV vaccination delay among adolescent and young adult females.

METHODS

This retrospective cohort study examined age at HPV vaccination initiation and missed opportunities for receipt of the first vaccine dose (HPV1) among 11-26 year-old females (n=22,900) receiving care at 16 urban academically-affiliated ambulatory care clinics between 2007 and 2011. Predictors of timely vaccination and post-licensure trends in age at HPV1 receipt were assessed using multivariable logistic regression and a generalized linear mixed model, respectively. Chlamydia trachomatis and Papanicolaou screening before HPV vaccination initiation, as markers of prior sexual experience and associated morbidity, were examined in a subcohort of subjects (n=15,049).

RESULTS

The proportion of 11-12 year-olds who initiated HPV vaccination increased over time (44.4% [2007] vs. 74.5% [2011], p<0.01). Initiation rates also improved among 13-26 year-olds. Thus, the mean age at HPV1 receipt remained unchanged between 2007 and 2011 (16.0 ± 2.7 vs. 15.9 ± 4.0 years, p=0.45). Spanish language was a positive predictor (AOR 1.62, 95% CI 1.05-2.48) of HPV vaccination initiation among 11-12 year-olds in 2011. The majority (70.8-76.4%) of unvaccinated subjects experienced missed vaccination opportunities. Of the subcohort, 36.9% underwent Chlamydia screening before HPV1 receipt (19.1% with ≥ 1 positive result). Of those with prior Papanicolaou screening (16.6%), 32.1% had ≥ 1 abnormal result.

CONCLUSIONS

These low-income, minority females frequently delayed initiation of HPV vaccination. Many had evidence of prior sexual experience and associated morbidity, placing them at risk of HPV-related complications. Promoting timely HPV vaccination and reducing missed vaccination opportunities are crucial.

Promising alternative settings for HPV vaccination of US adolescents

Vaccination in alternative settings, defined here as being outside of traditional primary care, can help address the pressing public health problem of low human papillomavirus vaccine coverage among adolescents in the United States. Pharmacies are promising because they are highly accessible and have well established immunization practices. However, pharmacies currently face policy and reimbursement challenges. School-located mass vaccination programs are also promising because of their high reach and demonstrated success in providing other vaccines, but control by local policymakers and challenges in establishing community partnerships complicate widespread implementation. Health centers in schools are currently too few to greatly increase access to human papillomavirus vaccine. Specialty clinics have experience with vaccination, but the older age of their patient populations limits their reach. Future steps to making alternative settings a success include expanding their use of statewide vaccine registries and improving their coordination with primary care providers.

School-based vaccination of young US males: impact of health beliefs on intent and first dose acceptance

Little is known about adolescent males and their parents with respect to intent and first dose uptake of the human papillomavirus (HPV) vaccine outside of primay care settings. The purpose of this study was to evaluate potential predictors of parental intent to vaccinate (study was conducted in November 2010-December 2012) and of first dose uptake of HPV vaccine among a sample of young adolescent males, 11-15 years of age, who received care at a school-based health center (SBHC). We also examined intent as a potential mediator of the relationships between predictors (health beliefs and perceived spousal agreement) and vaccination. Slightly more than half (n=135 of 249) of parents reported an intention to vaccinate and 28% (n=69) of males received their first dose of the HPV vaccine. Two of three health beliefs were significantly associated with both intention and uptake as was perceived spousal agreement. We found intention to vaccinate was a partial mediatator between the perceived benefits of HPV vaccine and first dose acceptance. We also determined that intent was a strong mediator between both general immunization benefits and perceived spousal agreement and first dose uptake. While vaccine uptake was lower than expected, particularly considering that many barriers to vaccine initiation were eliminated because of the SBHC setting, this rate is higher than in traditional settings. After controlling for intent, only perceived benefits of the HPV vaccine remained a significant predictor of first dose acceptance.

Focusing on flu: adolescents' perspectives on school-located immunization programs for influenza vaccine

INTRODUCTION

To describe adolescents' perspectives regarding the use of school-located immunization programs (SLIP) for influenza vaccination. More importantly, adolescents were asked what factors would make them more or less likely to use a SLIP offering influenza vaccine.

RESULTS

Participants were generally found to be knowledgeable about influenza and to have positive attitudes toward receiving the vaccine via SLIP. Students were more willing to participate in a SLIP if it were low cost or free, less time-consuming than going to a doctor, and if they felt they could trust vaccinators. Overall, high school and middle school students ranked the benefits of SLIP similarly to each other.

METHODS

Focus groups using nominal group method were conducted with middle and high school students in a large, urban school district. Responses were recorded by each school, and then, responses were ranked across all participating schools for each question.

CONCLUSIONS

A wide range of issues are important to middle and high school students when considering participation in SLIPs including convenience, public health benefits, trust in the program, program safety, and sanitary issues. Further research will be needed regarding the generalizability of these findings to larger populations of students.

Update on adolescent immunizations: selected review of US recommendations and literature

PURPOSE OF REVIEW

To provide a clinically relevant synopsis of recent research findings as well as updated recommendations from the American Academy of Pediatrics (AAP) and Advisory Committee on Immunization Practices (ACIP) regarding adolescent immunizations.

RECENT FINDINGS

Coverage rates for the adolescent vaccinations continue to lag behind those of the childhood vaccinations, despite their importance. Recent research has focused on the reasons for suboptimal adolescent vaccination rates as well as strategies for improvement. By more fully understanding the barriers to immunization, efforts can be implemented to address these concerns and to ensure that all eligible adolescents receive their vaccinations. In addition, much work has focused on the duration of protection induced by childhood and adolescent vaccinations and the need for booster doses in older adolescents. Because immunity has been found to wane after vaccination, these booster doses can serve to more fully protect adolescents. This article reviews selected recent publications on human papillomavirus, meningococcal conjugate, and tetanus and diphtheria toxoids and acellular pertussis vaccines.

SUMMARY

Adolescent vaccinations will continue to be studied and this research will serve to shape future recommendations. Through this work, we can learn the best methods to optimize the protection of all adolescents against these very serious diseases.

Correlates of comfort with alternative settings for HPV vaccine delivery

Low uptake of human papillomavirus (HPV) vaccine calls for innovative approaches. Offering the vaccine in settings outside the traditional medical home, such as schools and pharmacies, could increase use. We sought to characterize the acceptability of HPV vaccine delivery in these alternative settings using a national (US) sample of parents of adolescent males ages 11-17 y (n = 506) and their sons (n = 391) who completed our online surveys in Fall 2010. We used multivariable regression to identify correlates of parents' and sons' comfort with (i.e., acceptability of) alternative settings. Half of parents (50%) and over one-third of sons (37%) reported that they were comfortable with schools or pharmacies as locations for the sons to receive HPV vaccine. Parents and sons were more comfortable with HPV vaccination in alternative settings if the sons had not recently visited their health care providers or had previously received vaccines at school, or if parents and sons were comfortable talking with each other about new vaccines. Parents who perceived greater barriers to HPV vaccination were more comfortable with alternative settings, as were sons who perceived that their peers were more accepting of HPV vaccine (all p < 0.05). Offering HPV vaccine in alternative settings may increase vaccination, especially among hard-to-reach adolescents. For example, our results suggest that offering the vaccine in alternative settings to boys who had not had recent health care visits could increase uptake by more than 10%. Study findings also highlight factors that should be addressed to maximize the potential success of HPV vaccination programs.