Communication technologies to improve HPV vaccination initiation and completion: A systematic review

Promoting Rural-Residing Parents' Receptivity to HPV Vaccination: Targeting Messages and Mobile Clinic Implementation

Interventions are needed to increase low HPV vaccination rates within rural areas in the United States, particularly in the state of Florida, which has the seventh highest number of HPV-related cancers. Florida also ranks low compared to other states in terms of HPV vaccination. Rural-residing parents may benefit from two evidence-based strategies to increase vaccination rates: reminder messages informing and prompting vaccination appointments and mobile clinics to reduce transportation barriers. We sought to identify parental attitudes towards (1) message features that promote rural-residing parents' receptivity to HPV vaccination; (2) parents' acceptability of three reminder message modalities (text, postcard, phone); and (3) implementation factors that promote parents' acceptability of using a mobile clinic for vaccination. We recruited 28 rural-residing parents of 9- to 12-year-old children (unvaccinated for HPV) for focus group and individual interviews and thematically analyzed transcripts. Three features promoted parents' receptivity to HPV vaccination messages: source credibility, specific information coverage, and personalization (name and birthday wishes). Parents most preferred text messages and identified three factors promoting parents' mobile clinic use: convenience and feasibility, trustworthiness, and detailed information. The findings indicate rural-residing parents' acceptability of reminder messages and mobile clinics as well as the importance of trust and feasibility when implementing these evidence-based strategies for rural-residing parents.

A multilevel intervention to promote HPV vaccination among young adults in Texas: protocol for a randomized controlled trial

BACKGROUND

Human papillomavirus (HPV) infections can cause cancers of the cervix, vagina, vulva, penis, anus, and oropharynx. The most recently approved HPV vaccine, Gardasil-9, protects against HPV infection and can prevent HPV-associated invasive cancers. However, Gardasil-9 is one of the most underused vaccines in the US today. Young adults are at risk for HPV infection, but many are not vaccinated. This study uses a randomized controlled trial (RCT) to test an innovative multilevel intervention to increase HPV vaccination rates among young adults. In this paper, we describe the research protocol.

METHODS

The study uses a two by three factorial design. A total of 1200 young adults in Texas, age 18-26 years, who have not been previously fully vaccinated against HPV will be randomly assigned to one of six conditions to receive: (1) standard CDC information about HPV vaccination (control); (2) video narratives about HPV vaccination; (3) written narratives about HPV vaccination; or (4-6) enhanced access to HPV vaccine combined with (4) standard CDC information, (5) video narratives, or (6) written narratives. The two primary outcomes are the rate of HPV vaccination initiation by 3-month follow-up and rate of HPV vaccination completion by 9-month follow-ups. We will determine the impact of the individual level intervention (i.e., persuasive narratives through video or written format), the systemic level intervention (i.e., enhanced access to HPV vaccines), and the combination of both levels, on HPV vaccination initiation and completion. We will also use purposive sampling to select participants to take part in semi-structured interviews/focus groups to better understand the mechanisms of the intervention.

DISCUSSION

Recruitment and data collection began in March 2022. We expect to complete data collection by March 2026. We expect that narratives, enhanced access, and the combination of both will improve HPV vaccination initiation and completion rates among young adults. If proven successful, these individual- and system-level interventions can be easily disseminated in regions with low HPV vaccination rates to improve HPV vaccination, and ultimately decrease HPV-related cancer burden.

TRIAL REGISTRATION

NCT05057312.

Co-development of a school-based and primary care-based multicomponent intervention to improve HPV vaccine coverage amongst French adolescents (the PrevHPV Study)

INTRODUCTION

Despite various efforts to improve human papillomavirus (HPV) vaccine coverage in France, it has always been lower than in most other high-income countries. The health authorities launched in 2018 the national PrevHPV research programme to (1) co-develop with stakeholders and (2) evaluate the impact of a multicomponent complex intervention aimed at improving HPV vaccine coverage amongst French adolescents.

OBJECTIVE

To describe the development process of the PrevHPV intervention using the GUIDance for rEporting of intervention Development framework as a guide.

METHODS

To develop the intervention, we used findings from (1) published evidence on effective strategies to improve vaccination uptake and on theoretical frameworks of health behaviour change; (2) primary data on target populations' knowledge, beliefs, attitudes, preferences, behaviours and practices as well as the facilitators and barriers to HPV vaccination collected as part of the PrevHPV Programme and (3) the advice of working groups involving stakeholders in a participatory approach. We paid attention to developing an intervention that would maximise reach, adoption, implementation and maintenance in real-world contexts.

RESULTS

We co-developed three components: (1) adolescents' and parents' education and motivation using eHealth tools (web conferences, videos, and a serious video game) and participatory learning at school; (2) general practitioners' e-learning training on HPV using motivational interviewing techniques and provision of a decision aid tool and (3) easier access to vaccination through vaccination days organised on participating middle schools' premises to propose free of charge initiation of the HPV vaccination.

CONCLUSION

We co-developed a multicomponent intervention that addresses a range of barriers and enablers of HPV vaccination. The next step is to build on the results of its evaluation to refine it before scaling it up if proven efficient. If so, it will add to the small number of multicomponent interventions aimed at improving HPV vaccination worldwide.

PATIENT OR PUBLIC CONTRIBUTION

The public (adolescents, their parents, school staff and health professionals) participated in the needs assessment using a mixed methods approach. The public was also involved in the components' development process to generate ideas about potential activities/tools, critically revise the successive versions of the tools and provide advice about the intervention practicalities, feasibility and maintenance.

Attitudes towards COVID Vaccine and Vaccine Hesitancy in Dermatology: A Narrative Review

Vaccine hesitancy has been a contentious issue even before the pandemic. The COVID-19 crisis has further amplified vaccine hesitancy, with worries about adverse effects, cultural and religious beliefs, and misinformation on social media. In dermatology, patients with pre-existing skin conditions may have specific concerns about the impact of the vaccine on their skin health. Factors such as cutaneous reactions, potential flares of underlying conditions, and fears of psoriasis worsening post-vaccination contribute to vaccine hesitancy. Healthcare professionals, including dermatologists, play a crucial role in addressing vaccine hesitancy by providing accurate information, addressing concerns, and understanding the psychological impact on patients. The concept of vaccine fatigue is also explored, noting the challenges in sustaining vaccine acceptance over time, especially with regards to booster vaccinations. Overcoming vaccine hesitancy requires trust-building, effective communication strategies, and collaboration between healthcare workers and non-healthcare individuals to combat misinformation. By recognizing and addressing psychological factors, dermatologists can increase vaccine acceptance and improve public health efforts.

The use of technology in vaccine safety communication: A systematic review of randomised controlled trials

OBJECTIVES

To identify technologies used in vaccine safety communication and evaluate their impact on vaccination intention, uptake, knowledge, attitude, and perceptions of consumers.

METHODS

We searched 6 electronic databases to identify randomised controlled trials assessing the impact of using technology in vaccine safety communication. The Cochrane Collaboration's tool for assessing risk of bias was used to evaluate each study.

RESULTS

We included 22 studies involving 27,109 participants from 8 countries; 15 studies assessed the use of videos and 7 examined innovative technologies. Using videos significantly improved knowledge (n = 3) and participant engagement (n = 2) compared to printed material. Among the innovative technologies, the use of virtual reality, and smartphone applications incorporating social networking or gamification significantly increased vaccination knowledge, confidence, and engagement. The studies showed that narrative messaging increased perceived disease severity (n = 2) and vaccination intention (n = 2).

CONCLUSIONS

While the use of innovative technologies is increasing, videos currently remain the most popular technology for vaccine safety communication. Communication technology, particularly with narrative messaging, improves patient engagement and comprehension.

PRACTICE IMPLICATIONS

Health authorities should increase focus on using videos and smartphone applications for vaccine safety communication. Collaboration among stakeholders is essential to develop guidelines on effective message content to complement the technology.

Evaluating Human Papillomavirus eHealth in Hmong Adolescents to Promote Vaccinations: Pilot Feasibility Study

BACKGROUND

Human papillomavirus (HPV) is a common sexually transmitted infection, causing multiple cancers, including cervical, penile, and anal. Infection and subsequent health risks caused by HPV can be diminished by HPV vaccination. Unfortunately, vaccination rates among Hmong Americans are substantially lower than those among other racial and ethnic groups, despite having higher cervical cancer rates than non-Hispanic White women. Such disparities and sparse literature highlight the need for innovative and culturally appropriate educational interventions to improve HPV vaccine rates in Hmong Americans.

OBJECTIVE

We aimed to develop and evaluate the effectiveness and usability of an innovative web-based eHealth educational website, the Hmong Promoting Vaccines website (HmongHPV website), for Hmong-American parents and adolescents to improve their knowledge, self-efficacy, and decision-making capacities to obtain HPV vaccinations.

METHODS

Through social cognitive theory and community-based participatory action research process, we created a theory-driven and culturally and linguistically appropriate website for Hmong parents and adolescents. We conducted a pre-post intervention pilot study to assess the website's effectiveness and usability. Overall, 30 Hmong-American parent and adolescent dyads responded to questions about HPV and HPV vaccine knowledge, self-efficacy, and decision-making at preintervention, 1 week after intervention, and at the 5-week follow-up. Participants responded to survey questions about website content and processes at 1 and 5 weeks, and a subset of 20 dyad participants participated in telephone interviews 6 weeks later. We used paired t tests (2-tailed) to measure the change in knowledge, self-efficacy, and decision-making processes, and used template analysis to identify a priori themes for website usability.

RESULTS

Participants' HPV and HPV vaccine knowledge improved significantly from pre- to postintervention stage and follow-up. Knowledge scores increased from preintervention to 1 week after intervention for both parents (HPV knowledge, P=.01; vaccine knowledge, P=.01) and children (HPV knowledge, P=.01; vaccine knowledge, P<.001), which were sustained at the 5-week follow-up. Parents' average self-efficacy score increased from 21.6 at baseline to 23.9 (P=.007) at post intervention and 23.5 (P=.054) at follow-up. Similar improvements were observed in the teenagers' self-efficacy scores (from 30.3 at baseline to 35.6, P=.009, at post intervention and 35.9, P=.006, at follow-up). Collaborative decision-making between parents and adolescents improved immediately after using the website (P=.002) and at follow-up (P=.02). The interview data also revealed that the website's content was informative and engaging; in particular, participants enjoyed the web-based quizzes and vaccine reminders.

CONCLUSIONS

This theory-driven, community-based participatory action research-designed and culturally and linguistically appropriate educational website was well received. It improved Hmong parents' and adolescents' knowledge, self-efficacy, and decision-making processes regarding HPV vaccination. Future studies should examine the website's impact on HPV vaccine uptake and its potential for broader use across various settings (eg, clinics and schools).

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

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

The Role of Health Information Technology in Improving Awareness of Human Papillomavirus and Human Papillomavirus Vaccine Among U.S. Adults

Objective: Although human papillomavirus (HPV) vaccines prevent cancer-causing HPV infections and cervical precancers, there is suboptimal awareness and limited global accessibility of HPV and HPV vaccine. Emerging evidence suggests that health information technology (HIT) may influence HPV-related awareness and improve vaccine adoption. The objective of this study was to evaluate the link between HIT and HPV-related awareness Methods: Data were obtained from 1,866 U.S. adults aged 18-45 years who completed the 2017 and 2018 Health Information National Trends Survey. We conducted multivariable logistic regression to analyze the association between HIT utilization and HPV-related awareness. Results: Awareness of HPV and HPV vaccine were 72.7% and 67.5%, respectively. Participants who used electronic means to look up health information (adjusted odds ratio [aOR] = 3.05; p = 0.001), communicate with health care provider (aOR = 1.68; p = 0.026), look up test results (aOR = 1.94; p = 0.005), and track health costs (aOR = 1.65; p = 0.04) were more likely to report HPV awareness than those who did not. Participants who used an electronic device to look up health information (aOR = 3.10; p = 0.003), communicate with clinicians (aOR = 1.72; p = 0.008), look up test results (aOR = 1.63; p = 0.021), and track health care charges (aOR = 1.90; p = 0.006) were more likely to report HPV vaccine awareness than those who did not. Discussion and Conclusion: Our findings suggest a positive association between HIT utilization and HPV-related awareness. Given the rapid and exponential increase in mobile technology access globally, these results are encouraging and offer a potential opportunity to leverage digital technology in primary cancer prevention for HPV-related cancers, especially in low- and middle-income countries with unsophisticated health infrastructures.

Using Electronic Reminders to Improve Human Papillomavirus (HPV) Vaccinations among Primary Care Patients

The COVID-19 pandemic led to delays in routine preventative primary care and declines in HPV immunization rates. Providers and healthcare organizations needed to explore new ways to engage individuals to resume preventive care behaviors. Thus, we evaluated the effectiveness of using customized electronic reminders with provider recommendations for HPV vaccination to increase HPV vaccinations among adolescents and young adults, ages 9-25. Using stratified randomization, participants were divided into two groups: usual care (control) (N = 3703) and intervention (N = 3705). The control group received usual care including in-person provider recommendations, visual reminders in exam waiting rooms, bundling of vaccinations, and phone call reminders. The intervention group received usual care and an electronic reminder (SMS, email or patient portal message) at least once, and up to three times (spaced at an interval of 1 reminder per month). The intervention group had a 17% statistically significantly higher odds of uptake of additional HPV vaccinations than the usual care group (Adjusted Odds Ratio: 1.17, 95% CI: 1.01-1.36). This work supports previous findings that electronic reminders are effective at increasing immunizations and potentially decreasing healthcare costs for the treatment of HPV-related cancers.

Differences in stakeholder-reported barriers and implementation strategies between counties with high, middle, and low HPV vaccine initiation rates: a mixed methods study

BACKGROUND

A greater understanding of the county-level differences in human papillomavirus (HPV) vaccination rates could aid targeting of interventions to reduce HPV-related cancer disparities.

METHODS

We conducted a mixed-methods study to compare the stakeholder-reported barriers and efforts to increase HPV vaccination rates between counties within the highest, middle, and lowest HPV vaccine initiation (receipt of the first dose) rates among 22 northern Florida counties. Between August 2018 and April 2019, we recruited stakeholders (n = 68) through purposeful and snowball sampling to identify potential participants who were most knowledgeable about the HPV vaccination activities within their county and would represent a variety of viewpoints to create a diverse picture of each county, and completed semi-structured interviews. County-level HPV vaccine initiation rates for 2018 were estimated from the Florida Department of Health's immunization registry and population counts. Implementation strategies were categorized by level of importance and feasibility using the Expert Recommendations for Implementing Change (ERIC) taxonomy. We compared the barriers and implementation strategies for HPV vaccination between tercile groups of counties by HPV vaccine initiation rates: highest (18 stakeholders), middle (27 stakeholders), and lowest (23 stakeholders).

RESULTS

The majority of the 68 stakeholders were female (89.7%), non-Hispanic white (73.5%), and represented a variety of clinical and non-clinical occupations. The mentioned barriers represented five themes: healthcare access, clinician practices, community partnerships, targeted populations, and cultural barriers. Within themes, differences emerged between county terciles. Within healthcare access, the highest rate county stakeholders focused on transportation, lowest rate county stakeholders focused on lack of clinicians, and middle county stakeholders mentioned both. The number of ERIC quadrant I strategies, higher feasibility, and importance described decreased with the tercile for HPV vaccination: highest = 6, middle = 5, and lowest =3 strategies.

CONCLUSIONS

The differing barriers and strategies between the highest, middle, and lowest vaccination rate counties suggest that a tailored and targeted effort within the lowest and middle counties to adopt strategies of the highest rate counties may reduce disparities.

Increasing HPV Vaccination Rates Using Text Reminders: An Integrative Review of the Literature

INTRODUCTION

Human papillomavirus (HPV) is the most common sexually transmitted infection among youth in the United States. Although HPV vaccinations are readily available, HPV immunizations remain lower than target rates. The purpose of this review is to consider text message reminder system efficacy to improve HPV vaccination rates in eligible children.

METHOD

A literature review was conducted using Cumulative Index to Nursing and Allied Health Literature and PubMed databases to search articles illustrating the effect of text message reminder systems.

RESULTS

Research is primarily conclusive of improved HPV vaccination rates through text message reminder systems, indicating the need for practice guidelines directed at text message delivery and text message content.

DISCUSSION

This integrative review synthesizes and highlights available literature on implementing text message reminder systems to improve HPV vaccination rates. Once the text message reminder system is in place, automatic arrangement of preventive care service is hassle-free for practices.

[Approaches to increase HPV vaccination rate in Germany - challenges and opportunities. A qualitative study]

BACKGROUND

In Germany, the prevalence of infections with the human papilloma virus (HPV) among women and men is high. High-risk HPV types can lead to certain types of cancer (e. g., cervical cancer). Vaccination against HPV infections associated with cancer and genital warts was introduced in Germany in 2007. Currently, HPV vaccination is recommended for girls and boys by the German Standing Committee on Vaccination. The vaccination rate, however, remains rather low, with rates below 50% in 15-year-old girls and of about 5% in 15-year-old boys in 2019. This suggests that new approaches are urgently needed to increase HPV vaccination coverage in Germany in the coming years.

OBJECTIVES

This qualitative study aimed at identifying opportunities and challenges related to the application and implementation of different approaches designed to increase HPV vaccination uptake among male and female adolescents in Germany according to expert views.

MATERIALS AND METHODS

From April to July 2020, 43 experts from the field of HPV vaccination in Germany were interviewed using a semi-standardized interview guide. The audiotaped interviews were transcribed and analyzed using qualitative content analysis by Udo Kuckartz.

RESULTS AND CONCLUSION

According to the experts interviewed the following would be the most promising approaches to increase HPV vaccination rates in Germany: educational measures, school vaccination programs, increasing participation in the adolescent health check-up "J1", reminder and recall systems. The most reasonable solution would be to pursue several approaches simultaneously. According to the experts, more political support with implementing strategies and reducing bureaucratic obstacles as well as an increase in cooperation between relevant stakeholders is required to achieve the effective implementation of these strategies.

Helping Children to Participate in Human Papillomavirus-Related Discussions: Mixed Methods Study of Multimedia Messages

BACKGROUND

Human papillomavirus (HPV) can cause several types of cancers and genital warts. A vaccine is available to prevent HPV infections, and several efforts have been made to increase HPV education and, eventually, vaccination. Although previous studies have focused on the development of messages to educate children about HPV and the existence of the HPV vaccine, limited research is available on how to help children better communicate with their parents and health care professionals about the HPV vaccination. In addition, limited research is available on the target audience of this study (Italian children).

OBJECTIVE

This manuscript describes a study assessing the feasibility of using an evidence-based animated video and a web-based game to help children (aged 11-12 years) participate in discussions about their health-in particular when such conversations center around the HPV vaccination-and improve several HPV-related outcomes. The study also compares the effects of these 2 educational multimedia materials on children's knowledge and perceptions of HPV prevention.

METHODS

A mixed methods approach consisting of focus group discussions and an experiment with children (N=35) was used to understand children's experiences with, and perceptions of, the animated video and the game and to measure possible improvements resulting from their interaction with these materials.

RESULTS

Both the animated video and a web-based game increased children's knowledge and positive perceptions about HPV and HPV vaccination. Any single message was not more effective than the others. The children discussed aspects of the features and characters they liked and those that need improvements.

CONCLUSIONS

This study shows that both materials were effective for improving children's education about the HPV vaccine and for helping them to feel more comfortable and willing to communicate with their parents and health care professionals about their health. Several elements emerged that will allow further improvements in the design and development of the messages used in this study as well as the creation of future campaigns.

Video-based messages to reduce COVID-19 vaccine hesitancy and nudge vaccination intentions

Vaccines are highly effective for curbing the spread of SARS-CoV-2 (COVID-19). Yet, millions of Americans remain hesitant about getting vaccinated, jeopardizing our ability to end the COVID-19 pandemic by fueling the spread and development of new variants. We show that brief video-based messages of encouragement addressing specific COVID-19 vaccine concerns increase vaccination intentions, and that vaccination intentions, in turn, are predictive of future vaccine uptake. Results from our online experiment reveal that willingness to get vaccinated is driven by messages that increase confidence in COVID-19 vaccines and perceived behavioral control to get vaccinated. Importantly, messages were particularly effective among more skeptical populations including people who identify as politically conservative or moderate and those who express low trust in government institutions. Our findings corroborate the real-world behavioral significance of vaccination intentions, and devise how even short, scalable online messages can provide governments and health authorities an inexpensive, yet effective tool for increasing intentions to vaccinate against COVID-19 among populations most reluctant to get them.

Awareness Levels of the Link Between Oropharyngeal Cancer and HPV Infection Among Spanish Women: a Hospital-Based Cross-sectional Study

Several observational studies have demonstrated the increased awareness of human papillomavirus (HPV) as an etiological factor of oropharyngeal cancers (OPCs). The incidence of OPCs has increased in recent times, particularly among younger women, and the efficacy of the HPV vaccine in preventing these cancers has gained attention among the medical community. The aim of this study was to explore the health literacy of Spanish adult women regarding factors associated with HPV and its link to OPCs, as well as their awareness of the HPV vaccination. A survey was distributed to 508 women, and 409 (70.5%) were considered as valid participants. The majority of the participants were Caucasian (97.8%) with a mean age of 44.1 ± 11.6. Out of all the participants, only 48.9% women identified HPV as a possible etiology of OPC. The most common sources of information regarding this association were the internet (31.3%), video media (28.9%), and healthcare professionals (28.9%), whereas 16.1% of the participants reported that they had obtained information from three or more sources. The average number of correct answers in the 16-item survey which was used to determine the participants' knowledge of HPV-related diseases was 8.7 ± 4.2, and the average number of correct answers in the 6-item survey regarding the usefulness of the HPV vaccination was 3.3 ± 1.6. According to bivariate models, the variables associated with a poorer level of awareness were related mainly to education (p < 0.001), sexual behavior (p < 0.001), and employment status (p < 0.001). This study contributes toward the discovery of the previously unforeseen psychosocial burden of HPV and its related diseases among Spanish women.

mHealth video gaming for human papillomavirus vaccination among college men-qualitative inquiry for development

BACKGROUND

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. Persistent infection with HPV can cause various cancers; however, HPV vaccination can prevent infections associated with high risk, cancerous strains of the virus. As it relates to HPV, college age men have been identified as one of the catch-up vaccination groups. Among college age men, gaming is an extremely popular extracurricular activity. Further, video games have emerged as a popular public health intervention tool. Therefore, this study aims to collect qualitative data on how to develop, implement and evaluate the effectiveness of a gaming intervention to increase HPV risk perceptions, improve self-efficacy and increase intention to receive the HPV vaccine among male college students (18-26 years old).

METHODS

Four focus group sessions ranging from eight to ten individuals were conducted among male college students from one large research-intensive university in the South. Using grounded theory, data from focus group interviews were coded using NVivo software to identify emergent themes.

RESULTS

Participants emphasized that although customization was not viewed as important by college aged males, the ability to tailor in game experiences or experience different things each time they played (creative freedom) was more important. They encouraged that the digital game be created on a mobile platform, incorporate health messages, and be informative to reach their population. Furthermore, they suggested innovative way to disseminate the game, which included having health department/health care providers prescribe the game to patients as an end of clinical interaction strategy.

CONCLUSIONS

College age men, are natural avid gamers, enjoy game play, and can engage in learning online or offline. While platform preference varies among gamer type, college age men in our study emphasized that mobile based gaming is the most advantageous way to increase knowledge/awareness and encourage positive in game behavior which can impact out of game behaviors such as vaccination. Because of the level of access and natural disposition of mHealth technology seen as an "extension of the self", games for health developers should consider the mobile platform as the ideal for the target demographic.

Long-Term Multilevel Intervention Impact on Human Papillomavirus Vaccination Rates Spanning the COVID-19 Pandemic

OBJECTIVE

The aim of the study was to evaluate the long-term sustainability of a multilevel intervention and the COVID-19 pandemic impact on adolescent human papillomavirus (HPV) vaccination coverage.

MATERIALS AND METHODS

In 2016, a pediatric and family medicine practice within a federally qualified health center completed a multilevel intervention, Development of Systems and Education for Human Papillomavirus Vaccination. We examined the intervention impact on HPV vaccine initiation and completion rates among adolescents 10-18 years between March 2016 and October 2020. We determined the total number of HPV vaccine doses administered monthly. Data were plotted on statistical process control charts.

RESULTS

Vaccine initiation increased from an average of 14% to an average of 42% for 10-year-old patients and from an average of 72% to an average of 92% for 11- to 12-year-old patients between March 2016 and January 2017 and remained stable through March 2020. Complete vaccination by age 13 years increased from 62% to 88% through October 2020.

CONCLUSIONS

This intervention led to continued improvement for on-time HPV vaccination coverage 4 years after intervention completion.Clinical Trial Registration: This trial has been registered at http://www.clinicaltrials.gov (identifier NCT02812732).

Application of theoretical frameworks on human papillomavirus vaccine interventions in the United States: systematic review and meta-analysis

PURPOSE

Theoretical frameworks are useful tools to explain the dynamics of behavioral change, develop, and implement intervention studies. The purpose of this systematic review and meta-analysis is to evaluate the application of theoretical frameworks and models to HPV vaccination intervention studies in the United States (US) from January 2006 to December 2019.

METHODS

A comprehensive search across databases, including PubMed, EMBASE, ERIC, CINAHL, Academic Search Complete, Scopus, Web of Science, and PsycINFO, was conducted. Articles were included in the systematic analysis if at least one theory was used to develop the intervention phase. All intervention studies targeting populations in the US without restrictions of age, income, sex, and ethnicity were included. Articles were included in the meta-analysis if vaccine uptake and/or vaccine completion was addressed.

RESULTS

The Health Belief Model, Motivational Interviewing, Theory of Planned Behavior, and Information-Motivation-Behavioral Skills were the most used theories. Based on theory integrity, theory rationale, and theory operationalization, most of the studies (60%) were rated high for the application of the theoretical frameworks. Our results suggest a preference for theoretical frameworks targeting individual change rather than community change and the existence of gender disparities in the application of theoretical frameworks. The association between theory and increase of likelihood in vaccine uptake and completion was not supported.

CONCLUSION

This review spotlights common issues in the application of theoretical frameworks in HPV vaccine interventions in the US. Our results suggest we are still in a developmental phase on several aspects of theory application to HPV vaccination.

The Use of Digital Technologies to Support Vaccination Programmes in Europe: State of the Art and Best Practices from Experts' Interviews

Digitalisation offers great potential to improve vaccine uptake, supporting the need for effective life-course immunisation services. We conducted semi-structured in-depth interviews with public health experts from 10 Western European countries (Germany, Greece, Italy, Luxembourg, Malta, the Netherlands, Norway, Poland, Portugal, and the United Kingdom) to assess the current level of digitalisation in immunisation programmes and retrieve data on interventions and best practices. Interviews were performed using an ad hoc questionnaire, piloted on a sample of national experts. We report a mixed level of digital technologies deployment within vaccination services across Europe: Some countries are currently developing eHealth strategies, while others have already put in place robust programmes. Institutional websites, educational videos, and electronic immunisation records are the most frequently adopted digital tools. Webinars and dashboards represent valuable resources to train and support healthcare professionals in immunisation services organisation. Text messages, email-based communication, and smartphone apps use is scattered across Europe. The main reported barrier to the implementation of digital-based programmes is the lack of resources and shared standards. Our study offers a comprehensive picture of the European context and shows the need for robust collaboration between states and international institutions to share best practices and inform the planning of digital intervention models with the aim of countering vaccine hesitancy and increasing vaccine uptake.

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.

Communication research at the National Cancer Institute, 2013-2019: a grant portfolio analysis

PURPOSE

To analyze communication-focused grants funded by the National Cancer Institute (NCI) between fiscal years 2013 and 2019 to provide insight into the characteristics of funded projects and identify promising areas for future research.

METHODS

iSearch, a portfolio analysis tool, was queried to identify communication-related grants funded by NCI. Abstracts and specific aims were coded for key study characteristics. 344 unique competing grants with a substantial communication component were included in the final analysis. SAS version 9.4 was used to calculate code frequencies.

RESULTS

Most communication grants focused on cancer prevention (n = 197), with fewer targeting diagnosis, treatment, survivorship, or end-of-life. Tobacco product use was the most frequently addressed topic (n = 128). Most grants targeted or measured outcomes at the individual (n = 332) or interpersonal level (n = 127). Cancer patients/survivors (n = 101) and healthcare providers (n = 63) were often the population of focus, while caregivers or those at increased risk for cancer received less attention. Studies were often based in healthcare settings (n = 125); few studies were based in schools or worksites. Many grants employed randomized controlled trials (n = 168), but more novel methods, like optimization trials, were uncommon.

CONCLUSION

NCI's support of health communication research covers a diverse array of topics, populations, and methods. However, the current analysis also points to several promising opportunities for future research, including efforts focused on communication at later stages of the cancer control continuum and at multiple levels of influence, as well as studies that take advantage of a greater diversity of settings and leverage novel methodological approaches.

E-health roadmap for COVID-19 vaccine coverage in Iran

BACKGROUND

Vaccination is the effective and long-term pharmacological solution to deal with COVID-19. Information technology (IT) and electronic immunization can be effective in accelerating and improving vaccine coverage. The aim of this paper is to develop multi-dimensional framework of e-health roadmap to response Covod-19 pandemic and examine the role of IT for improving vaccine distribution in Iran.

METHODS

The study methodology was based on a two-stage Delphi method which included literature studies at the beginning. Key steps in creating a roadmap in this study include definition, development and evaluation. The initial conceptual model was developed after literature review. Proposed roadmap was reviewed and evaluated in two stages based on the Delphi method by experts in the fields of E-health.

RESULTS

In the e-health roadmap model, 14 stages of vaccine distribution were presented in three phases of vaccination and then were determined the type of technology in each phase. The 4 conceptual models were approved based on the two stages Delphi approach in a survey of 14 e-health experts. In the second phase of the Delphi process, the selected items were sent back to the specialists to verification. Then e-health roadmap was confirmed by experts and was finalized the approved model.

CONCLUSIONS

The technology-based roadmap is one plan in the form of a transfer strategy that aligns goals with specific technical solutions and helps to meet them. This roadmap empowers decision makers to decide on alternative paths and achieve goals.

A Systematic Review of Interventions to Improve HPV Vaccination Coverage

Human papillomavirus (HPV) infection is the most common sexually transmitted infection worldwide. Although most HPV infections are transient and asymptomatic, persistent infection with high-risk HPV types may results in diseases. Although there are currently three effective and safe prophylactic HPV vaccines that are used across the world, HPV vaccination coverage remains low. This review evaluates the effects of the interventions to improve HPV vaccination coverage. We searched the Cochrane Central Register of Controlled Trials, PubMed, Web of Science, Scopus, and the World Health Organization International Clinical Trials Registry Platform and checked the reference lists of relevant articles for eligible studies. Thirty-five studies met inclusion criteria. Our review found that various evaluated interventions have improved HPV vaccination coverage, including narrative education, outreach plus reminders, reminders, financial incentives plus reminders, brief motivational behavioral interventions, provider prompts, training, training plus assessment and feedback, consultation, funding, and multicomponent interventions. However, the evaluation of these intervention was conducted in high-income countries, mainly the United States of America. There is, therefore, a need for studies to evaluate the effect of these interventions in low-and middle-income countries, where there is a high burden of HPV and limited HPV vaccination programs.

Digital Health Strategies for Cervical Cancer Control in Low- and Middle-Income Countries: Systematic Review of Current Implementations and Gaps in Research

BACKGROUND

Nearly 90% of deaths due to cervical cancer occur in low- and middle-income countries (LMICs). In recent years, many digital health strategies have been implemented in LMICs to ameliorate patient-, provider-, and health system-level challenges in cervical cancer control. However, there are limited efforts to systematically review the effectiveness and current landscape of digital health strategies for cervical cancer control in LMICs.

OBJECTIVE

We aim to conduct a systematic review of digital health strategies for cervical cancer control in LMICs to assess their effectiveness, describe the range of strategies used, and summarize challenges in their implementation.

METHODS

A systematic search was conducted to identify publications describing digital health strategies for cervical cancer control in LMICs from 5 academic databases and Google Scholar. The review excluded digital strategies associated with improving vaccination coverage against human papillomavirus. Titles and abstracts were screened, and full texts were reviewed for eligibility. A structured data extraction template was used to summarize the information from the included studies. The risk of bias and data reporting guidelines for mobile health were assessed for each study. A meta-analysis of effectiveness was planned along with a narrative review of digital health strategies, implementation challenges, and opportunities for future research.

RESULTS

In the 27 included studies, interventions for cervical cancer control focused on secondary prevention (ie, screening and treatment of precancerous lesions) and digital health strategies to facilitate patient education, digital cervicography, health worker training, and data quality. Most of the included studies were conducted in sub-Saharan Africa, with fewer studies in other LMIC settings in Asia or South America. A low risk of bias was found in 2 studies, and a moderate risk of bias was found in 4 studies, while the remaining 21 studies had a high risk of bias. A meta-analysis of effectiveness was not conducted because of insufficient studies with robust study designs and matched outcomes or interventions.

CONCLUSIONS

Current evidence on the effectiveness of digital health strategies for cervical cancer control is limited and, in most cases, is associated with a high risk of bias. Further studies are recommended to expand the investigation of digital health strategies for cervical cancer using robust study designs, explore other LMIC settings with a high burden of cervical cancer (eg, South America), and test a greater diversity of digital strategies.

Barriers to Human Papillomavirus Vaccine Series Completion among Insured Individuals in an Integrated Healthcare Setting

Introduction:

Infection with certain types of human papillomavirus (HPV) can lead to cervical cancer as well as other cancers in both men and women. However, the requirement for multiple doses may limit the vaccine’s effectiveness for cancer prevention. We conducted a pilot study to investigate barriers to HPV vaccine series completion among members of an integrated healthcare system with clinical documentation of only 1 dose.

Methods:

We surveyed parents or legal guardians of 11-17-year-old girls (n = 10) and boys (n = 18), as well as 18-31-year-old women (n = 20) and men (n = 9), about their reasons for not completing the HPV vaccine series.

Results:

Most participants (70.2%) were non-Hispanic white. Among parents of children, commonly reported barriers to HPV vaccine series completion included not being aware or informed of the need for additional doses (28.6%), as well as the inconvenience of returning for additional doses (17.9%). Concerns about the HPV vaccine or vaccines in general were more common among parents of girls (30.0%) compared with parents of boys (16.7%). Among adults, barriers to HPV vaccine series completion included the inconvenience of returning for additional doses (31.0%), not being aware or informed of the need for additional doses (10.3%), and forgetting (10.3%).

Conclusion:

Our findings suggest that clinicians and healthcare systems can play a greater role in promoting awareness of the multiple-dose requirement, addressing vaccine concerns, and increasing opportunistic vaccination in a variety of settings. Increasing these efforts may facilitate HPV vaccine completion and increase its effectiveness in cancer prevention.

The Impact of Theory in HPV Vaccination Promotion Research: A Systematic Review and Meta-Analysis

OBJECTIVE

Numerous studies examined HPV vaccination promotional strategies. However, an overview of theory use, a synthesis of strategies' effectiveness and an examination of the moderating influence of theory are absent.

DATA SOURCE

We retrieved studies from Academic Search Complete, Business Source Complete, PubMed, PsycINFO, Web of Science, CMMC, CINAHL, and MEDLINE.

STUDY INCLUSION AND EXCLUSION CRITERIA

1) peer-reviewed articles written in English, 2) experimental or quasi-experimental, 3) measure HPV vaccination-related outcomes, 4) had to contain a control condition and report statistics necessary for conversion (for meta-analysis only).

DATA EXTRACTION

70 and 30 studies were included for the systematic review and meta-analysis respectively.

DATA SYNTHESIS

Four major categories were coded: study information, theory use, type of theory, and outcomes. Two independent coders coded the sample (Cohen's Kappa ranged from .8 to 1).

RESULTS

Most of the studies were based in the U.S. (77%, k = 54) with convenient samples (80%, k = 56), targeted toward females (46%, k = 32), and around a quarter did not employ any theories (47%, k = 33). Among theory-driven studies, the most commonly used were Framing (22%, k = 19), Health Belief Model (HBM; 13%, k = 12), and Narrative (7%, k = 6). Among controlled studies, promotional strategies were significantly more effective compared to the control (r+ = .25, p < .001). Strategies guided by the information, motivation, behavioral skills model (IMB) were more effective (r+ = .75, p < .001) than studies guided by framing theory (r+ = -.23, p < .001), HBM (r+ = .01, p < .001), and other theories (r+ = .11, p < .001).

CONCLUSION

This review contributes to HPV vaccination promotion literature by offering a comprehensive overview of promotional strategies and practical suggestions for future research and practices.

Multi-level determinants to HPV vaccination among Hispanic farmworker families in Florida

Background: HPV vaccination is the primary prevention method for HPV-related cancers, although among Hispanic populations, migrant farmworkers may experience exacerbated challenges to HPV vaccination due to intersecting political, social, and personal contexts. This study explored multi-level determinants of HPV vaccination among Hispanic migrant farmworker families.Methods: Using a community-engaged approach and guided by the socio-ecological model, Intervention Mapping, and PRECEDE-PROCEED constructs, we recruited parents who had a daughter and/or son age 9-15 years from a rural, faith-based, community organization in Florida. Three focus groups (n = 13) were conducted in Spanish and constant comparison methods were used to analyze qualitative data.Results: Micro-level determinants included moderate HPV vaccine knowledge, desire for more HPV vaccine information, concerns about HPV vaccine completion, health/preventive motivations, past experiences with the healthcare system, and parental gender roles related to health care. Macro-level determinants included facilitators (e.g. transportation services, clinics open after work hours, governmental programs) and barriers (e.g. supervisor/employment inflexibility, long clinic wait times) to accessing health care and vaccination in general (including HPV vaccination). Participants shared their preferences for future interventions that would meet the needs of this community, and discussed potential content and mechanisms for receiving HPV information, as well as what might facilitate their overall access, uptake, and completion of the HPV vaccine series.Discussion: Determinants to HPV vaccination emerged and underscore the importance of addressing the multi-level factors when designing and delivering an HPV vaccine intervention for this Hispanic migrant farmworker population. Improving HPV vaccination rates requires responding to situational and structural hardships that disproportionately impact this group. Thus, community-tailored and culturally appropriate multi-level interventions are needed, while emphasizing existing knowledge assets and preferences favorable towards HPV vaccination, with the ultimate goal of the decreasing HPV-related disparities. Findings suggest interventions must reach beyond the individual level to account for this unique population's lived experiences.

A narrative review of HPV vaccination interventions in rural U.S. communities

Uptake of human papillomavirus (HPV) vaccine in the United States (U.S.) is far below the Healthy People 2020 goal of 80% coverage among adolescents. In rural communities, HPV vaccination coverage is low, yet incidence and mortality rates of HPV-associated cancer are high. Much of the research focused on HPV vaccination in rural U.S. communities has involved qualitative investigations, observations, survey research, and secondary data analysis with limited implementation of interventional study designs. The purpose of this narrative review was to examine intervention studies to increase HPV vaccination in rural settings and to summarize study characteristics and associated outcomes. PubMed, PsycINFO, CINAHL, and Web of Science were searched utilizing systematic narrative review methodology for studies describing implementation of HPV vaccination interventions in rural U.S. settings from January 2006-December 2019. Using specific search criteria, 991 studies were identified. After abstract review, 30 full-text articles were assessed for eligibility, and 15 met the inclusion criteria. The 15 articles - published from 2011 to 2019 - described HPV vaccination interventions in rural settings of six states, including communities, health clinics, and schools. A range of primary and secondary outcomes were reported, including HPV vaccine receipt (series initiation, continuation, and/or completion); HPV vaccine knowledge; and/or cervical cancer knowledge. Across the studies, there was an absence of the description of rural context. As compared to the broader HPV vaccination intervention literature, interventions in rural settings were limited. More interventional research is needed in rural communities given the elevated rates of HPV-related cancer and low rates of HPV vaccine uptake.

Can mHealth interventions contribute to increased HPV vaccination uptake? A systematic review

The objective of this review was to synthesize existing evidence on mobile health (mHealth) interventions geared at improving HPV related knowledge, HPV vaccination intent and HPV vaccination uptake. Between November and December 2019, systematic searches were performed in the databases PubMed, Ebsco/CINAHL, Ebsco/PsycINFO, and Clarivate Analytics/Web of Science Social Science Citation Index (SSCI). We identified 805 articles of which 92 were eligible for inclusion after abstract screening. 19 articles met the inclusion criteria of the review based on full article review and all but one of the included interventions were conducted in the United States. mHealth interventions ranged from text messages, phone calls to interactive voice recordings and software on tablets. All four interventions which attempted to improve HPV knowledge and vaccination intent, reported positive findings, however, only two interventions reported statistically significant improvements between intervention and control groups. 14 interventions reported an increase in HPV vaccination uptake and vaccination series completion among the intervention groups; including when mHealth interventions were compared to control groups or non-mHealth interventions. Some factors noted in the successful interventions included frequency of messages, combinations of multiple interventions including in-person education session, written educational materials, texts alongside call or emails; tailored messages as well as participant's intent to vaccinate at baseline. mHealth interventions potentially show promise as tools in improving short-term vaccination knowledge, intent, and uptake of HPV vaccination. There is however a need to refine components which can promote mHealth interventions' success as well as for the evaluation of such interventions in different contexts and over time.

Internal and External Validity of Social Media and Mobile Technology-Driven HPV Vaccination Interventions: Systematic Review Using the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) Framework

Social media human papillomavirus (HPV) vaccination interventions show promise for increasing HPV vaccination rates. An important consideration for the implementation of effective interventions into real-world practice is the translation potential, or external validity, of the intervention. To this end, we conducted a systematic literature review to describe the current body of evidence regarding the external validity of social media HPV vaccination-related interventions. Constructs related to external validity were based on the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework. Seventeen articles published between 2006 and 2020 met the inclusion criteria. Three researchers independently coded each article using a validated RE-AIM framework. Discrepant codes were discussed with a fourth reviewer to gain consensus. Of these 17 studies, 3 were pilot efficacy studies, 10 were randomized controlled trials (RCTs) to evaluate effectiveness, 1 was a population-based study, and 3 did not explicitly state which type of study was conducted. Reflecting this distribution of study types, across all studies the mean level of reporting RE-AIM dimensions varied with reach recording 90.8%, effectiveness (72.1%), adoption (40.3%), implementation (45.6%), and maintenance (26.5%). This review suggests that while the current HPV vaccination social media-driven interventions provide sufficient information on internal validity (reach and effectiveness), few have aimed to gather data on external validity needed to translate the interventions into real world implementation. Our data suggest that implementation research is needed to move HPV vaccination-related interventions into practice. Included in this review are recommendations for enhancing the design and reporting of these HPV vaccination social media-related interventions.

Misinformation Drives Low Human Papillomavirus Vaccination Coverage in South African Girls Attending Private Schools

Background: Cervical cancer, caused by persistent human papillomavirus (HPV) infection, is the leading cause of female cancer deaths in South Africa. In 2014, the South African National Department of Health introduced a free public sector school-based HPV vaccination programme, targeting grade 4 girls aged ≥9 years. However, private sector school girls receive HPV vaccination through their healthcare providers at cost. This study investigated HPV vaccination knowledge, attitudes and practices of caregivers of girls aged ≥9 years in grades 4-7 attending South African private schools. Methods: A link to an online survey was circulated to caregivers via an email sent to school principals of all private schools in four provinces enrolling girls in grades 4-7. Following a poor post-reminder response, a paid Facebook survey-linked advert targeting South African Facebook users aged ≥25 years nationally was run for 4 days, and placed on the South African Vaccination and Immunisation Centre's Facebook page for 20 days. Results: Of 615 respondents, 413 provided HPV vaccination data and 455 completed the knowledge and attitudes tests. Most (76.5%) caregivers had good knowledge and 45.3% had positive attitudes. Of their daughters, 19.4% had received ≥1 dose of HPV vaccine. Of caregivers of unvaccinated girls, 44.3% and 41.1%, respectively were willing to vaccinate their daughters if vaccination was offered free and at their school. Caregivers of unvaccinated girls were more likely [odds ratio (OR): 3.8] to have been influenced by "other" influences (mainly online articles and anecdotal vaccine injury reports). Of caregivers influenced by their healthcare providers, caregivers of unvaccinated girls were more likely (OR: 0.2) to be influenced by alternative medical practitioners. Caregivers of vaccinated girls were more likely to have good knowledge (OR: 3.6) and positive attitudes (OR: 5.2). Having good knowledge strongly predicted (OR: 2.8) positive attitudes. Having negative attitudes strongly predicted (OR: 0.2) girls being unvaccinated. Conclusion: Providing free school-based HPV vaccination in the private sector may not increase HPV vaccination coverage to an optimal level. Since misinformation was the main driver of negative attitudes resulting in <20% of girls being vaccinated, an advocacy campaign targeting all stakeholders is urgently needed.

A feasibility trial of parent HPV vaccine reminders and phone-based motivational interviewing

Background

We assessed the feasibility and acceptability of a sequential approach of parent-targeted HPV vaccine reminders and phone-based Motivation Interviewing (MI).

Methods

In 2016, we selected all 11- to 12-year-old boys and girls seen in one clinic whose vaccine records did not include the HPV vaccine (n=286). By gender, we individually randomized parents of adolescents to an interactive text message (74 girls and 45 boys), postcard reminder (46 boys and no girls because of previously demonstrated efficacy), or standard care group (75 girls and 46 boys). Reminders were sent with medical director permission and a HIPAA waiver. Two months after reminders, among the adolescents whose vaccine records still did not include the HPV vaccine, we selected a gender-stratified random sample of 20 parents for phone-based MI. We assessed the percentage of deliverable messages, the percentage of parents’ responding to the interactive text message, parent acceptability of receiving a text message, and MI parent responsiveness and interviewer competence (MI Treatment Integrity Coding system).

Results

Nearly all messages were deliverable (98% of postcards and 74% of text messages). Six of the 88 parents (7%) receiving text messages scheduled an appointment through our interactive system. The acceptability survey response rate was 37% (38/102). Respondents were favorable toward vaccine reminders for all parents (82%). Among 20 sampled parents, 17 were reached by phone of whom 7 completed MI, 4 had or were getting the HPV vaccine for their child, and 5 expressed disinterest. Across the 7 MI calls, the interviewer was rated 100% MI adherent and scored an average 4.19 rating for Global Spirit.

Conclusion

Without providing explicit consent to receive vaccine-related messages, parents nonetheless found postcards and interactive text messages acceptable. Centralizing MI to phone calls with trained staff was acceptable to parents and resulted in highly MI-adherent interviews.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-10132-6.

Evaluation of a Text Messaging-Based Human Papillomavirus Vaccination Intervention for Young Sexual Minority Men: Results from a Pilot Randomized Controlled Trial

BACKGROUND

Men who have sex with men (MSM) are at high risk for human papillomavirus (HPV) infection and HPV-related anal cancer. Although a safe and effective vaccine is available to prevent HPV infection, HPV vaccine uptake among young MSM remains low.

PURPOSE

This pilot randomized controlled trial tested the acceptability, feasibility, and preliminary efficacy of a text messaging-based HPV vaccination intervention for young sexual minority men.

METHODS

In 2018, unvaccinated sexual minority men aged 18-25 years were recruited from Chicago to participate in a 9 month sexual health program called txt2protect. Participants (N = 150) were randomized to the intervention or control condition. Intervention condition messages focused primarily on HPV vaccination, with only a brief mention of other sexual health practices (e.g., condom use and HIV testing), while control condition messages focused on a variety of sexual health practices with only a brief mention of HPV vaccination. Participants received daily text messages for the first 3 weeks and monthly text messages for the remaining ~8 months of the trial. Participants completed surveys at baseline and 3 week and 9 month follow-ups.

RESULTS

Participants reported high satisfaction with the intervention. Although trial retention was high (with over 88% completing the 9 month survey), the study fell short of meeting its recruitment goal. HPV vaccine series initiation was significantly higher among intervention participants (19.4%) compared to control participants (6.6%), odds ratio = 3.43, 95% confidence interval: 1.17, 10.08.

CONCLUSIONS

Findings suggest that txt2protect is an acceptable and potentially promising intervention for increasing HPV vaccine initiation among young sexual minority men.

CLINICAL TRIAL REGISTRATION

NCT02994108.

Postcard reminders for HPV vaccination mainly primed parents for providers' recommendations

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Postcard reminders increased vaccination rates during preventive care visits.

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Postcards may prime parents for provider recommendations.

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Reminders may be most effective if combined with provider-targeted interventions.

Parent-targeted reminders increase human papillomavirus (HPV) vaccination rates. Our postcard reminders increased HPV vaccine initiation (receipt of at least one dose) by 60% among girls, but not substantially among boys. To select a complementary intervention that would maximize the effect of reminders, we assessed the percentage increase in HPV vaccine initiation from reminders increasing preventive care visits or increasing the likelihood of vaccine receipt during preventive care.

We conducted a secondary analysis of the postcard reminders from a quasi-experimental, factorial designed, feasibility trial conducted in 2013–2014 among 2,470 11- to 17-year-old girls enrolled in Florida’s Medicaid or Children’s Health Insurance Programs. We used log-linear models and a 4-way decomposition method to estimate the mediating and interacting effects of preventive visits on the effect of postcards on HPV vaccination.

After receiving a preventive visit, 76% (269/356) of girls remained unvaccinated. Nearly half of the effect of postcards on HPV vaccination was mediated by preventive visits (44%; 95% CI = 9.2% to 78.0%). Postcards increased HPV vaccine initiation mainly by increasing the likelihood of HPV vaccine receipt during preventive visits (pure indirect effect = 32.3%; 95% CI = 1.5% to 63.1%), and also by increasing the occurrence of preventive visits (mediated interaction = 11.3%; 95% CI = 1.5 to 21.1).

Reminders likely increased vaccination rates during well visits by priming parents for HPV vaccine conversations with their child’s health care provider. Thus, reminder effectiveness may be increased if timed closely to preventive care visits and/or combined with interventions that improve provider recommendations.

Trial Registration: ClinicalTrials.gov, NCT04208269, Registered 23, December 2019 – Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04208269.

Does the use of personal electronic health records increase vaccine uptake? A systematic review

BACKGROUND

Although Personal Electronic Health Records (PEHR) have been identified as innovative tools enabling the provision of patient-centered care and prevention, evidence on the impact of their use is scant. With PEHRs being more and more marketed as easily implementable and cost-effective instruments to provide people with direct control on their health, the question on whether their use might be associated with the priority to improve vaccine coverage arises.

METHODS

We conducted a systematic review following the PRISMA guidelines to retrieve, quantitatively pool and critically appraise the effectiveness of PEHR access on vaccine uptake. Analysis on PEHR effectiveness were carried out for the following comparison strata: i) PEHR access vs no intervention (standard care, no access to PEHR), ii) PEHR access only vs access to PEHR with additional features (e.g. health education materials, active reminders).

RESULTS

Of 3114 identified citations, 8 studies were included, the majority published in the US and before 2015; 62% were randomized trials, the rest having an observational study design. Evidence suggests a moderate positive impact of PEHR access in increasing vaccine uptake, with data available for influenza and pneumococcal vaccines, diabetic patients and childhood immunization. Pooled data report the addition of digital communication features, i.e. the delivery of educational messages, reminders and availability of scheduling features might increase vaccine uptake, as compared to PEHR access alone. However, evidence is not conclusive.

CONCLUSION

While immunization programs are struggling to achieve optimal coverage targets, it seems the potential of PEHRSs supporting informed adherence to vaccines recommendations is neither fully exploited nor explored. Which factors mediate the association between PEHRs access and vaccine uptake? Which PEHRs' design and functional components can maximize their impact? On which target populations? Which PEHR models works better for high-risk populations? Our findings can only partially answer those questions and further experimental research is needed.

Vaccine hesitancy and perceived behavioral control: A meta-analysis

OBJECTIVES

The World Health Organization recognizes that vaccine hesitancy is a top threat to the public health. To address vaccine hesitancy, much research guided by behavioral theories attempted to examine factors that contribute to vaccination intentions. The current study synthesizes the summary effects of attitude, norms and perceived behavioral control on vaccination intentions.

METHODS

We searched five databases with relevant keyword combinations without time constraints. A sample of 5149 participants was included for final analysis.

RESULTS

Attitude, norms and perceived behavioral control were significant predictors of vaccination intentions with attitude being the strongest. Type of recipient significantly moderated the PBC-intention relationship, while norm-intention correlations were significantly moderated by type of norm measures. Formative belief elicitation research had no moderating influences.

CONCLUSION

Our findings demonstrate clear support for the utility of theory of planned behavior in explaining vaccine hesitancy. Research is needed on how interventions can change these constructs to motivate vaccination.

Challenges and Lessons Learned From a Mobile Health, Web-Based Human Papillomavirus Intervention for Female Korean American College Students: Feasibility Experimental Study

BACKGROUND

Mobile health (mHealth) and Web-based research methods are becoming more commonplace for researchers. However, there is a lack of mHealth and Web-based human papillomavirus (HPV) prevention experimental studies that discuss potential issues that may arise.

OBJECTIVE

This study aimed to assess the feasibility of research procedures and discuss the challenges and lessons learned from an mHealth and Web-based HPV prevention experimental study targeting female Korean American college students in the United States.

METHODS

A pilot randomized controlled trial (RCT) was conducted in an mHealth and Web-based platform with 104 female Korean American college students aged 18-26 years between September 2016 and December 2016. Participants were randomized to either the experimental group (a storytelling video intervention) or the comparison group (a nonnarrative, information-based intervention). Outcomes included the feasibility of research procedures (recruitment, eligibility, randomization, and retention).

RESULTS

From September 2016 to October 2016, we recorded 225 entries in our initial eligibility survey. The eligibility rate was 54.2% (122/225). This study demonstrated a high recruitment rate (95.6%, 111/122) and retention rate (83.7%, 87/104) at the 2-month follow-up.

CONCLUSIONS

Findings from this study demonstrated sufficient feasibility in terms of research procedures to justify a full-scale RCT. Given the increased possibility of invalid or misrepresentative entries in mHealth and Web-based studies, strategies for detection and prevention are critical.

TRIAL REGISTRATION

ISRCTN Registry ISRCTN12175285; http://www.isrctn.com/ISRCTN12175285.

Communication around HPV vaccination for adolescents in low- and middle-income countries: a systematic scoping overview of systematic reviews

BACKGROUND

Human papillomavirus (HPV) infection causes cervical cancer. More than 80% of those diagnosed with cervical cancer live in low- and middle-income countries (LMICs). The World Health Organization recommends vaccination as a public health measure against cervical cancer. Communication interventions are able to change how people think about vaccination and are thus instrumental in addressing vaccine hesitancy. Our aim was to provide a broad scoping overview of the available evidence on communication with adolescents, parents, and other stakeholders around HPV vaccination for adolescents, with a specific focus on LMICs.

METHODS

We conducted a systematic scoping overview of systematic reviews addressing a range of questions regarding communication around HPV vaccination. We considered reviews published between 2007 and 2018 focusing on communication around HPV vaccination and that searched for qualitative or quantitative studies for inclusion. We searched the Epistemonikos database which includes reviews from multiple electronic databases. Two overview authors screened titles and abstracts and examined potentially eligible reviews in full text. Data extraction was performed by one overview author and verified by a second. We assessed the reliability of the included reviews using an adapted version of AMSTAR 2.

RESULTS

We included twelve reviews in our overview. Four reviews assessed the effectiveness of communication interventions. These interventions intended to inform or educate about HPV and HPV vaccination, such as videos and fact sheets, or to remind or recall, such as text message reminders. Eight reviews assessed factors associated with HPV vaccination uptake, including communication-related factors such as whether the vaccine was recommended by a physician and people's knowledge regarding the vaccine. Nine reviews searched for studies from LMICs, but most found only a small number of studies from these countries.

CONCLUSIONS

The small number of studies identified from LMICs is of concern as these countries face the largest burden of disease related to HPV. This scoping overview also found and excluded a number of reviews because of important methodological limitations, highlighting the need for future reviews to use appropriate methods. The overview indicates areas in which further primary studies are needed on HPV vaccination communication in LMICs.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework https://osf.io/agzb4/.

Immunization Campaigns and Strategies against Human Papillomavirus in Italy: The Results of a Survey to Regional and Local Health Units Representatives

Objective. The study aimed to assess the impact of HPV immunization campaigns organizational aspects, the characteristics of immunization program (vaccination targets and type of offer), and communicative strategies adopted by four Italian administrative regions on vaccination coverage observed. Methods. From November 2017 to March 2018, regional and Local Health Units (LHUs) representatives were invited to complete an online survey including 54 questions evaluating vaccination invite systems, access systems to vaccination centres, reminder and recall systems, and adverse events surveillance. An overall descriptive analysis was conducted. Since observed vaccine coverage (VC) obtained in females (2002-2004 birth cohorts) was lower than objectives fixed by the Italian Ministry of Health, variables were assessed using the national VC mean obtained in the 2003 girls birth cohort as outcome. Results. Twenty-six LHUs belonging to 4 Northern and Southern Italian regions participated in the study. Organizational aspects significantly related to VC lower than the national mean were access to vaccine centres without appointment and parents' reservation as appointment planning system. Recall systems for both the first and the second dose, including the appointment in the invitation letter, the availability of regional immunization registry, and education of healthcare workers on universal HPV immunization strategies, instead, were related to higher VC. As regards preadolescent immunization strategies, both VC obtained in girls and boys were far from the Ministerial goals. Only 20% of LHUs introduced multicohort female strategies while all LHUs adopted copayment targeting both men and women. Immunizations strategies targeting subjects at risk were implemented only in half of participating LHUs. Conclusions. VC observed in participating LHUs are largely lower than the national objectives in all anti-HPV vaccine targets. Both organizational and educational strategies have to be implemented to improve the VC goals.

Understanding the use of digital technology to promote human papillomavirus vaccination - A RE-AIM framework approach

The human papillomavirus virus (HPV) vaccine is effective at preventing various cancers, but coverage falls short of targets that are needed for community protection. Here, we use the RE-AIM implementation framework (Reach, Effectiveness, Adoption, Implementation, Maintenance) to understand how text, email, and electronic health record (EHR) reminders and social media campaigns can be used as part of policy and practice interventions to increase HPV vaccination. These technology-based interventions could be used together and mainstreamed into clinical and system-based practice to have the greatest impact. Of the interventions explored, text-based, email-based, and EHR reminders have the most evidence behind them to support their effectiveness. While there are several studies of promotion of the HPV vaccine on social media, more studies are needed to demonstrate their effects and better methods are needed to be able to attribute results to these interventions.

Physician clinical decision support system prompts and administration of subsequent doses of HPV vaccine: A randomized clinical trial

BACKGROUND

HPV vaccine is effective in preventing several cancers and anogenital warts, yet rates of HPV vaccination series completion in the United States are low. A primary reason identified by parents for vaccinating children against HPV is a health care provider's recommendation. Although most clinicians embrace vaccine recommendations, they are not always carried out evenly and subsequent HPV vaccines are missed.

METHODS

Using an electronic health records-based decision support system (CHICA) clinicians were randomized to either usual practice or to receive an automated reminder to recommend the 2nd or 3rd dose of HPV vaccine. The reminder was delivered to clinicians of all intervention group eligible adolescents who had already initiated the vaccine series. Logistic regression models with generalized estimating equations were used for data analysis.

RESULTS

A total of 1285 clinical encounters were observed across 29 randomized pediatric providers over a 13-month time frame (50.7% control group, 49.3% intervention group). Overall, patients were 44.9% female, 59.4% Black, 22.1% Hispanic, and 48.8% were ages 11-12 yrs. Within the control group, 421 (64.7%) received a subsequent HPV vaccine, compared to 481 (75.9%) (OR: 1.72, (95% CI 1.35-2.19)). Adjusted analysis showed no difference between the groups (aOR 1.52 (95% CI 0.88-2.62)) or when examined by age (11-12yrs aOR 1.66, (95% CI 0.79-3.48)) and 13-17yrs (aOR 1.19, (95% CI 0.76-1.85)) or gender female (aOR 1.39 (95% CI 0.71-2.72)) and males (aOR 1.67 (95% CI 0.95-2.92)). When results were stratified by both age and gender, there was similarly no statistically significant effect between the two groups.

CONCLUSIONS

Automated physician reminders for subsequent 2nd and 3rd doses of HPV vaccination were used. Despite increased rates of vaccination in the intervention group, the differences did not reach the level of statistical significance. Future studies with multifaceted approaches may be needed to examine the efficacy of computer-based reminders.

CLINICAL TRIAL REGISTRATION

NCT02558803, "HPV Vaccination: Evaluation of Reminder Prompts for Doses 2 & 3".

How Health Care Providers Can Use Digital Health Technologies to Inform Human Papillomavirus (HPV) Decision Making and Promote the HPV Vaccine Uptake Among Adolescents and Young Adults

High-risk stains of human papillomavirus (HPV) is linked to causing cancer, is highly prevalent, and has increased incidence among adolescents and young adults. However, vaccination rates are low. Health care provider recommendation is the biggest influencer toward vaccine uptake. Since more health care providers are using digital health technologies in their medical practices, this study investigated the feasibility of technology to increase informed decision making. A convenience sample of 210 students completed an online survey. Participants were 18–25 years of age (88%), female (85%), Caucasian (60%), and never been diagnosed with HPV (92.9%). Overwhelmingly, participants owned a smartphone (98.9%) and used mobile apps for health/health tracking (65.5%). However, only 29.3% indicated that they received text messages from their health care provider. Digital health technology can be a cost-effective way for increasing HPV knowledge, removing barriers, and increasing vaccine uptake. Health care providers should explore using various platforms to empower their health care decision making.

Effective HPV Vaccination Strategies: What Does the Evidence Say? An Integrated Literature Review

PROBLEM

The updated Advisory Committee on Immunization Practices (ACIP) 2016 guidelines recommends vaccination for the human papillomavirus (HPV) for all adolescents starting at ages 11-12 years. The United States continues to fall short of the benchmarks set by Healthy People 2020. The national vaccination rates hover at 49.5%, creating much room for improvement in health care systems. The purpose of this literature review was to identify evidence-based interventions to implement for improved outcomes.

ELIGIBILITY CRITERIA

An integrative literature review was conducted using the CINAHL, EBSCO, Academic Search Complete, ProQuest and Medline databases. The search was limited to studies published in peer reviewed journals in the last 10 years.

SAMPLE

Of the available studies, 201 met inclusion criteria with 46 studies meriting further review.

RESULTS

Barriers to vaccination included missed opportunities due to lack of provider recommendation and awareness of current guidelines, and parental vaccination hesitancy. Effective strategies included reminder systems and strong provider recommendations.

CONCLUSIONS

No one method has been effective in maintaining increases in vaccination rates. Multi-method strategies demonstrate the highest rates of maintaining increases in HPV vaccination. Strong provider recommendations are a cornerstone to any multi-method intervention.

IMPLICATIONS

Providers and nurses need to shift conversations to strong recommendations for the HPV vaccination and include additional reminder systems, including protocols to meet Healthy People 2020 goals for HPV vaccination.

Impact of Electronic Point-of-Care Prompts on Human Papillomavirus Vaccine Uptake in Retail Clinics

INTRODUCTION

Human papillomavirus (HPV) vaccination rates nationally are low. This study determined if an electronic point-of-care prompt in the retail clinic setting increases HPV vaccination rates among an eligible population.

STUDY DESIGN

An interrupted time series assessed change in weekly HPV vaccination rates with the introduction of an electronic point-of-care prompt and rate change in post-intervention period.

SETTING/PARTICIPANTS

The study sites were two similar retail care clinics in Rochester, Minnesota. Participants were patients who presented to the retail clinics setting between the ages of 9 and 26 years from September 12, 2016, to September 30, 2017.

INTERVENTION

HPV vaccine (nonavalent) was made available at both retail clinics. Staff completed a 2-hour lecture on HPV vaccine and one-on-one training for use of the prompt. Pre- and post-intervention rates of HPV vaccination after initiation of electronic point-of-care prompt were measured. A satisfaction survey was given to all patients or parents/guardians between the ages of 9 and 26 years regardless of HPV vaccine status.

MAIN OUTCOME MEASURES

HPV vaccination rates per week before and after the introduction of the electronic point-of-care prompt along with satisfaction with HPV vaccine availability and the point-of-care prompt in the retail clinic setting. Data analysis was completed January 2018.

RESULTS

The point-of-care prompt increased the median weekly HPV vaccination rate by 8.6 per 100 patient visits (95% CI=5.8, 11.5, p<0.001). Patients thought it was convenient having HPV vaccine available and helpful to be reminded of the need for HPV vaccine.

CONCLUSIONS

This study demonstrates a significant increase of HPV vaccine rates in the retail clinic setting with use of a point-of-care prompt.

Outreach and Reminders to Improve Human Papillomavirus Vaccination in an Integrated Primary Care System

This study evaluated the impact of health system-based outreach and reminders on human papillomavirus (HPV) vaccine series initiation and completion. Parents of 10 to 12 year olds (n = 1805) were randomized to receive either (1) an outreach letter and brochure recommending HPV vaccination followed by automated HPV vaccine reminders or (2) usual care. We interviewed a subset of 50 parents to assess program acceptability. Outcomes were HPV vaccine initiation during the study period and on-time series completion. Rates of HPV vaccine initiation during the study period (July 2015 to August 2016) were similar between the intervention and control groups, but initiation within 120 days of randomization was higher in the intervention group (23.6% and 18.8%, P = .04) as was completion during the study period (10.3% vs 6.8%, P = .04). Reminders for doses 2 and 3 did not affect completion. The program was acceptable to parents. This study provides evidence that health system-based outreach and reminders can improve HPV vaccination.

Impact of human papillomavirus vaccination on racial/ethnic disparities in vaccine-type human papillomavirus prevalence among 14-26 year old females in the U.S

BACKGROUND

Low human papillomavirus (HPV) vaccination rates early after introduction, particularly among low income and minority adolescents, may have resulted in disparities in vaccine-type HPV prevalence (types 6, 11, 16, 18). The purpose of this study was to examine racial/ethnic variations in HPV prevalence, and evaluate how HPV vaccination has affected vaccine-type HPV prevalence across time.

METHODS

This study was a retrospective analysis of 6 cycles of the National Health and Nutrition Examination Survey (NHANES) data (2003-2014). Results on HPV status from vaginal samples of 14-26 year old females who responded about HPV vaccination were used to determine HPV prevalence. Prevaccine HPV prevalence was compared to post-licensure prevalence. Racial/ethnic comparisons were made across time, and models were developed to examine the role of HPV vaccination in observed variations for vaccine-type HPV prevalence.

RESULTS

Among 4080 females, 29.7% were black, 25.6% were Mexican American, 8.9% were Hispanic, and 35.8% were white. Compared to prevaccine years (2003-2006), vaccine-type HPV did not decrease until late post-licensure years (2011-2014; 14.2% vs. 5.2%, p < 0.001). Most of the decrease occurred among white females between prevaccine and late post-licensure periods (15.2% vs. 4.1%, p < 0.001). Although a decrease in prevalence was observed among black females during the same periods (16.9% vs. 9.8%, p < 0.05), it was not as large as among white females. Prevalence decreased among Mexican Americans (8.2 vs. 4.0, p > 0.05) during the same periods, but the difference was not significant. Interactions between race and time were significant (p < 0.001), with uneven vaccination between black and white females contributing to the disparities observed.

CONCLUSIONS

HPV vaccination was low in among black and Mexican American females, which contributed to disparities in HPV prevalence. Increasing vaccination among all adolescents, particularly 11-12 year olds, is important because most children this age will not have been exposed.