Multilevel correlates for human papillomavirus vaccination of adolescent girls attending safety net clinics

Use of concept mapping to inform a participatory engagement approach for implementation of evidence-based HPV vaccination strategies in safety-net clinics

BACKGROUND

Multiple evidence-based strategies (EBS) for promoting HPV vaccination exist. However, adolescent HPV vaccination rates remain below target levels in communities at high risk for HPV-associated cancers and served by safety-net clinics. Participatory engaged approaches are needed to leverage the expertise of community and clinical partners in selecting EBS relevant to their local context. We engaged concept mapping as a method to inform the adoption and adaptation of EBS that seeks to empower implementation partners to prioritize, select, and ultimately implement context-relevant EBS for HPV vaccination.

METHODS

Using 38 EBS statements generated from qualitative interviews and national HPV vaccine advocacy sources, we conducted a modified concept mapping activity with partners internal to safety-net clinics and external community members in two study sites of a larger implementation study (Greater Los Angeles and New Jersey), to sort EBS into clusters and rate each EBS by importance and feasibility for increasing HPV vaccination within safety-net clinics. Concept mapping findings (EBS statement ratings, ladder graphs and go-zones) were shared with leaders from a large federally qualified health center (FQHC) system (focusing on three clinic sites), to select and implement EBS over 12 months.

RESULTS

Concept mapping participants (n=23) sorted and rated statements, resulting in an eight-cluster solution: 1) Community education and outreach; 2) Advocacy and policy; 3) Data access/quality improvement monitoring; 4) Provider tracking/audit and feedback; 5) Provider recommendation/communication; 6) Expanding vaccine access; 7) Reducing missed opportunities; and 8) Nurse/staff workflow and training. The FQHC partner then selected to intervene on eight of 17 EBS statements in the "go-zone" for action, with three from "reducing missed opportunities," two from "nurse/staff workflow and training," and one each from "provider tracking/audit and feedback," "provider recommendation/communication," and "expanding vaccine access," which the research team addressed through the implementation of three multi-level intervention strategies (e.g., physician communication training, staff training and workflow assessment, audit and feedback of clinic processes).

CONCLUSIONS

Concept mapping provided a powerful participatory approach to identify multilevel EBS for HPV vaccination relevant to the local safety-net clinic context, particularly when several strategies exist, and prioritization is necessary. This study demonstrates how a clinic system benefited directly from the ratings and prioritization of EBS by multilevel clinic and community partners within the broader safety-net clinic context to identify and adapt prioritized solutions needed to advance HPV vaccine equity.

Optimizing timing of adolescent vaccines: Impact of initiating HPV vaccination before Tdap or meningococcal vaccination on timely completion of the HPV vaccine series

To explore the impact on timely series completion of initiating the HPV vaccine series prior to other vaccines in the adolescent platform (Tdap or meningococcal vacccines), we created a cohort of children aged 9 in 2015 who were continuously enrolled through the age of 13 (2019) from a national administrative database of employee-sponsored insurance in the United States (MarketScan). Logistic regressions were used to predict the odds of HPV vaccine series completion among those who started the series prior to, concurrent with, or after receiving Tdap or meningococcal vaccination. The cohort included 100,857 eligible children. Compared with adolescents who received their HPV and Tdap or HPV and meningococcal vaccinations concurrently, those who received HPV prior to other vaccines had higher completion (aOR = 1.38 for Tdap, aOR 1.62 for meningococcal), while those who received their HPV vaccination after other vaccines had lower odds of HPV vaccine series completion (aOR = 0.68 for Tdap, aOR = 0.62 for meningococcal). Other factors associated with series completion included female sex, residing in an urban (vs. rural) area, residing in the Northeast, and receiving primary care from a pediatrician (vs. family medicine physician). These data indicate that beginning the HPV vaccine series prior to the adolescent platform may improve on-time series completion.

"We will do whatever it takes": Understanding Socioecological Level Influences on Hmong-American Adolescents and Parents' Perceptions of the Human Papillomavirus Vaccine

Human papillomavirus (HPV) vaccination completion rates in Asian-American populations are substantially lower than most White Americans. Our objective was to identify the knowledge, perceptions, and decision-making processes about HPV vaccinations in the Hmong population, an Asian-American group with increased risks of HPV-related cancers. We conducted eight focus groups with Hmong adolescents (n = 12) and parents (n = 13) to learn about barriers, facilitators, and decision-making processes regarding general vaccinations and the HPV vaccine. The focus group results were analyzed using thematic analysis, informed by the socioecological model and asset lens. Findings showed that at the individual level, Hmong adolescents and parents had low HPV and HPV vaccine awareness levels (barrier) and strong desires to learn about HPV and the HPV vaccine (facilitator). Community-level barriers included salient narratives about traumatic experiences with vaccines and vaccine research, while facilitators included strong community connections. At the institutional level, barriers included structural constraints in health care settings, while facilitators included ease of obtaining vaccines at school-based clinics and provider authoritative decision-making. Additionally, a range of decision-making processes between parents, adolescents, and providers were present, with parents expressing a strong appeal to engage in more shared decision-making with providers. A linguistically and culturally specific HPV educational program for Hmong adolescents and parents could address the barriers and build on facilitators and assets to promote HPV vaccine uptake in this growing Asian-American community.

Factors contributing to missed opportunities for human papillomavirus vaccination among adolescents, ages 11 to 13, in Iowa

Introduction

Rates of human papillomavirus (HPV) vaccination remain low and missed opportunities for HPV vaccination are widespread. Researchers have identified factors related to HPV vaccination, but less is known about missed opportunities.

Methods

We used medical claims data from a large Midwestern insurance provider to explore relationships between adolescent and provider characteristics and missed opportunities for HPV vaccination. We stratified models by initiation status with adolescents who had received one or more HPV vaccinations in one group (n = 6,123) and adolescents with no record of an HPV vaccination in the other (n = 8,107).

Results

There were significant differences in comparisons of all variables between initiators and non-initiators. Notably, non-initiators had lower rates of vaccination for HPV and other adolescent vaccinations, and fewer well-child visits. For all adolescents, birth year, having other recommended vaccines, and number of well-child visits were significantly associated with missed opportunities. Additionally, among initiators, pediatrician as a primary care provider and being in a rural area were significantly associated.

Discussion

Overall, adolescents with greater healthcare utilization had more missed opportunities, indicating that, despite increased numbers of visits, providers are not taking advantage of these opportunities to vaccinate. Future research should prioritize developing a deeper understanding of why these missed opportunities are occurring and implementing new and existing strategies to prevent them. Reducing missed opportunities will help to prevent future HPV-related cancers and the significant morbidity and mortality that they can cause.

Factors Associated With Receipt of Meningococcal B Vaccine Among United States Adolescents, National Immunization Survey-Teen, 2017-2018

PURPOSE

In this study, we evaluated factors associated with receipt of meningococcal serogroup B (MenB) vaccine among adolescents in the United States.

METHODS

We used public use data files from the National Immunization Survey-Teen from 2017 to 2018. Logistic regression was used to model associations among sociodemographic, healthcare, and vaccination variables of interest and MenB vaccine receipt (≥1 vs. 0 dose). To explore associations between state-level meningococcal vaccination requirements and MenB vaccine uptake, we performed a secondary analysis stratified by presence of a quadrivalent meningococcal (MenACWY) vaccination requirement for secondary school attendance in the adolescent's state of residence (no requirement vs. a one- or two-dose requirement).

RESULTS

Among 7,288 adolescents, MenB vaccine receipt was significantly associated with up-to-date human papillomavirus (adjusted odds ratio [aOR] 1.74, 95% confidence interval [CI] 1.29-2.35) and MenACWY (aOR 5.81, 95% CI 4.14-8.13) vaccination status in multivariable analysis. Adolescents with private insurance were less likely to be vaccinated (aOR .61, 95% CI .46-.79) compared to adolescents with other health insurance types. In secondary analyses, health insurance was no longer significantly associated with MenB vaccine uptake among adolescents in states with a MenACWY requirement.

CONCLUSIONS

We found that MenB vaccination is associated with receipt of other vaccines recommended for use in adolescents. Adolescents with private health insurance were less likely to be vaccinated against MenB, although state MenACWY requirements appeared to modify the effect of insurance on MenB vaccine receipt. Further work to understand how these factors may influence delivery and acceptance of MenB vaccine can inform interventions and strategies to improve uptake.

Factors associated with HPV vaccination initiation among United States college students

Human papillomavirus (HPV) remains the most common sexually transmitted infection (STI) in the U.S. despite widespread availability of a safe, effective vaccine. Although young adults are at greatest risk of HPV infection, extensive vaccine promotion and intervention efforts has been directed toward 11-12-year-olds. College students represent an ideal audience for HPV vaccine "catch-up;" however, research indicates inconsistent HPV vaccination rates within this demographic. An online survey assessing HPV and HPV vaccine knowledge and behaviors was distributed to all undergraduate college students at a large, public university in the Deep South region of the U.S. The primary outcome was receipt of HPV vaccination (binary response options of Yes/No). Logistic regression analyses were performed to determine predictors of HPV vaccination. Of the 1,725 who completed the survey, 47.0% reported having received at least one dose of HPV vaccine; overall series completion (series = 3 doses for this population) was 17.4%. The primary outcome was HPV initiation among college students, defined as having received at least one dose of the HPV vaccine. Results indicated substantial gaps in participants' knowledge of their vaccination status. Provider and parental recommendations as well as social influences were shown to significantly impact student vaccination status, emphasizing the importance of incorporating these elements in future interventions, potentially as multi-level strategies. Future college interventions should address HPV and vaccination knowledge and the importance of provider and parental recommendations.

"There's Always Next Year": Primary Care Team and Parent Perspectives on the Human Papillomavirus Vaccine

Acceptance of the human papillomavirus (HPV) vaccination among parents and clinicians is high, but uptake remains low. Little is known about organizational and primary care team factors that influence the uptake of the HPV vaccine. Interviews with clinicians, clinic support staff, and parents of adolescent patients were conducted to better understand the interrelationships among the people and the organizational processes that influence HPV vaccine uptake at the point of care. Between July 2016 and February 2017, semi-structured interviews of 40 participants (18 clinicians, 12 clinic support staff, and 10 parents of adolescent patients) in a primary care network were conducted. Organizational structures and processes, such as electronic provider reminders, availability of "vaccination only" appointments, and knowledgeable primary care team members contributed to HPV vaccine uptake. Consistently high support of HPV vaccination was found among key informants; however, rather than refuse HPV vaccination, parents are opting to delay vaccination to a future visit. When parents express the desire to delay, clinicians and care team members described often recommending addressing HPV vaccination at a future visit, giving parents the impression that receiving the vaccine was not time-sensitive for their child. Discordance in HPV vaccination recommendations among providers and clinic support staff may contribute to delayed HPV vaccination. Strong, high-quality HPV vaccine recommendations are needed from all primary team members. Clinic interventions to accelerate HPV vaccine uptake may benefit from a team-based approach where every member of the primary care team is delivering the same consistent messaging about the importance of timely HPV vaccination.

Vaccination coverage rates and predictors of HPV vaccination among eligible and non-eligible female adolescents at the Brazilian HPV vaccination public program

Background

Since March 2014, the quadrivalent HPV vaccine has been incorporated into the Brazilian Unified Health Care System and began to be offered, without direct costs, for girls from 9 to 13 years of age. Older female adolescents would have the option to be vaccinated at private health care system being responsible for the payment of HPV vaccine. The present study aimed to evaluate the coverage rates and predictors of HPV vaccination in Brazil among two groups of female adolescents: eligible and non-eligible for the HPV vaccination public program.

Methods

We used data from the 2015 Brazilian National Adolescent School-Based Health Survey, which involved a probabilistic sample of 5404 female adolescents students at public and private schools. Using a questionnaire, we gathered information on sociodemographic characteristics, sexual behavior, and respondent perception of parental supervision and have been vaccinated for HPV. Age-specific vaccination rates were analyzed in girls aged 9 to 13 at the time of public vaccination (eligible for public policy), as well among those 14 to 17 years old not eligible by the Ministry of Health for vaccination. We used Poisson regression models to investigate associated factors.

Results

HPV vaccine coverage was 83.5 and 21.8% among eligible and non-eligible populations, respectively. In both populations, the chance of being vaccinated decreased with older age. In the eligible population there is a greater chance of being vaccinated among ethnic group “pardas” but not with other indicators of socioeconomic status. In the non-eligible population, there was a clear association between higher vaccine coverage and greater maternal education and living with the mother.

Conclusion

Our findings highlight the importance of public policies to minimize inequities in access to cancer prevention measures in vulnerable adolescents. A public policy of HPV vaccination for older female adolescents would increase coverage with possible reduction of HPV-related diseases in this group of women.

Factors associated with adolescent HPV vaccination in the U.S.: A systematic review of reviews and multilevel framework to inform intervention development

Multilevel factors impact HPV vaccine series initiation and completion among adolescents in the U.S. Synthesis of these factors is needed to inform intervention development and to direct future research. Current frameworks synthesizing factors focus on females only and do not include both series initiation and completion outcomes. We conducted a systematic review of reviews to identify modifiable individual-, provider-, and clinic-level factors associated with HPV vaccination outcomes among U.S. adolescents and developed a multilevel framework illustrating relations between factors to inform intervention development. We searched Medline, PsychInfo, Pubmed, CINAHL, and ERIC databases and included reviews published 2006 to July 2, 2018 describing individual-, provider-, or clinic-level factors quantitatively associated with HPV vaccination among U.S. adolescents. Two coders independently screened reviews, extracted data, and determined quality ratings. Sixteen reviews containing 481 unique primary studies met criteria. Factors synthesized into the multilevel framework included parent psychosocial factors (knowledge, beliefs, outcome expectations, intentions) and behaviors, provider recommendation, and patient-targeted and provider-targeted clinic systems. The scope of our framework and review advances research in two key ways. First, the framework illustrates salient modifiable factors at multiple levels on which to intervene to increase HPV vaccination. Second, the review identified critical gaps in the literature at each level. Future research should link the body of literature on parental intentions to vaccination outcomes, identify provider psychosocial factors associated with recommendation behaviors and subsequent vaccine uptake in their patient population, and understand clinic factors associated with successful implementation of patient- and provider-targeted system-level interventions.

Do traditional economic theories of free riding behavior explain spatial clustering of HPV vaccine uptake?

Rationale

Geographic clusters of low vaccination uptake reduce the population-level efficacy of vaccination programs. However, little is known about the mechanisms that drive geographic patterns in vaccination rates. Traditional economic theory considers vaccination as a classic public good and suggests that free riding-individuals taking advantage of public goods by relying on others' immunization behavior without contributing toward them-is a primary cause of low vaccination rates. However, behavioral economics suggests that free riding does not fully explain observed individual behavior, and the presence of both high and low clusters of vaccination rates suggest that this theory alone does not fully explain geographic patterns of vaccination.

Objective

We assessed geographic clustering of HPV vaccination uptake and examined the evidence for or against free riding in HPV vaccination decisions.

Methods

We analyzed HPV vaccination decisions of low-income adolescent females (N = 601) residing in urban neighborhoods in Dallas, Texas, USA during 2011-2012. Spatial econometric models were estimated to assess the relationship between neighborhood vaccination rates and individual vaccination decisions.

Results

We found a positive and significant relationship between individual HPV vaccination choices and the average neighborhood vaccination rate at the time parents were making vaccine decisions for their adolescent daughters while controlling for neighborhood sorting and other confounders.

Conclusion

Individuals were more likely to complete the HPV vaccination series when others in their neighborhood had already completed the series. We do not find evidence for free riding in HPV vaccination decisions.

Characterizing safety-net providers' HPV vaccine recommendations to undecided parents: A pilot study

OBJECTIVE

Although provider recommendation is a key predictor of HPV vaccination, how providers verbalize recommendations particularly strong ones is unknown. We developed a tool to describe strength and content of provider recommendations.

METHODS

We used electronic health records to identify unvaccinated adolescents with appointments at six safety-net clinics in Dallas, Texas. Clinic visit audio-recordings were qualitatively analyzed to identify provider recommendation types (presumptive vs. participatory introduction; strong vs. weak), describe content communicated, and explore patterns between recommendation type and vaccination.

RESULTS

We analyzed 43 audio-recorded discussions between parents and 12 providers. Most providers used a participatory introduction (42 discussions) and made weak recommendations (24 discussions) by using passive voice or adding a qualification (e.g., not school required). Few providers (11 discussions) gave strong recommendations (clear, personally-owned endorsement). HPV vaccination was lowest for those receiving only weak recommendations and highest when providers coupled the recommendation with an adjacent rationale.

CONCLUSION

Our new tool provides initial evidence of how providers undercut their recommendations through qualifications or support them with a rationale. Most providers gave weak HPV vaccine recommendations and used a participatory introduction.

PRACTICE IMPLICATIONS

Providers would benefit from communication skills training on how to make explicit recommendations with an evidence-based rationale.

Developing a Tablet-Based Self-Persuasion Intervention Promoting Adolescent HPV Vaccination: Protocol for a Three-Stage Mixed-Methods Study

Background

Human papillomavirus (HPV)-related cancers are a significant burden on the US health care system that can be prevented through adolescent HPV vaccination. Despite guidelines recommending vaccination, coverage among US adolescents is suboptimal particularly among underserved patients (uninsured, low income, racial, and ethnic minorities) seen in safety-net health care settings. Many parents are ambivalent about the vaccine and delay making a decision or talking with a provider about it. Self-persuasion—generating one’s own arguments for a health behavior—may be particularly effective for parents who are undecided or not motivated to make a vaccine decision.

Objective

Through a 3-stage mixed-methods protocol, we will identify an optimal and feasible self-persuasion intervention strategy to promote adolescent HPV vaccination in safety-net clinics.

Methods

In Stage 1, we will define content for a tablet-based self-persuasion app by characterizing (1) parents’ self-generated arguments through cognitive interviews conducted with parents (n=50) of patients and (2) parent-provider HPV vaccine discussions through audio recordings of clinic visits (n=50). In Stage 2, we will compare the effects of the four self-persuasion intervention conditions that vary by cognitive processing level (parents verbalize vs listen to arguments) and choice of argument topics (parents choose vs are assigned topics) on parental vaccine intentions in a 2 × 2 factorial design randomized controlled trial (n=160). This proof-of-concept trial design will identify which intervention condition is optimal by quantitatively examining basic self-persuasion mechanisms (cognitive processing and choice) and qualitatively exploring parent experiences with intervention tasks. In Stage 3, we will conduct a pilot trial (n=90) in the safety-net clinics to assess feasibility of the optimal intervention condition identified in Stage 2. We will also assess its impact on parent-provider discussions.

Results

This paper describes the study protocol and activities to date. Currently, we have developed the initial prototype of the tablet app for English- and Spanish-speaking populations, and completed Stage 1 data collection.

Conclusions

Our systematic collaboration between basic and applied behavioral scientists accelerates translation of promising basic psychological research into innovative interventions suitable for underserved, safety-net populations. At project’s end, we plan to have a feasible and acceptable self-persuasion intervention that can affect key cancer disparities in the United States through prevention of HPV-related cancers.

Trial Registration

ClinicalTrials.gov http://clinicaltrials.gov/ct2/show/NCT02537756 and http://clinicaltrials.gov/ct2/show/NCT02535845 (Archived by WebCite at http://www.webcitation.org/6e5XcOGXz and http://www.webcitation.org/6e5XfHoic, respectively).

Promoting HPV Vaccination in Safety-Net Clinics: A Randomized Trial

OBJECTIVES

Evaluate effects of a multicomponent intervention (human papillomavirus [HPV] vaccine-specific brochure and recalls) on HPV vaccination and secondarily examine if race/ethnicity moderates effects.

METHODS

Unvaccinated girls aged 11 to 18 years attending 4 safety-net pediatric clinics and their parent/guardian (n = 814 dyads) were randomized to (1) active comparison (general adolescent vaccine brochure), or (2) intervention consisting of a HPV vaccine-specific brochure, telephone recalls to parents who declined, and recalls to patients overdue for doses 2 and 3. HPV 1-dose and 3-dose coverages were assessed via electronic health records 12 months after randomization. Multivariate logistic regressions estimated adjusted odds and marginal predicted vaccine coverage by study arm and race/ethnicity.

RESULTS

Intent-to-treat analyses found no main effect of the HPV vaccine-specific brochure on 1-dose coverage (42.0% vs 40.6%); however, secondary analyses found race/ethnicity was a significant moderator such that the intervention was effective only for Hispanic individuals (adjusted odds ratio [AOR] 1.43; 95% confidence interval [CI] 1.02-2.02), and not effective for black individuals (AOR 0.64; 95% CI 0.41-1.13). Recalls to parents who declined the vaccine during the index visit were not effective, but recalls to patients overdue for doses 2 and 3 were effective at increasing 3-dose coverage regardless of race/ethnicity (AOR 1.99; 95% CI 1.16-3.45).

CONCLUSIONS

Educational materials describing only the HPV vaccine were effective for Hispanic but not black individuals. Future research should test mechanisms that may mediate intervention effects for different racial/ethnic groups, such as different informational needs or vaccine schemas (experiences, beliefs, norms).

Predictors of Human Papillomavirus Vaccine Completion Among Female and Male Vaccine Initiators in Family Planning Centers

OBJECTIVES

We estimated human papillomavirus (HPV) vaccine series completion and examined predictors of completion among adolescents and young adults in a large family planning network.

METHODS

Our retrospective cohort study of vaccine completion within 12 months and time to completion used electronic health record data from 119 Planned Parenthood health centers in 11 US states for 9648 patients who initiated HPV vaccination between January 2011 and January 2013.

RESULTS

Among vaccine initiators, 29% completed the series within 12 months. Patients who were male, younger than 22 years, or non-Hispanic Black or who had public insurance were less likely to complete within 12 months and completed more slowly than their counterparts. Gender appeared to modify the effect of public versus private insurance on completion (adjusted hazard ratio = 0.76 for women and 0.95 for men; relative excess risk due to interaction = 0.41; 95% confidence interval = 0.09, 0.73).

CONCLUSIONS

Completion was low yet similar to previous studies conducted in safety net settings.

Attitudes toward Human Papilloma Virus Vaccination and Head and Neck Cancer Prevention in a Diverse, Urban Population

OBJECTIVE

(1) To understand if awareness of the human papilloma virus (HPV) vaccination's potential to prevent head and neck cancer improves acceptability of the vaccine in a large urban population and (2) to identify characteristics of those in whom such discussions would have the greatest impact.

STUDY DESIGN

In-person, anonymous survey.

SETTING

Academic public hospital between March 2014 and June 2014.

SUBJECTS

Patients aged 12 to 24 years and their parents or guardians awaiting scheduled outpatient pediatric appointments.

METHODS

Demographics and modified Carolina HPV Immunization Attitudes and Beliefs Scales data were cross-analyzed, followed by univariate binomial logistic regression to identify predictors for major outcomes of interest.

RESULTS

More than 78% of those surveyed indicated they would be more receptive to the HPV vaccine if given strong evidence that it prevented head and neck cancer. Respondents were more likely to increase receptivity to HPV vaccination if they held the belief that they did not have enough information about the vaccine or indicated they preferred to wait because the vaccine was too new.

CONCLUSION

Increasing public awareness of head and neck cancer prevention with HPV vaccination could increase HPV vaccination acceptance.

Does intention to recommend HPV vaccines impact HPV vaccination rates?

Despite recommendations for routine vaccination, HPV vaccination rates among adolescent females have remained low. The objective of this prospective cohort study was to determine whether clinician intention to recommend HPV vaccines predicts HPV vaccine series initiation among previously unvaccinated 11 to 18 year-old girls (N=18,083) who were seen by a pediatric clinician (N=105) from a large primary care network within 3 years of vaccine introduction. We used multivariable logistic regression with generalized estimating equations, Cox Regression and standardized survival curves to measure the association between clinician intention and time to and rate of first HPV vaccine receipt among eligible females. All models adjusted for patient age, race/ethnicity, payor category, visit type, and practice location. Eighty-5 percent of eligible 11 to 12 year-old and 95% of 13 to 18 year-old girls were seen by a provider reporting high intention to recommend HPV vaccines. However, only 30% of the cohort initiated the HPV vaccine series and the mean number of days from first eligible visit to series initiation was 190 (95% C.I. 184.2, 195.4). After adjusting for covariates, high clinician intention was modestly associated with girls' likelihood of HPV vaccine series initiation (OR 1.36; 95 % C.I. 1.07, 1.71) and time to first HPV vaccination (HR 1.22; 95% 1.06, 1.40). Despite high intention to vaccinate among this cohort of pediatric clinicians, overall vaccination rates for adolescent girls remained low. These findings support ongoing efforts to develop effective strategies to translate clinician intention into timely HPV vaccine receipt.

Correlates of human papillomavirus vaccination among female university students

Human papillomavirus (HPV) is the most frequently occurring sexually transmitted infection in the United States, but only one third of adolescent girls have received the HPV vaccine (Centers for Disease Control and Prevention [CDC], 2012; Committee on Infectious Diseases, 2012). Understanding correlates of vaccination behavior among young women has important implications for health care delivery and public service messages targeting HPV vaccination. Female college students (N = 313) completed web-based surveys during their sophomore (second) year of college, fall 2008. Surveys included questions about HPV vaccination, demographic factors (ethnicity/race, socioeconomic status [SES]), individual characteristics (romantic relationship status, grade point average, religiosity), and sexual behavior. Lifetime HPV vaccination was reported by 46.5% of participants. Being African American/Black was associated with a lower likelihood of vaccination. Having a mother with more education, adhering to religious teachings about sex-related principles, and having engaged in recent penetrative sex were associated with a higher likelihood of vaccination. Health care providers should consider young women to be an important group for HPV vaccine education and catch-up, particularly for African American/Black young women and young women from lower SES backgrounds. Providing vaccine education and access to young women before they become sexually active is critical.

Insurance continuity and human papillomavirus vaccine uptake in Oregon and California federally qualified health centers

OBJECTIVES

We examined the association between insurance continuity and human papillomavirus (HPV) vaccine uptake in a network of federally qualified health clinics (FQHCs).

METHODS

We analyzed retrospective electronic health record data for females, aged 9-26 years in 2008 through 2010. Based on electronic health record insurance coverage information, patients were categorized by percent of time insured during the study period (0%, 1%-32%, 33%-65%, 66%-99%, or 100%). We used bilevel multivariable Poisson regression to compare vaccine-initiation prevalence between insurance groups, stratified by race/ethnicity and age. We also examined vaccine series completion among initiators who had at least 12 months to complete all 3 doses.

RESULTS

Significant interactions were observed between insurance category, age, and race/ethnicity. Juxtaposed with their continuously insured peers, patients were less likely to initiate the HPV vaccine if they were insured for less than 66% of the study period, aged 13 years or older, and identified as a racial/ethnic minority. Insurance coverage was not associated with vaccine series completion.

CONCLUSIONS

Disparities in vaccine uptake by insurance status were present in the FQHCs studied here, despite the fact that HPV vaccines are available to many patients regardless of ability to pay.

Exploring the role of neighborhood socio-demographic factors on HPV vaccine initiation among low-income, ethnic minority girls

Little is known about whether neighborhood factors are associated with human papillomavirus (HPV) vaccine uptake, especially among disadvantaged groups that can benefit most from the vaccine. We used data collected from immigrant, low-income mothers of adolescent girls and data from the 2005-2009 American Community Survey to investigate the relationship between HPV vaccine initiation and neighborhood characteristics. We compared initiation rates across levels of neighborhood disadvantage and employed multilevel logistic regression models to examine contextual effects on uptake. Overall, 27 % of girls (n = 479) initiated the vaccine. Initiation rates were highest among girls from the most disadvantaged neighborhoods (30 %), however, neighborhood factors were not independently associated with vaccine initiation after adjusting for individual factors. Mother's awareness of HPV, age, and insurance status were strong predictors for initiation. Future interventions should focus on improving awareness among low-income mothers as well as targeting vulnerable families outside the catchment area of public programs.

Urban and rural safety net health care system clinics: no disparity in HPV4 vaccine completion rates

OBJECTIVE

Safety net health care centers in the US serve vulnerable and underinsured females. The primary aim of this work was to determine if HPV4 dosing compliance differs between females who receive doses at rural vs. urban core safety net health care locations.

METHODS

Females exclusively receiving health care in the Truman Medical Center (TMC) safety net system at the urban core and rural locations were identified by their HPV4 vaccine records. Dates and number of HPV4 doses as well as age, gravidity, parity and race/ethnicity were recorded from the electronic medical record (EMR). Appropriate HPV4 dosing intervals were referenced from the literature.

RESULTS

1259 females, 10-26 years of age, received HPV4 vaccination at either the rural (23%) or urban core location (77%). At the rural location, 23% received three doses on time, equal to the 24% at the urban core. Females seen in the urban core were more likely to receive on-time doublet dosing than on-time triplet dosing (82% vs. 67%, p<0.001). Mistimed doses occurred equally often among females receiving only two doses, as well as those receiving three doses.

CONCLUSIONS

Compliance with on-time HPV4 triplet dose completion was low at rural and urban core safety net health clinics, but did not differ by location.

The influence of free quadrivalent human papillomavirus vaccine (HPV4) on the timely completion of the three dose series

OBJECTIVE

Economic incentives can positively influence social determinants to improve the health care of the uninsured and underserved populations. The aim of this study was to determine if free HPV4 vaccine would lead to on-time series completion in our safety net health care system in the US Midwest.

METHODS

A nested retrospective cohort study of females receiving HPV4 vaccine between 2006 and 2009 was conducted. Patient characteristics and payor source for each of the three HPV4 doses were abstracted from electronic records. Logistic regression was used to predict on-time completion rates.

RESULTS

The proportion of adolescent and adult females completing three on-time HPV4 doses was equal (21% (28/136) vs. 18% (66/358), respectively) from among the 494 females receiving 927 HPV4 doses in this study. No adolescent receiving free HPV4 vaccine completed three doses. Grant sponsorship of at least one HPV4 dose among adults did not predict three dose on-time completion (OR=1.56, 95%CI: 0.80, 3.06). Neither was adult grant sponsorship of HPV4 significant when analyzing exclusive payor sources vs. a combination of payor sources (OR=0.72, 95%CI: 0.10, 5.17).

CONCLUSIONS

Free HPV4 vaccine does not influence the on-time completion rates among adults.

Barriers to human papillomavirus vaccination among US adolescents: a systematic review of the literature

IMPORTANCE

Since licensure of the human papillomavirus (HPV) vaccine in 2006, HPV vaccine coverage among US adolescents has increased but remains low compared with other recommended vaccines.

OBJECTIVE

To systematically review the literature on barriers to HPV vaccination among US adolescents to inform future efforts to increase HPV vaccine coverage.

EVIDENCE REVIEW

We searched PubMed and previous review articles to identify original research articles describing barriers to HPV vaccine initiation and completion among US adolescents. Only articles reporting data collected in 2009 or later were included. Findings from 55 relevant articles were summarized by target populations: health care professionals, parents, underserved and disadvantaged populations, and males.

FINDINGS

Health care professionals cited financial concerns and parental attitudes and concerns as barriers to providing the HPV vaccine to patients. Parents often reported needing more information before vaccinating their children. Concerns about the vaccine's effect on sexual behavior, low perceived risk of HPV infection, social influences, irregular preventive care, and vaccine cost were also identified as potential barriers among parents. Some parents of sons reported not vaccinating their sons because of the perceived lack of direct benefit. Parents consistently cited health care professional recommendations as one of the most important factors in their decision to vaccinate their children.

CONCLUSIONS AND RELEVANCE

Continued efforts are needed to ensure that health care professionals and parents understand the importance of vaccinating adolescents before they become sexually active. Health care professionals may benefit from guidance on communicating HPV recommendations to patients and parents. Further efforts are also needed to reduce missed opportunities for HPV vaccination when adolescents interface with the health care system. Efforts to increase uptake should take into account the specific needs of subgroups within the population. Efforts that address system-level barriers to vaccination may help to increase overall HPV vaccine uptake.

Racial disparities in human papillomavirus vaccination: does access matter?

PURPOSE

To examine the association between race/ethnicity and human papillomavirus (HPV) vaccine initiation and to determine how access to health care influences this relationship.

METHODS

We used nationally representative data from the National Survey of Family Growth to assess HPV vaccine initiation in 2,168 females aged 15-24 years. A series of regression analyses were performed to determine the independent effect of race/ethnicity on HPV vaccine initiation after controlling for sociodemographic variables and health care access measures. Age-stratified regression analyses were also performed to assess whether the relationship between race/ethnicity and HPV vaccine initiation differed among females aged 15-18 and 19-24 years.

RESULTS

There were significant racial/ethnic disparities in HPV vaccination; United States (US)-born Hispanics, foreign-born Hispanics, and African-Americans were less likely to have initiated vaccination than were whites (p < .001). Adjusting for sociodemographic characteristics attenuated the disparity for both US-born and foreign-born Hispanics (adjusted odds ratio [AOR], .76; 95% confidence interval [CI], .50-1.16; and AOR, .67; 95% CI, .37-1.19) but not for African-Americans (AOR, .47, 95% CI, .33-.66). Adding health care access measures further attenuated the disparity for US-born and foreign-born Hispanics (AOR, .85, 95% CI, .54-1.34; and AOR, .84, 95% CI, .45-1.55). However, African-Americans remained less likely than whites to have initiated vaccination (AOR, .49, 95% CI, .36-.68). These racial/ethnic trends were similar for females aged 15-18 and 19-24 years.

CONCLUSIONS

Lower rates of HPV vaccination among African-American females do not appear to be explained by differential access to health care. More research is necessary to elucidate factors contributing to HPV vaccination in this population.

Quantifying clinical HPV4 dose inefficiencies in a safety net population

PURPOSE

HPV4 is the most expensive vaccine requiring three appropriately timed doses to provide maximal efficacy against two oncogenic HPV types. The primary purpose of this study is to quantify the use of HPV4 vaccine in a safety net health care system in terms of its inefficiencies.

METHODS

A retrospective study of HPV4 dosing from 2006-2009, among females 10-26 years old who sought care in a safety net health care system was conducted to determine dose usage patterns among those at highest risk for cervical cancer. Dose descriptors abstracted from the electronic medical record (EMR) included timing and number in series as well as characteristics of the person to whom and visit at which the dose was given. Dose inefficiencies were separated into "less than three doses" and "mistimed doses" for analysis.

RESULTS

The majority (66%) of HPV4 doses administered were insufficient to induce the maximal immune response necessary for HPV infection prevention. Among on-time doses, 58% were singleton or doublet doses. Mistimed doses accounted for 19% of all doses administered with late intervals being more common than early intervals among those receiving more than one dose (9% vs. 4%, p<0.001). Third doses were mistimed twice as often as second doses (10% vs. 5%, p<0.001). Black women were more likely to have a mistimed second dose and Hispanic women more likely to have a mistimed third dose compared to white women (OR = 1.70 (95% CI: 1.11, 2.61 and 2.44 (1.19, 5.00), respectively). The HPV4-only visit type at which HPV4 was initiated was the most significant predictor of on-time doublet completion.

CONCLUSIONS

In a safety net health care system the large inefficiencies associated with HPV4 vaccination must be addressed in order to maximize our patient's cervical cancer prevention.

Are HPV vaccination services accessible to high-risk communities? A spatial analysis of HPV-associated cancer and Chlamydia rates and safety-net clinics

PURPOSE

While HPV vaccines can greatly benefit adolescents and young women from high-risk areas, little is known about whether safety-net immunization services are geographically accessible to communities at greatest risk for HPV-associated diseases. We explore the spatial relationship between areas with high HPV risk and proximity to safety-net clinics from an ecologic perspective.

METHODS

We used cancer registry data and Chlamydia surveillance data to identify neighborhoods within Los Angeles County with high risk for HPV-associated cancers. We examined proximity to safety-net clinics among neighborhoods with the highest risk. Proximity was measured as the shortest distance between each neighborhood center and the nearest clinic and having a clinic within 3 miles of each neighborhood center.

RESULTS

The average 5-year non-age-adjusted rates were 1,940 cases per 100,000 for Chlamydia and 60 per 100,000 for HPV-associated cancers. A large majority, 349 of 386 neighborhoods with high HPV-associated cancer rates and 532 of 537 neighborhoods with high Chlamydia rates, had a clinic within 3 miles of the neighborhood center. Clinics were more likely to be located within close proximity to high-risk neighborhoods in the inner city. High-risk neighborhoods outside of this urban core area were less likely to be near accessible clinics.

CONCLUSIONS

The majority of high-risk neighborhoods were geographically near safety-net clinics with HPV vaccination services. Due to low rates of vaccination, these findings suggest that while services are geographically accessible, additional efforts are needed to improve uptake. Programs aimed to increase awareness about the vaccine and to link underserved groups to vaccination services are warranted.

Organizational correlates of adolescent immunization: findings of a state-wide study of primary care clinics in North Carolina

OBJECTIVE

To analyze organizational correlates of immunization coverage among adolescents served by high-volume primary care providers in North Carolina.

METHODS

We randomly selected 91 clinics with at least 200 active records for patients ages 11-18 in the North Carolina Immunization Registry. For the 105,121 adolescents served by these clinics, we obtained immunization status for 6 vaccines, including human papillomavirus (HPV) vaccine (females only); meningococcal conjugate; and tetanus, diphtheria, and pertussis booster (Tdap).

RESULTS

Clinics specializing in pediatrics had higher coverage for meningococcal vaccine (OR=1.79, 95% CI: 1.25-2.55), Tdap vaccine (OR=1.22, 95% CI: 1.00-1.50), and childhood vaccines. However, pediatric clinics had lower coverage for HPV vaccine initiation (OR=0.70, 95% CI: 0.52-0.94). Other correlates, which varied by vaccine, included policies related to vaccine documentation and the age at which clinics recommended vaccines.

CONCLUSION

Overall, adolescents were more likely to receive vaccines, except HPV vaccine, if they attended a pediatric clinic with supportive clinical policies.

Predictors of three dose on-time compliance with HPV4 vaccination in a disadvantaged, underserved, safety net population in the US Midwest

BACKGROUND

HPV4 is approved as a series of three timed doses expected to result in efficacy against specific HPV infections. Completion rates in the US are quite low at the same time the structure of health care delivery is changing. The aim of this study was to determine how the patient-, clinic- and systems-level characteristics facilitate or hinder the timely completion of three HPV4 doses in both adolescent and adult female populations in a high-risk safety net population.

METHODS

This is a retrospective study in which patient-, clinic- and systems-level data are abstracted from the electronic medical record (EMR) for all females 10-26 years of age receiving at least one dose of HPV4 between July 1, 2006 and October 1, 2009.

RESULTS

Adults were more likely to complete the three dose series if they had at least one health care visit in addition to their HPV4 visit, (aOR = 1.54 (95% CI:1.10, 2.15). Adults were less likely to complete the three dose series if they received their second HPV4 dose at an acute health care, preventive care or postpartum visits compared to an HPV4-only visit (aOR = 0.31 (95% CI: 0.13, 0.72), 0.12 (0.04, 0.35), 0.30 (0.14, 0.62), respectively). Hispanic adults were less likely than whites to complete the series (aOR = 0.24 (95% CI:0.10, 0.59). 39% of adolescents who completed two doses completed the series.

CONCLUSIONS

HPV4 is more likely to be effectively administered to adults in a safety net population if multiple health care needs can be met within the health care system.

Inequalities in the uptake of human papillomavirus vaccination: a systematic review and meta-analysis

Background The human papillomavirus (HPV) vaccine offers an opportunity to reduce health inequalities associated with cervical cancer provided the vaccine is delivered equitably at population level.

Method We reviewed evidence of inequalities in HPV vaccine uptake in young women after undertaking a comprehensive search of databases from inception to March 2012. Studies that compared HPV vaccination initiation and/or completion by at least one ethnicity or socioeconomic-related variable in adolescent young women were included. There were no language restrictions. Data were extracted by two reviewers and pooled in a meta-analysis using a random-effects model; sub-analyses and meta-regression were undertaken to investigate sources of heterogeneity.

Results In all, 29 publications related to 27 studies were included in the review. Black young women were less likely to initiate HPV vaccination compared with White young women (combined OR: 0.89, 95% CI: 0.82–0.97). In the USA, young women without healthcare insurance were less likely to initiate (combined OR: 0.56, 95% CI: 0.40–0.78). There was no strong evidence that lower family income (combined OR: 1.16, 95% CI: 1.00–1.34) or lower parental education (combined OR 1.06, 95% CI: 0.92–1.22) influenced HPV vaccination initiation.

Conclusions We found strong evidence for differences in HPV vaccination initiation by ethnicity and healthcare coverage, but did not find a strong association with parental education or family income variables. The majority of studies originated from the USA. Population-based studies reporting both initiation and completion of the HPV vaccination programme are required to establish patterns of uptake in different healthcare contexts.

Effects of socioeconomic status and health care access on low levels of human papillomavirus vaccination among Spanish-speaking Hispanics in California

Little is known about the effect of language preference, socioeconomic status, and health care access on human papillomavirus (HPV) vaccination. We examined these factors in Hispanic parents of daughters aged 11 to 17 years in California (n = 1090). Spanish-speaking parents were less likely to have their daughters vaccinated than were English speakers (odds ratio [OR] = 0.55; 95% confidence interval [CI] = 0.31, 0.98). Adding income and access to multivariate analyses made language nonsignificant (OR = 0.68; 95% CI = 0.35, 1.29). This confirms that health care use is associated with language via income and access. Low-income Hispanics, who lack access, need information about free HPV vaccination programs.

Trends in HPV vaccine initiation among adolescent females in North Carolina, 2008-2010

BACKGROUND

To better target future immunization efforts, we assessed trends and disparities in human papillomavirus (HPV) vaccine initiation among female adolescents in North Carolina over 3 years.

METHODS

We analyzed data from a stratified random sample of 1,427 parents who, between 2008 and 2010, completed two linked telephone surveys: the Behavioral Risk Factor Surveillance System and the Child Health Assessment and Monitoring Program surveys. Weighted analyses examined HPV vaccine initiation for girls ages 11 to 17 years.

RESULTS

HPV vaccine initiation increased modestly over time (2008, 34%; 2009, 41%; 2010, 44%). This upward trend was present within 11 subpopulations of girls, including those who lived in rural areas, were of minority (non-black/non-white) race, or had not recently received a preventive check-up. Looking at differences between groups, HPV vaccine initiation was less common among girls who attended private versus public school, were younger, or lacked a recent check-up. However, the latter difference narrowed over time. The low level of initiation among girls without recent check-ups increased substantially (from 11% to 41%), whereas initiation among girls with recent visits improved little (from 39% to 44%, P(interaction) = 0.007).

CONCLUSIONS

Although HPV vaccine initiation improved among several groups typically at higher risk for cervical cancer, the lack of progress among girls with recent check-ups suggests that missed opportunities for administration have hampered broader improvements.

IMPACT

Achieving widespread coverage of HPV vaccine will require redoubled efforts to vaccinate adolescents during routine care.