Provider communication about HPV vaccination: A systematic review

Increasing Oral Health Team's Knowledge, Attitudes, and Intention to Recommend the HPV Vaccine

This study aims to assess the impact of an educational intervention on the knowledge, attitudes, and intentions of oral health providers regarding the recommendation of the human papillomavirus (HPV) vaccine. A qualitative evaluation was conducted in 2021 with dental professionals who participated in a training program focused on HPV vaccination. Saturation was reached at 12. Results showed increased knowledge and awareness of the link between HPV infection and oropharyngeal cancers among participants. Intention to recommend was universally endorsed. The use of role-play with youth actors was highly regarded as an effective method for improving communication skills and confidence in recommending the vaccine. These findings emphasize the importance of targeted interventions to enhance oral health professional education and the intention to recommend HPV vaccine.

Quality Initiative to Increase Early Initiation and Series Completion of Human Papillomavirus Vaccine and its Impact on Health Disparities

OBJECTIVE

Human papillomavirus (HPV) infection is associated with a large burden of disease prevalence, morbidity, and known disparities. HPV vaccination rates remain lower than other childhood immunizations, despite vaccine safety and effectiveness. The objective of this quality improvement (QI) intervention was to improve HPV vaccination rate by 15% over 3-years through early initiation and analyze trends across health disparities.

METHODS

QI study in ages 9 to 13 at Nemours Primary Care from 2019 to 2022, which includes rural and urban regions and diverse populations. Interventions included updating electronic health records to begin at age 9, practice-level feedback, and updated education. Primary outcome measure was the Healthcare Effectiveness Data Information Set (HEDIS) rate for HPV vaccination (proportion completed by age 13). Process measure was early HPV vaccine initiation rate (proportion aged 9-10 with at least one dose). Year-end early HPV vaccine initiation rates were analyzed to assess trends by race and ethnicity, geography, insurance, and Child Opportunity Index (COI).

RESULTS

The number of eligible 9 and 10 year olds ranged from 16,466 to 17,925 annually. HEDIS rates improved over three years from 49.2% to 59.5% (P < 0.0001). Early initiation increased from 13.2% in 2019 to 42.2% in 2022 (P < 0.0001) and improved significantly across demographic variables (P < 0.0001). Groups with the lowest baseline early vaccination rates increased significantly.

CONCLUSION

HPV vaccine completion by 13 increased significantly with QI supporting early initiation. Demographic analyses showed the highest degree of improvement in populations with the lowest baseline rates. This supports altering Centers for Disease Control and Prevention (CDC) recommendation for HPV vaccination initiation at ages 9-12.

Understanding HPV Vaccine Initiation and Intention Among Central American Immigrant Parents in the United States: The Role of Vaccine Literacy and Healthcare Provider Recommendations

Background/Objectives: The HPV vaccine is key to preventing HPV-related cancers, yet vaccination rates are low, particularly among immigrant and ethnic minority groups. This study explored factors influencing HPV vaccine initiation and intention among Central American immigrant parents in the U.S. Methods: A cross-sectional study with parents of children aged 11 to 17 years. Results: Among the 168 parents (53.8% mothers, 46.2% fathers) in this study, 20% reported that their children had initiated the HPV vaccine and 23% of parents of unvaccinated children intended to vaccinate within the next 12 months. Sociodemographic factors, including the parent's gender and length of U.S. residence, were significant predictors of HPV vaccine initiation and intention. Higher vaccine literacy was also a key factor, with parents with higher vaccine literacy scores being more likely to initiate vaccination and express intent to vaccinate their children. HCP communication strongly predicted both vaccine initiation and intention, yet fewer than 30% of parents received HPV vaccine information from a HCP, and less than 28% received a vaccine recommendation. In the multiple logistic regression analysis, receiving HPV vaccine information from a HCP was the strongest predictor of vaccine initiation (AOR = 93.23, 95% CI = 14.50-599.63, p < 0.001), adjusting for other variables. For vaccination intention, significant predictors included the length of U.S. residence (AOR = 0.84, 95% CI = 0.75-0.95, p < 0.01), having a U.S.-born child (AOR = 10.47, 95% CI = 1.51-72.68, p < 0.05), and receiving vaccine recommendation from a HCP (AOR = 14.73, 95% CI = 1.77-122.32, p < 0.05). Conclusions: To improve vaccination rates, interventions should enhance HCP training, strengthen provider-patient communication, and address vaccine literacy through culturally tailored strategies and community engagement.

Human papillomavirus vaccination coverage among adolescent boys and girls in the United States: A birth year cohort analysis of the National Immunization Survey-Teen, 2016-2022

OBJECTIVE

To evaluate human papillomavirus (HPV) vaccination coverage among adolescents in the U.S. using birth cohort analysis.

METHODS

We conducted a birth cohort analysis among adolescents born during 1999-2009 using National Immunization Survey-Teen (NIS-Teen), a random-digit dialed household telephone survey that also includes vaccination data from providers. We analyzed 131,553 records from 2016 to 2022 NIS-Teen data to determine: trends in coverage with ≥1 HPV vaccine dose before age 13 years and cumulative coverage from age 13-17 years; sociodemographic factors associated with HPV vaccination before age 13 years; missed HPV vaccination opportunities and the potential achievable coverage if opportunities were not missed; and trends in completion of HPV vaccination series. Regression analysis and Kaplan-Meier method provided the average percentage increase in coverage, and cumulative coverage from age 13-17 years stratified by birth cohorts, respectively.

RESULTS

HPV vaccination initiation before age 13 years increased from 27.0 % among adolescents born in 1999 to 69.8 % among those born in 2009. Overall, cumulative percent with ≥1 HPV vaccine dose increased from 51.3 % before age 13 years to 74.9 % through age 17 years. Having a preventive visit at ages 11-12 years and being insured were associated with higher ≥1 HPV vaccine dose coverage. Among the 38,568 (29.3 %) adolescents unvaccinated for HPV, 31,513 (82.5 %) missed ≥1 HPV vaccination opportunity. The potential achievable coverage if opportunities were not missed was 94.8 %. Completion of HPV vaccination series before age 13 years increased from 10.3 % among adolescents born in 1999 to 42.2 % among those born in 2009.

CONCLUSIONS

Coverage with ≥1 HPV vaccine dose increased by birth cohort among adolescents born 1999-2009 but remained suboptimal, especially among uninsured adolescents. Missed opportunities may be reduced by effective HPV vaccination implementation and uptake strategies and by administering all recommended vaccines during the same visit.

Pilot Testing Digital Stories to Influence College Men's Intentions to Vaccinate Against HPV

College men are among those least likely to be vaccinated against the human papillomavirus (HPV). Viewing digital stories from other college men who were vaccinated against HPV as young adults may help influence them to seek the vaccine. Guided by the Theory of Planned Behavior, this research reports on the creation and pilot testing of digital stories to increase college men's intentions to vaccinate against HPV. We recruited college men vaccinated against HPV as young adults to participate in an online workshop to create a digital story about their HPV vaccine decision. To examine the persuasiveness of the digital stories, we then asked college-aged men who either had never been vaccinated against HPV or did not know their HPV vaccine status to complete a pretest, view the digital stories, respond to questions related to identification and emotional engagement with the stories, and complete a posttest. We used descriptive statistics to assess participants' identification and emotional engagement with the stories and paired-sample t-tests to evaluate changes in theoretical constructs from pre- to post-intervention. Results illustrated that exposure to the stories significantly influenced the participants' positive attitudes about the HPV vaccine (Mpretest = 3.41; Mposttest = 3.57, p < .02), subjective norms (Mpretest = 2.82; Mposttest = 3.33, p < .001), self-efficacy to vaccinate (Mpretest = 3.20; Mposttest = 3.39, p < .01), and intention to vaccinate against HPV within the next year (Mpretest = 2.64; Mposttest = 3.10, p < .001). Future research should assess the effectiveness of this intervention on HPV vaccine uptake.

Healthcare provider recommendations for COVID-19 vaccination: Prevalence, disparities, and correlates

OBJECTIVE

We assessed healthcare provider recommendations for COVID-19 vaccination, disparities across sociodemographic factors, and associations with health care coverage, social norms, COVID-19 vaccine hesitancy, and Fox News preference.

METHODS

We utilized random sample survey data of Arkansas residents (N = 2201) collected in October 2022 to identify adults with a personal provider who make up the analytical sample of this study (n = 1804).

RESULTS

Over a third (37.2 %; n = 607) of the weighted sample did not receive a recommendation. Adjusted odds of receiving a recommendation were positively associated with health care coverage (aOR=1.66; 95 % CI [1.05, 2.64]) and negatively associated with perceiving "very few" (aOR=0.48; 95 % CI [0.33, 0.72]) or "some but not many" (aOR=0.57; 95 % CI [0.41, 0.80]) rather than "nearly all" people close to them to be vaccinated. Adjusted odds of receiving a recommendation were negatively associated with being very hesitant (vs. not at all hesitant) (aOR=0.65; 95 % CI [0.47, 0.88]).

CONCLUSION

Provider recommendations for COVID-19 vaccination were not provided for a large portion of Arkansas adults, were inconsistently provided across sociodemographic groups, and were associated with health care coverage, social norms, and vaccine hesitancy.

PRACTICE IMPLICATIONS

Intervening on disparities in COVID-19 vaccination may require addressing disparities in provider recommendations.

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

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

When clinicians and patients disagree on vaccination: what primary care clinicians can learn from COVID-19-vaccine-hesitant patients about communication, trust, and relationships in healthcare

BACKGROUND

In the United States, discourse on COVID-19 vaccination has become polarized, and the positions of public health officials are met with skepticism by many vaccine-hesitant Americans. This polarization may impact future vaccination efforts as well as clinician-patient relationships.

METHODS

We interviewed 77 vaccine-hesitant patients and 41 clinicians about COVID-19 vaccination communication in primary care as part of a Veterans Affairs (VA) trial evaluating a vaccine-communication intervention. This paper reports the findings of a qualitative analysis focused on one aspect of those interviews-the disconnect between primary care clinicians' and patients' perceptions about COVID-19 vaccination communication and decision-making.

RESULTS

Rapid qualitative analysis of semi-structured interviews revealed fundamental differences in how clinicians and patients understood and described the reasoning, values, and concerns underlying COVID-19 vaccine hesitancy. These differences were significant and value-laden; they included negative judgments that could undermine communication between clinicians and patients and, over time, erode trust and empathy.

CONCLUSION

We advocate for empathic listening and suggest communication strategies to bridge the divide between clinicians and vaccine-hesitant patients.

Attitudes and beliefs of healthcare providers toward vaccination in the United States: A cross-sectional online survey

BACKGROUND

Healthcare providers' (HCPs') beliefs and practices regarding vaccination influence vaccine acceptance in patients.

OBJECTIVE

To describe HCPs' beliefs and practices regarding vaccines and perceptions of patient perspectives related to vaccine hesitancy.

METHODS

This was a non-interventional, cross-sectional, online survey administered to 1213 HCPs based in the United States from December 2021 through January 2022. HCPs provided responses regarding their demographic and professional characteristics, beliefs about vaccine safety and effectiveness, vaccination practices, and their views regarding patients' willingness to receive vaccination.

RESULTS

Study participants included doctors (55.4 %); physician assistants (11.2 %); pharmacists (11.7 %); nurse practitioners (11.1 %); and registered nurses (10.6 %) from across the United States (West, 35.6 %; Midwest, 27.0 %; South, 25.6 %; Northeast, 11.9 %). HCPs belonged to group practices or clinics (34.5 %), private practices (31.9 %), hospital-based practices (21.9 %), or pharmacies (11.7 %). Most HCPs strongly believed it was their duty to promote vaccination (78.1 %) and used in-person conversations to educate patients about vaccines (85.0 %); 95.1 % had been vaccinated against COVID-19. HCPs reported that 54.9 % of patients accept all vaccines without hesitation, 21.0 % accept all vaccines but hesitate, 16.8 % accept only select vaccines, and 7.2 % reject all vaccines. Reasons commonly cited by patients for being hesitant to accept vaccines or refusal included negative media (hesitancy: 64.6 %; refusal: 73.2 %), the influence of friends or family (hesitancy: 60.5 %; refusal: 68.7 %), distrust of the government (hesitancy: 45.8 %; refusal: 68.4 %), concerns over long-term side effects (hesitancy: 56.1 %; refusal: 68.3 %), and worries about vaccine-related autism or infertility (hesitancy: 49.7 %; refusal: 71.9 %). HCPs reported that the largest contributors to vaccine misinformation among patients were social media (91.0 %), celebrities/TV personalities (63.5 %), and mass media (61.1 %).

CONCLUSIONS

Despite most HCPs being active proponents of vaccination, misconceptions about vaccination and vaccine hesitancy persists. Consideration should be given to HCP training to support their efforts to promote vaccine acceptance.

Review of the Knowledge, Barriers, and Facilitators of HPV Vaccination among Latino Migrant and Seasonal Farmworkers in the United States

One subgroup of Latinos whose healthcare needs must be more thoroughly addressed is the roughly three million farmworkers pursuing seasonal agricultural work within the United States (U.S.). Latino migrant and seasonal farmworkers (MSFW) face compounded political, social, and personal contexts that complicate healthcare access. Although the human papillomavirus (HPV) vaccine prevents HPV infections and cancers, uptake among Hispanic adolescents remains suboptimal. Therefore, it is important to understand Latino MSFW's HPV knowledge, as well as barriers to and facilitators of vaccination so culturally appropriate measures can bolster vaccination. An integrative review was conducted in PubMed, Scopus, and Web of Science using key search terms. Results were evaluated for compatibility with inclusion/exclusion criteria, and selected articles were coded and evaluated via thematic analysis. Six studies of various designs were ultimately included in the review. While some Latino MSFW have baseline knowledge about HPV and the vaccine, knowledge gaps remain. Participants expressed curiosity about how the vaccine works, contents, side effects, dosing, recommended age, and information about prevented diseases. Although additional education and MSFW's receptiveness to provider's recommendations were cited as major facilitators, many barriers also need addressed. Providers must leverage MSFW's existing knowledge, provide education, and facilitate vaccination to protect farmworker families from HPV and related cancers. It must become standard practice for providers to recommend the HPV vaccine to MSFW, who are receptive to this conversation. Increasing vaccination can decrease the disproportionate burden of HPV-related cancers on patients and facilitate access to healthcare services.

A Cohort Study Exploring HPV Vaccination Beliefs Among Oral Health Providers: Broadening the Scope of Education and Administration

BACKGROUND/OBJECTIVES

There is potential utility and increasing interest in engaging professionals in non-traditional vaccination settings to participate in efforts to reduce human papillomavirus (HPV)-related cancer. This study assessed the impact of a multi-disciplinary HPV educational intervention on oral health care professionals' perceived role, comfort level, and scope of practice in HPV-related cancer prevention efforts.

METHODS

The virtual educational intervention was provided by a multi-disciplinary panel of experts. Seventy-three oral health care professionals attended the educational intervention and completed a questionnaire at three time points (pre-session, immediate post-session, and at the 1-month follow-up). Data were analyzed using Friedman's ANOVA and post-hoc analyses.

RESULTS

Respondent's median belief that it is the role of an oral health professional to recommend the HPV vaccine increased from pre-session (Median = 3.0, IQR = 3.0-4.0) to immediate post-session (median = 4.5, IQR = 4.0-5.0), and this increase was maintained 1 month after the session (median = 4.0, IQR = 4.0-4.5; p < 0.001). Additionally, respondent's belief that they were up-to-date on the latest guidelines for HPV vaccination also increased from pre-session to immediate post-session (p < 0.05), and this increase was maintained 1 month after the session (pre-session median = 2.0, IQR = 2.0-3.0 vs. 1-month post-session median = 4.0, IQR = 4.0-5.0; p < 0.005).

CONCLUSIONS

The multi-disciplinary HPV educational intervention was well-received by oral health professionals. Data suggest the intervention had a lasting impact on their beliefs about their role, comfort level, and scope of practice relating to HPV cancer prevention. More research needs to be conducted to better understand how obstetrician-gynecologists, other obstetric care providers, and oral health communities can support each other in promoting HPV-related cancer prevention.

Influence of Knowledge and Cultural Beliefs on Attitudes Toward HPV Vaccination Among Israeli Nurses and Nursing Students: Implications for Vaccine Advocacy

BACKGROUND

Human papillomavirus (HPV) poses a significant health burden, yet the vaccine which successfully prevents HPV and its associated cancers remains underutilized. Nurses play a crucial role in patient education and advocacy for HPV vaccination. This study explores how knowledge, along with cultural, religious, and social beliefs, shapes the attitudes of Israeli nurses and nursing students toward the HPV vaccine and their advocacy efforts.

METHODS

A cross-sectional study was conducted from August 2023 to January 2024 using an anonymous online questionnaire distributed via Facebook groups targeting Israeli nurses and nursing students. The questionnaire assessed demographic data, HPV-related knowledge, and attitudes toward HPV vaccination.

RESULTS

The study included 458 participants (229 nurses and 229 nursing students). Significant knowledge gaps were found, with 52% of participants incorrectly believing that the vaccine can cure existing infections and 47% mistakenly believing that it is administered in a single dose. Logistic regression revealed that nurses working in community settings were more likely to have positive attitudes toward HPV vaccination (OR = 2.98, 95% CI: 1.84-4.85). Higher levels of HPV-related knowledge (OR = 3.35, 95% CI: 2.10-5.35) and secular or traditional religious affiliations (OR = 2.45, 95% CI: 1.52-3.97) were strongly associated with positive attitudes toward and advocacy for the vaccine.

CONCLUSIONS

Targeted educational programs addressing knowledge gaps, especially those tailored to Israel's cultural and religious diversity, are crucial for empowering nurses and nursing students as advocates for HPV vaccination. Enhancing their understanding of HPV can increase vaccine uptake, reduce the incidence of HPV-related diseases, and strengthen public health initiatives in Israel.

Knowledge, attitude and perception of Italian dental students toward HPV-related oropharyngeal cancer and vaccination: a cross-sectional study

BACKGROUND

Human papillomavirus (HPV) infection is a leading cause of oropharyngeal squamous cell cancer (OPSCC). This study aimed to carry out a Knowledge, Attitude and Perception survey on HPV infection, HPV+ OPSCC, and HPV vaccination among Italian dental students.

METHODS

Through an online self-administered questionnaire consisting of 82 questions, data on dental students' sociodemographic characteristics, knowledge, attitudes and perceptions concerning HPV+ OPSCC, infection and vaccination were acquired. A statistical analysis, based on their year of attendance (early career, from 1st to 3rd year vs. late career, from 4th to 6th year) was also conducted.

RESULTS

A total of 412 dental students completed the questionnaire. Knowledge of HPV+ OPSCC was reported by 61% of early-career students and 73% of late-career students, with high awareness of the HPV-OPSCC correlation in both groups (85% vs. 89%, respectively). The percentage of correct responses regarding HPV infection knowledge was 61% for early-career and 73% for late-career students, while vaccine knowledge was 70% and 78%, respectively. Over 90% of students acknowledged the dentist's role in educating patients about HPV and OPSCC, and attitudes toward discussing HPV and vaccination were positive. However, only about half would recommend the vaccine to either gender. Statistically significant differences were found between early- and late-career groups across all knowledge sections (p < 0.001), while no significant differences emerged for perception (p = 0.076) or attitude (p = 0.147).

CONCLUSIONS

The study reveals encouraging results but highlights significant gaps in dental students' knowledge, perceptions, and attitudes toward HPV+ OPSCC, infection, and vaccination. Addressing these gaps through targeted education and training in dental curricula could improve HPV prevention awareness and patient education, ultimately enhancing public health outcomes.

Conceptualizing vaccine champions from an implementation science perspective: Findings from a national survey of primary care health professionals

OBJECTIVE

Clinical champions are healthcare professionals who help their colleagues improve the delivery of evidence-based care. Because little is known about champions working in the context of adolescent vaccination, we sought to identify vaccine champion roles among primary care health professionals (PCHPs).

METHODS

In 2022, we surveyed 2527 US PCHPs who serve adolescents. The survey assessed the extent to which respondents identified as vaccine champions and the activities they performed. Guided by the Consolidated Framework for Implementation Research, we used these data to categorize PCHPs as: champions who led projects to increase vaccination rates ("implementation leaders"); facilitating champions who more generally shared vaccination data, information, and encouragement ("facilitators"); or non-champions. We used multinomial logistic regression to identify correlates of being a leader or facilitator as opposed to a non-champion.

RESULTS

About one-fifth (21%) of PCHPs were implementation leaders, one-quarter (25%) were facilitators, and the remainder (54%) were non-champions. Leaders were more common among PCHPs with medium or high versus low practice experience (31% and 36% versus 20%, both p < .01) and adolescent patient volume (29% and 39% versus 17%, both p < .01). Being a facilitator was also associated with higher practice experience and patient volume. Leaders and facilitators reported a similar number of barriers to their work (mean = 1.8 and 1.9, respectively), with time and competing quality metrics being most common.

CONCLUSIONS

Our findings suggest that both implementation leaders and facilitators are common vaccine champions in adolescent primary care. These champions are more often found among PCHPs with higher experience and patient volume.

Communication Interactions, Needs, and Preferences During Clinical Encounters of African American Parent-Child Dyads

Human papillomavirus (HPV) vaccination rates remain suboptimal among African American adolescents. Although provider recommendations during clinical encounters are believed to be highly effective in increasing uptake and series completion, little has been reported about parent-child perspectives on the counseling received during these encounters. Among African American parent-child dyads, we sought to explore and compare interactions, needs, and preferences during clinical encounters by child's HPV vaccination status. We applied a qualitative, phenomenological study design to conduct semi-structured interviews with African American parent-child dyads representing children who were unvaccinated (n = 10), had initiated but not completed (n = 11), or had completed the HPV vaccine series (n = 9). Using iterative, inductive-deductive thematic analysis, five themes were generated: (1) parents' attitudes varied about the HPV vaccine but were mostly positive for vaccines in general; (2) patient-parent-provider clinical encounters from the parent perspective; (3) patient-parent-provider clinical encounters from the child perspective; (4) methods of distribution of supplemental HPV information; and (5) communication desired on HPV vaccination by parents and children. Parents stating they received a provider's recommendation increased by vaccination status (unvaccinated: 6 out of 10; initiated: 7 out of 11; completed: 9 out of 9). Most parents and children were not satisfied with provider communication on the HPV vaccine and used supplemental materials to inform decision-making. Ongoing communication on the HPV vaccine was requested even post-vaccination of the child. During clinical encounters, children and parental messaging needs are similar yet dissimilar. We offer communication strategies and messaging that can be used for African American parent-child dyads by child HPV vaccination status during a clinical encounter.

Pediatric Oncology Providers' HPV Vaccine Knowledge, Attitude, Self-Efficacy, and Practice after Communication Training: A Comparison with a National Survey

BACKGROUND/OBJECTIVES

Human papillomavirus (HPV) vaccinations prevent HPV infection and related cancers. Despite being at higher risk of secondary cancers linked to HPV, childhood cancer survivors (CCS) are undervaccinated. This study aimed to compare pediatric oncology providers' knowledge, attitudes, self-efficacy, and practices regarding HPV vaccination among those who participated in a multilevel educational HPV vaccine program with those of a national sample of oncology providers.

METHODS

Between February and March 2023, 39 providers from five pediatric oncology clinics in Texas completed online surveys, assessing knowledge about CCS risk for HPV-related cancers, attitudes towards the HPV vaccine, and confidence in recommending the vaccine to CCS. The results were compared with a national survey of providers conducted in 2019 (n = 195).

RESULTS

The findings showed that providers who participated in our program had greater knowledge of CCS increased risk for HPV-related cancers (96% vs. 38%; p < 0.001); greater confidence in discussing and recommending the HPV vaccine (100% vs. 66%, p < 0.001) and addressing parental concerns (100% vs. 69%, p < 0.001); and a more positive attitude about oncology providers than general pediatricians, recommending (96% vs. 71%; p = 0.006) and administering the HPV vaccine to CCS (96% vs. 53%, p < 0.001).

CONCLUSION

This study underscores the importance of educating oncology providers about the increased risk of CCS and improving their self-efficacy to recommend the HPV vaccine, promoting vaccination in the oncology setting.

HPV Vaccination Information Access, Needs, and Preferences Among Black and Hispanic Mothers

HPV-associated cancer disparities disproportionately affect Black/African American and Hispanic individuals in the U.S. HPV vaccination, which can prevent many HPV-associated cancers, should be clearly recommended by pediatricians to parents of adolescents aged 9-12, yet uptake and completion remain lower than other adolescent vaccinations. We used the Structural Influence Model of Health Communication to explore communication inequalities from interviews with 19 Black and Hispanic mothers of adolescents. We identified HPV vaccination information seeking behaviors, media use, and preferred channels to address information needs. This study provides insights into how mothers' nativity and ethno-racial identity influenced how they accessed and processed information from various sources. Preferences for digital and community-based strategies to address information gaps and hesitancy concerns are also presented. Findings suggest future prevention strategies must increase access to accurate information that resonates with NH-Black and Hispanic communities' needs and is disseminated via preferred communication channels to maximize the effects of multi-level interventions promoting HPV vaccination among communities experiencing disparities.

Attitudes toward Adolescent HPV Vaccination after the COVID-19 Pandemic: A National Survey of Mothers

In the United States, vaccination rates for many routinely recommended vaccines have recovered to pre-pandemic levels, yet human papillomavirus (HPV) vaccination rates still lag pre-pandemic levels. This study sought to uncover the potential effects of the pandemic on attitudes about the HPV vaccine, and factors associated with changes in attitudes. We conducted a national survey (n = 3968) of U.S. mothers with children aged 9-17 years. Outcome variables measured changes in attitude toward the HPV vaccine following the pandemic. Two logistic regression models identified predictors of (1) those who did not have attitude changes (always negative vs. always positive), and (2) those who reported attitude changes (change to negative vs. change to positive). Attitudes toward the HPV vaccine remained unchanged in 78.9% of participants (58.1% positive, 20.8% negative). Of the 21.1% reporting changed attitudes, 9.6% changed to positive and 11.5% to negative. Those reporting changing to a negative attitude had a greater odds of reporting conservative political views, and being unsure/undecided about vaccinating their child against HPV compared to those who reported changing to a positive attitude. Targeted strategies are needed to address erosion in confidence in the HPV vaccine and other vaccines resulting from mis- and disinformation associated with the COVID-19 pandemic and future pandemics.

Regional differences in provider recommendation of HPV vaccines among 13-to-17 year old adolescents from 2019 to 2021

PURPOSE

The prevalence of recommendation of human papillomavirus (HPV) vaccination by health care providers has improved over the last decade. However, research to determine whether the COVID-19 pandemic affected the progress in recommendation among adolescents across the U.S. regions has been limited. Therefore, the present study was conducted to determine if region was associated with provider recommendation of HPV vaccines in 2019-2021 and whether changes in recommendations varied by region.

METHOD

Using a cross-sectional design to examine National Immunization Survey-Teen (2019-2021) data, logistic regression and moderation analyses were performed to model region variation in HPV vaccine recommendations (n = 50,739 respondents).

RESULTS

The odds of recommendation were higher in the Midwest (aOR, 1.17 [95% CI, 1.06-1.29]), and Northeast (aOR, 1.38 [95% CI, 1.23-1.56]) regions than in the South region. Also, the odds of provider recommendation were higher in 2020 (aOR,1.16 [95% CI, 1.03-1.30]) than in 2019. Other variables-sex, age, race/ethnicity, health insurance status, and poverty status-were associated with recommendation of HPV vaccination.

CONCLUSION

Although the improvement in recommendation from 2019 to 2020 is an important public health gain, recommendation in the South still lags behind that in other regions. More efforts are needed to improve HPV vaccination recommendations in this region.

Moral persuasion for value-laden objections to human papillomavirus vaccination

The martial art of jiu jitsu capitalizes on the strength of a sparring partner by redirecting their momentum. Jiu jitsu persuasion similarly redirects the concerns motivating an objection in a manner that undermines the objection. This method of persuasion effectively addresses criticisms that motivate vaccine hesitancy, including moral criticisms. Critics argue that human papillomavirus vaccination causes young women to become more promiscuous. Evidence undermines this objection, but such evidence fails to persuade many objectors because of countervailing moral concerns regarding promiscuity. Healthcare professionals, therefore, need to consider supplementing evidence with moral arguments against the objection, using a framework that appeals to the core values motivating vaccine objections. A jiu jitsu model of persuasion is one such framework. By employing a jiu jitsu model healthcare professionals can facilitate collaborative, normative discussion that persuades more objectors and fulfills healthcare professionals' obligations with respect to patient care vis-à-vis vaccination.

Racial, Ethnic, and Gender Differences in the Timing of Initiating the HPV Vaccine in the United States: the Case of Southeast Asian Americans

Despite the availability of the human papillomavirus (HPV) vaccine, non-Latinx (NL) Southeast Asian Americans have the highest incidence of HPV-associated cervical cancer in the US. Little is known about NL-Southeast Asian Americans' HPV vaccination coverage due to being categorized under the "Asian American" monolith. Therefore, this study uses restricted data from the 2011-2018 National Health and Nutrition Examination Survey (NHANES) to disaggregate NL-Southeast Asian Americans and compare this population's age-specific probabilities of initiating HPV vaccinations to two Asian American subgroups (NL-East Asian and NL-South Asian Americans) and NL-White, NL-Black, and Latinx Americans. Multinomial logistic regression models examine the differences in the timing of initiating the HPV vaccine series, late (ages 13-26) or never, relative to on-time vaccination (by age 12). NL-Southeast Asian Americans are significantly more likely to never vaccinate and to vaccinate late than NL-White, NL-Black, and Latinx Americans, relative to on-time vaccination. NL-Southeast Asian American boys/men are significantly more likely to never initiate the HPV vaccine than Latinx boys/men, relative to on-time vaccination. NL-Southeast Asian American girls/women are significantly more likely to never vaccinate and vaccinate late than NL-White, NL-Black, and Latinx girls/women, relative to on-time vaccination. There are significant gender differences in uptake among all racial and ethnic groups, except among NL-Southeast and NL-East Asian Americans. Disaggregated data on NL-Southeast Asian Americans helps scholars and public health officials uncover health disparities and improve health interventions. Targeted HPV vaccine promotion and services for this population are needed to mitigate current and future health disparities and promote health equity.

"That Was an Eye Opener for Me": Mixed-Methods Outcomes Educating Texas Community Health Workers on HPV Vaccination Using Project ECHO®

Human papillomavirus (HPV) is known to cause six different types of cancer. HPV vaccination can prevent over 90% of these cancers. Community health workers (CHWs) have the potential to drive HPV vaccination demand through education and navigation by addressing vaccine hesitancy and dis/misinformation and by reaching non-English speaking, vulnerable, or rural populations. Despite their possible reach, there is limited research on HPV vaccination education programs for CHWs. In 2020-2021, the American Cancer Society (ACS) HPV Cancer Free Texas (HPVCFT) Project implemented the eight-session Mission: HPVCFT Vaccination ECHO-CHW Program ten times. This manuscript details the program's implementation processes and outcomes. The program used the Project ECHO model and was offered in both English and Spanish. One hundred and forty-six Texan CHWs completed pre- and post-training surveys. The participants demonstrated significant HPV vaccination knowledge increases and desirable shifts in their foundational HPV vaccination beliefs, including the belief that the HPV vaccine is for cancer prevention. The participants also reported increased confidence in communicating about the HPV vaccine in the community. Improving knowledge, beliefs, and confidence in HPV vaccination is the first step in addressing concerns and increasing uptake. Future research and interventions are needed to better understand how CHWs can be more systematically linked to vaccination opportunities or provided with clearer paths for directing patients to providers that vaccinate.

Effective communication by health care workers to promote HPV vaccination: Lessons learned from Kenya, India, and Nigeria

Health care workers play an essential role in maintaining the public trust in vaccination programmes globally, and more specifically, in low- and middle-income countries. This role is particularly important in building trust in the human papillomavirus (HPV) vaccine. While there are many factors that affect HPV vaccine acceptance, health care workers are one of the most critical influences in the decision-making process among parents as well as adolescent girls. In this paper, we sought to better understand how health care workers in a diverse set of countries communicate and promote HPV vaccines. We summarize communication approaches and lessons learned by health care workers in Kenya, India, and Nigeria through a case study approach. In Kenya, the utilization of a multisectoral approach proved to be very important. In India, intense social mobilization with targeted messaging by target audience laid the groundwork for community acceptance. An evolving communication strategy was essential in Nigeria, where there is no national HPV vaccination programme. Given the increase in vaccine hesitancy globally, the lessons learned through these three country examples highlight the importance of communication efforts in increasing vaccine acceptance.

'We were having a rather long conversation about the uproar': memorable messages about COVID-19 vaccinations in a mostly young, white sample

BACKGROUND

Interpersonal communication motivates many decisions related to COVID-19 prevention practices. Previous research shows that the frequency of interpersonal communication is significant. Less is known, however, about who messages interpersonal communication about COVID-19 and what information those messages convey. We sought to understand better these interpersonal communication messages for individuals who are asked to become vaccinated against COVID-19.

METHODS

Using a memorable messages approach, we interviewed 149 adults, mostly young, white, college students, about their vaccination choices as they were influenced by messages about vaccination they had received from respected members of their interpersonal networks. Date was analyzed using thematic analysis.

RESULTS

Three themes emerged from these interviews of primarily young, white, college students: a dialectic of feeling forced to become vaccinated vs. choice to become vaccinated; a tension between protecting oneself vs. protecting others through vaccination; and, finally, perceptions that family members who were also medical experts were particularly influential.

CONCLUSIONS

The dialectic between feelings of choice versus force may require further study into the longer-term impacts of messages that may prompt feelings of reactance and produce undesired outcomes. The dialectic between messages being remembered for their altruism as compared to their selfishness opens opportunities to consider the relative influence of these two impulses. These findings also provide insight into broader topics about countering vaccine hesitancy for other diseases. These findings may not be generalizable to older, more diverse populations.

School children's perceptions about being offered the HPV vaccination - A focus group study

AIM

There is limited knowledge about the perceptions of HPV vaccination in middle-school children. This qualitative study aimed to explore their views.

METHODS

We conducted focus group interviews with children, 10-11 years of age, who had been offered HPV vaccination through the school health services in mid-north Sweden in spring of 2023. Data were analysed with qualitative content analysis.

RESULTS

This study included six focus group interviews with 49 children (boys n = 29; girls n = 20), mean of 11 years of age. Participating children expressed the need to feel safe to be of utmost importance and the means to do so was to be prepared and informed by someone the child trusted. The school nurse was perceived as the expert, best suited to provide factual information, support and motivation, both to children and their parents.

CONCLUSION

We confirm that healthcare providers' recommendations are crucial for HPV vaccine acceptance also from the child's perspective. Improved information about HPV vaccination to children is necessary. Children's right to participate on their own terms is not fulfilled today. Vaccine promotion, both to children and parents, should be actively managed by the school nurse.

Physicians' Human Papillomavirus Vaccine Communication With Parents of Different Skin Color: Feasibility of Measuring Indicators of Implicit Bias With Virtual Reality

PURPOSE

Virtual reality (VR) may be a viable method to observe and describe signals of implicit bias. Using the context of the human papillomavirus vaccine counseling, we sought to describe physicians' communication practices exploring differences when counseling parents with different skin colors.

METHODS

Physicians (N = 90) at an academic primary care center were recruited for a VR study in which they counseled dark or light-skinned parent avatars who expressed hesitation about human papillomavirus vaccination for their adolescent child. Investigators coded previously recorded simulations. Associations between communication and parent skin color were examined using t-tests and Chi-square tests.

RESULTS

Both direct (e.g., addressing the concern immediately) and circuitous (e.g., providing alternative information) communication patterns were observed. Physicians used passive voice less commonly when counseling dark-skinned versus light-skinned avatars (p < .05).

DISCUSSION

VR demonstrated feasibility in capturing clinicians' communication behaviors including measuring eight distinct indicators of implicit bias.

Multiple Messaging Strategies for Increasing HPV Vaccination Intentions among English- and Spanish-Speaking Parents in the United States and Mexico

The reported study compared the impact of four influence strategies (agency assignment, enhanced active choice, deviance regulation marking, and temporal framing) on English- and Spanish-speaking parents' reported intention to vaccinate their children for HPV. An online experiment was conducted to examine the impact of the strategies. In a fractional factorial design, participating parents (N = 1663) were exposed to combinations of influence strategies in text messages presented as reminders they might receive from a healthcare provider about their child's eligibility for the vaccine series. The results indicated small but significant impacts of agency assignment, enhanced active choice, and deviance regulation marking on parents' reported vaccination intentions. The study adds to the research literature on HPV vaccination communication in two important respects. First, it demonstrated how incorporating evidence-based influence strategies into reminder messages can increase parents' vaccination intentions, an important precursor and predictor of actual vaccine uptake. Second, it sets an important precedent by examining the effects of influence strategies on vaccination intentions across different languages.

Influenza Vaccine Hesitancy among Cancer Survivors in China: A Multicenter Survey

BACKGROUND

Cancer survivors are at higher risk of developing severe complications from influenza due to their compromised immune systems. Despite their increased vulnerability to influenza and the availability of vaccines, vaccine hesitancy among cancer survivors remains a significant public health concern in China.

METHODS

A multicenter, cross-sectional study was conducted among cancer survivors in China from January to December 2023. A total of 500 participants were recruited from the oncology departments of five tertiary hospitals. A structured, self-administered questionnaire was used to collect data on socio-demographic characteristics, cancer-related information, medical history, lifestyle factors, and influenza vaccine hesitancy. Univariate and multivariate logistic regression analyses were performed to identify factors associated with influenza vaccine hesitancy.

RESULTS

The response rate was 97.0% (485/500). Among all participants, 204 (42.06%) reported vaccine hesitancy. The results of multiple logistic regression showed that the longer the end of anti-cancer treatment, without a history of adverse vaccine reactions, and the level of family support played a protective role in vaccine hesitancy. Current rehabilitation status, frequent colds, not being informed by doctors about vaccination, exercising, lack of community vaccination education programs, and concerns about vaccine safety were risk factors that increase vaccine hesitancy.

CONCLUSIONS

A high proportion of cancer survivors in our study reported influenza vaccine hesitancy. Addressing concerns about vaccine safety, improving access to vaccination services, and enhancing doctor-patient communication are crucial for increasing influenza vaccine uptake in this vulnerable population.

Barriers to the assessment and recommendation of HPV vaccination among healthcare providers in Texas

Background

Healthcare providers (HCPs) recommendations for HPV vaccination plays a critical role in increasing vaccination uptake. This study assesses the prevalence of reported barriers to HPV vaccination assessment and recommendation among HCPs in Texas.

Methods

Study data were obtained from a population-based survey of HCPs currently practicing in Texas. Participants were asked about their HPV vaccination assessment and recommendation practices and the reasons for not assessing or recommending the vaccine. Barriers were stratified by HCP characteristics including age, sex, race/ethnicity, location of practice, provider type, and type of facility.

Results

Among the 826 HCPs included in this study, 47.3 % never, 49.6 % sometimes, and 3.0 % often/always assessed a patient's HPV vaccination status. Similarly, 36.0 % never, 36.2 % sometimes, and 27.9 % often/always recommended HPV vaccination. The most frequently reported barriers to assessment and recommendation of HPV vaccination were time constraints (22.9 %), delegating the task to others (15.0 %), lack of effective tools and information to give patients (12.0 %), and requiring additional training (9.2 %). HCPs who were female, less than 35 years old, non-Hispanic black, and nonphysician HCPs (Physician Assistant, Nurse Practitioner) most frequently reported lacking effective tools and information and a need for additional training.

Conclusion

The assessment and recommendation for HPV vaccination among HCPs in Texas is suboptimal. Barriers reported varied based on the provider's characteristics. Addressing these barriers, such as by providing more effective tools and information and offering additional training to HCPs, could potentially increase HPV vaccination rates in Texas. The findings also suggest that interventions should be tailored to specific demographic groups.

Effect of an HPV Vaccination Multi-Level, Multi-Component Program on HPV Vaccination Initiation and Completion in a Pediatric Clinic Network

Despite clear evidence of the public health benefits of the human papillomavirus (HPV) vaccine in preventing HPV-related cancers and genital warts, underutilization of HPV vaccination in the United States persists. Interventions targeting multi-level determinants of vaccination behavior are crucial for improving HPV vaccination rates. The study's purpose was to implement and evaluate the adapted Adolescent Vaccination Program (AVP), a clinic-based, multi-level, multi-component intervention aimed at increasing HPV vaccine initiation and completion rates in a five-clinic pediatric network in Bexar County, Texas. The adaptation process was guided by established frameworks and involved formative work with clinic stakeholders. The study utilized a quasi-experimental single group pre- and post- study design, with an external comparison data using the National Immunization Survey-Teen (NIS-Teen) datasets for the same time period to examine the AVP's effect on HPV vaccination initiation and completion. A series of interrupted time series analyses (ITSA) compared the clinic system patient outcomes (HPV vaccination initiation and completion rates) in the post-intervention to the general adolescent population (NIS-Teen). Of the 6438 patients (11-17 years) with clinic visits during the 3-year study period, HPV vaccination initiation rates increased from 64.7% to 80.2% (p < 0.05) and completion rates increased from 43.2% to 60.2% (p < 0.05). The AVP was effective across various demographic and economic subgroups, demonstrating its generalizability. ITSA findings indicated the AVP improved HPV vaccination initiation and completion rates in clinic settings and that AVP strategies facilitated resilience during the pandemic. The minimal adaptation required for implementation in a new clinic system underscores its feasibility and potential for widespread adoption.

HPV Vaccine Awareness, Past Behaviors, and Future Intentions Among a Diverse Sample of Fathers Aged 27 to 45 Years: A National Survey

Men aged 27 to 45 are eligible for human papillomavirus (HPV) vaccination as of 2019, yet relatively little is known about whether they have received or intend to receive it. We conducted a cross-sectional, online survey among fathers aged 27 to 45 between March and April 2022, to assess associations between HPV vaccination awareness, behaviors, intentions, and psychosocial constructs from the Health Belief Model. We examined the characteristics of those who had (a) heard of the HPV vaccine, (b) already received ≥ 1 dose, and (c) intentions for future vaccination among those who had never been vaccinated. Among 400 men who completed the survey, 32% were not aware of the HPV vaccine. Among those who were aware, 41% had received ≥ 1 dose. Sixty-three percent of unvaccinated men reported that they intended to get vaccinated in the future. Multivariable logistic regression analyses revealed that age and race/ethnicity were associated with having been vaccinated previously. Among the unvaccinated, multivariable logistic regression analyses revealed that those with a higher perceived risk of HPV-associated cancer had 3.73 greater odds of reporting they would seek vaccination compared to those with lower perceived risk (95% confidence interval [CI] = [1.28, 12.3]). We did not find perceived benefits, barriers, or decision self-efficacy to be related to future vaccine intentions. Since recommendations for this group include shared clinical decision-making, public health efforts should focus on raising awareness of vaccine eligibility, emphasizing risk factors for HPV-associated cancers so that individuals have an accurate perception of risk, and encouraging conversation between men and their providers.

Identifying Healthcare Professionals With Lower Human Papillomavirus (HPV) Vaccine Recommendation Quality: A Systematic Review

PURPOSE

Strengthening healthcare professionals' (HCPs) communication is an evidence-based approach to increasing human papillomavirus (HPV) vaccine uptake among adolescents. To better target future interventions, we sought to synthesize evidence on HCP subgroups who most need to improve their HPV vaccine recommendation quality.

METHODS

We searched five databases for quantitative studies published from 2012 to 2022 on HPV vaccine recommendation quality, including recommendation consistency and strength, for United States adolescents. Two coders independently abstracted data from each eligible study, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We summarized variation in recommendation quality by clinical and HCP characteristics.

RESULTS

The 28 eligible studies indicated that relatively low proportions of HCPs used higher-quality recommendation practices (median: 61% across 30 measures) and that recommendation quality varied across HCP subgroups. The most consistent findings were that more pediatric HCPs used higher-quality recommendations than family medicine HCPs (8 of 11 studies, 2-60 percentage point difference) and that HPV-related knowledge was associated with higher recommendation quality (four of seven studies). Most studies observed no differences in recommendation quality by clinical role (e.g., provider vs. nurse) or HCP demographics (e.g., gender, age, race/ethnicity).

DISCUSSION

Studies suggest a substantial need to improve HCPs' recommendation quality, with opportunities for targeting future interventions.

Who are vaccine champions and what implementation strategies do they use to improve adolescent HPV vaccination? Findings from a national survey of primary care professionals

BACKGROUND

Implementation science researchers often cite clinical champions as critical to overcoming organizational resistance and other barriers to the implementation of evidence-based health services, yet relatively little is known about who champions are or how they effect change. To inform future efforts to identify and engage champions to support HPV vaccination, we sought to describe the key characteristics and strategies of vaccine champions working in adolescent primary care.

METHODS

In 2022, we conducted a national survey with a web-based panel of 2527 primary care professionals (PCPs) with a role in adolescent HPV vaccination (57% response rate). Our sample consisted of pediatricians (26%), family medicine physicians (22%), advanced practice providers (24%), and nursing staff (28%). Our survey assessed PCPs' experience with vaccine champions, defined as health care professionals "known for helping their colleagues improve vaccination rates."

RESULTS

Overall, 85% of PCPs reported currently working with one or more vaccine champions. Among these 2144 PCPs, most identified the champion with whom they worked most closely as being a physician (40%) or nurse (40%). Almost all identified champions worked to improve vaccination rates for vaccines in general (45%) or HPV vaccine specifically (49%). PCPs commonly reported that champion implementation strategies included sharing information (79%), encouragement (62%), and vaccination data (59%) with colleagues, but less than half reported that champions led quality improvement projects (39%). Most PCPs perceived their closest champion as being moderately to extremely effective at improving vaccination rates (91%). PCPs who did versus did not work with champions more often recommended HPV vaccination at the earliest opportunity of ages 9-10 rather than later ages (44% vs. 33%, p < 0.001).

CONCLUSIONS

Findings of our national study suggest that vaccine champions are common in adolescent primary care, but only a minority lead quality improvement projects. Interventionists seeking to identify champions to improve HPV vaccination rates can expect to find them among both physicians and nurses, but should be prepared to offer support to more fully engage them in implementing interventions.

Effectiveness of provider communication training for increasing human papillomavirus vaccine initiation at a safety-net health system

Background

Strong provider recommendation can increase uptake of human papillomavirus (HPV) vaccination. Therefore, we developed and implemented a provider education intervention on communication strategies for recommending HPV vaccination with clinic-level audit and feedback (HPV: Communicating about HPV to Adults and Teens [HPV CHAT]). We aimed to evaluate the effect of HPV CHAT on HPV vaccine uptake in seven family medicine and pediatric clinics in a large urban health system (USA).

Methods

We used a quasi-experimental design, where the eligible population included people aged 9-26 years with at least one encounter in June 2020-February 2023 at one of the participating community health clinics. We used interrupted time-series analysis to assess changes in the prevalence of HPV vaccine uptake. We used segmented Poisson regression with a log link function to estimate prevalence ratios (PR) and 95% confidence limits (CL) for level (immediate) and slope (over time) changes with adjustment for seasonality using Fourier transformation.

Results

Our study population comprised 60,328 observations in which the median age was 17 years (interquartile range: 13-21). A majority (58%) were female and 87% were racial/ethnic minorities. Overall, we observed no sizeable effect of the intervention on HPV vaccination uptake. Nonetheless, heterogeneity was observed by age group with modest increases in individuals aged 9-12 and 13-17 years.

Conclusion

Our provider feedback intervention had minimal effect on increasing prevalence of HPV vaccination in seven family medicine and pediatric clinics. Novel strategies are needed to address provider barriers related to HPV vaccination.

Improving clinician communication to increase adolescent HPV vaccination rates

ABSTRACT

Despite the proven effectiveness of human papillomavirus (HPV) vaccination, this vaccine is underused in the United States and is associated with many disparities and barriers to acceptance. Adolescent HPV vaccination rates failed to meet the Healthy People 2020 goal of 80% vaccine coverage when nearly all other routine adolescent vaccines met or were near this goal. When introducing the HPV vaccine series, many clinicians use a conversational approach, although years of research show that an announcement approach is more effective at increasing HPV vaccination rates. This article reviews current HPV vaccine communication practices used by clinicians and recommends evidence-based best practices to improve adolescent HPV vaccination rates in the United States.

Screening for High-Risk Human Papillomavirus Reveals HPV52 and HPV58 among Pediatric and Adult Patient Saliva Samples

Previous research has demonstrated that the human papillomavirus (HPV) can infect a wide range of human tissues, including those within the oral cavity. High-risk oral HPV strains have been associated with the development and progression of oral cancers, including oral squamous cell carcinomas. Although many studies have examined the prevalence of the high-risk strains HPV16 and HPV18, far fewer have assessed the prevalence of other high-risk HPV strains. An approved study protocol was used to identify HPV52 and HPV58 among clinical samples (n = 87) from a saliva biorepository. Quantitative polymerase chain reaction (qPCR) and validated primers for HPV52 and HPV58 were used to facilitate this screening. This screening demonstrated that a total of n = 4/45 or 8.9% of adult saliva samples harbored high-risk HPV52, and n = 2/45 or 4.4% tested positive for high-risk HPV58. In addition, a total of n = 6/42 or 14.3% of the pediatric saliva samples tested positive for high-risk HPV, including n = 5/42 or 11.9% with HPV52 and n = 3/42 or 7.1% for HPV58. These data demonstrate the presence of the high-risk oncogenic HPV52 and HPV58 strains among both adult and pediatric clinical patient samples. More detailed longitudinal research must be conducted to determine whether this prevalence may be increasing or decreasing over time. In addition, these data strongly support public health prevention efforts, such as knowledge and awareness of the nine-valent HPV vaccine covering additional high-risk strains, including HPV52 and HPV58.

Human Papillomavirus (HPV) Vaccine Coverage and Confidence in Italy: A Nationwide Cross-Sectional Study, the OBVIOUS Project

BACKGROUND

Human Papillomavirus (HPV) vaccination rates are still below the target due to vaccine refusal or delay, lack of knowledge, and logistical challenges. Understanding these barriers is crucial for developing strategies to improve HPV vaccination rates.

METHODS

This cross-sectional study used a questionnaire to investigate social and behavioral factors influencing decision making about the HPV vaccine. The survey was conducted from 11 April to 29 May 2022 and involved 10,000 Italian citizens aged ≥ 18 years. The sample was stratified based on region of residence, gender, and age group.

RESULTS

3160 participants were surveyed about themselves, while 1266 respondents were surveyed about their children's vaccine uptake. Among females aged ≥ 26 years, the national average HPV vaccine uptake was 21.7%, with variations across different regions. In the 18-25 age group, females had a vaccine uptake (80.8%) twice as much as males (38.1%), while vaccine uptake among male and female children aged 9-11 was similar.

CONCLUSIONS

The OBVIOUS study in Italy reveals factors influencing low HPV vaccine uptake, suggesting targeted approaches, tailored information campaigns, heightened awareness of eligibility, promoting early vaccination, addressing low-risk perception among males, addressing safety concerns, and enhancing perceived accessibility to improve vaccine uptake and mitigate health risks.

School Nurses' Experiences and Roles in Promoting and Administering the HPV Vaccine: A Systematic Review Using the Socioecological Framework

Understanding the school nurse's experience in human papillomavirus (HPV) vaccine promotion can reduce vaccine disparities. HPV vaccination is critical to cancer prevention. Despite the importance of the school nurse in vaccine promotion, there is a lack of understanding. This article aims to examine the knowledge, attitude, experience, and role of school nurses related to HPV vaccination and promotion in school settings. A systematic search for school nurses and their experiences related to HPV vaccination was conducted. A thematic synthesis was undertaken using the socioecological model. This review highlights the complexity of HPV vaccine promotion in schools over time. Multilevel factors impact nursing practice. Nurses have good vaccine knowledge and positive attitudes. Poor workflow processes, competing demands, and vaccine communication challenge school nurses. The themes that were synthesized informed the LEADS model. With the support of school nurses, reaching the goal of eliminating cervical cancer as a public health problem is possible.

Integrating human-centered design in public health data dashboards: lessons from the development of a data dashboard of sexually transmitted infections in New York State

OBJECTIVE

The increased availability of public data and accessible visualization technologies enhanced the popularity of public health data dashboards and broadened their audience from professionals to the general public. However, many dashboards have not achieved their full potential due to design complexities that are not optimized to users' needs.

MATERIAL AND METHODS

We used a 4-step human-centered design approach to develop a data dashboard of sexually transmitted infections for the New York State Department of Health: (1) stakeholder requirements gathering, (2) an expert review of existing data dashboards, (3) a user evaluation of existing data dashboards, and (4) an usability evaluation of the prototype dashboard with an embedded experiment about visualizing missing race and ethnicity data.

RESULTS

Step 1 uncovered data limitations and software requirements that informed the platform choice and measures included. Step 2 yielded a checklist of general principles for dashboard design. Step 3 revealed user preferences that influenced the chart types and interactive features. Step 4 uncovered usability problems resulting in features such as prompts, data notes, and displaying imputed values for missing race and ethnicity data.

DISCUSSION

Our final design was accepted by program stakeholders. Our modifications to traditional human-centered design methodologies to minimize stakeholders' time burden and collect data virtually enabled project success despite barriers to meeting participants in-person and limited public health agency staff capacity during the COVID-19 pandemic.

CONCLUSION

Our human-centered design approach and the final data dashboard architecture could serve as a template for designing public health data dashboards elsewhere.

Impact of COVID-19 on HPV Vaccination Rates in New York City and Long Island

BACKGROUND

In the United States, uptake of human papillomavirus (HPV) vaccination has been exceptionally low as compared with other vaccines. During the coronavirus disease (COVID-19) pandemic, routine vaccinations were deferred or delayed, further exacerbating HPV vaccine hesitancy. The specific effect of the pandemic on HPV vaccination rates in the United States has not been yet described.

METHODS

We aimed to determine the percentage of children achieving full HPV vaccination (2 doses) by age 15 years and to compare prepandemic to pandemic rates of HPV vaccination at pediatric practices across our institution. A retrospective chart review was performed to compare HPV vaccination rates in the "prepandemic" and "pandemic" periods for all children 9 through 14 years of age. Additionally, peaks in COVID-19 positivity were compared with HPV vaccination rates.

RESULTS

Of children 9-14 years old, 49.3% received at least 1 dose of HPV vaccine in the prepandemic period, compared with 33.5% during the pandemic ( P < 0.0001). Only 33.5% of patients received the full 2-dose series of HPV prepandemic, compared with 19.0% of patients during the pandemic ( P < 0.0001). When COVID-19 positivity rates peaked, HPV vaccination also declined.

CONCLUSIONS

The issue of low HPV vaccination rates was amplified due to the COVID-19 pandemic, as illustrated by the correlation between peaks in COVID-19 positivity and low rates of HPV vaccination.

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

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

HPV vaccine recommendations by age: A survey of providers in federally qualified health centers

Clinician recommendation remains a critical factor in improving HPV vaccine uptake. Clinicians practicing in federally qualified health centers were surveyed between October 2021 and July 2022. Clinicians were asked how they recommended HPV vaccination for patients aged 9-10, 11-12, 13-18, 19-26, and 27-45 y (strongly recommend, offer but do not recommend strongly, discuss only if the patient initiates the conversation, or recommend against). Descriptive statistics were assessed, and exact binomial logistic regression analyses were utilized to examine factors associated with HPV vaccination recommendation in 9-10-y-old patients. Respondents (n = 148) were primarily female (85%), between the ages of 30-39 (38%), white, non-Hispanic (62%), advanced practice providers (55%), family medicine specialty (70%), and practicing in the Northeast (63%). Strong recommendations for HPV vaccination varied by age: 65% strongly recommended for ages 9-10, 94% for ages 11-12, 96% for ages 13-18, 82% for age 19-26, and 26% for ages 27-45 y. Compared to Women's Health/OBGYN specialty, family medicine clinicians were less likely to recommend HPV vaccination at ages 9-10 (p = .03). Approximately two-thirds of clinicians practicing in federally qualified health centers or safety net settings strongly recommend HPV vaccine series initiation at ages 9-10. Additional research is needed to improve recommendations in younger age groups.

High vaccine confidence and strong approval of the mandatory immunization schedule among Bulgarian general practitioners in 2022

In a context of recently decreasing childhood immunization coverage and low uptake of COVID-19 vaccines in Bulgaria, this study measures vaccine hesitancy among general practitioners (GPs) in the country, as they are central to forming patients' attitudes. In 2022, a face-to-face survey was conducted through a simple random sample from an exhaustive national database of Bulgarian GPs. This study measured attitudes on vaccine importance, safety, and effectiveness, and attitudes toward the Bulgarian immunization schedule. Information was collected on demographic and GP practice characteristics and possible predictors of vaccine confidence in order to test for associations with attitudes toward immunization. GP attitudes toward vaccines and the immunization schedule in Bulgaria were generally positive. Among 358 respondents, 351 (98%,95%CI96-99%) strongly agreed/agreed that vaccines are important, 352 (98%,95%CI96-99%) that vaccines are effective, and 341 (95%,95%CI93-97%) that vaccines are safe. 347 respondents (97%,95%CI95-98%) affirmed that "it's good that vaccines from the children's immunization schedule are mandatory", and 331 (92%,95%CI89-95%) agreed with the statement "Bulgaria's childhood immunization has my approval". Trust in information from official institutions was among the strongest predictors of vaccine confidence. Respondents' vaccine confidence levels are within the ranges reported by GPs in other European countries and above those reported within the general Bulgarian population. GPs' vaccine confidence is highly associated with trust in official institutions. It is important to maintain trust in official institutions and to support GPs in communicating vaccine knowledge with patients so that vaccine hesitancy in the general population is countered.

Assessing Barriers to Human Papillomavirus (HPV) Vaccination in At-Risk Rural Communities of Western North Carolina, United States

Human papillomavirus (HPV) vaccination among adolescents in rural, western North Carolina (NC) remains suboptimal. Data are needed to understand the barriers to HPV vaccination in these communities. We conducted a cross-sectional pilot study of parental attitudes and provider practices regarding HPV vaccination in rural western NC counties with lower HPV vaccination rates. Eight health department clinics were enrolled in the study. Further, 29 provider and 32 parent surveys were analyzed along with environmental scans. Median provider comfort regarding knowledge of HPV-associated diseases was 85% (IQR = 75-95), on a scale of 0-100% (100% representing complete comfort). Median parental comfort level regarding knowledge of HPV-associated diseases and the HPV vaccine was 75% (IQR = 50-89) and 75% (IQR = 49-96), respectively. Less than 25% of parents rated the HPV vaccine as 'extremely effective' against genital (16.7%) and anal cancers (17.9%). Parents were more likely to rate the vaccine as 'extremely effective' to 'very effective' if their child was female. There was no significant difference between parental- and provider-reported comfort with knowledge about HPV-associated diseases (p = 0.0725) and the HPV vaccine (p = 0.167). This study identified multiple opportunities to increase HPV vaccine coverage among unvaccinated adolescents at parental, provider, and clinic levels. Health education of rural NC residents and providers in public health settings may identify future interventions to increase HPV vaccine uptake.

Association between administration or recommendation of the human papillomavirus vaccine and primary care physicians' knowledge about vaccination during proactive recommendation suspension: a nationwide cross-sectional study in Japan

OBJECTIVE

The Japanese government suspended the proactive recommendation of the human papillomavirus vaccine (HPVv) in 2013, and the vaccination rate of HPVv declined to <1% during 2014-2015. Previous studies have shown that the recommendation by a physician affects a recipient's decision to receive a vaccine, and physicians' accurate knowledge about vaccination is important to increase vaccine administration. This study aimed to evaluate the association between physicians' knowledge of vaccination and the administration or recommendation of HPVv by primary care physicians (PCPs) in the absence of proactive recommendations from the Japanese government.

DESIGN

Cross-sectional study analysed data obtained through a web-based, self-administered questionnaire survey.

SETTING

The questionnaire was distributed to Japan Primary Care Association (JPCA) members.

PARTICIPANTS

JPCA members who were physicians and on the official JPCA mailing list (n=5395) were included.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary and secondary outcomes were the administration and recommendation of HPVv, respectively, by PCPs. The association between PCPs' knowledge regarding vaccination and each outcome was determined based on their background and vaccination quiz scores and a logistic regression analysis to estimate the adjusted ORs (AORs).

RESULTS

We received responses from 1084 PCPs and included 981 of them in the analysis. PCPs with a higher score on the vaccination quiz were significantly more likely to administer the HPVv for routine and voluntary vaccination (AOR 2.28, 95% CI 1.58 to 3.28; AOR 2.71, 95% CI 1.81 to 4.04, respectively) and recommend the HPVv for routine and voluntary vaccination than PCPs with a lower score (AOR 2.17, 95% CI 1.62 to 2.92; AOR 1.88, 95% CI 1.32 to 2.67, respectively).

CONCLUSIONS

These results suggest that providing accurate knowledge regarding vaccination to PCPs may improve their administration and recommendation of HPVv, even in the absence of active government recommendations.

Knowledge, beliefs, and practice regarding human papillomavirus (HPV) vaccination among American college students: Application of the health belief model

Objective: To identify facilitators and barriers to human papillomavirus (HPV) vaccination among college students.Methods: A cross-sectional survey with college students (N = 306) between the ages of 18 and 26 was conducted using a computer-delivered survey via iPad. A survey was designed to assess HPV/HPV vaccine-related knowledge, beliefs, and vaccination practices.Results: Low completion rates for the HPV vaccination series (females: 28.9%; males: 11.5%) were observed among college students. The compliance was lower among students who were black American and did not speak English at home. In contrast, the compliance was higher among those who had received any recommendation for HPV vaccination, those with higher knowledge about HPV and HPV vaccine, and higher perceived benefits of vaccination.Conclusions: Increasing knowledge of HPV infection, including the benefits of HPV vaccination and health care providers recommending the HPV vaccine, may increase HPV vaccination among college students and reduce the incidence of the disease.

Can physicians and schools mitigate social inequalities in human papillomavirus vaccine awareness, uptake and vaccination intention among adolescents? A cross-sectional study, France, 2021 to 2022

BackgroundIn France, human papillomavirus (HPV) vaccination coverage varies across socioeconomic levels.AimWe aimed at assessing HPV vaccine awareness, uptake and vaccination intention among adolescents in France.MethodsIn a cluster-randomised study, 13-15-year-old students in 61 French middle schools completed a web-based questionnaire. We used multivariable logistic regression to evaluate determinants of HPV vaccine awareness, self-reported uptake and vaccination intention among unvaccinated students and interaction terms to explore effects of visits to family physician and remembering school lessons on vaccination. The French deprivation index of school municipalities served as proxy for socioeconomic levels.ResultsAmong 6,992 participants, awareness was significantly associated with parental education (odds ratio (OR) = 0.82; 95% confidence interval (CI): 0.71-0.95), language spoken at home (OR = 0.59; 95% CI: 0.52-0.66) and deprivation level (OR = 0.57; 95% CI: 0.44-0.71), regardless of physician visit or school lessons. Vaccine uptake was associated with parental education without a recent physician visit (OR = 0.31; 95% CI: 0.16-0.59, vs OR = 0.64; 95% CI: 0.52-0.78 with a visit, interaction p = 0.045). Vaccination intention among unvaccinated was associated with deprivation level (moderate-low vs low) among students not remembering school lessons on vaccination (OR = 0.17; 95% CI: 0.05-0.62, vs OR = 0.93; 95% CI: 0.51-1.67 remembering school lessons, interaction p = 0.022). Parental education was associated with vaccination intention among students reporting a physician visit (OR = 0.41; 95% CI: 0.26-0.64 vs OR = 1.05; 95% CI: 0.50-2.20 without a visit, interaction p = 0.034).ConclusionOur results suggest that healthcare and school could promote vaccination and mitigate social inequalities in HPV vaccination coverage.

Deciphering Knowledge and Opinions of Human Papillomavirus and Human Papillomavirus Vaccination for Facilitation of Point-of-Care Vaccination in Adults

Importance

Human papillomavirus (HPV) vaccination rates remain significantly below rates for other common childhood vaccines, which has implications for future rates of HPV-associated oropharyngeal squamous cell carcinoma (OPSCC).

Objective

To assess whether individuals who were aware of the association between HPV and OPSCC would be more likely to have been previously vaccinated.

Design, Setting, and Participants

This survey study included patients aged 18 to 45 years who sought routine outpatient care at the otolaryngology clinic at Boston Medical Center from September 1, 2020, to May 19, 2021. A survey (HPV-Associated Head and Neck Cancer Epidemiology, Awareness and Demographics) [HEAD]) composed of validated questions to assess patient knowledge of HPV and HPV vaccination and barriers to vaccination was delivered to participants. The survey was paired with a novel point-of-care vaccination program housed within an otolaryngology department.

Main Outcomes and Measures

The main outcome was prevalence of knowledge of the relationship between HPV infection and OPSCC based on survey responses. The association of knowledge of HPV-associated OPSCC with likelihood of having been vaccinated was assessed in the overall cohort and by demographic characteristics using multivariate logistic regression.

Results

Of 405 patients given the survey, 288 (71.1%) responded. Of these patients, 271 (94.1%) had surveys included; 158 (58.3%) were female, and median age was 29 years (IQR, 24-35 years). The baseline vaccination rate in the surveyed population was low (26.6%; n = 72) overall (10.6% among men [12 of 113]; 37.9% among women [60 of 158]). Few participants understood the relationship between HPV infection and OPSCC (63 of 271 [23.3%]) or that HPV-associated OPSCC is the most common HPV-associated cancer type (9 of 121 [7.4%]). Compared with men, women were more likely to have been previously vaccinated (odds ratio [OR], 6.5; 95% CI, 3.0-13.9), more aware that HPV causes cancer (OR, 3.7; 95% CI, 1.9-7.1), and more likely to have heard about HPV and HPV vaccination from their health care practitioner (OR, 2.6; 95% CI, 1.2-5.7). Knowledge of the relationship between HPV infection and cancer and between HPV and OPSCC was associated with increased likelihood of having been vaccinated (HPV and cancer: OR, 4.1 [95% CI, 1.8-9.5]; HPV and OPSCC: OR, 3.7 [95% CI, 1.8-7.6]). Among 156 unvaccinated participants, 12 of 98 men (12.2%) and 7 of 131 women (5.3%) received point-of-care vaccination.

Conclusions

Most participants in this survey study were unaware that HPV causes OPSCC. Understanding that HPV causes OPSCC was associated with increased likelihood of having been vaccinated. However, most patients surveyed were not informed of this relationship by their health care practitioners. Targeted education aimed at unvaccinated adults establishing the relationship between HPV infection and OPSCC, paired with point-of-care vaccination, may be an innovative strategy for increasing HPV vaccination rates in adults.

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

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

Acceptability and readiness to promote human papillomavirus vaccination at ages 9-10 years: a feasibility study among North Carolina clinics

While 9-valent human papillomavirus (HPV) vaccination is approved by the US Food and Drug Administration for use in adolescents as young as age 9, providers typically recommend it at ages 11-12. Studies suggest that recommending HPV vaccination at 9 or 10 years of age could increase up-to-date vaccination by age 13, which could especially benefit rural populations with reduced access to primary health care and lower HPV vaccination coverage than urban areas. This study aimed to assess the feasibility of the age-9 recommendation of HPV vaccination in rural clinics. We conducted in-depth interviews with providers and staff from two primary care clinics in central North Carolina to understand attitudes toward recommending HPV vaccination to 9- and 10-year-olds. All interviewees agreed that HPV vaccination was important for cancer prevention and should be recommended before the onset of sexual activity, agreeing that HPV vaccination could be initiated before age 11 to improve timeliness and completion of the vaccination series. However, opinions were mixed on whether HPV vaccination should be initiated as young as 9 years old. Two key informants recruited from two university-affiliated clinics described their experiences recommending HPV vaccination to 9- and 10-year-olds, including a modified vaccination schedule that promotes HPV vaccination during routine well-child visits, prior to pubertal onset, and alongside other recommended adolescent vaccines. Age-9 recommendation and administration of HPV vaccination is possible with minimal changes to current clinical practices and could increase the convenience and acceptability of HPV vaccination in under-vaccinated settings.