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

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.

A Qualitative Analysis of Social-Ecological Factors Shaping Childhood Immunisation Hesitancy and Delay in the Eastern Province of Saudi Arabia

(1) Background: Immunisation is a crucial and effective method for preventing infectious diseases, with its success dependent on high immunisation rates to protect under-immunised individuals and promote herd immunity. This qualitative descriptive study is part of a larger explanatory sequential mixed method design that aims to explore factors influencing parents' decision making to complete childhood immunisation in the Eastern Province of Saudi Arabia, a country experiencing disparities in immunisation coverage across its population. (2) Methods: The sample consisted of a subset of participants from the initial quantitative phase, which included a survey on the immunisation attitudes of parents living in Qatif. This initial phase included n = 350 participants, who were over 18, had access to one of the 27 Primary Health Care (PHC) Centres in Qatif, and had a child under 24 months. This paper presents the qualitative-descriptive phase, which used a qualitative survey to gain open-ended responses from parents (n = 20) and analysed using thematic analysis. (3) Results: Participants identified certain vaccines, particularly MMR, as influencing their immunisation practices. Specific factors identified as deterring parents from immunising their children included fear of autism and other developmental delays, concerns about risks and side effects, mistrust in vaccine efficacy, and discouraging information from the media. Parents' immunisation decisions were evidently affected by policy compliance, family and friends, and social networking sites. These factors are explained through the socio-ecological model. Moreover, the COVID-19 pandemic influenced parents' decisions on vaccine completion in terms of perceived barriers, perceived benefits, and perceived trust. (4) Conclusions: By examining the social-ecological factors shaping parents' decisions to immunise their children in the Eastern Province of Saudi Arabia, this research contributes to the literature and informs the Saudi National Childhood Immunisation Programme about factors contributing to childhood immunisation hesitancy, helping to address a critical healthcare issue.

Association of Social-Ecological Factors With Delay in Time to Initiation of Postoperative Radiation Therapy: A Prospective Cohort Study

Importance

Timely initiation of postoperative radiation therapy (PORT) is associated with reduced recurrence rates and improved overall survival in patients with head and neck squamous cell carcinoma (HNSCC). Measurement of the association of social-ecological variables with PORT delays is lacking.

Objective

To assess individual and community-level factors associated with PORT delay among patients with HNSCC.

Design, Setting, and Participants

This prospective cohort study carried out between September 2018 and June 2022 included adults with untreated HNSCC who were enrolled in a prospective registry at a single academic tertiary medical center. Demographic information and validated self-reported measures of health literacy were obtained at baseline visits. Clinical data were recorded, and participant addresses were used to calculate the area deprivation index (ADI), a measure of community-level social vulnerability. Participants receiving primary surgery and PORT were analyzed. Univariable and multivariable regression analysis was performed to identify risk factors for PORT delays.

Exposures

Surgical treatment and PORT.

Main Outcomes and Measures

The primary outcome was PORT initiation delay (>42 days from surgery). Risk of PORT initiation delay was evaluated using individual-level (demographic, health literacy, and clinical data) and community-level information (ADI and rural-urban continuum codes).

Results

Of 171 patients, 104 patients (60.8%) had PORT delays. Mean (SD) age of participants was 61.0 (11.2) years, 161 were White (94.2%), and 105 were men (61.4%). Insurance was employer-based or public among 65 (38.5%) and 75 (44.4%) participants, respectively. Mean (SD) ADI (national percentile) was 60.2 (24.4), and 71 (41.8%) resided in rural communities. Tumor sites were most commonly oral cavity (123 [71.9%]), with 108 (63.5%) classified as stage 4 at presentation. On multivariable analysis, a model incorporating individual-level factors with health literacy in addition to community-level factors was most predictive of PORT delay (AOC= 0.78; R2, 0.18).

Conclusions and Relevance

This cohort study provides a more comprehensive assessment of predictors of PORT delays that include health literacy and community-level measures. Predictive models that incorporate multilevel measures outperform models with individual-level factors alone and may guide precise interventions to decrease PORT delay for at-risk patients with HNSCC.

Exploring HPV vaccination policy and payer strategies for opportunities to improve uptake in safety-net settings

Introduction

We explored priorities and perspectives on health policy and payer strategies for improving HPV vaccination rates in safety-net settings in the United States.

Methods

We conducted qualitative interviews with policy and payer representatives in the greater Los Angeles region and state of New Jersey between December 2020 and January 2022. Practice Change Model domains guided data collection, thematic analysis, and interpretation.

Results

Five themes emerged from interviews with 11 policy and 8 payer participants, including: (1) payer representatives not prioritizing HPV vaccination specifically in incentive-driven clinic metrics; (2) policy representatives noting region-specific HPV vaccine policy options; (3) inconsistent motivation across policy/payer groups to improve HPV vaccination; (4) targeting of HPV vaccination in quality improvement initiatives suggested across policy/payer groups; and (5) COVID-19 pandemic viewed as both barrier and opportunity for HPV vaccination improvement across policy/payer groups.

Discussion

Our findings indicate opportunities for incorporating policy and payer perspectives into HPV vaccine improvement processes. We identified a need to translate effective policy and payer strategies, such as pay-for-performance programs, to improve HPV vaccination within safety-net settings. COVID-19 vaccination strategies and community efforts create potential policy windows for expanding HPV vaccine awareness and access.

Which interventions improve HPV vaccination uptake and intention in children, adolescents and young adults? An umbrella review

BACKGROUND

Human papillomavirus (HPV) vaccination offers protection against the virus responsible for cervical, oropharyngeal, anal, vulval and penile cancers. However, there is considerable variation across, and even within, countries as to how HPV vaccination is offered and accepted. This review aimed to identify what interventions exist to promote uptake and how effective they are.

METHODS

We conducted an umbrella review using the JBI (Joanna Briggs Institute) methodology to evaluate routine or catch-up interventions to increase HPV vaccination uptake and/or intention for children aged 9 years and older, adolescents and young adults up to 26. Comprehensive searches for English language quantitative systematic reviews, published between January 2011 and July 2021, were conducted across five databases. After reviewing titles and abstract, relevant papers were independently assessed in detail.

MAIN RESULTS

From 1046 records identified, 10 articles were included in the review. They reported on 95 randomised controlled trials, 28 quasi-experimental studies, 14 cohort studies, 6 non-randomised pretest/post-test studies with control groups, 5 single-group pretest/post-test studies, 1 single-group post-test study and 1 randomised longitudinal study. Some interventions promoted change at the individual, community or organisational level, while others used a multicomponent approach. Face-to-face presentations, printed information and supplementing both strategies with additional components appear effective at increasing vaccination intention, while reminders and multicomponent strategies, especially ones that include some intervention aimed at provider level, appear effective at increasing vaccination uptake. Interventions that did not lead to an improvement in HPV vaccination intention or uptake varied in design and impacts were inconsistent across children/adolescents, young adults or parents.

CONCLUSION

The evidence suggests that there is no single solution to increasing vaccination uptake and that different approaches may be better suited to certain populations. However, generalisations are limited by poor reporting and a paucity of studies beyond the USA. Further high-quality studies, therefore, are needed to understand how best to increase HPV vaccination uptake in different target populations.

“(Meth) Will Hurt You and Hurt Your Teeth”: Teen, Parent, and Dental Practitioner Perspectives on Implementing Crystal Meth Use Prevention Messaging in the Dental Office Setting

Objectives

Crystal methamphetamine (“meth”) use among youth living in rural areas is higher than the national average. Given how drastically meth affects teeth (i.e., “meth mouth”), engaging dental professionals as one of multiple channels in rural areas to deliver meth prevention messaging is a novel approach. The objective of this research was to assess the feasibility and acceptability of incorporating meth use prevention messaging into dental visits with teenagers.

Methods

We conducted phenomenological, qualitative research with dental practitioners, teens, and parents/guardians in three communities in North Idaho, from 2015 to 2016. We recruited practitioners using a snowball sampling strategy and placed phone calls to dental practices and contacted teens and parents through schools, libraries, local sporting events, and word-of-mouth. Using NVivo 12-Plus, parent- and teen-specific codebooks and themes were developed from guides and transcripts. Transcripts of the dentists and hygienists were reviewed to ascertain the main ideas and themes.

Results

Overall, practitioner, teen, and parent participants viewed meth prevention messages delivered by dental professionals as acceptable and feasible. Compared to those in private practice, public health dental providers were invested in meth prevention and were eager to help. Barriers to overall acceptability and feasibility included hygienists' low self-efficacy to deliver a communication-based intervention, infrequency of dental visits impacting the ability to reach enough teens through this venue, and the fact that teens could feel “targeted” by providers. Teens also raised concerns about scary messages exacerbating preexisting dental visit anxiety. Facilitators included the following: dental practitioners already engaging in health education with their patients, parents, and teens seeing dental professionals as appropriate purveyors of antimeth messaging and support for increased meth prevention efforts given the impact of meth use in their communities.

Conclusions

Well-crafted, developmentally appropriate meth prevention messages would likely be well received by teens and supported by parents in dental offices. These data are being used to develop a novel, theory-based communication and behavioral strategy to integrate dental professionals into the delivery of messages aimed at preventing the initiation of meth use among rural Idaho teens.

Racial and Ethnic Disparities in Adult Vaccination: A Review of the State of Evidence

Background

Adult vaccination coverage remains low in the United States, particularly among racial and ethnic minority populations.

Objective

To conduct a comprehensive literature review of research studies assessing racial and ethnic disparities in adult vaccination.

Search Methods

We conducted a search of PubMed, Cochrane Library, ClinicalTrials.gov, and reference lists of relevant articles.

Selection Criteria

Research studies were eligible for inclusion if they met the following criteria: (1) study based in the United States, (2) evaluated receipt of routine immunizations in adult populations, (3) used within-study comparison of race/ethnic groups, and (4) eligible for at least one author-defined PICO (patient, intervention, comparison, and outcome) question.

Data Collection and Analysis

Preliminary abstract review was conducted by two authors. Following complete abstraction of articles using a standardized template, abstraction notes and determinations were reviewed by all authors; disagreements regarding article inclusion/exclusion were resolved by majority rule. The Social Ecological Model framework was used to complete a narrative review of observational studies to summarize factors associated with disparities; a systematic review was used to evaluate eligible intervention studies.

Results

Ninety-five studies were included in the final analysis and summarized qualitatively within two main topic areas: (1) factors associated with documented racial-ethnic disparities in adult vaccination and (2) interventions aimed to reduce disparities or to improve vaccination coverage among racial-ethnic minority groups. Of the 12 included intervention studies, only 3 studies provided direct evidence and were of Level II, fair quality; the remaining 9 studies met the criteria for indirect evidence (Level I or II, fair or poor quality).

Conclusions

A considerable amount of observational research evaluating factors associated with racial and ethnic disparities in adult vaccination is available. However, intervention studies aimed at reducing these disparities are limited, are of poor quality, and insufficiently address known reasons for low vaccination uptake among racial and ethnic minority adults.