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Mansfield LN, Kahn BZ, Kokitkar S, Kritikos KI, Brantz SN, Brewer NT. HPV vaccine standing orders and communication in primary care: A qualitative study. Vaccine 2024; 42:3981-3988. [PMID: 38816304 PMCID: PMC11242613 DOI: 10.1016/j.vaccine.2024.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 04/26/2024] [Accepted: 05/09/2024] [Indexed: 06/01/2024]
Abstract
BACKGROUND Standing orders may improve HPV vaccination rates, but clinical staff's readiness to use them has not been well-explored. We sought to explore benefits and challenges to using HPV vaccine standing orders for adolescents ages 9 to 12, understand clinical staff roles in communication about HPV vaccine, and how standing orders can reduce barriers contributing to vaccine disparities among racial and ethnic marginalized groups. METHODS Participants were a sample of 16 U.S. nurses, medical assistants, and healthcare providers working in primary care, recruited from June to September 2022. Trained staff conducted virtual, semi-structured qualitative interviews. We analyzed the resulting data using reflexive thematic analysis. RESULTS Themes reflected benefits and challenges to using HPV vaccine standing orders and strategies to address clinic barriers to improve vaccine access and HPV vaccine communication. Benefits included faster and efficient clinic flow; fewer missed vaccine opportunities and promotion of early vaccination; and normalization of HPV vaccination as routine care. Challenges included possible exacerbation of existing HPV vaccine communication and recommendation barriers; and how the complexity of the vaccine administration schedule lessens nurses' and medical assistants' confidence to use standing orders. Strategies to address vaccine access barriers included using nurse-only visits to empower nurse autonomy and catch up on HPV vaccination; engaging clinical staff to follow up with overdue children; and educating parents on HPV vaccine before their child is vaccine eligible. CONCLUSION Using HPV vaccine standing orders can promote autonomy for nurses and medical assistants and address vaccine access barriers. Clinical staff engagement and clinic support to mitigate existing vaccine communication barriers are needed to empower staff to use of HPV vaccine standing orders.
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Affiliation(s)
- Lisa N Mansfield
- School of Nursing, University of North Carolina, Chapel Hill, NC, USA; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA.
| | - Benjamin Z Kahn
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Saayli Kokitkar
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Katherine I Kritikos
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA
| | - Sierra N Brantz
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Noel T Brewer
- Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, NC, USA; Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
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2
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Savas LS, Shegog R, Frost EL, Healy CM, Mantey DS, Coan SP, Shay LA, Teague TA, Ferreris JJ, Preston SM, Vernon SW. Effect of an HPV Vaccination Multi-Level, Multi-Component Program on HPV Vaccination Initiation and Completion in a Pediatric Clinic Network. Vaccines (Basel) 2024; 12:510. [PMID: 38793761 PMCID: PMC11126005 DOI: 10.3390/vaccines12050510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 04/13/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024] Open
Abstract
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.
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Affiliation(s)
- Lara S. Savas
- Center for Health Promotion and Prevention Research, UTHealth Houston School of Public Health, Houston, TX 77030, USA; (R.S.); (E.L.F.); (S.P.C.); (T.A.T.); (S.W.V.)
| | - Ross Shegog
- Center for Health Promotion and Prevention Research, UTHealth Houston School of Public Health, Houston, TX 77030, USA; (R.S.); (E.L.F.); (S.P.C.); (T.A.T.); (S.W.V.)
| | - Erica L. Frost
- Center for Health Promotion and Prevention Research, UTHealth Houston School of Public Health, Houston, TX 77030, USA; (R.S.); (E.L.F.); (S.P.C.); (T.A.T.); (S.W.V.)
| | - C. Mary Healy
- Department of Pediatrics, Infectious Diseases Section, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Dale S. Mantey
- Michael & Susan Dell Center for Healthy Living, UTHealth Houston School of Public Health in Austin, Austin, TX 78701, USA;
| | - Sharon P. Coan
- Center for Health Promotion and Prevention Research, UTHealth Houston School of Public Health, Houston, TX 77030, USA; (R.S.); (E.L.F.); (S.P.C.); (T.A.T.); (S.W.V.)
| | - L. Aubree Shay
- Center for Health Promotion and Prevention Research, UTHealth Houston School of Public Health in San Antonio, San Antonio, TX 78229, USA;
| | - Travis A. Teague
- Center for Health Promotion and Prevention Research, UTHealth Houston School of Public Health, Houston, TX 77030, USA; (R.S.); (E.L.F.); (S.P.C.); (T.A.T.); (S.W.V.)
| | - Juan J. Ferreris
- Christus Health, Children’s General Pediatric Clinic, San Antonio, TX 78257, USA;
| | - Sharice M. Preston
- Center for Health Promotion and Prevention Research, UTHealth Houston School of Public Health, Houston, TX 77030, USA; (R.S.); (E.L.F.); (S.P.C.); (T.A.T.); (S.W.V.)
| | - Sally W. Vernon
- Center for Health Promotion and Prevention Research, UTHealth Houston School of Public Health, Houston, TX 77030, USA; (R.S.); (E.L.F.); (S.P.C.); (T.A.T.); (S.W.V.)
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Kong WY, Queen TL, Gottfredson O'Shea N, Heisler-MacKinnon J, Liu A, Ozawa S, Brewer NT, Gilkey MB. Impact of visit characteristics on intention to recommend HPV vaccine: An experiment with US health care professionals. Prev Med 2024; 179:107841. [PMID: 38160884 PMCID: PMC10872220 DOI: 10.1016/j.ypmed.2023.107841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/23/2023] [Accepted: 12/26/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE Presumptive recommendations that assume parents want to vaccinate can increase human papillomavirus (HPV) vaccine uptake. We sought to examine how visit characteristics affect health care professionals' (HCPs) intention to use this evidence-based recommendation style. METHODS In 2022, we conducted an online experiment with 2527 HCPs who had a role in adolescent vaccination in the United States. Participants read 1 of 8 randomly assigned vignettes about a well-child visit. Using a 2 × 2 × 2 between-subjects factorial design, the vignettes varied the following visit characteristics: patient age (9 vs. 12-year-old), prior parental vaccine refusal (yes vs. no), and time pressure on the HCP (low vs. high). HCPs reported on their intention to use a presumptive HPV vaccine recommendation, as well as on related attitudes, subjective norms, and self-efficacy. Analyses used 3-way analysis of variance and parallel mediation. RESULTS Participants were pediatricians (26%), family/general medicine physicians (22%), advanced practitioners (24%), and nursing staff (28%). Overall, about two-thirds of HCPs (64%) intended to use a presumptive recommendation. Intentions were higher for older children (b = 0.23) and parents without prior vaccine refusal (b = 0.39, both p < 0.001). Time pressure had no main effect or interactions. HCPs' attitudes and self-efficacy partially mediated effects of patient age and prior vaccine refusal (range of b = 0.04-0.28, all p < 0.05). CONCLUSION To better support visits with younger children and parents who have refused vaccines, HCPs may need more training for making presumptive recommendations for HPV vaccine. Reinforcing positive attitudes and self-efficacy can help HCPs adopt this evidence-based recommendation style.
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Affiliation(s)
- Wei Yi Kong
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, United States of America.
| | - Tara L Queen
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, United States of America
| | - Nisha Gottfredson O'Shea
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, United States of America; RTI International, Research Triangle Park, North Carolina, United States of America
| | - Jennifer Heisler-MacKinnon
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, United States of America; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, North Carolina, United States of America
| | - Amy Liu
- School of Medicine, University of North Carolina at Chapel Hill, North Carolina, United States of America
| | - Sachiko Ozawa
- UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, North Carolina, United States of America; Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, United States of America
| | - Noel T Brewer
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, United States of America; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, North Carolina, United States of America
| | - Melissa B Gilkey
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, North Carolina, United States of America; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, North Carolina, United States of America
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Perkins RB, Humiston S, Oliver K. Evidence supporting the initiation of HPV vaccination starting at age 9: Collection overview. Hum Vaccin Immunother 2023; 19:2269026. [PMID: 37824444 PMCID: PMC10572037 DOI: 10.1080/21645515.2023.2269026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023] Open
Affiliation(s)
- Rebecca B Perkins
- Department of Obstetrics and Gynecology, Boston University School of Medicine/Boston Medical Center, Boston, MA, USA
| | | | - Kristin Oliver
- Departments of Environmental Medicine and Public Health, Pediatrics, Icahn School of Medicine, New York, NY, USA
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Kohler RE, Wagner RB, Careaga K, Btoush R, Greene K, Kantor L. Mothers' perceptions and attitudes about HPV vaccination initiation among 9- and 10-year-olds. Hum Vaccin Immunother 2023; 19:2270842. [PMID: 37955127 PMCID: PMC10653617 DOI: 10.1080/21645515.2023.2270842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 10/11/2023] [Indexed: 11/14/2023] Open
Abstract
HPV vaccination has potential to prevent 90% of HPV-associated cancers. The Advisory Committee on Immunization Practices recommends HPV vaccination for 11- and 12-year-olds, but vaccine initiation can start at age 9. The purpose of this study was to explore perceptions about starting HPV vaccination at a younger age to inform future interventions that promote initiation at ages 9 and 10 years. This was part of a larger study about vaccine hesitancy among racially/ethnically diverse parents of adolescents in the Greater Newark Area of New Jersey. We thematically analyzed transcripts from 16 interviews with English- and Spanish-speaking mothers who had at least one child ≤ 10 years. Analyses focused on perceptions of HPV-related disease risk, attitudes toward HPV vaccination need, and vaccine confidence specifically for 9- and 10-year-olds. Few parents with young adolescents reported receiving vaccination recommendations, and only one reported series initiation before age 11. Mothers' hesitation about younger HPV vaccination initiation revolved around: 1) low perceived necessity among English-speaking mothers due to young adolescents not being sexually active, 2) concerns about potential side effects associated with vaccinating prepubescent adolescents, and 3) a desire for adolescents to be old enough to provide assent. Participants were not opposed to younger initiation but wanted and relied on pediatricians to inform them about vaccination for younger adolescents. These findings suggest mothers are willing to vaccinate at younger ages after clear provider recommendations. Equipping providers with evidence about vaccine safety and cancer prevention communication strategies may promote initiation and timely completion at younger ages.
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Affiliation(s)
- Racquel E. Kohler
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- School of Public Health, Rutgers University, New Brunswick, NJ, USA
| | - Rachel B. Wagner
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
- School of Public Health, Rutgers University, New Brunswick, NJ, USA
| | - Katherine Careaga
- Center for Cancer Health Equity, Rutgers Cancer Institute of New Jersey, New Brunswick, NJ, USA
| | - Rula Btoush
- School of Nursing, Rutgers University, New Brunswick, NJ, USA
| | - Kathryn Greene
- School of Communication & Information, Rutgers University, New Brunswick, NJ, USA
| | - Leslie Kantor
- School of Public Health, Rutgers University, New Brunswick, NJ, USA
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Christensen T, Zorn S, Bay K, Treend K, Averette C, Rhodes N. Effect of immunization registry-based provider reminder to initiate HPV vaccination at age 9, Washington state. Hum Vaccin Immunother 2023; 19:2274723. [PMID: 37929936 PMCID: PMC10629428 DOI: 10.1080/21645515.2023.2274723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 10/20/2023] [Indexed: 11/07/2023] Open
Abstract
Human papillomavirus (HPV) vaccination rates are lower than Tetanus-diphtheria-pertussis (Tdap) and Meningococcal conjugate (MenACWY) rates, although the Advisory Committee on Immunization Practices recommends all three vaccines be given routinely at age 11-12. Evidence is mounting that children who initiate HPV vaccination starting at age 9 are more likely to complete the series on time. Washington state implemented a provider reminder through its immunization information system (WAIIS) in January 2023 to increase HPV vaccine initiation at 9-years-old by updating the forecasted recommended age for HPV from age 11 to 9. The effectiveness of provider reminders when implemented via an immunization information system (IIS) is poorly understood. We evaluated the impact of this forecast update using a seasonally adjusted interrupted time series regression of weekly HPV initiations at 9-years-old before and after implementation. We also examined time series trends of vaccine administration between 2018 and 2023 for HPV initiation at age 9, as well as Tdap, MenACWY and HPV initiation at age 11. The WAIIS forecast update doubled the weekly rate of HPV initiation among 9-year-olds in Washington state, although the weekly count of initiation at 9 remains far lower than initiations at 11. Jurisdictions wanting to increase HPV vaccine initiation at earlier ages should consider updating their forecast algorithm and investing in complementary evidence-based strategies such as provider and parent education, and clinic-based quality improvement efforts. The reach of IIS forecaster updates may be enhanced by working with administrators of electronic medical record systems to ensure parity of provider prompts with IIS.
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Affiliation(s)
| | - Sherri Zorn
- Washington State HPV Free Task Force, Tumwater, Washington, USA
| | - Kathy Bay
- Washington State Department of Health, Tumwater, Washington, USA
| | - Katherine Treend
- Washington State Department of Health, Tumwater, Washington, USA
| | | | - Nicole Rhodes
- Washington State Department of Health, Tumwater, Washington, USA
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Khalid K, Lee KY, Mukhtar NF, Warijo O. Recommended Interventions to Improve Human Papillomavirus Vaccination Uptake among Adolescents: A Review of Quality Improvement Methodologies. Vaccines (Basel) 2023; 11:1390. [PMID: 37631958 PMCID: PMC10459466 DOI: 10.3390/vaccines11081390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 06/27/2023] [Accepted: 07/17/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND Routine human papillomavirus (HPV) vaccine uptake continues to be suboptimal since its recommendation in 2006 for girls and in 2011 for boys. This paper aims to review published quality improvement (QI) methodologies on interventions to improve HPV vaccine uptake among adolescents. METHODS Science Direct and Scopus databases were searched for QI initiatives evaluating the effect of multimodal interventions to improve HPV vaccination rates (initiation and/or completion of series) among adolescents. Studies that included an outcome of interest among adolescents aged 10 to 18 years old were included. Two investigators worked independently to screen for potential articles and a designated investigator extracted data on study characteristics and evaluated the outcomes. RESULTS A preliminary search yielded a total of 523 articles and 13 were included in the final analysis. Common strategies were provider-specific (i.e., webinar, telementoring, train-the-trainer approach) and patient- and/or parent-specific interventions (i.e., reminder emails, phone calls and text messages, social events), with an emphasis on education and knowledge empowerment. System-level interventions such as policy changes and revised protocols were less commonly prescribed despite being associated with a more significant weight on the overall outcome. CONCLUSIONS Creative, sustainable, and economical multilevel interventions that focus not only on provider training and public education but also incorporate local policies and system enhancements can substantially improve HPV vaccination coverage among adolescents.
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Affiliation(s)
- Karniza Khalid
- Specialized Diagnostic Centre, Institute for Medical Research, National Institutes of Health, Ministry of Health Malaysia, Kuala Lumpur 50588, Malaysia
| | - Kun Yun Lee
- Institute for Health Management, National Institutes of Health, Ministry of Health Malaysia, Shah Alam 40170, Malaysia;
| | - Nur Farihan Mukhtar
- Department of Obstetrics and Gynecology, Hospital Tuanku Fauziah, Ministry of Health Malaysia, Kangar 01000, Malaysia;
| | - Othman Warijo
- Kedah State Health Department, Ministry of Health Malaysia, Alor Setar 05400, Malaysia;
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