Strengthening HPV vaccination delivery: findings from a qualitative service evaluation of the adolescent girls' HPV vaccination programme in England

A systematic literature review of human papillomavirus vaccination strategies in delivery systems within national and regional immunization programs

The uptake of human papillomavirus (HPV) vaccine remains suboptimal despite being a part of routine vaccination within national immunization program(s). This indicates probable challenges with the implementation of HPV immunization program(s) in various countries. The objective of this systematic literature review (SLR) was to identify implementation strategies for HPV vaccination within national and regional immunization programs worldwide with an aim to provide guidance for countries targeting to increase their HPV vaccine coverage rate (VCR). A comprehensive literature search was conducted across Medline and Embase and included articles published between January 2012 and January 2022. Of the 2,549 articles retrieved, 168 met inclusion criteria and were included in the review. Strategies shown to improve HPV vaccination uptake in the reviewed literature include campaigns to increase community awareness and knowledge of HPV, health care provider trainings, integrating HPV vaccination within school settings, coordinated efforts via multi-sectoral partnerships, and vaccination reminder and recall systems. Findings may help national authorities understand key considerations for HPV vaccination when designing and implementing programs aiming to increase HPV VCR in adolescents.

HPV vaccination coverage: slightly improved two-dose schedule completion estimates and historical estimates lower on AIR than HPV Register

OBJECTIVE

To compare Australian Immunisation Register (AIR) human papillomavirus (HPV) vaccination coverage against historical data from the former National HPV Vaccination Program Register and estimate two-dose vaccination coverage.

METHODS

Cross-sectional analysis of registry data for adolescent birth cohorts (1998-2007). Denominator populations were Medicare enrolments (AIR) and ABS estimated resident populations (HPV register).

RESULTS

For adolescents aged <17 years, AIR coverage estimates were several percentage points lower than HPV register estimates due to a larger Medicare enrolment denominator. Completed course coverage (two or three valid doses) for 15-year-old females in 2020 was 81.5% and for males 78.6%, higher than completed course coverage in 15-year-olds in 2019 (79.7 and 76.8% respectively). First dose coverage was similar for Indigenous adolescents but course completion was lower, although improving over time. Course completion was slightly lower (3.5-5.7%) in areas of lowest socioeconomic status and greatest remoteness.

CONCLUSIONS

Coverage is slightly lower using AIR than HPV register estimates. Moving from three to two doses has slightly improved completion, likely due to the wider dose spacing, but equity gaps remain.

IMPLICATIONS FOR PUBLIC HEALTH

An ongoing focus on equity in vaccine delivery is needed. Systems, reminders and catch-up opportunities to ensure course completion remain important.

Which young women are not being vaccinated against HPV? Cross-sectional analysis of a UK national cohort study

OBJECTIVES

HPV vaccination is highly effective in preventing HPV-associated disease, including cervical cancer, which disproportionately affects women from disadvantaged and minority ethnic backgrounds. We examined inequalities in initiation of the HPV vaccination schedule among young women in the UK and reasons given by their parents for non-initiation.

DESIGN

Cross sectional analyses of a prospective nationally representative cohort study.

SETTING

Four UK countries.

PARTICIPANTS

5,695 young women (39.9% from households in lowest income quintiles, 5.1% ever excluded from school, 0.5% not attending school) whose parents (14.3% from minority ethnic backgrounds; 54.1% with no stated religious faith) took part in interviews conducted when their daughters were 14 years old.

MAIN OUTCOME MEASURES

Parent-reported initiation of HPV vaccination and reasons for non-initiation. The adjusted odds (aORs) and 95% Confidence Intervals (CI) of initiating HPV vaccination were estimated using logistic regression after mutual adjustment for household income, school exclusion, school attendance and parental ethnic background and religious faith.

RESULTS

92.3% (5265) had initiated HPV vaccination at time of interview. Initiation was less likely among those living in the poorest households (aOR; 95% CI: 0.44; 0.30 to 0.64 for those in lowest household income quintile), who did not attend school (0.11; 0.04 to 0.33), had ever been excluded from school (0.47; 0.29 to 0.76), or whose parents were from Black African (0.49; 0.26 to 0.95) or Any Other (0.34; 0.17 to 0.66) ethnic backgrounds. A reason consistent with a conscious or practical decision was reported by 53.3% (219) and 24.1% (90) parents respectively.

CONCLUSIONS

Although most young women are immunised, marked social inequalities in access to HPV vaccination initiation remain. Practical steps to address this are possible and should be implemented to reduce inequalities in primary prevention of cancers and to ensure equitable access to this important public health intervention.

Does electronic consent improve the logistics and uptake of HPV vaccination in adolescent girls? A mixed-methods theory informed evaluation of a pilot intervention

OBJECTIVES

To evaluate the usability and acceptability of an electronic consent pilot intervention for school-based immunisations and assess its impact on consent form returns and human papilloma virus (HPV) vaccine uptake.

DESIGN

Mixed-methods theory-informed study applying qualitative methods to examine the usability and acceptability of the intervention and quantitative methods to assess its impact.

SETTING AND PARTICIPANTS

The intervention was piloted in 14 secondary schools in seven London boroughs in 2018. Intervention schools were matched with schools using paper consent based on the proportion of students with English as a second language and students receiving free school meals. Participants included nurses, data managers, school-link staff, parents and adolescents.

INTERVENTIONS

An electronic consent portal where parents could record whether they agreed to or declined vaccination, and nurses could access data to help them manage the immunisation programme.

PRIMARY AND SECONDARY OUTCOME MEASURES

Comparison of consent form return rates and HPV vaccine uptake between intervention and matched schools.

RESULTS

HPV vaccination uptake did not differ between intervention and matched schools, but timely consent form return was significantly lower in intervention schools (73.3% vs 91.6%, p=0.008). The transition to using electronic consent was not straightforward, while schools and staff understood the potential benefits, they found it difficult to adapt to new ways of working which removed some level of control from schools. Reasons for lower consent form return in e-consent schools included difficulties encountered by some parents in accessing and using the intervention. Adolescents highlighted the potential for electronic consent to by-pass their information needs.

CONCLUSIONS

The pilot intervention did not improve consent form return or vaccine uptake due to challenges encountered in transitioning to new working practice. New technologies require embedding before they become incorporated in everyday practice. A re-evaluation once stakeholders are accustomed with electronic consent may be required to understand its impact.

Burden and Prevention of HPV. Knowledge, Practices and Attitude Assessment Among Pre-Adolescents and their Parents in Italy

Despite infections due to HPV nowadays represent the most common sexually transmitted diseases worldwide with recognized effective and safe preventive strategies, knowledge, attitudes; however, awareness on HPV is considerably low. The present study has two main objectives: 1. To conduct a literature review to analyze the evolution of preventive tools, the complexity of the vaccine choice process, and the challenges posed by HPV vaccine hesitancy and refusal among pre-adolescents and their parents; 2. To assess knowledge, practices and attitudes toward HPV infection and vaccination in a sample of Italian pre-adolescents and their parents. The observational study was carried out through the use of two anonymous and self-administered pre- and post-intervention questionnaires dedicated to the target populations. Between the administrations of the pre- and post-intervention questionnaires, an educational intervention on HPV infection and related diseases, and prevention strategies was conducted. All participants demonstrated suboptimal knowledge and positive attitudes in the pre-intervention questionnaire. Higher levels of knowledge and attitudes were observed among pre-adolescents thatused social networks and had heard of sexually transmitted diseases at home/school/physician and from parents and also who had heard of HPV from General Practitioners, Gynecologists, family members and newspapers. A significant increase in HPV vaccination awareness was observed among pre-adolescents after the educational sessions. Health education programs aimed at increasing knowledge, attitudes and awareness on HPV are needed to implement the outcomes of HPV immunization programs, especially if supported by the physicians involved in counselling and recommendation processes.

School-based vaccination programmes: An evaluation of school immunisation delivery models in England in 2015/16

Schools are increasingly being used to deliver vaccines. In 2015/16 three school-based vaccination programmes were delivered to adolescents in England: human papillomavirus (HPV), meningococcal groups A, C, W and Y disease (MenACWY) and tetanus, diphtheria and polio (Td/IPV). We assessed how school delivery models impact vaccine coverage and how a delivery model for one programme may impact another. Routinely collected national data were analysed to ascertain the school grade achieving highest coverage within each one-dose programme and to compare two-dose delivery models (within year vs across years) for the HPV vaccine. We also assessed whether the HPV delivery model was associated with coverage in other programmes. MenACWY and Td/IPV coverage was highest in younger school grades. Overall similar HPV coverage was achieved with both models (86.7% two doses within one year, 85.8% two doses across two years, p = 0.20). High two-dose HPV coverage in 2015/16 was reported in areas that achieved high HPV coverage in 2013/14 when three doses were required. Areas with high three-dose coverage in 2013/14 achieved higher coverage with a within-one-year approach (92.0% vs 85.2%, p < 0.001), whilst areas reporting low coverage in 2013/14 achieved lower but similar coverage in 2015/16 with both models (79.2% vs 80.9% p = 0.29). MenACWY and Td/IPV coverage were higher in areas with high HPV coverage in 2013/14. Among high HPV coverage areas, MenACWY coverage was higher when HPV doses were delivered within year. School-based programmes should be offered as early as feasible and acceptable to optimise coverage. The choice of delivery model for HPV should take into account local performance and provider experience. Single providers may delivery multiple vaccines and the delivery for one programme may affect the performance of other programmes. Providers should consider local circumstances including past and current vaccine coverage and factors influencing coverage when deciding what delivery model to adopt.

Optimising informed consent in school-based adolescent vaccination programmes in England: A multiple methods analysis

The process of obtaining informed consent for school-based adolescent immunisation provides an opportunity to engage families. However, the fact that parental consent needs to be obtained remotely adds complexity to the process and can have a detrimental effect on vaccine uptake. We conducted a multiple methods analysis to examine the practice of obtaining informed consent in adolescent immunisation programmes. This involved a thematic analysis of consent related data from 39 interviews with immunisation managers and providers collected as part of a 2017 service evaluation of the English adolescent girls' HPV vaccine programme and a descriptive statistical analysis of data from questions related to consent included in a 2017 survey of parents' and adolescents' attitudes to adolescent vaccination. The findings indicated that the non-return of consent forms was a significant logistical challenge for immunisation teams, and some were piloting opt-out consent mechanisms, increasing the proportion of adolescents consenting for their own immunisations, and introducing electronic consent. Communicating vaccine related information to parents and schools and managing uncertainties about obtaining adolescent self-consent for vaccination were the main practical challenges encountered. Survey data showed that parents and adolescents generally agreed on vaccine decisions although only 32% of parents discussed vaccination with their teenager. Parental awareness about the option for adolescents to self-consent for vaccination was limited and adolescents favoured leaving the decision-making to parents. From the interviews and variability of consent forms it was evident that health professionals were not always clear about the best way to manage the consent process. Some were also unfamiliar with self-consent processes and lacked confidence in assessing for 'Gillick competency'. Developing pathways and related interventions to improve the logistics and practice of consent in school-based adolescent immunisation programmes could help improve uptake.