Health care providers' perspectives on low HPV vaccine uptake and adherence in Appalachian Kentucky

Facilitators and barriers of HPV vaccination: a qualitative study in rural Georgia

INTRODUCTION

Human papillomavirus (HPV) vaccination protects against HPV-associated cancers and genital warts. Healthy People 2030 goal for HPV vaccine uptake is 80%, but as of 2021, only 58.5% of adolescents are up to date in Georgia. The purpose of the study is to assess the attitudes, vaccine practices, facilitators, and barriers to receiving the HPV vaccine in southwest Georgia.

METHODS

We conducted 40 semi-structured interviews in the United States from May 2020-Feburary 2022 with three different audiences (young adults, parents, and providers and public health professionals) guided by the P3 (patient-, provider-, practice-levels) Model. The audiences were recruited by multiple methods including fliers, a community advisory board, Facebook ads, phone calls or emails to schools and health systems, and snowball sampling. Young adults and parents were interviewed to assess their perceived benefits, barriers, and susceptibility of the HPV vaccine. Providers and public health professionals were interviewed about facilitators and barriers of patients receiving the HPV vaccine in their communities. We used deductive coding approach using a structured codebook, two coders, analyses in MAXQDA, and matrices.

RESULTS

Out of the 40 interviews: 10 young adults, 20 parents, and 10 providers and public health professionals were interviewed. Emerging facilitator themes to increase the uptake of the HPV vaccine included existing knowledge (patient level) and community outreach, providers' approach to the HPV vaccine recommendations and use of educational materials in addition to counseling parents or young adults (provider level) and immunization reminders (practice level). Barrier themes were lack of knowledge around HPV and the HPV vaccine (patient level), need for strong provider recommendation and discussing the vaccine with patients (provider level), and limited patient reminders and health education information around HPV vaccination (practice level). Related to socio-ecology, the lack of transportation and culture of limited discussion about vaccination in rural communities and the lack of policies facilitating the uptake of the HPV vaccine (e.g., school mandates) were described as challenges.

CONCLUSION

These interviews revealed key themes around education, knowledge, importance of immunization reminders, and approaches to increasing the HPV vaccination in rural Georgia. This data can inform future interventions across all levels (patient, provider, practice, policy, etc.) to increase HPV vaccination rates in rural communities.

Facilitators and barriers of HPV vaccination: a qualitative study in rural Georgia

Introduction

Human papillomavirus (HPV) vaccination protects against HPV-associated cancers and genital warts. Healthy People 2030 goal for HPV vaccine uptake is 80%, but as of 2021, only 58.5% of adolescents are up to date in Georgia. The purpose of the study is to assess the attitudes, vaccine practices, facilitators, and barriers to receiving the HPV vaccine in southwest Georgia.

Methods

We conducted 40 semi-structured interviews with three different audiences (young adults, parents, and providers and public health professionals) guided by the P3 (patient-, provider-, practice-levels) model and used deductive coding approach. Young adults and parents were interviewed to assess their perceived benefits, barriers, and susceptibility of the HPV vaccine. Providers and public health professionals were interviewed about facilitators and barriers of patients receiving the HPV vaccine in their communities.

Results

Out of the 40 interviews: 10 young adults, 20 parents, and 10 providers and public health professionals were interviewed. Emerging facilitator themes to increase the uptake of the HPV vaccine included existing knowledge (patient level), providers' approach to the HPV vaccine recommendations (provider level) and immunization reminders (practice level). Barrier themes were lack of knowledge around HPV and the HPV vaccine (patient level), need for strong provider recommendation and discussing the vaccine with patients (provider level), and limited patient reminders and information (practice level).

Conclusions

These interviews revealed key themes around education, knowledge, importance of immunization reminders, and approaches to increasing the HPV vaccination in rural Georgia. This data can inform future interventions across all levels (patient, provider, practice, policy, etc.) to increase HPV vaccination rates in rural communities.

#4Corners4Health Social Media Cancer Prevention Campaign for Emerging Adults: Protocol for a Randomized Stepped-Wedge Trial

BACKGROUND

Many emerging adults (EAs) are prone to making unhealthy choices, which increase their risk of premature cancer morbidity and mortality. In the era of social media, rigorous research on interventions to promote health behaviors for cancer risk reduction among EAs delivered over social media is limited. Cancer prevention information and recommendations may reach EAs more effectively over social media than in settings such as health care, schools, and workplaces, particularly for EAs residing in rural areas.

OBJECTIVE

This pragmatic randomized trial aims to evaluate a multirisk factor intervention using a social media campaign designed with community advisers aimed at decreasing cancer risk factors among EAs. The trial will target EAs from diverse backgrounds living in rural counties in the Four Corners states of Arizona, Colorado, New Mexico, and Utah.

METHODS

We will recruit a sample of EAs (n=1000) aged 18 to 26 years residing in rural counties (Rural-Urban Continuum Codes 4 to 9) in the Four Corners states from the Qualtrics' research panel and enroll them in a randomized stepped-wedge, quasi-experimental design. The inclusion criteria include English proficiency and regular social media engagement. A social media intervention will promote guideline-related goals for increased physical activity, healthy eating, and human papillomavirus vaccination and reduced nicotine product use, alcohol intake, and solar UV radiation exposure. Campaign posts will cover digital and media literacy skills, responses to misinformation, communication with family and friends, and referral to community resources. The intervention will be delivered over 12 months in Facebook private groups and will be guided by advisory groups of community stakeholders and EAs and focus groups with EAs. The EAs will complete assessments at baseline and at 12, 26, 39, 52, and 104 weeks after randomization. Assessments will measure 6 cancer risk behaviors, theoretical mediators, and participants' engagement with the social media campaign.

RESULTS

The trial is in its start-up phase. It is being led by a steering committee. Team members are working in 3 subcommittees to optimize community engagement, the social media intervention, and the measures to be used. The Stakeholder Organization Advisory Board and Emerging Adult Advisory Board were formed and provided initial input on the priority of cancer risk factors to target, social media use by EAs, and community resources available. A framework for the social media campaign with topics, format, and theoretical mediators has been created, along with protocols for campaign management.

CONCLUSIONS

Social media can be used as a platform to counter misinformation and improve reliable health information to promote health behaviors that reduce cancer risks among EAs. Because of the popularity of web-based information sources among EAs, an innovative, multirisk factor intervention using a social media campaign has the potential to reduce their cancer risk behaviors.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05618158; https://classic.clinicaltrials.gov/ct2/show/NCT05618158.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/50392.

Boot Camp Translation using Community-Engaged messaging for adolescent Vaccination: A Cluster-Randomized trial

BACKGROUND

Routine vaccination coverage for adolescents living in the rural US is lower than adolescents living in urban areas. We sought to measure the effect of Boot Camp Translation (BCT), a community-based participatory intervention, on rural adolescent vaccination coverage.

METHODS

A cluster randomized controlled trial was performed September 2018-November 2021 involving 16 rural Colorado counties. Intervention county community members engaged in BCT to develop interventions to improve adolescent vaccination locally. Adolescent vaccination coverage was measured using the Colorado Immunization Information System.

RESULTS

For 11-12-year-olds, HPV initiation, HPV up-to-date, MenACWY, and Tdap vaccination coverage was lower post- versus pre-intervention in the control and intervention groups. For 11-12-year-olds in the intervention group, there was no significant difference post- versus pre-intervention in the odds of HPV vaccine initiation (adjusted ratio of odds ratios [aROR] = 0.93, 95 %: 0.85-1.02, p = 0.10) or up-to-date HPV vaccination (aROR: 1.10, 95 % CI: 0.98-1.23, p = 0.11) compared with the control group. Among 11-12-year-olds, the decrease in the proportion vaccinated with MenACWY and Tdap in the intervention group was significantly greater than the control group. Among 13-17-year-olds, there were significant increases in HPV initiation, HPV up-to-date, MenACWY, and Tdap vaccination coverage from pre- to post-intervention for both groups, with no significant differences between groups.

CONCLUSION

11-12-year-old vaccination coverage decreased slightly from pre- to post-intervention while 13-17-year-old vaccination coverage increased. We saw no effect from the BCT intervention. Our findings about the effectiveness of BCT for improving vaccine uptake may not be generalizable because the study coincided with the COVID-19 pandemic.

CLINICAL TRIAL REGISTRY

This study was registered with ClinicalTrials.gov, NCT03955757.

Acceptability of HPV Vaccines: A Qualitative Systematic Review and Meta-Summary

In 2006, the human papillomavirus (HPV) vaccine was approved for use as an effective intervention for reducing the risk of developing cervical cancer; however, its successful implementation is dependent on acceptability. This study aims to provide a comprehensive understanding of the reasons that favor or do not favor the acceptability of HPV vaccines.

METHODS

We conducted a systematic review and meta-summary of qualitative research on 16 databases. A total of 32 articles that considered the perspectives of vaccine users, their parents, and the professionals who care for them were reviewed. Synthesis was conducted as described by Sandelowski and Barroso.

RESULTS

We used inductive and deductive methods to obtain a total of 22 dimensions, out of which three issues stood out that should be considered to improve acceptability and are formed by three groups of study, namely, information about the vaccine, fears and side effects, and sexuality associated with the vaccine.

CONCLUSIONS

Acceptability, as well as adherence to HPV vaccination, is a complex concept. This review highlights the perspectives of the three sets of actors involved in the process (i.e., users, parents, and professionals) and views these factors in relation to acceptability as a guide for new interventions.

Vaccination intention and uptake within the Black community in Appalachia

OBJECTIVE

Black communities have disproportionately experienced adverse health effects from the COVID-19 pandemic while simultaneously having less vaccination access and decreased vaccine utilization. As such, predictors of vaccination uptake within Black communities are a public health imperative. Black Americans from socio-geographic regions associated with health inequities (e.g., Appalachia), including vaccination disparities, represent an intersection of racial, economic, and ethnic social identities. To better understand the preventive health needs of Black communities in Appalachia and elsewhere, this study examined psychosocial predictors of vaccination intention or behavior.

METHOD

Adults (n = 336) identifying as Black or African American from West Virginia indicated demographics, reported COVID-19 vaccination intention, flu vaccination uptake, and human papillomavirus (HPV) vaccination uptake, and completed assessments of vaccine hesitancy, medical mistrust, and racial discrimination. Hierarchical logistic regression modeling examined potential associations between psychosocial predictors and each vaccine type.

RESULTS

Results showed variation in significant predictors across the vaccines of focus. Racial discrimination (OR = 0.64) and medical mistrust (OR = 0.93) were negatively associated with COVID-19 vaccination intention. Vaccine confidence was positively associated with COVID-19 vaccination intention (OR = 2.17) and HPV vaccination uptake (OR = 1.77). Total household income was the only predictor associated with flu vaccination uptake (OR = 1.12).

CONCLUSIONS

These findings suggest that social interventions targeting racial discrimination in healthcare may significantly help address vaccination disparities in rural Black communities. Moreover, results emphasize unique aspects of vaccination behavior in the Black community within Appalachia that may generalize to other Black communities living in rural regions. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Nurses' perceptions, experiences, and practices regarding human papillomavirus vaccination: results from a cross-sectional survey in Montana

BACKGROUND

Nationally, much of the focus on improving human papillomavirus (HPV) vaccine uptake has been on effective strategies that physicians use to promote vaccination. However, in large, predominately rural states like Montana, nurses and medical assistants play critical roles in immunization services delivery, and their viewpoints are imperative in designing strategies to increase vaccination rates. We conducted a cross-sectional, descriptive study to determine nurses' perceptions, experiences, and practices regarding human papillomavirus vaccination in a rural and medically underserved region of the United States.

METHODS

We designed, pilot-tested, and disseminated an online survey instrument to nurses and medical assistants working in clinics participating in the Vaccines for Children program in Montana. The online surveys were administered from November 2020 to March 2021. Survey questions focused on clinic vaccination practices, respondents' perceptions of the HPV vaccine, perceived barriers to vaccine uptake, and general opinions on potential strategies to improve HPV vaccination rates.

RESULTS

We analyzed data from 227 respondents. Overall, 90% of nurses strongly agreed or agreed that the HPV vaccine is important and had confidence in the vaccine's safety. More nurses reported experiencing greater parental vaccine refusal or delay for male patients regardless of age. About 53.7% of nurses reported that their clinics had reminder/recall systems to encourage parents to bring their children for vaccination. Nurses identified misinformation from social media, infrequent wellness visits, and vaccine safety concerns as barriers to HPV vaccine uptake.

CONCLUSIONS

Study findings identified several promising initiatives to accelerate vaccination in primarily rural states like Montana, including promoting widespread adoption of reminder/recall systems, training nurses in evidence-based techniques to provide strong vaccine recommendations, and leveraging social media to disseminate consistent messages about the HPV vaccine recommendations for both sexes and its role in cancer prevention.

A qualitative descriptive study of providers’ perspectives on human papillomavirus vaccine administration among Latino/a adolescents in South Texas clinics: barriers and facilitators

Background

South Texas Latinas experience higher cervical cancer incidence and mortality compared to Latinas nationwide. Despite the availability of effective human papillomavirus vaccines, South Texas Latino/a adolescents sub-optimally complete the series. Research shows provider recommendation strongly predicts vaccine uptake, but minority adolescents are less likely to report that their provider recommended the vaccine and series completion. There is also scant information on the HPV vaccine administration process in clinic practices providing vaccination services to Latino adolescents with limited access to healthcare resources. The purpose of the study was to describe providers’ experience with administering the HPV vaccine to Latino/a patients in their practices.

Methods

The study used qualitative description to describe the experience of 15 South Texas healthcare providers (doctors and nurses) with the process of HPV vaccine administration in their practices. We conducted open ended, audio-recorded interviews, which were subsequently transcribed verbatim and uploaded into Atlas.(ti) 7.0 for analysis. The interviews yielded detailed descriptions of barriers and facilitators that could potentially impact HPV vaccine uptake.

Results

Providers identified parental exposure to provider recommendation as enhancing HPV acceptance and existing policies and implementation of evidence-based practices as facilitators of HPV vaccine uptake. Barriers ranged from parental fears of adolescent sexual activity and potential vaccine side effects to lack of transportation and the cost of the vaccine.

Conclusion

These findings reflect barriers and facilitators to administering the HPV vaccine previously identified and also highlight issues unique to the situation among Latinos in South Texas. Implications include the need to design and implement efforts to improve provider-parent communication and enhance parental and adolescent patients’ understanding of and confidence in the HPV vaccine. Furthermore, policy changes are needed to rectify organizational/structural challenges to HPV vaccine administration.

Successful Multi-Level HPV Vaccination Intervention at a Rural Healthcare Center in the Era of COVID-19

Objectives: To develop and test a human papillomavirus (HPV) vaccination intervention that includes healthcare team training activities and patient reminders to reduce missed opportunities and improves the rate of appointment scheduling for HPV vaccination in a rural medical clinic in the United States.

Methods: The multi-level and multi-component intervention included healthcare team training activities and the distribution of patient education materials along with technology-based patient HPV vaccination reminders for parents/caregivers and young adult patients. Missed vaccination opportunities were assessed pre- and post-intervention (n = 402 and n = 99, respectively) by retrospective chart review and compared using Pearson χ². The patient parent/caregiver and young adult patient population (n = 80) was surveyed following the reminder messages and penalized logistic regression quantified unadjusted odds of scheduling a visit.

Results: Missed opportunities for HPV vaccination declined significantly from the pre-intervention to the post-intervention period (21.6 vs. 8.1%, respectively, p = 0.002). Participants who recalled receipt of a vaccination reminder had 7.0 (95% CI 2.4–22.8) times higher unadjusted odds of scheduling a visit compared with those who did not recall receiving a reminder. The unadjusted odds of confirming that they had scheduled or were intending to schedule a follow-up appointment to receive the HPV vaccine was 4.9 (95% CI 1.51–20.59) times greater among those who had not received the vaccine for themselves or for their child.

Conclusions: Results from this intervention are promising and suggest that vaccination interventions consisting of provider and support staff education and parent/caregiver and patient education materials, and reminders can reduce missed opportunities for vaccinations in rural settings.

Place, Power, and Premature Mortality: A Rapid Scoping Review on the Health of Women in Appalachia

OBJECTIVE

Appalachian women continue to die younger than in other US regions. We performed a rapid scoping review to summarize women's health research in Appalachia from 2000 to 2019, including health topics, study populations, theoretical frameworks, methods, and findings.

DATA SOURCE

We searched bibliographic databases (eg, PubMed, PsycINFO, Google Scholar) for literature focusing on women's health in Appalachia.

STUDY INCLUSION AND EXCLUSION CRITERIA

Included articles were: (1) on women's health in Appalachia; (2) published January 2000 to June 2019; (3) peer-reviewed; and (4) written in English. We excluded studies without reported data findings.

DATA EXTRACTION

Two coders reviewed articles for descriptive information to create summary tables comparing variables of interest.

DATA SYNTHESIS

Two coders co-reviewed a sub-sample to ensure consensus and refine data charting categories. We categorized major findings across the social-ecological framework.

RESULTS

A search of nearly 2 decades of literature revealed 81 articles, which primarily focused on cancer disparities (49.4%) and prenatal/pregnancy outcomes (23.5%). Many of these research studies took place in Central Appalachia (eg, 42.0% in Kentucky) with reproductive or middle-aged women (82.7%). Half of the studies employed quantitative methods, and half used qualitative methods, with few mixed method or community-engaged approaches (3.7%). Nearly half (40.7%) did not specify a theoretical framework. Findings included complex multi-level factors with few articles exploring the co-occurrence of factors across multiple levels.

CONCLUSIONS

Future studies should: 1) systematically include Appalachian women at various life stages from under-represented sub-regions; 2) expand the use of rigorous methods and specified theoretical frameworks to account for complex interactions of social-ecological factors; and 3) build upon existing community assets to improve health in this vulnerable population.

A narrative review of HPV vaccination interventions in rural U.S. communities

Uptake of human papillomavirus (HPV) vaccine in the United States (U.S.) is far below the Healthy People 2020 goal of 80% coverage among adolescents. In rural communities, HPV vaccination coverage is low, yet incidence and mortality rates of HPV-associated cancer are high. Much of the research focused on HPV vaccination in rural U.S. communities has involved qualitative investigations, observations, survey research, and secondary data analysis with limited implementation of interventional study designs. The purpose of this narrative review was to examine intervention studies to increase HPV vaccination in rural settings and to summarize study characteristics and associated outcomes. PubMed, PsycINFO, CINAHL, and Web of Science were searched utilizing systematic narrative review methodology for studies describing implementation of HPV vaccination interventions in rural U.S. settings from January 2006-December 2019. Using specific search criteria, 991 studies were identified. After abstract review, 30 full-text articles were assessed for eligibility, and 15 met the inclusion criteria. The 15 articles - published from 2011 to 2019 - described HPV vaccination interventions in rural settings of six states, including communities, health clinics, and schools. A range of primary and secondary outcomes were reported, including HPV vaccine receipt (series initiation, continuation, and/or completion); HPV vaccine knowledge; and/or cervical cancer knowledge. Across the studies, there was an absence of the description of rural context. As compared to the broader HPV vaccination intervention literature, interventions in rural settings were limited. More interventional research is needed in rural communities given the elevated rates of HPV-related cancer and low rates of HPV vaccine uptake.

Knowledge gaps and acquisition about HPV and its vaccine among Brazilian medical students

Objective

To analyze factors associated with knowledge gaps and acquisition about HPV and its vaccine among medical students.

Method

Cross-sectional and analytical study conducted at the University of São Paulo Medicine School, in 2016. A convenience sample of students completed a data collection instrument containing questions on knowledge about HPV and its vaccine, and vaccine acceptability. The level of knowledge and acceptability established as a "good level" was 80% of correct answers on the questionnaire. Internal validity was calculated with Cronbach's alpha value (α) = 0.74. Bivariate and multiple analyzes were performed using the Stata® program (Stata Corp, College Station, USA) 14.0.

Results

To evaluate the internal consistency of the instrument applied, the Cronbach's alpha equation was used, obtaining the alpha value (α) = 0.74 for this population. This value attests that the consistency of the answers obtained with this questionnaire is considered substantial and acceptable. Among the 518 medical students who completed the survey, the majority were men 312 (60.4%) with a mean age of 23 (± 2.8) years old; 199 (38.3%) of the students were in the final years of graduation (5th and 6th years). Students in the first, second and third year of study had a 51% higher risk of a knowledge gap when compared to students in the final years of graduation [PR 1.51 (1.3:1.8); p <0.001]. Men were at 22% higher risk of unsatisfactory knowledge than women are [PR 1.22 (1.07: 1.39). There was no knowledge acquisition during medical school in the following questions (p <0.05), indication of vaccine for individuals with HIV and contraindication in pregnant patients.

Conclusion

Male medical students, in the first year of medical school, and those who were not vaccinated had significant knowledge gaps about HPV. The novelty of the study includes the finding of non- acquisition of knowledge during the medical school graduation on safety and vaccination schedule and vaccine administration in specific populations.

Human Papillomavirus Vaccine Uptake, Knowledge, and Acceptance for Youth: A Systematic Review of Appalachia

Though vaccine uptake and public support have risen since the release of the first HPV vaccines, the United States has far lower initiation and completion rates for the HPV vaccine series in comparison to other vaccines indicated for youth. Disparities are even greater in the Appalachian regions. Understanding factors contributing to these discrepancies is vital to improving vaccine rates in Appalachia. A comprehensive literature search identified all articles pertaining to HPV vaccination in children and adolescents living in Appalachia. The final 15 articles were included in a systematic review of the topic.

HPV Vaccination Coverage Among US Teens Across the Rural-Urban Continuum

BACKGROUND

In this study, we used data from the National Immunization Survey-Teen (NIS-Teen) to examine HPV vaccination uptake by rural and urban residence defined by ZIP code.

METHODS

We used 2012-2013 NIS-Teen data to examine associations of HPV vaccination among teens aged 13-17 years with ZIP code measures of rural/urban (Rural-Urban Commuting Area (RUCA) codes, population density). Multivariable logistic regression was used to estimate the odds of HPV vaccination initiation (≥ 1 dose) and completion (≥ 3 doses).

RESULTS

HPV vaccination was lower among girls from isolated small rural towns (≥1 dose 51.0%; ≥3 doses 30.0%) and small rural towns (≥1 dose 50.2%; ≥3 doses 26.8%) than among urban girls (≥1 dose 56.0%; ≥3 doses 35.9%). Girls from small rural towns had lower odds of completion (0.74, 95% CI: 0.60-0.91) than girls from urban areas. HPV vaccination was lower among boys from isolated small rural towns (≥1 dose 17.3%; ≥3 doses 5.31%) and small rural towns (≥1 dose 18.7%; ≥3 doses 5.50%) than those in urban areas (≥1 dose 28.7%; ≥3 doses 10.7%). Boys in isolated small rural towns had statistically significantly lower odds of initiation (0.68, 95% CI: 0.52-0.88) and completion (0.63, 95% CI: 0.41-0.97) than urban boys. Girls and boys from high-poverty rural areas had lower odds of initiation and completion than did their counterparts from high-poverty urban areas.

CONCLUSION

Rural girls had lower odds of completing the HPV vaccine than their urban counterparts. Rural boys had lower odds than urban boys for HPV vaccination initiation and completion.

Barriers and Facilitators to Improving Virginia's HPV Vaccination Rate: A Stakeholder Analysis With Implications for Pediatric Nurses

PURPOSE

Despite the evidence, the availability since 2006, and strong recommendations from many professional organizations, the human papillomavirus (HPV) vaccine has had a low uptake rate nationally and these trends have been even lower in the state of Virginia.

DESIGN AND METHODS

We explored key stakeholders' perspectives on factors influencing HPV vaccination in central and southern Virginia organized within the socio-ecological model (SEM) framework. We conducted semi-structured key informant interviews with 31 stakeholders involved in HPV vaccination or cancer prevention.

RESULTS

Stakeholders identified barriers at all SEM levels: Knowledge gaps and sexuality concerns (parent-child dyad level), time constraint and inconsistent recommendation (interpersonal level), lack of leadership and informational support (organizational and community level), and an ineffective mandate (policy level). Facilitators identified were realistic/receptive attitude (parent-child dyad level), provider's strong recommendation and educational support (interpersonal level), team approach and useful data (organizational level), educational outreach and community resources (community level), and support from federal and professional organizations (policy level).

CONCLUSIONS

The stakeholder analysis provided an environmental scan of the barriers and facilitators so that an effective HPV vaccination strategy can be planned and implemented in the Commonwealth of Virginia by public health nurses.

Barriers and facilitators to HPV vaccination among rural Alabama adolescents and their caregivers

INTRODUCTION

Half of all new human papillomavirus (HPV) infections occur in adolescents and young adults, and this population has poor HPV vaccination rates. Rural areas of the U.S. have high rates of HPV-related diseases and low vaccination rates as well. The purpose of this study was to determine the perceived barriers and facilitators to HPV vaccination among adolescents and their caregivers in rural south Alabama.

METHODS

Vaccinated and non-vaccinated adolescents ages 11-18 years old and primary caregivers were recruited from three rural counties in south Alabama. Participants completed individual interviews to discuss perceived barriers to vaccination and factors influencing their decision to vaccinate. Discussion groups were held to determine potential solutions to barriers elucidated from the interviews. Interview and discussion group transcripts were analyzed, and themes were identified.

RESULTS

Approximately 62.5% of adolescents had not initiated the HPV vaccine series. Of those adolescents who started the vaccine series (n = 9, 37.5%), about half completed it (n = 5). Few participants in this study reported speaking with their health care provider (HCP) about the vaccine in the past year. Lack of information about the vaccine, its side effects, and no HCP recommendation were common barriers cited by non-vaccinators. Facilitators to vaccination included cancer prevention, discussion with HCP, and peer testimonials. Potential solutions to barriers were also discussed.

CONCLUSIONS

Proposed strategies to increase HPV vaccination were similar between vaccinated and non-vaccinated groups. Education about HPV and the HPV vaccine is needed throughout these rural south Alabama communities to ensure informed decisions are made about vaccination and to increase vaccination rates.

Predictors of Human Papillomavirus Vaccine Follow-Through Among Privately Insured US Patients

OBJECTIVES

To assess predictors of timely human papillomavirus (HPV) vaccine follow-through among privately insured individuals initiating the 3-dose series.

METHODS

Using MarketScan Commercial claims data, we identified 1 332 217 privately insured US individuals aged 9 to 26 years who initiated the bivalent or quadrivalent HPV vaccine series from 2006 to 2014, with follow-up data extending through 2015. The study outcome was receipt of third HPV dose within 12 months of the first, compared by year of initiation. Control variables were age, region, insurance plan type, provider type, and seasonal influenza vaccination.

RESULTS

Timely HPV vaccine follow-through fell over time. The trend was especially pronounced for females (from 67% in 2006 to 38% in 2014), but was also present for males (from 36% in 2011 to 33% in 2014). Similar patterns were present when we controlled for patient and provider characteristics or used alternative definitions of follow-through. Other positive predictors of timely follow-through included receipt of flu vaccine in the prior year and receipt of first HPV vaccine dose from an obstetrician/gynecologist.

CONCLUSIONS

HPV vaccine follow-through is low and has declined over time.

US Health Care Clinicians' Knowledge, Attitudes, and Practices Regarding Human Papillomavirus Vaccination: A Qualitative Systematic Review

Clinicians' recommendation for the human papillomavirus (HPV) vaccine appears to be an important driver of parental decisions about vaccination. Our aim was to synthesize the best available evidence exploring the perceptions and experiences regarding HPV vaccination, from the perspective of the US clinician. We conducted a comprehensive literature search of Academic Search Complete, CINAHL Plus, Communication & Mass Media Complete, Consumer Health Complete (EBSCOhost), ERIC, Health and Psychosocial Instruments, MEDLINE with full text, and PsycINFO databases. We identified 60 eligible articles: 48 quantitative and 12 qualitative. We extracted the following information: study purpose, use of theory, location, inclusion criteria, and health care provider classification. Results were organized into 5 categories: 1) clinicians' knowledge and beliefs about HPV and the HPV vaccine, 2) clinicians' attitudes and beliefs about recommending HPV vaccines, 3) clinicians' intention to recommend HPV vaccines, 4) clinicians' professional practices regarding HPV vaccination, and 5) patient HPV vaccination rates. Although clinicians were generally supportive of HPV vaccination, there was a discrepancy between clinicians' intentions, recommendation practices, and patient vaccination rates. Studies reported that clinicians tended not to provide strong, consistent recommendations, and were more likely to recommend HPV vaccines to girls versus boys and to older versus younger adolescents. Analyses revealed a number of facilitating factors and barriers to HPV vaccination at the clinician, parent/patient, and systems levels, including clinician knowledge, clinician beliefs, and office procedures that promote vaccination. This review provides an evidence base for multilevel interventions to improve clinician HPV vaccine recommendations and vaccination rates.

Early Outcomes of a Multilevel Human Papillomavirus Vaccination Pilot Intervention in Federally Qualified Health Centers

OBJECTIVE

Human papillomavirus (HPV) vaccine coverage in the United States remains low compared with other adolescent vaccines. As the largest primary care network in the United States, safety net clinics such as federally qualified health centers (FQHCs) serve patients at a disproportionate risk of HPV-related cancers. In this pilot project, the American Cancer Society (ACS) leveraged its primary care workforce to implement quality improvement interventions in the unique context of 30 FQHC systems across the country, including 130 clinic sites reaching >20,000 adolescents in a variety of geographic settings.

METHODS

FQHC systems were randomly selected to receive either a $90,000 2-year grant, a $10,000 3-month grant, or training and technical assistance without funding. All 3 intervention groups conducted provider training and education, completed a capacity assessment tool, and measured HPV vaccination rates. Annual HPV vaccine series initiation and completion rates for active, 11- to 12-year-old patients were measured to evaluate project outcomes.

RESULTS

HPV vaccine series initiation rates among 11- to 12-year-old patients increased by 14.6 percentage points from a baseline of 41.2% before the intervention (2014) to the intervention year (2015). Changes in HPV second dose and series completion rates were not statistically significant. Meningococcal and tetanus, diphtheria, and acellular pertussis vaccination rates also increased significantly, by 13.9 and 9.9 percentage points from baseline rates of 49.1% and 52.5%, respectively.

CONCLUSIONS

The first year of this pilot project showed early success, particularly with HPV vaccine series initiation. On the basis of these promising results, ACS is expanding clinical quality improvement projects to increase HPV vaccination across the country.

Implementation of a Postpartum HPV Vaccination Program in a Southeast Texas Hospital: A Qualitative Study Evaluating Health Care Provider Acceptance

Introduction The objective of this qualitative study was to assess healthcare providers' acceptability of an ongoing postpartum human papillomavirus (HPV) vaccination program in Southeast Texas and its integration into everyday clinical care. Methods In 2012, the Department of Obstetrics & Gynecology at the University of Texas Medical Branch (UTMB) began offering HPV vaccination as part of standard postpartum care to increase vaccination rates among young women in Galveston County. Initial vaccine doses were offered on the postpartum unit while subsequent doses were coordinated with postpartum and well-baby visits. Thirty months after project initiation, semi-structured interviews of physicians (n = 12) and nurses (n = 6) involved in postpartum and pediatric care at UTMB were conducted. Interview transcripts were analyzed using thematic analysis in Nvivo10. Results Overall, providers demonstrated "pro-vaccine" attitudes and stated the program was an effective strategy for vaccinating hard-to-reach women. Cancer prevention was the main perceived benefit while follow-up compliance was the primary perceived patient barrier. The initial challenges with integrating postpartum HPV vaccination included miscommunication between providers regarding vaccine orders and coordination issues with well-baby visits for follow-up doses. One novel finding was providers' beliefs that women's personal HPV vaccine practices may positively impact their decisions about later vaccinating their children against HPV. Providers' suggestions to improve the program included: enhancing postpartum HPV vaccine education for patients, offering more continuing education for providers, and increasing community awareness of HPV vaccination. Discussion These findings can help providers of postpartum care understand how to integrate postpartum HPV vaccination into their current practices and how to overcome perceived vaccination barriers.

Provider communication about HPV vaccination: A systematic review

BACKGROUND

Improving HPV vaccination coverage in the US will require healthcare providers to recommend the vaccine more effectively. To inform quality improvement efforts, we systematically reviewed studies of provider communication about HPV vaccination.

METHODS

We searched MEDLINE, CINAHL, EMBASE, and POPLINE in August 2015 to identify studies of provider communication about HPV vaccination.

RESULTS

We identified 101 qualitative and quantitative studies. Providers less often recommended HPV vaccine if they were uncomfortable discussing sex, perceived parents as hesitant, or believed patients to be low risk. Patients less often received recommendations if they were younger, male, or from racial/ethnic minorities. Despite parents' preference for unambiguous recommendations, providers often sent mixed messages by failing to endorse HPV vaccine strongly, differentiating it from other vaccines, and presenting it as an "optional" vaccine that could be delayed.

CONCLUSION

Interventions are needed to help providers deliver effective recommendations in the complex communication environment surrounding HPV vaccination.

Fatalistic beliefs and completion of the HPV vaccination series among a sample of young Appalachian Kentucky women

PURPOSE

Uptake and completion of the 3-dose human papillomavirus (HPV) vaccine is important for the primary prevention of cervical cancer. However, HPV vaccination rates among adolescent females and young women remain low in certain geographic areas of the United States, including Appalachia. Although greater fatalistic beliefs have been previously associated with lower rates of preventive cancer behaviors among adults, little research exists on the impact of fatalism on HPV vaccination behaviors, especially among younger individuals. Therefore, the purpose of this study was to examine the association between fatalistic beliefs and completion of the full HPV vaccine series among young women, ages 18-26, in Appalachian Kentucky.

RESULTS

Data from this study were from a baseline survey completed by 344 women randomized into a communication intervention trial focused on increasing adherence to the 3-dose HPV vaccine series. Principal components analysis was used to construct 2 fatalism-related subscales from 8 survey questions.

FINDINGS

In a controlled analysis, 1 subscale--"lack of control over cancer"--was significantly associated with not completing the full HPV vaccine series. In a rural area that experiences higher rates of cervical cancer, poverty, limited access to health care, and negative cancer-related attitudes and experiences, fatalism may be common, even among young people.

CONCLUSION

Future educational and interventional research addressing fatalistic beliefs in a culturally sensitive manner may be warranted to improve HPV vaccination behaviors and impact cancer disparities among Appalachian women.

Designing for dissemination: lessons in message design from "1-2-3 pap"

Despite a large number of evidence-based health communication interventions tested in private, public, and community health settings, there is a dearth of research on successful secondary dissemination of these interventions to other audiences. This article presents the case study of "1-2-3 Pap," a health communication intervention to improve human papillomavirus (HPV) vaccination uptake and Pap testing outcomes in Eastern Kentucky, and explores strategies used to disseminate this intervention to other populations in Kentucky, North Carolina, and West Virginia. Through this dissemination project, we identified several health communication intervention design considerations that facilitated our successful dissemination to these other audiences; these intervention design considerations include (a) developing strategies for reaching other potential audiences, (b) identifying intervention message adaptations that might be needed, and (c) determining the most appropriate means or channels by which to reach these potential future audiences. Using "1-2-3 Pap" as an illustrative case study, we describe how careful planning and partnership development early in the intervention development process can improve the potential success of enhancing the reach and effectiveness of an intervention to other audiences beyond the audience for whom the intervention messages were originally designed.

School-based vaccination programs and the HPV vaccine in 16 Appalachian Kentucky school districts: results from a pilot study

The purpose of this article is to describe a pilot study of 16 Appalachian Kentucky school districts designed to gather information about their school vaccination and health education programs in relation to the Human Papillomavirus (HPV) vaccine. School district administrators were contacted by a professional telephone interviewer and asked to participate in a structured interview that also included open-ended questions. Results suggest that few schools have school-based vaccination programs, and of those that do, very few programs include the HPV vaccine. A majority of respondents reported that information leaflets about HPV are available in the schools, whereas few schools include discussions of HPV in their health programs. Almost all respondents reported an excellent relationship with their county health departments, school nurses, and school social workers, although most schools lacked the presence of a school social worker. Implications for social work practice and policy and directions for future research are also discussed.