Adolescents' perspectives on vaccination outside the traditional medical home: a survey of urban middle and high school students

Schoolteachers' experiences of implementing school-based vaccination programs against human papillomavirus in a Chinese community: a qualitative study

Background

Cervical cancer was the fourth most common cancer among women worldwide in 2012 and was the eighth most common cancer in 2014 and the eighth greatest cause of female cancer deaths in Hong Kong in 2015. Human papillomavirus (HPV) vaccination has been clinically documented to have a high efficacy in reducing HPV-related cervical intraepithelial neoplasia incidence. Therefore, receiving vaccination is a crucial public health measure to reduce disease burden. Significant others, such as schools and schoolteachers, have prominent influence in shaping adolescents’ health perceptions and behavior. Therefore, the perspective of schools and schoolteachers regarding vaccination can significantly influence students’ acceptance and accessibility of the vaccine. However, few studies have analyzed the perceptions of schoolteachers toward HPV vaccination, and even fewer have concerned how schoolteachers’ perceptions influence their schools’ motivation in implementing school-based HPV vaccination programs. This study was thus conducted to fill this literature gap.

Methods

With a Chinese community as the field site of this study, a qualitative approach of five focus group interviews was conducted with 35 schoolteachers from five primary and eight secondary schools in Hong Kong between July 2014 and January 2015. Thematic content analysis was used for data analysis.

Results

Perceptual, institutional, student and parental, and collaborator barriers interacted to discourage the sampled schoolteachers from organizing school-based HPV vaccination programs. Lack of knowledge regarding HPV vaccination, perception of HPV vaccination as inappropriate given the students’ age, violation of traditional cultural values, lack of perceived needs and perceived risk, opposition from schools, low priority of HPV vaccination over other health education topics, lack of government support, lack of interest from parents and students, and lack of confidence in implementing organizations, all were the mentioned barriers.

Conclusions

The sampled schoolteachers were demotivated to organize school-based HPV vaccination programs because of their perceptions and various social and cultural factors. As significant influencers of adolescent students, schoolteachers and schools should receive more support and information on organizing school-based HPV vaccination programs in the future.

Barriers and enablers to adolescent self-consent for vaccination: A mixed-methods evidence synthesis

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Synthesis of studies related to self-consent procedures for adolescent vaccination.

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Robust systematic review methodology used to identify and appraise the literature.

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There is a need to clarify policy and address professionals’ misunderstandings.

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Concerns about professional practice and relationships with parents create barriers.

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Enabling adolescent self-consent entails disputing the primacy of parental consent.

Introduction

The recent global expansion of routine adolescent vaccination programmes has the potential to protect young people against infectious diseases and improve their health. Although the legal framework in many countries permits young people to consent for vaccinations if competent, lack of written parental consent can still prevent uptake. We aimed to review systematically the associated barriers and enablers to implementation of adolescent self-consent procedures.

Methods

A comprehensive search strategy of ten databases from inception to June 2018 was undertaken to identify relevant qualitative and quantitative studies. Titles, abstracts and full texts were assessed for eligibility, and the methodological quality of eligible primary studies evaluated. Thematic synthesis methods were used to interpret and combine qualitative data, and to identify overarching themes as well as similarities and differences within themes. Quantitative data were summarised and, because the data were sufficiently similar in focus, were integrated within the qualitative framework.

Results

Twenty-five publications related to 23 studies were included. Three themes were identified which related to the policy framework, protection, and self-determination. Despite supportive national policy frameworks, implementation of adolescent self-consent procedures can be prevented by local policies, professionals’ misunderstandings of the legal framework and the context in which the vaccination programme is delivered. Motivation to protect young people’s health increased acceptability of adolescent self-consent, but implementation might be prevented to protect the reputation of professionals or relationships with parents. Further, maintaining the role of parents as decision-makers for their child’s healthcare was frequently prioritised over enabling young people’s autonomy to consent.

Conclusions

Barriers to the implementation of adolescent self-consent procedures have implications for young people’s health and uptake of vaccination programmes. There is a need to clarify the policy framework and challenge the primacy of parental consent.

Systematic review registration

PROSPERO CRD42017084509.

Acceptability of School-Based Health Centers for Human Papillomavirus Vaccination Visits: A Mixed-Methods Study

BACKGROUND

Countries with high human papillomavirus (HPV) vaccination rates have achieved this success largely through school-based vaccination. Using school-based health centers (SBHCs) in the United States, where HPV vaccine remains underutilized, could improve uptake. In this mixed-methods study, we examined acceptability, facilitators, and barriers of HPV vaccination visits at SBHCs from the perspectives of adolescents and parents.

METHODS

We conducted qualitative interviews and structured surveys with adolescents and parents recruited from an urban, hospital-based clinic. Interviews with parents (N = 20) and adolescents (N = 20) were audio-recorded and transcribed for analysis using an iterative thematic approach. Quantitative measures for a survey administered to parents (N = 131) were derived from the qualitative findings. Survey results were analyzed by chi-square tests.

RESULTS

Many participants expressed favorable opinions of HPV vaccination at SBHCs in qualitative interviews. Facilitators included convenience, ease of scheduling, and not missing work or school. However, barriers were noted including concerns about obtaining care outside the medical home, fragmentation of medical records, and negative perceptions about SBHCs. Quantitative findings revealed that a higher proportion of parents with experience using SBHCs were willing to use a middle school (59.5%) or high school (80.5%) SBHC for HPV vaccinations compared with those who had not used SBHCs (p < .05 for both comparisons).

CONCLUSIONS

HPV vaccination visits at SBHCs were acceptable, and SBHC users expressed more favorable attitudes. Barriers to HPV vaccination at SBHCs can be addressed through more education about SBHCs' role, and improvement of systems to coordinate care.

Practical Approaches to Optimize Adolescent Immunization

With the expansion of the adolescent immunization schedule during the past decade, immunization rates notably vary by vaccine and by state. Addressing barriers to improving adolescent vaccination rates is a priority. Every visit can be viewed as an opportunity to update and complete an adolescent's immunizations. It is essential to continue to focus and refine the appropriate techniques in approaching the adolescent patient and parent in the office setting. Health care providers must continuously strive to educate their patients and develop skills that can help parents and adolescents overcome vaccine hesitancy. Research on strategies to achieve higher vaccination rates is ongoing, and it is important to increase the knowledge and implementation of these strategies. This clinical report focuses on increasing adherence to the universally recommended vaccines in the annual adolescent immunization schedule of the American Academy of Pediatrics, the American Academy of Family Physicians, the Centers for Disease Control and Prevention, and the American Congress of Obstetricians and Gynecologists. This will be accomplished by (1) examining strategies that heighten confidence in immunizations and address patient and parental concerns to promote adolescent immunization and (2) exploring how best to approach the adolescent and family to improve immunization rates.

Promising alternative settings for HPV vaccination of US adolescents

Vaccination in alternative settings, defined here as being outside of traditional primary care, can help address the pressing public health problem of low human papillomavirus vaccine coverage among adolescents in the United States. Pharmacies are promising because they are highly accessible and have well established immunization practices. However, pharmacies currently face policy and reimbursement challenges. School-located mass vaccination programs are also promising because of their high reach and demonstrated success in providing other vaccines, but control by local policymakers and challenges in establishing community partnerships complicate widespread implementation. Health centers in schools are currently too few to greatly increase access to human papillomavirus vaccine. Specialty clinics have experience with vaccination, but the older age of their patient populations limits their reach. Future steps to making alternative settings a success include expanding their use of statewide vaccine registries and improving their coordination with primary care providers.