Provider recommendation mediates the relationship between parental human papillomavirus (HPV) vaccine awareness and HPV vaccine initiation and completion among 13- to 17-year-old U.S. adolescent children

An Interactive Educational Tool to Improve Human Papillomavirus Vaccine Knowledge and Recommendation Among Nurses

In United States, only 57% of  women and 53% of men in the recommended age groups have received all recommended doses of the human papillomavirus (HPV) vaccine. Healthcare provider education has been associated with strong vaccine recommendation and vaccination uptake. Our objective was to create a 7-min interactive online educational tool to improve knowledge and willingness to recommend the HPV vaccine among nurses. This is a prospective pre-test/post-test study to evaluate the effectiveness of the educational tool consisting of 10 flashcards in a question-answer format. Oncology nurses at our cancer center were invited to participate by email, which led them to the educational tool (i.e., intervention) along with pre- and post-test questions on HPV-associated cancers, vaccine-eligible age groups, dosing schedules, adverse events, and willingness to recommend. Of the 110 participants (mean age of 41.2 ± 11.4, 98% female, 64% >10 years of practice), there was improvement in knowledge after intervention in HPV-associated cancers (81% to 97%; p = 0.02), percentage of cervical caused by HPV (33% to 64%; p < 0.05), and dosing schedule (47% to 93%; p < 0.05). All participants correctly stated that continued screening is needed after vaccination both pre- and post-intervention. Eighty-five percent strongly agreed that the intervention improved their HPV knowledge, and 77% stated they were more likely to recommend the HPV vaccine after the intervention. While nurses are willing to recommend the vaccine, there remains persistent knowledge gaps. A brief 7-min self-administered online interactive flashcard educational intervention is effective in improving the HPV vaccine knowledge among nurses.

Intentions for catch-up HPV vaccination in Japan: an internet survey

PURPOSE

In Japan, Japan's Ministry of Health, Labor, and Welfare decided to suspend govermental recommendation for HPV vaccination in FY 2013. The HPV vaccination rate for those born in FY 2000 or thereafter declined dramatically. In 2021, the "suspension of recommendation" ended. The catch-up vaccinations for the unvaccinated have been offered nationwide from FY 2022 to FY 2024. We aimed to quantify the vaccination intentions and characteristics of those young women now eligible for catch-up vaccination.  METHODS: In February of 2022, we conducted an internet survey targeted women who were born in 1997-2004 but who had not yet been HPV vaccinated.

RESULTS

We received 1,648 valid responses. 41.6% of the respondents wanted to uptake the catch-up HPV vaccination, 29.7% were undecided, and 28.7% did not want to be vaccinated. The intention to uptake catch-up HPV vaccination was associated with a good history of gynecological visits, intention to receive cervical cancer screening, sexual activity, degree of anxiety about cervical cancer, familiarity with problems associated with cervical cancer, experience with vaccination recommendations, and knowledge about cervical cancer (p < 0.05, respectively). In the vaccinated generation, the proportion of the group that did not want to be vaccinated was significantly higher (p < 0.05). In the vaccine-suspended generation, the proportion of the group that wanted to be vaccinated was significantly higher (p < 0.05).

CONCLUSION

Our survey revealed that catch-up vaccination intentions differed depending on the vaccination environment. It is necessary for all organizations involved with HPV vaccination, such as government, medical institutions, and educational institutions, to make recommendations based on an understanding of the characteristics of the "vaccinated generation" and the "vaccine-suspended generation".

Applying the Hornik & Woolf Approach to Identify Messaging Themes and Improve COVID-19 Vaccine Confidence Among Federally Qualified Health Centers' Workforce in Wisconsin

The Federally Qualified Health Centers (FQHCs) in Wisconsin serve the most under-resourced communities in the state and are trusted sources in local communities. Although healthcare workers can be leveraged to champion COVID-19 vaccines, existing vaccine hesitancy among the FQHC workforce itself calls for research to identify promising messaging themes that can boost their vaccine confidence. In spring 2021, through a partnership with the Wisconsin Primary Health Association, we took a community-engaged approach to develop and field a survey including 46 beliefs (Ms = 1.36-4.25, SDs = 0.81-1.46, all on 5-point Likert scales) among employees of 10 out of the 17 FQHCs in Wisconsin. In total, 347 clinical team members and 349 non-clinical staff members (a) indicated their levels of (dis)agreement with all 46 belief items and (b) reported vaccine acceptance (dichotomized, acceptance = 77.6%) as well as recommendation intentions (dichotomized, yes = 73.9%). We carried out the Hornik & Woolf analyses in a multilevel logistic regression framework with bootstrapping to rank order all beliefs, segmented by subgroup and behavioral outcome. Our results suggest that communication-based interventions should promote beliefs such as those related to perceived safety and efficacy, rather than normative pressure from peers, while aiming to reduce doubts about information withholding and manipulation, the safety of the mRNA technology, the approval process, and "unnatural" ingredients in the vaccines. Subgroup-specific belief rankings are also provided. This study demonstrates the usefulness of incorporating the H&W approach into community-engaged research with local healthcare systems to improve health messaging for vaccine promotion.

Factors Affecting Human Papillomavirus Vaccine Trends in the United States of America

Background Routine immunization of both girls and boys starting from nine years of age with the human papillomavirus (HPV) vaccine is the current recommendation. The objective of this retrospective study using National Health and Nutrition Examination Survey data was to evaluate the influence of sociodemographic factors on the series initiation and completion of the HPV vaccine from 2011 to 2020. Methodology The chi-square test was used to examine the statistical significance of the association between categorical variables and receipt of the HPV vaccine. The Cochran-Armitage test for trend was employed to assess the statistical significance of temporal trends in risk factors associated with rates of HPV vaccination. These trends were further quantified by a significant rate ratio by comparing them against the most recent survey years. Results HPV vaccine uptake was higher in the 9-14-year age group across survey years and had increased for both males and females over that time. The first dose of the HPV vaccine was most likely to be received by the 11-18-year age group. In the most recent survey of 2017-2020, the highest number of vaccination series completion was achieved for Gardasil®. Conclusions Improved physician efforts and strategies to vaccinate males, low socioeconomic strata patients, and ethnic minorities in more numbers are needed.

Patient-Provider Health Communication Strategies: Enhancing HPV Vaccine Uptake among Adolescents of Color

Cervical cancer remains a public health issue in the United States, particularly among stigmatized racial and ethnic populations. The human papillomavirus (HPV) vaccine has been clinically proven to prevent cervical cancers, and other HPV-associated cancers, among men and women. However, HPV vaccine uptake is suboptimal; only 55% of adolescents complete the two-dose series by age 15. Past research has shown that provider HPV vaccine communication for people of marginalized races/ethnicities is subpar. This article focuses on provider communication strategies to promote HPV vaccine uptake effectively and equitably. The authors reviewed the literature on evidence-based patient-provider HPV vaccine communication techniques to create a set of communication language providers could use and avoid using to enhance HPV vaccine acceptance and uptake among adolescents of marginalized racial and ethnic groups. Evidence has shown that information and the manner of dissemination are critical for influencing HPV vaccine uptake. These communication strategies must be suited to the context of the targeted population, and the message content can be broadly categorized into source, content, and modality. Strategies to improve patient-provider communication among adolescents of color using source, modality, and content include the following: (1) Source: increase provider self-efficacy to provide the recommendation, building rapport between providers and parents; (2) Content: persistent, forceful language with minimal acquiescence should be employed, reframing the conversation focus from sex to cancer; and (3) Modality: use multiple vaccine reminder modalities, and work with the community to culturally adapt the vaccination language. Utilizing effective behavior-change communication adapted for adolescents of color can reduce missed opportunities for HPV prevention, potentially decreasing racial and ethnic disparities in HPV-related morbidity and mortality.

User Engagement on a Novel Educational Health Intervention Aimed at Increasing HPV Vaccine Uptake in Hong Kong: a Qualitative Study

HPV vaccine uptake rates are suboptimal in Hong Kong. A multi-disciplinary school-based HPV health-promotion programme (MDL-SHPVP) aimed at raising HPV knowledge levels and increasing vaccine uptake has therefore been developed to address vaccine hesitancy. This qualitative study was conducted to collect user feedback and identify the strengths and limitations of the educational resources developed for the programme among key vaccination stakeholders including adolescent girls and their mothers. Twenty-six participants including eight mother-daughter dyads, four teachers, three social workers, two school principals and one school nurse were recruited. To cater to the diverse audience, ten educational videos, three animations, a digital game and one booklet were developed for the programme and distributed to the participants for viewing. Semi-structured interviews were then conducted to collect feedback on the acceptability and effectiveness of the resources. Interviews were audio-recorded, transcribed verbatim, and resulting data were thematically analysed. Three themes and six sub-themes emerged. The educational materials were well-received and effective in raising HPV-knowledge levels, generating confidence in vaccine safety and effectiveness, and boosting vaccination intention. Some doubts regarding vaccine necessity remained, and recommendations for improving resource presentation and accessibility were provided. Our findings suggest that the MDL-SHPVP has the potential to boost HPV vaccine uptake. Future studies may explore educational interventions which target to increase not only HPV vaccination intention but also the sense of urgency so as to encourage timely vaccination for adolescents at the ideal age. Study findings may also provide directions for the development of future health education interventions.

Understanding barriers to vaccination against invasive meningococcal disease: a survey of the knowledge gap and potential solutions

INTRODUCTION

Invasive meningococcal disease (IMD) is a leading cause of life-threatening bacterial meningitis and septicemia. Evidence points to a knowledge gap among parents, teenagers, and healthcare providers (HCPs) regarding IMD and available vaccines, including those against the highly prevalent serogroup B.

AREAS COVERED

An online survey was conducted between March 27 and April 12, 2019, to gather insights into the knowledge that parents/guardians have about IMD vaccines. The children were aged 2 months-10 years in Australia, Brazil, Germany, Greece, Italy, and Spain, 5-20 years in the UK, and 16-23 years in the US. The findings were discussed in the context of the available literature and solutions were proposed to minimize the knowledge gap and the barriers to vaccination against IMD.

EXPERT OPINION

The survey demonstrated that parents have a good understanding of IMD but a limited understanding of the different serogroups and vaccines. The available literature highlighted multiple barriers to IMD vaccine uptake; these may be reduced through education of HCPs, clear recommendations to parents by HCPs, the use of technology, and disease-awareness initiatives that engage parents through physical and digital channels. Further studies are warranted to assess the impact of the COVID-19 pandemic on IMD vaccination.

Clinician communication strategies associated with increased uptake of the human papillomavirus (HPV) vaccine: A systematic review

Human papillomavirus (HPV) is currently linked to almost 35,000 new cases of cancer in women and men each year in the United States. Gardasil-9 (Merck &amp; Company), the only HPV vaccine now available in the United States, is nearly 100% effective at preventing precancers caused by oncogenic HPV types. In the United States, however, only about one half of adolescents are up to date with HPV vaccination. It is well known that health care clinicians' recommendations play a significant role in parents' decisions regarding HPV vaccination. A growing body of literature examines specific communication strategies for promoting uptake of the HPV vaccine. A comprehensive review of the evidence for each of these strategies is needed. The authors searched the PubMed, EMBASE, Cochrane Central Register of Controlled Trials, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and Web of Science Complete databases for original articles with a defined clinician communication strategy and an outcome of HPV vaccine uptake or intention to vaccinate (PROSPERO registry no. CRD42020107602). In total, 46 studies were included. The authors identified two main strategies with strong evidence supporting their positive impact on vaccine uptake: strong recommendation and presumptive recommendation. Determinations about a causal relationship were limited by the small numbers of randomized controlled trials. There is also opportunity for more research to determine the effects of motivational interviewing and cancer-prevention messaging.

Social Media Perceptions and Internet Verification Skills Associated With Human Papillomavirus Vaccine Decision-Making Among Parents of Children and Adolescents: Cross-sectional Survey

BACKGROUND

Human Papillomavirus (HPV) vaccination is recommended for children aged 11-12 years in the United States. One factor that may contribute to low national HPV vaccine uptake is parental exposure to misinformation on social media.

OBJECTIVE

This study aimed to examine the association between parents' perceptions of the HPV vaccine information on social media and internet verification strategies used with the HPV vaccine decision-making stage for their child.

METHODS

Parents of children and adolescents aged 9-17 years were recruited for a cross-sectional survey in North Texas (n=1192) and classified into 3 groups: children and adolescents who (1) were vaccinated, (2) unvaccinated and did not want the vaccine, and (3) unvaccinated and wanted the vaccine. Multinomial logistic regression models were estimated to identify factors associated with the HPV vaccine decision-making stage with children and adolescents who were vaccinated as the referent group.

RESULTS

Of the 1192 respondents, 44.7% (n=533) had an HPV-vaccinated child, 38.8% (n=463) had an unvaccinated child and did not want the vaccine, and 16.4% (n=196) had an unvaccinated child and wanted the vaccine. Respondents were less likely to be "undecided/not wanting the vaccine" if they agreed that HPV information on social media is credible (adjusted odds ratio [aOR] 0.40, 95% CI 0.26-0.60; P=.001), disagreed that social media makes them question the HPV vaccine (aOR 0.22, 95% CI 0.15-0.33; P<.001), or had a higher internet verification score (aOR 0.74, 95% CI 0.62-0.88; P<.001).

CONCLUSIONS

Interventions that promote web-based health literacy skills are needed so parents can protect their families from misinformation and make informed health care decisions.

Is tailored messaging more effective? An analysis of a digital health intervention to promote HPV vaccination intent among Latinx

Latinx populations have unique barriers to HPV vaccination. In the current study, we assessed the effectiveness of an online intervention to increase HPV vaccination intentions among patients of clinics that principally serve a Latinx population (n = 85%) as part of a randomized control trial (RCT). Participants viewed on an iPad either an individually tailored educational website (CHiCOS) or untailored information derived from the Vaccine Information Sheet (VIS) for HPV. Vaccination intention and related covariates were assessed via survey items administered before (pre-test) and after (post-test) viewing the material. No statistically significant differences were seen in changes of intention to vaccinate between groups (N = 1294). However, 16% of all (tailored and untailored combined) participants increased in their intention to vaccinate, while 7% decreased in intention. Overall 72% of participants had high intentions to vaccinate, yet far fewer actually received a vaccine dose. The current study explores implications of the demonstrated intention-behavior gap. As such, it presents opportunities to improve future interventions-specifically those that employ tailored messaging.

Factors contributing to missed opportunities for human papillomavirus vaccination among adolescents, ages 11 to 13, in Iowa

Introduction

Rates of human papillomavirus (HPV) vaccination remain low and missed opportunities for HPV vaccination are widespread. Researchers have identified factors related to HPV vaccination, but less is known about missed opportunities.

Methods

We used medical claims data from a large Midwestern insurance provider to explore relationships between adolescent and provider characteristics and missed opportunities for HPV vaccination. We stratified models by initiation status with adolescents who had received one or more HPV vaccinations in one group (n = 6,123) and adolescents with no record of an HPV vaccination in the other (n = 8,107).

Results

There were significant differences in comparisons of all variables between initiators and non-initiators. Notably, non-initiators had lower rates of vaccination for HPV and other adolescent vaccinations, and fewer well-child visits. For all adolescents, birth year, having other recommended vaccines, and number of well-child visits were significantly associated with missed opportunities. Additionally, among initiators, pediatrician as a primary care provider and being in a rural area were significantly associated.

Discussion

Overall, adolescents with greater healthcare utilization had more missed opportunities, indicating that, despite increased numbers of visits, providers are not taking advantage of these opportunities to vaccinate. Future research should prioritize developing a deeper understanding of why these missed opportunities are occurring and implementing new and existing strategies to prevent them. Reducing missed opportunities will help to prevent future HPV-related cancers and the significant morbidity and mortality that they can cause.

Factors associated with COVID-19 vaccine receipt at two integrated healthcare systems in New York City: a cross-sectional study of healthcare workers

OBJECTIVES

To examine the factors associated with COVID-19 vaccine receipt among healthcare workers and the role of vaccine confidence in decisions to vaccinate, and to better understand concerns related to COVID-19 vaccination.

DESIGN

Cross-sectional anonymous survey among front-line, support service and administrative healthcare workers.

SETTING

Two large integrated healthcare systems (one private and one public) in New York City during the initial roll-out of the COVID-19 vaccine.

PARTICIPANTS

1933 healthcare workers, including nurses, physicians, allied health professionals, environmental services staff, researchers and administrative staff.

PRIMARY OUTCOME MEASURES

The primary outcome was COVID-19 vaccine receipt during the initial roll-out of the vaccine among healthcare workers.

RESULTS

Among 1933 healthcare workers who had been offered the vaccine, 81% had received the vaccine at the time of the survey. Receipt was lower among black (58%; OR: 0.14, 95% CI 0.1 to 0.2) compared with white (91%) healthcare workers, and higher among non-Hispanic (84%) compared with Hispanic (69%; OR: 2.37, 95% CI 1.8 to 3.1) healthcare workers. Among healthcare workers with concerns about COVID-19 vaccine safety, 65% received the vaccine. Among healthcare workers who agreed with the statement that the vaccine is important to protect family members, 86% were vaccinated. Of those who disagreed, 25% received the vaccine (p<0.001). In a multivariable analysis, concern about being experimented on (OR: 0.44, 95% CI 0.31 to 0.6), concern about COVID-19 vaccine safety (OR: 0.39, 95% CI 0.28 to 0.55), lack of influenza vaccine receipt (OR: 0.28, 95% CI 0.18 to 0.44), disagreeing that COVID-19 vaccination is important to protect others (OR: 0.37, 95% CI 0.27 to 0.52) and black race (OR: 0.38, 95% CI 0.24 to 0.59) were independently associated with COVID-19 vaccine non-receipt. Over 70% of all healthcare workers responded that they had been approached for vaccine advice multiple times by family, community members and patients.

CONCLUSIONS

Our data demonstrated high overall receipt among healthcare workers. Even among healthcare workers with concerns about COVID-19 vaccine safety, side effects or being experimented on, over 50% received the vaccine. Attitudes around the importance of COVID-19 vaccination to protect others played a large role in healthcare workers' decisions to vaccinate. We observed striking inequities in COVID-19 vaccine receipt, particularly affecting black and Hispanic workers. Further research is urgently needed to address issues related to vaccine equity and uptake in the context of systemic racism and barriers to care. This is particularly important given the influence healthcare workers have in vaccine decision-making conversations in their communities.

Using concept mapping to identify opportunities for HPV vaccination efforts: Perspectives from the Midwest and West Coast

Human papillomavirus (HPV) infection significantly contributes to the burden of cancer in the United States, despite the existence of a highly effective vaccine. While numerous interventions to address vaccination uptake exist, vaccination rates remain low. We conducted a concept mapping exercise to solicit perspectives on barriers and facilitators to HPV vaccination from state-level stakeholders in five states in the Midwest and West Coast of the U.S. We identified 10 clusters of barriers and facilitators based on participants' statements. For rural areas specifically, clusters rated as most important included education and provider influence; those rated as most feasible were education and coordinated/consistent messaging. Our results suggest that a combination of important (but potentially more difficult to implement) strategies, combined with those rated as most feasible (but potentially less impactful) may be beneficial. Our findings highlight similarities across diverse states, suggesting that states can learn from each other and work together to improve HPV vaccination rates. Using concept mapping proved to be an efficient way to collect information from diverse, stakeholders in different locations, and is a methodology that could be used for program planning in areas beyond HPV vaccination.

Disparities in healthcare access and utilization and human papillomavirus (HPV) vaccine initiation in the United States

Currently in the United States, Human Papillomavirus (HPV) vaccination coverage among eligible individuals is lower compared to coverage goals of 80% set by the HealthyPeople 2030 initiative. In this study, we used the National Health and Nutrition Examination Survey (NHANES) 2015-2016 and 2017-2018 datasets to determine the association between HPV vaccine initiation among individuals of ages 9 to 26 years and their patterns of healthcare access and utilization. In particular, we examined the following healthcare characteristics: 1) having a routine place of healthcare, 2) having health insurance coverage, 3) frequency of healthcare visits per year, and 4) type of routine place of healthcare (outpatient primary care vs. ED, etc.). We fit independent multivariable logistic regression models for each NHANES dataset and controlled for sociodemographic characteristics and interactions with healthcare access and utilization characteristics. Our findings suggest that HPV vaccine initiation is positively associated with having a routine place of healthcare (2015-2016: aOR 1.92, 95% CI 1.25-2.95; 2017-2018: aOR 1.99, 95% CI 1.07-3.68). Relatedly, HPV vaccine initiation is negatively associated with never having received healthcare in the past year (2015-2016: aOR 0.61, 95% CI 0.41-0.90; 2017-2018: aOR 0.45, 95% CI 0.27-0.75). The results of this study suggest that interventions to promote HPV vaccination should include strategies that promote access to and utilization of routine health care services. Our findings are particularly salient in light of the drop in HPV vaccine initiation and healthcare access and utilization among adolescents during the COVID-19 pandemic.

Attitudes and Communication Preferences for Vaccines among Pregnant Women Receiving Care at a Safety-net Hospital

OBJECTIVE

We aimed to understand pregnant women's perceptions of vaccination during pregnancy and to assess their reaction to different vaccine messages.

STUDY DESIGN

English-speaking pregnant women aged 18 years or older who received prenatal care at a safety-net hospital participated in qualitative interviews. Interview topics included attitudes toward vaccinations in general and toward influenza and tetanus-diphtheria-pertussis vaccination in pregnancy. Participants were also queried regarding sources of vaccine information, and were asked to provide feedback on specific messages regarding maternal vaccination.

RESULTS

Twenty-eight pregnant women participated in interviews. Participant age ranged from 18 to 40 years old; 64% were insured through Medicaid. All participants had positive attitudes toward routine vaccinations and had received vaccinations for themselves and their children. Attitudes were less favorable for influenza vaccines than other vaccines. Participants reported receiving vaccine information from multiple sources. Stories about vaccine harms worried participants, even when they did not trust the sources of negative information. All stated that their health care providers were the most trusted source of information. Participants felt that the most important messages to encourage maternal vaccination were that maternal vaccination protects the baby after birth and maternal vaccination is safe for both mother and baby. Participants were not motivated to vaccinate by messages about the severity of maternal disease.

CONCLUSIONS

Maternal vaccinations are important to protect pregnant women and infants from influenza and pertussis. Focusing on messages related to vaccine safety and protection of the infant are motivating to mothers, especially when delivered by trusted health care providers.

Women's acceptability of and experience with primary human papillomavirus testing for cervix screening: HPV FOCAL trial cross-sectional online survey results

OBJECTIVE

To study participant's acceptability of and attitudes towards human papillomavirus (HPV) testing compared with cytology for cervical cancer screening and what impact having an HPV positive result may have in future acceptability of screening.

DESIGN

Cross-sectional online survey of clinical trial participants.

SETTING

Primary care, population-based Cervix Screening Program, British Columbia, Canada.

PARTICIPANTS

A total of 5532 participants from the HPV FOCAL trial, in which women received HPV and cytology testing at study exit, were included in the analysis. Median age was 54 years. The median time of survey completion was 3 years after trial exit.

OUTCOME MEASURES

Acceptability of HPV testing for primary cervical cancer screening (primary); attitudes and patient perceptions towards HPV testing and receipt of HPV positive screen results (secondary).

RESULTS

Most respondents (63%) were accepting of HPV testing, with the majority (69%) accepting screening to begin at age 30 years with HPV testing. Only half of participants (54%) were accepting of an extended screening interval of 4-5 years. In multivariable logistic regression, women who received an HPV positive screen test result during the trial (OR=1.41 95% CI 1.11 to 1.80) or were older (OR=1.01, 95% CI 1.00 to 1.02) were more likely to report HPV testing as acceptable.

CONCLUSIONS

In this evaluation of acceptability and attitudes regarding HPV testing for cervix screening, most are accepting of HPV testing for screening; however, findings indicate heterogeneity in concerns and experiences surrounding HPV testing and receipt of HPV positive results. These findings provide insights for the development of education, information and communication strategies during implementation of HPV-based cervical cancer screening.

TRIAL REGISTRATION NUMBERS

ISRCTN79347302 and NCT00461760.

Factors affecting human papillomavirus (HPV) vaccination in men: A systematic literature review (Preprint)

Background

Despite the high risks associated with human papillomavirus (HPV), the HPV vaccination rate of men is far lower than women. Most previous review studies have focused on female vaccination and related affecting factors. However, previous studies have reported that the factors affecting HPV vaccination differ by gender.

Objective

The aim of this review was to identify the factors affecting HPV vaccine initiation in men through a systematic review approach.

Methods

A literature review was conducted across 3 central electronic databases for relevant articles. A total of 30 articles published between 2013 and 2019 met the inclusion criteria and were reviewed in this study.

Results

In total, 50 factors affecting HPV vaccination in men were identified, including 13 sociodemographic factors and social structure factors, 12 belief-related variables, 4 family factors, 4 community factors, 14 variables related to needs, and 3 environmental factors.

Conclusions

To increase HPV vaccination rates in men, strategies targeting young males and their families should consider frequent visits to or contact with health care providers so that health care professionals can provide recommendations for HPV vaccination.

Human Papillomavirus Vaccination Rates by Gender Identity and Sexual Orientation Among 18-44-Year-Olds in the U.S

In the U.S., human papillomavirus (HPV) vaccination has been recommended for individuals up to age 26, although the vaccination is currently approved for all people up to the age of 45. This research sought to explore HPV vaccination disparities by age with subgroup analysis by gender identity and sexual orientation groups, as well as sociodemographic factors that may serve as barriers to or facilitators of vaccination. This study used data from the 2018 Behavioral Risk Factor Surveillance System. Only data for individuals who reported their gender identity, sexual orientation, and HPV vaccination status were included in the analytic sample (n = 7330). HPV vaccination rates for this sample were low, as only 18.2% (n = 1332) of the sample had received the HPV vaccination. These low rates of vaccination were similar across all subsamples: cisgender men (9.8%, n = 343), cisgender women (25.8%, n = 985), heterosexuals (17.5%, n = 1197), lesbian women or gay men (20.8%, n = 40), and bisexuals (30.8%, n = 95). In multivariable logistic regression models, younger participants (18-34) were more likely to report receiving the HPV vaccination across all subsamples. Further modeling indicated several common factors associated with higher odds of vaccination: living in a metropolitan area, having insurance coverage, and having at least one provider. Understanding vaccination disparities, as well as vaccination facilitators and barriers, is important to inform policy and program efforts. This is especially significant for adults between the ages of 35 and 44 who were excluded from the initial vaccination recommendations but are vulnerable due to changing cultural norms, including delayed marriage, nonmonogamous long-term relationships, and the ending of long-term partnerships.

Barriers towards HPV Vaccinations for Boys and Young Men: A Narrative Review

Background: HPV vaccination of both girls and boys can protect against infection and eliminate the risk for HPV-associated cancer. Due to a common misconception that the virus only poses risks to women, vaccine coverage is suboptimal among men in many countries. It is urgent to identify barriers to vaccination of boys and men. Methods: We conducted a narrative review of publications examining attitudes and beliefs regarding HPV vaccination for boys and young men. The electronic databases searched were PubMed, PsychInfo and Scopus (December 2020; last update July 2021). A total of 103 original articles were included in the final analysis. Results: The central barriers against vaccination of boys and men are: (1) lack of knowledge, (2) vaccine hesitancy in general, (3) lack of recommendation from and/or discussions with healthcare providers, (4) cost and logistics, and (5) the idea that HPV vaccination may promote promiscuity. Men who have sex with men and families belonging to ethnic minorities express a need for information tailored to their situation. Conclusions: Boys should be included in national immunization programs and men should also be offered catch-up vaccinations. Future studies should focus on addressing vaccine hesitancy and developing interventions to promote pan-gender HPV vaccination.

Diverse caregivers' HPV vaccine-related awareness and knowledge

Objectives: To assess factors associated with HPV vaccine-related awareness and knowledge among caregivers of adolescents from five ethnic community groups in Utah.Design: For this community-based participatory research study, we surveyed N = 228 caregivers of teens aged 11-17 years from African American, African refugee, American Indian/Alaskan Native, Hispanic/Latino, and Native Hawaiian/Pacific Islander community groups in Utah about their HPV vaccine awareness and knowledge.Results: Participants exhibited high awareness of cervical cancer (71.05%), moderate awareness of HPV (53.95%), and low awareness of the HPV vaccine (46.49%). HPV vaccine-related knowledge was mostly worse, with fewer than half the participants reporting knowing that HPV can cause cervical cancer (46.93%), that most people are infected with HPV at some point in their lives (28.95%), that HPV is asymptomatic in females (36.40%) and males (37.28%), that the HPV vaccine is recommended for adolescent females (41.67%) and males (36.40%), and that the HPV vaccine requires more than one dose (27.19%). HPV vaccine-related awareness and knowledge were significantly associated with race/ethnicity, educational attainment, income, occupation, birthplace, parents' birthplace, English usage, health insurance coverage, type of health insurance, and child having a primary care provider (all p < 0.05). HPV vaccine-related knowledge (p < 0.05) and awareness (p < 0.05) of caregivers were associated with a child in the household receiving the HPV vaccine.Conclusion: Our findings indicate a need to develop educational interventions in collaboration with diverse communities in Utah. We underscore the importance of promoting knowledge about the existence of the HPV vaccine, as well as deeper HPV vaccine-related issues (e.g. HPV risks, treatment, and recommendations).

Intentions of public school teachers in British Columbia, Canada to receive a COVID-19 vaccine

BACKGROUND

To control the COVID-19 pandemic high vaccine acceptability and uptake will be needed. Teachers represent a priority population to minimize social disruption and ensure continuity in education, which is vital for the well-being and healthy development of youth during the pandemic. The objective of this analysis was to measure public school teachers' intentions to receive a COVID-19 vaccine in British Columbia (BC), Canada.

METHODS

A population-wide cross-sectional online survey from August to November 2020 asked all BC public school teachers with an available email address how likely they were to receive a COVID-19 vaccine. Two multivariable logistic regression models explored separately sociodemographic and vaccine hesitancy predictors for intention to receive a COVID-19 vaccine.

RESULTS

A total of 5,076 teachers participated. The majority, 89.7%, reported they were likely or very likely to accept a COVID-19 vaccine. In multivariable regression, sociodemographic predictors of intention to be vaccinated included being male, having an educational background in science or engineering, and using reliable information sources on vaccination such as public health and health care providers. Teachers who reported lower levels of vaccine hesitancy, higher general vaccine knowledge, and belief that COVID-19 was a serious illness were more likely to intend to receive a COVID-19 vaccine.

CONCLUSION

A high proportion of public-school teachers in BC intend to receive a COVID-19 vaccine. Continued monitoring of vaccine intentions will be important to inform public health vaccine implementation.

A brief educational intervention can improve nursing students' knowledge of the human papillomavirus vaccine and readiness to counsel

Provider recommendation is a primary reason for patient uptake of the human papillomavirus (HPV) vaccine. Most provider-focused educational interventions are focused on physicians, even though nurses are also important sources of vaccine-related information for their patients. This study examined whether a HPV educational intervention could improve nursing students' HPV knowledge, beliefs, and comfort with counseling. The same lecture on HPV and HPV vaccination was given to both medical and nursing students. To determine the effects of the lecture, students were asked to complete identical pre- and post-lecture tests with questions on demographics, knowledge, attitudes, and comfort with counseling on the HPV vaccine. Pre- and post-lecture test scores were compared between nursing and medical students to assess whether there were differences in pre-lecture test scores and/or changes in post-lecture test scores. On the pre-lecture tests, fewer nursing students responded correctly to knowledge questions, indicated positive attitudes or comfort with counseling about the HPV vaccine compared to medical students. However, similar frequencies of nursing and medical students responded correctly to knowledge questions and indicated a positive attitude, as well as a high comfort level with counseling on the post-lecture tests. Study results show that integrating lectures in a nursing program curriculum could be a feasible way to increase students' HPV knowledge. Having health-care providers with similar levels of knowledge, attitudes, and comfort with counseling on HPV vaccination is ideal, as all share the responsibility of recommending the vaccine to patients.

Changes in Strength of Recommendation and Perceived Barriers to Human Papillomavirus Vaccination: Longitudinal Analysis of Primary Care Physicians, 2008-2018

OBJECTIVES

To evaluate among pediatricians and family physicians human papillomavirus (HPV) vaccination recommendation practices for 11- to 12-year-old youth; report parental refusal/deferral of HPV vaccination; and report barriers to HPV vaccination changed over time.

STUDY DESIGN

We surveyed nationally representative networks of pediatricians and family physicians in 2008, 2010, 2013-2014, and 2018. Male vaccination questions were not asked in 2008; barriers and parental vaccine refusal questions were not asked in 2010.

RESULTS

Response rates were 80% in 2008 (680/848), 72% in 2010 (609/842), 70% in 2013-2014 (582/829), and 65% in 2018 (588/908). The proportion of physicians strongly recommending HPV vaccination for 11- to 12-year-old patients increased from 53% in 2008 to 79% in 2018 for female patients and from 48% in 2014 to 76% in 2018 for male patients (both P < .0001). The proportion of physicians indicating ≥50% of parents refused/deferred HPV vaccination remained steady for female patients (24% in 2008 vs 22% in 2018, P = .40) and decreased for male patients (42% in 2014 vs 28% in 2018, P < .001). Physician barriers to providing HPV vaccination were rare and decreased over time. Increasing numbers of physicians reported perceived parental barriers of vaccine safety concerns (5% "major barrier" in 2008 vs 35% in 2018, P < .0001) and moral/religious concerns (5% in 2008 vs 25% in 2018, P < .0001).

CONCLUSIONS

Between 2008 and 2018, more primary care physicians reported recommending HPV vaccination for adolescents, fewer reported barriers, and more physicians reported parents who had vaccine safety or moral/religious concerns.

Development and evaluation of an online continuing education course to increase healthcare provider self-efficacy to make strong HPV vaccine recommendations to East African immigrant families

OBJECTIVE

To develop and evaluate an online continuing education (CE) course designed to improve healthcare provider self-efficacy to make strong adolescent HPV vaccine recommendations to East African immigrant families.

METHODS

Focus groups with providers and East African immigrant mothers informed course development. Providers serving East African immigrant families were recruited to view the course and complete pre-/post-test and two-month follow-up surveys. Pre-/post differences were compared with paired t-tests.

RESULTS

202 providers completed the course and pre-/post-test; 158 (78%) completed two-month follow-up. Confidence to make strong HPV vaccine recommendations to East African families increased from 68% pre-test to 98% post-test. Confidence to address common parental concerns also increased: safety, 54% pre-test, 92% post-test; fertility, 55% pre-test, 90% post-test; child too young, 68% pre-test, 92% post-test; and pork gelatin in vaccine manufacturing, 38% pre-test, 90% post-test. Two-month follow-up scores remained high (97% for overall confidence, 94%-97% for addressing parental concerns). All pre-/post-test and pre-test/two-month follow-up comparisons were statistically significant (p < 0.05).

CONCLUSIONS

The online CE course focused on culturally appropriate strategies for making strong recommendations and addressing specific parental concerns was effective for increasing provider self-efficacy to recommend HPV vaccination to East African families. Similar courses could be tailored to other priority populations.

Barriers to Human Papillomavirus Vaccine Series Completion among Insured Individuals in an Integrated Healthcare Setting

Introduction:

Infection with certain types of human papillomavirus (HPV) can lead to cervical cancer as well as other cancers in both men and women. However, the requirement for multiple doses may limit the vaccine’s effectiveness for cancer prevention. We conducted a pilot study to investigate barriers to HPV vaccine series completion among members of an integrated healthcare system with clinical documentation of only 1 dose.

Methods:

We surveyed parents or legal guardians of 11-17-year-old girls (n = 10) and boys (n = 18), as well as 18-31-year-old women (n = 20) and men (n = 9), about their reasons for not completing the HPV vaccine series.

Results:

Most participants (70.2%) were non-Hispanic white. Among parents of children, commonly reported barriers to HPV vaccine series completion included not being aware or informed of the need for additional doses (28.6%), as well as the inconvenience of returning for additional doses (17.9%). Concerns about the HPV vaccine or vaccines in general were more common among parents of girls (30.0%) compared with parents of boys (16.7%). Among adults, barriers to HPV vaccine series completion included the inconvenience of returning for additional doses (31.0%), not being aware or informed of the need for additional doses (10.3%), and forgetting (10.3%).

Conclusion:

Our findings suggest that clinicians and healthcare systems can play a greater role in promoting awareness of the multiple-dose requirement, addressing vaccine concerns, and increasing opportunistic vaccination in a variety of settings. Increasing these efforts may facilitate HPV vaccine completion and increase its effectiveness in cancer prevention.

A Mixed-Methods Examination of Factors Related to HPV Vaccination Promotion in Private Dental Settings, Iowa, 2019

INTRODUCTION

Human papillomavirus (HPV)-associated oropharyngeal cancer rates are rising, particularly in males, although rates of other HPV-related cancers are decreasing. Although the HPV vaccine is safe and effective, vaccination rates remain below the Healthy People 2030 goal of 80% coverage. Engaging dental providers, who have experience with patient education and oropharyngeal cancer, may prove useful in efforts to increase vaccination rates. Our research explores dental providers' (dentists, dental hygienists) willingness to participate in continuing education about HPV, educate parents of adolescents, recommend the vaccine for adolescents, and refer parents to medical providers.

METHODS

We used a mixed-methods approach and conducted a survey with dental hygienists and semistructured interviews with dental providers. We produced frequencies and descriptive statistics for all variables and used regression modeling to explore factors related to willingness to promote the HPV vaccine. We used a deductive approach to code interview transcripts.

RESULTS

Regression models using survey data (n = 470) showed that after controlling for demographic and practice-level characteristics, higher levels of willingness were associated with thinking that parents would act on a recommendation and thinking that engaging in HPV promotion is within the scope of practice. Interview data reflected willingness of dental providers to work on HPV vaccination, but revealed barriers (eg, time, knowledge) that need to be addressed.

DISCUSSION

Overall, dental providers expressed a willingness to participate in HPV vaccine promotion, and future efforts should focus on addressing barriers to doing so. Engaging dental providers in HPV vaccine recommendation and referral can help prevent future HPV-related cancers.

Health care provider use of motivational interviewing to address vaccine hesitancy in college students

BACKGROUND

Vaccine-preventable diseases significantly influence the health and academic success of college students. Despite the known negative impact of these diseases, vaccination rates routinely fall short of national goals and recommendations. Although vaccination decisions are complex, a recommendation from a health care provider is one of the key motivators for individuals receiving a vaccine. Motivational interviewing (MI), a counseling approach primarily used to address substance abuse, can be applied to other health-related behaviors.

LOCAL PROBLEM

Despite previous quality improvement efforts aimed at increasing vaccine rates for influenza, human papillomavirus (HPV), and meningitis B (MenB), vaccinations at large university health centers have been well below benchmarks set by Healthy People 2020.

METHODS

This study was guided by the Theory of Planned Behavior and included MI training and regular reinforcement for health care providers to address vaccine hesitancy with college students.

RESULTS

Influenza vaccination rates improved, but HPV vaccine rates remained stable and MenB vaccine rates decreased compared with the previous year. Clinicians demonstrated a significant increase in knowledge of MI techniques after a targeted educational intervention. Repeat measures indicate the potential for sustained improvement when ongoing reinforcement is provided.

CONCLUSION

MI can be an effective part of a strategy to increase vaccination rates.

Effect of a multi-component intervention on providers' HPV vaccine communication

Objective: To evaluate the effect of a multi-component intervention including communication training on provider beliefs and recommendation practices around the human papillomavirus (HPV) vaccine using both self-reports and audio-recordings of clinical interactions. Methods: We conducted a mixed method study at five family medicine and pediatric practices. Providers self-reported beliefs and practices about HPV vaccination via surveys and qualitative interviews conducted pre- and post-intervention. We also assessed provider recommendation style using audio-recordings of clinical interactions pre- and post-intervention. Content analysis was used to identify themes in qualitative interviews. Matched pre- and post-intervention surveys were analyzed for changes in provider beliefs and attitudes. Pre- and post-intervention audio recordings of clinical interactions were analyzed for observed differences in recommendation styles. Bivariate analyses of quantitative data used Chi-square and Fisher's exact tests; t-tests were used for continuous variables. Results: Providers reported in interviews that the intervention led to communication changes by increasing their knowledge, reframing the HPV vaccine as a routine vaccination, and providing tools for engaging with parents. Surveys indicated that the proportion of providers reporting that the HPV vaccine is one of the most important adolescent vaccines increased from 71% pre-intervention to 100% post-intervention (p = .03). Audio-recording analysis demonstrated that use of an indicated (presumptive) recommendation style increased from 62.5% pre-intervention to 79.6% post-intervention (p = .047). Conclusions: Educating providers about HPV vaccination and giving them tools to facilitate communication with parents can reframe HPV as a routine adolescent vaccination and motivate providers to routinely use effective recommendation styles in practice.

A National Survey Assessing SARS-CoV-2 Vaccination Intentions: Implications for Future Public Health Communication Efforts

With SARS-CoV-2 vaccines under development, research is needed to assess intention to vaccinate. We conducted a survey (N = 3,159) with U.S. adults in May 2020 assessing SARS-CoV-2 vaccine intentions, intentions with a provider recommendation, and sociodemographic and psychosocial variables. Participants had high SARS-CoV-2 vaccine intentions (M = 5.23/7-point scale), which increased significantly with a provider recommendation (M = 5.47). Hierarchical linear regression showed that less education and working in health care were associated with lower intent, and liberal political views, altruism, and COVID-19-related health beliefs were associated with higher intent. This work can inform interventions to increase vaccine uptake, ultimately reducing COVID-19-related morbidity and mortality.

Identifying Strategies to Reduce Missed Opportunities for HPV Vaccination in Primary Care: A Qualitative Study of Positive Deviants

The objectives of this study were to assess the contextual factors, practice strategies, and sustainability of interventions implemented during a national quality improvement (QI) project to raise human papillomavirus (HPV) vaccination rates. We conducted semistructured interviews with positive deviant practices that successfully reduced missed opportunities by ≥20% for HPV vaccination in the prior year. We assessed leadership support, motivators, interventions used, and sustainability. Key themes related to QI teams included strong leadership support, multidisciplinary teams, having a practice champion, and a collaborative environment. Themes related to the interventions included using a presumptive bundled recommendation for all appropriate vaccines at age 11, previsit planning, and reminders for preventive visits, which were sustainable for most practices 1-year postintervention. Both internal practice-level factors (multidisciplinary teams, collaboration, and previsit planning) and organizational factors (institutional support and health system-level reminders for preventive visits) were key to a successful QI intervention to improve HPV vaccination.

HPV Vaccination Hesitancy Among Latina Immigrant Mothers Despite Physician Recommendation

Purpose

Human papillomavirus (HPV) vaccination uptake continues to be low in the United States. While a recommendation from a health care provider (HCP) has been shown to be associated with vaccine acceptability among parents, little is known about factors associated with hesitancy despite HCP recommendation. We examined factors associated with HPV vaccine hesitancy, despite a physician recommendation, among Latina immigrant mothers of daughters aged 9-12 years.

Methods

As part of a group randomized trial to promote HPV vaccination between 2013 and 2016, we conducted a baseline interviewer-administered survey of mothers to assess sociodemographics, knowledge and perceived risk of cervical cancer/HPV infection, self-efficacy, and intention to vaccinate their unvaccinated daughters. Hesitancy was defined as "don't know/not sure" (DK/NS) in response to the question: "If your daughter's doctor recommended that she gets the HPV vaccine, would you let her get it?"

Results

Of the 317 participants, 35.3% indicated hesitancy to vaccinate their daughters if their physician recommended it. Although a number of variables were associated with HPV vaccine hesitancy in the univariate model, five remained significant in the final multivariable model: daughter's health insurance status; HPV awareness; perceived risk of HPV infection for their daughters; perceived self-risk of cervical cancer; and a self-efficacy score of ability to complete the HPV vaccination series.

Conclusions

A recommendation by a health care provider may be not enough to motivate Latina immigrant mothers to vaccinate their daughters. Further efforts should focus on increasing awareness regarding HPV and cervical cancer, heightening perceived risk of HPV infection among daughters and boosting self-efficacy to get their children vaccinated against HPV.

Factors Associated with Initiation of HPV Vaccination Among Young Women and Girls in Urban and Suburban New Orleans

Vaccination coverage against human papilloma virus (HPV) in the United States remains low. This study aimed to identify factors associated with initiation of HPV vaccination among young women and girls in New Orleans, Louisiana. The study was conducted in Pediatrics and Obstetrics & Gynecology clinics in New Orleans between 2014 and 2017. Surveys were administered to women ages 18 through 26, and guardians of girls ages 12 through 17. Demographics, health history, sources of medical information, knowledge of HPV and HPV vaccination, opinions on vaccination, expected support for vaccination, and systems-level barriers were assessed. Participants self-reported discussion of the vaccine with a healthcare provider, and whether they or their child had been vaccinated. Participants were predominantly black and low-income. Among young adults, 61/121 (50%) had received any doses of the HPV vaccine; 71/94 (75%) of girls had received it (p < 0.01). In both groups, knowledge of the HPV vaccine, believing the vaccine was available from their usual healthcare provider, and having discussed the vaccine with their provider were associated with increased odds of vaccination. Among young adults, additional factors associated with vaccination were younger age, distance from a healthcare center, knowledge of HPV, and expectation of support from parents. Among guardians, holding negative views on vaccination was associated with decreased odds of vaccination. Discussion of the vaccine with a healthcare provider was the factor most strongly associated with initiation of HPV vaccination in both groups. The results provided actionable items to increase HPV vaccination uptake in these populations.

Effect of an educational intervention on human papillomavirus (HPV) knowledge and attitudes towards HPV vaccines among healthcare workers (HCWs) in Western China

BACKGROUND

Healthcare workers (HCWs) play a key role in the recommendation of HPV vaccination. Our study aimed to understand to what extent a structured health intervention could change the knowledge and attitudes toward HPV and its vaccines among HCWs in Western China.

METHODS

This was a multi-center, questionnaire-based interventional study conducted across 12 cities of seven provinces in Western China, from November 2018 to July 2019. Participants were recruited from local health systems by e-invitation. Questionnaires were administered to participants before and after the intervention.

RESULTS

A total of 1448 HCWs attended the educational lectures and 1354 participants completed both pre- and post-study questionnaires. In general, HCWs had satisfactory baseline knowledge regarding HPV and its vaccines compared with other populations, and a significantly higher knowledge level was observed after the intervention. However, some more specific knowledge on the vaccination procedures, other HPV-related diseases and whether HPV testing was required before vaccination was relatively poor. Following the educational intervention, the correct responses to the above questions increased (P < .001). However, it was still lower compared with answers to other questions. Change was also detected regarding HCWs' willingness to recommend HPV vaccines to the appropriate population (P < .001).

CONCLUSION

Educational intervention on HPV and its vaccines is effective in improving HCWs' knowledge levels and willingness to recommend HPV vaccines. Future educational interventions should focus more on knowledge regarding HPV-related diseases and HPV vaccination. Education campaigns targeting rural HCWs are urgently needed in the near future.

Balancing Between Being Proactive and Neutral: School Nurses' Experiences of Offering Human Papilloma Virus Vaccination to Girls

The aim of this study was to describe the experiences of Swedish school nurses when they offered the human papilloma virus (HPV) vaccination to girls aged 10-12 years. Four focus groups with a total of 17 school nurses were conducted and analyzed using inductive content analysis. The results showed that the school nurses were balancing between keeping a neutral role and the need to increase the uptake of the HPV vaccination. They described the consent forms and information that they gave the girls and their parents to help them make an informed decision about the vaccination. There were also ethical and moral dilemmas that arose with regard to the HPV vaccinations. Our findings demonstrate the need to provide school nurses with clear guidelines and support, so they can play an active role in interacting with the girls and their parents when they offer the HPV vaccination.

Evaluation of a vaccination seminar in regard to medical students' attitudes and their theoretical and practical vaccination-specific competencies

Aim: Despite having a generally positive attitude toward vaccinations, medical students show gaps in their own immunization histories and knowledge about vaccinations. Future practicing physicians will be confronted with the need to evaluate protective immunity and make vaccination recommendations. This study aims to investigate the extent to which a seminar on the topic of vaccination can improve students' attitudes, knowledge and practical skills in interpreting vaccination certificates. Project description: Two different one-hour seminars were developed and integrated into the required clinical curriculum. A third of the students attended a theory-based seminar; the other two-thirds completed a predominantly practice-based seminar. The theoretical seminar consisted of a lecture on the principles and theoretical aspects of immunization. In the practical seminar, the curricular content was case-based and taught using fictive examples of vaccination certificates. Before the seminar was held, a voluntary and anonymous survey of the students was conducted regarding their attitudes toward and knowledge of immunization. At the conclusion of the seminar, the students' ability to understand vaccination certificates was tested. After completing the seminar, all of the participants received a link to participate in a voluntary online survey to evaluate the seminar. Results: Of the 149 seminar attendees in the 2017/18 winter semester, 148 participated in the study. Attitude: Students have a positive attitude toward vaccinations. Regardless of the type of seminar attended, the agreement with statements on vaccination could be significantly increased primarily among students who already at the start of the seminar expressed a high degree of agreement. Students vaccinated against influenza showed significantly stronger agreement than unvaccinated students. Knowledge: Regardless of teaching format, students' knowledge about vaccination topics could be increased. For those vaccinated against influenza, the mean value for agreement with the statement, "The vaccination of healthcare workers prevents nosocomial transmission of diseases," saw an increase on a five-point Likert scale from 3.97 to 4.4 (p<0.001; R=0.67). For the unvaccinated students, the mean value rose from 4.04 to 4.19 (p=0.06; R=0.29). Practical skills: The students who attended the theory-based seminar tended to score higher on interpreting vaccination certificates than those who attended the practical seminar; however, this difference was not statistically significant. Seminar evaluation: The online evaluation was completed by 18% of the participants. The theoretical seminar received the grade of 2.9 based on the conventional German academic grading scale; the practical seminar received 1.9. This difference is statistically significant (p=0.02). Conclusion: Precisely for skeptical students it was only possible to minimally change existing views with a seminar that offers very brief instruction. Attendees of the theoretical seminar tended to score somewhat higher on interpreting vaccination certificates than those who took the practical seminar. The practical seminar was rated significantly better on the course evaluation than the theoretical one. The advantage that the students attending the theoretical seminar had can be explained best by the structured review of the current vaccination recommendations as part of the seminar, which should, as a consequence, be integrated into the practical seminar.

Intersectoral cooperation to increase HPV vaccine coverage: an innovative collaboration between Managed Care Organizations and state-level stakeholders

In order to reduce disparities in human papillomavirus (HPV) vaccine coverage, intersectoral approaches are needed to reach vulnerable populations, including Medicaid enrollees. This manuscript describes a collaboration between Medicaid Managed Care Organizations (MCOs), the American Cancer Society, and a state health department in a Midwestern state to address HPV vaccination. Qualitative interviews (n = 11) were conducted via telephone with key stakeholders from the three participating organizations using an interview guide designed to capture the process of developing the partnership and implementing the HPV-focused project. Interviews were transcribed and coded using thematic analysis. Interviewees described motivation to participate, including shared goals, and facilitators, like pooled resources. They cited barriers, such as time and legal challenges. Overall, interviewees reported that they believed this project is replicable. Conducting this project revealed the importance of shared vision, effective communication, and the complementary resources and experiences contributed by each organization. Valuable lessons were learned about reaching the Medicaid population and groundwork was laid for future efforts to serve vulnerable populations and reduce health disparities. This work has significant implications for other organizations seeking to partner with large nonprofits, state health departments, MCOs, or others, and the lessons learned from this project could be translated to other groups working to improve vaccination rates in their communities.

Impact of HPV Immunization Training on Dental Hygiene Students' Attitudes and Confidence Regarding HPV Preventive Education

Human Papilloma Virus (HPV)-related oropharyngeal cancers (OPC) have increased significantly despite availability of the HPV vaccine. HPV-positive oropharyngeal cancer is becoming more prevalent than tobacco-related OPC. Dental professionals screen for OPC and risk factors, but many are not prepared to address HPV immunization and prevention with patients. The aim of this study was to implement and assess a training module on HPV to increase dental providers' knowledge, promote confidence in their ability to provide effective prevention interventions, and instill a positive attitude about recommending HPV immunization to their patients. The study used a pretest-posttest design. Participants were dental hygiene students in one U.S. dental hygiene program in 2017. The students completed the pretest, then viewed the online training module, and completed the posttest one week later. Of the 40 students who participated in the module, 37 completed both pretest and posttest, for a response rate of 93%. From pretest to posttest, the respondents showed a significant increase (CI=0.5, p<0.001) in knowledge of HPV prevention with mean scores increasing from 8.75 to 13.32 on a 15-point scale. The students demonstrated an increase (p<0.05) in confidence and comfort in providing HPV immunization counseling on the posttest, as well as an increase (p<0.05) in positive attitudes about recommending HPV immunization. This study found that the participants' knowledge and confidence regarding HPV, HPV-related OPC, and HPV immunization increased after the module, suggesting that effective education and preparation for HPV counseling can be accomplished through modular-based education. This education would be beneficial in an institutional or professional setting.

Human Papilloma Virus Vaccination After Pediatric Sexual Abuse Evaluations in the Outpatient Child Sexual Abuse Subspecialty Clinic: A Quality Improvement Project

The nonavalent human papilloma virus (HPV) vaccination prophylactically contributes to the prevention of nine types of HPV-associated oral and genital cancers. HPV vaccination rates remain lower than the national Healthy People 2020 goal of 80%. Victims of pediatric sexual abuse are at a higher risk for acquiring and developing HPV-related outcomes. Current research supports vaccination after sexual abuse as soon as eligible and suggests utilizing multiple types of medical encounters to increase vaccination rates.An institutional-review-board-approved quality improvement project was developed to determine the impact of promoting and providing HPV vaccination during the medical encounter after pediatric sexual abuse in a child protection team (CPT) clinic. Twenty percent of the 111 total clinic patients evaluated in the preintervention period and 21% of the 99 patients evaluated in the postintervention period were HPV vaccine eligible, illustrating a significant opportunity for impact. During the intervention period, 62% of patients who were vaccine eligible and presented for their CPT clinic visit received HPV vaccine. Barriers to vaccination in the outpatient CPT clinic setting included high appointment no-show rates, high social and medical visit complexity, and absence of an appropriate consenting caretaker. Implications for forensic nursing practice are discussed.

The potential population-based impact of an HPV vaccination intervention in Colorado

Background

Human papillomavirus (HPV) infection is the most common cause of cervical cancer and can be prevented with vaccination, but HPV vaccination rates remain low. An intervention to improve health care provider communication about vaccination has been shown to increase HPV vaccination rates in an initial trial in Colorado, where about 160 cases of cervical cancer are diagnosed each year.

Methods

Census data were combined with Colorado cancer and immunization registry data to identify clinics in locations that would most benefit from implementation of this intervention to improve HPV vaccination rates. ArcGIS Pro was used to map cervical cancer incidence, immunization rates, population data, and location of clinics participating in practice‐based research networks (PBRNs). Results from the provider communication intervention trial and published estimates of the number needed to vaccinate to prevent a case of cervical cancer were used to predict the number of cervical cancer cases prevented based on increased vaccination due to the intervention.

Results

Ninety‐eight Colorado PBRN clinics were analyzed. For the 10 clinics with the highest predicted number of cervical cancer cases prevented, 5218 additional patients would be vaccinated and 43 cervical cancer cases prevented with implementation of the intervention. If implemented in all 98 clinics, the intervention would lead to 20 490 additional patients vaccinated (range 7‐658/clinic) and 171 cases of cervical cancer prevented (range 0.05‐5.48/clinic).

Conclusions

Geographic data from cancer and immunization registries can inform the dissemination of evidence‐based practices like the provider communication intervention for HPV vaccination to maximize impact on public health.

Understanding the use of digital technology to promote human papillomavirus vaccination - A RE-AIM framework approach

The human papillomavirus virus (HPV) vaccine is effective at preventing various cancers, but coverage falls short of targets that are needed for community protection. Here, we use the RE-AIM implementation framework (Reach, Effectiveness, Adoption, Implementation, Maintenance) to understand how text, email, and electronic health record (EHR) reminders and social media campaigns can be used as part of policy and practice interventions to increase HPV vaccination. These technology-based interventions could be used together and mainstreamed into clinical and system-based practice to have the greatest impact. Of the interventions explored, text-based, email-based, and EHR reminders have the most evidence behind them to support their effectiveness. While there are several studies of promotion of the HPV vaccine on social media, more studies are needed to demonstrate their effects and better methods are needed to be able to attribute results to these interventions.

Importance of a team approach to recommending the human papillomavirus vaccination

BACKGROUND AND PURPOSE

Few studies have examined human papillomavirus (HPV) vaccine communication in the context of the health care team.

METHODS

In 2016, the investigators conducted a national, online survey of U.S. parents who reported having discussed HPV vaccination with their adolescent's health care team. Multivariable logistic regression assessed associations between HPV vaccine initiation (≥1 dose) and having: 1) discussed HPV vaccination with multiple team members and 2) received congruent recommendations about HPV vaccination.

CONCLUSIONS

Of the 795 parents in the sample, about half (52%) reported discussing HPV vaccination with multiple team members, including nurse practitioners, nurses, and physicians. Most reported receiving congruent recommendations for (76%) or against (12%) HPV vaccination; few (12%) received mixed recommendations. Parents who discussed HPV vaccination with multiple team members had greater odds of series initiation (odds ratio [OR] = 2.34, 95% CI: 1.61-3.40), whereas those who received mixed versus congruent recommendations for HPV vaccination had lower odds of vaccination (OR = 0.56, 95% CI: 0.33-0.95).

IMPLICATIONS FOR PRACTICE

Findings suggest that a coordinated team approach to recommendations may encourage HPV vaccination. Nurse practitioners are well positioned to facilitate coordination efforts within their clinical practices.

Implementation of Strategies to Improve Human Papillomavirus Vaccine Coverage: A Provider Survey

INTRODUCTION

Human papillomavirus (HPV) vaccine coverage in the U.S. is persistently suboptimal, despite research describing barriers to vaccination and strategies to increase vaccination coverage. The objective was to assess providers' approach to the HPV vaccine and their implementation of strategies to increase HPV vaccination coverage. The hypothesis was that adoption of improvement measures to address underuse of the HPV vaccine has not occurred.

METHODS

Community pediatric providers from two Midwestern practice-based research networks completed self-administered electronic surveys. Data were collected over 6 months in 2015 and organized and analyzed in 2016.

RESULTS

There were 100 providers that participated. Despite agreement with national recommendations, some providers delayed their recommendation until the adolescent was older and many reported missed vaccination opportunities. Many providers experienced parental concerns including safety of the HPV vaccine, belief their child was not at risk of HPV infection, and their child's resistance to receiving multiple shots. Providers identified the following as barriers to adherence to Advisory Committee on Immunization Practices guidelines: bad publicity of the HPV vaccine, information about the HPV vaccine on the web, and a lack of a follow-up system for those who delayed HPV vaccine initiation. Approximately half of the participants had implemented strategies to address these barriers beyond offering immunization-only appointments.

CONCLUSIONS

Participants were aware of barriers to HPV vaccine use, but many had not adopted a systematic approach to increase vaccine coverage. A better understanding of the challenges facing providers to adopting improvement measures and a strategy to address barriers to implementation are needed to improve HPV coverage.

Acceptability of two- versus three-dose human papillomavirus vaccination schedule among providers and mothers of adolescent girls: a mixed-methods study in five countries

PURPOSE

The World Health Organization revised its human papillomavirus (HPV) vaccination recommendations to include a two (2-) dose schedule for girls aged ≤ 15 years. We investigated acceptability of 2- versus 3-dose schedule among adolescent vaccination providers and mothers of adolescent girls in five countries.

METHODS

Adolescent vaccination providers (N = 151) and mothers of adolescent girls aged 9-14 years (N = 118) were recruited from Argentina, Malaysia, South Africa, South Korea, and Spain. We assessed providers' preference for a 2- versus 3-dose HPV vaccination schedule via quantitative surveys. Mothers' attitudes towards a 2-dose schedule were assessed through focus group discussions.

RESULTS

Most adolescent providers preferred a 2- over a 3-dose HPV vaccination schedule (overall: 74%), with preference ranging from 45.2% (South Africa) to 90.0% (South Korea). Lower cost, fewer clinic visits, and higher series completion were commonly cited reasons for 2-dose preference among providers and mothers. Safety and efficacy concerns were commonly cited barriers to accepting a 2-dose HPV vaccination schedule among providers and mothers. Mothers generally accepted the reduced schedule, however requested further information from a trusted source.

CONCLUSIONS

Adolescent vaccination providers and mothers preferred the 2-dose over 3-dose HPV vaccination schedule. Acceptability of a 2-dose HPV vaccination could be improved with additional information to providers and mothers on HPV vaccination safety and efficacy.

Provider and Parent Perspectives on Enhanced Communication Tools for Human Papillomavirus Vaccine-Hesitant Parents

OBJECTIVE

Human papillomavirus (HPV) vaccine initiation and completion rates remain far below the Healthy People 2020 goal, suggesting that additional tools and training may be needed to help medical staff provide a quality recommendation. As part of a larger pragmatic trial, we conducted a qualitative study to understand how a multifaceted communication intervention used by medical staff with HPV vaccine-hesitant parents can improve HPV vaccination rates in the primary care setting.

METHODS

At 8 primary care intervention clinics in the Denver metro area, medical staff and parents of adolescent boys and girls ages 11 to 17 years eligible to start the HPV vaccine series at a recent well care visit were recruited for study participation. Focus groups with medical staff and in-depth interviews with hesitant parents were conducted during the post-intervention period. All data were recorded, transcribed, and analyzed using established qualitative methods.

RESULTS

Twenty parents and 46 medical staff participated. All parents and medical staff felt that the overall intervention was beneficial and should continue to be used and preferred the HPV vaccine fact sheet component. Medical staff reported that communication trainings (intervention component) that taught a presumptive approach and motivational interviewing were the most beneficial for introducing the HPV vaccine and for countering HPV vaccine hesitancy, respectively. Least favorable components were the decision aid, disease images, and parent website.

CONCLUSIONS

Select components of a multifaceted communication intervention were seen as beneficial to HPV vaccine-hesitant parents and medical staff. Future studies should look at how to implement these intervention components in a greater number of primary care settings.

A retrospective and prospective look at strategies to increase adolescent HPV vaccine uptake in the United States

The HPV vaccine debuted more than ten years ago in the United States and many strategies have been evaluated to increase HPV vaccination rates, which include not only improving current vaccination behaviors but also sustaining these behaviors. Researchers and practitioners from a variety of backgrounds have engaged in this work, which has included efforts directed at public health and government policies, health education and health promotion programs, and clinical and patient-provider approaches, as well as work aimed to respond to and combat anti-HPV vaccination movements in society. Using a previously developed conceptual model to organize and summarize each of these areas, this paper also highlights the need for future HPV vaccine promotion work to adopt a multi-level and, when possible, integrated approach in order to maximize impact on vaccination rates.

HPV vaccination: Pilot study assessing characteristics of high and low performing primary care offices

This pilot study was undertaken to identify characteristics and approaches (e.g., social, behavioral, and/or systems factors) which differentiate primary care medical offices achieving higher rates of HPV vaccination. Eligible primary care practice sites providing care to adolescent patients were recruited within an eight county region of western New York State between June 2016 and July 2016. Practice sites were categorized as higher (n = 3) or lower performing (n = 2) based on three dose series completion rates for HPV vaccinations among females aged 13-17 years. Interviewer administered surveys were completed with office staff (n = 37) and focused on understanding approaches to adolescent vaccination. Results were summarized using basic descriptive statistics. Higher performing offices reported more full-time clinical staff (median = 25 vs. 9.5 in lower performing clinics), larger panels of patients ages 11-17 years (median = 3541 vs. 925) and completion of NYSIIS data entry within two weeks of vaccination. (less than a month vs. two). Staff in higher performing offices reviewed medical charts prior to scheduled visits (100% vs. 50) and identified their office vaccine champion as a physician and/or a nurse manager (75% vs. 22%). Also, staffs from higher performing offices were more likely to report the combination of having an office vaccine champion, previewing charts and using standing orders. These preliminary findings support future research examining implementation of organizational processes including identifying a vaccine champion, using standing orders and previewing medical charts prior to office visits as strategies to increase rates of HPV vaccination in primary care offices.

Effect of a Health Care Professional Communication Training Intervention on Adolescent Human Papillomavirus Vaccination: A Cluster Randomized Clinical Trial

IMPORTANCE

The incidence of human papillomavirus (HPV)-related cancers is more than 35 000 cases in the United States each year. Effective HPV vaccines have been available in the United States for several years but are underused among adolescents, the target population for vaccination. Interventions to increase uptake are needed.

OBJECTIVE

To evaluate the effect of a 5-component health care professional HPV vaccine communication intervention on adolescent HPV vaccination.

DESIGN, SETTING, AND PARTICIPANTS

A cluster randomized clinical trial using covariate-constrained randomization to assign study arms and an intent-to-treat protocol was conducted in 16 primary care practices in the Denver, Colorado, metropolitan area. Participants included 188 medical professionals and 43 132 adolescents.

INTERVENTIONS

The 5 components of the intervention were an HPV fact sheet library to create customized information sheets relevant to each practice's patient population, a tailored parent education website, a set of HPV-related disease images, an HPV vaccine decision aid, and 2½ hours of communication training on using a presumptive vaccine recommendation, followed by motivational interviewing if parents were resistant to vaccination. Each practice participated in a series of 2 intervention development meetings over a 6-month period (August 1, 2014, to January 31, 2015) before the intervention.

MAIN OUTCOMES AND MEASURES

Differences between control and intervention changes over time (ie, difference in differences between the baseline and intervention period cohorts of patients) in HPV vaccine series initiation (≥1 dose) and completion (≥3 doses) among patients aged 11 to 17 years seen at the practices between February 1, 2015, and January 31, 2016. Vaccination data were obtained from the practices' records and augmented with state immunization information system data.

RESULTS

Sixteen practices and 43 132 patients (50.3% female; median age, 12.6 years [interquartile range, 10.8-14.7 years] at the beginning of the study period) participated in this trial. Adolescents in the intervention practices had significantly higher odds of HPV vaccine series initiation (adjusted odds ratio [aOR], 1.46; 95% CI, 1.31-1.62) and completion (aOR, 1.56; 95% CI, 1.27-1.92) than those in the control practices (a 9.5-absolute percentage point increase in HPV vaccine series initiation and a 4.4-absolute percentage point increase in HPV vaccine series completion in intervention practices). The intervention had a greater effect in pediatric practices compared with family medicine practices and in private practices compared with public ones. Health care professionals reported that communication training and the fact sheets were the most used and useful intervention components.

CONCLUSIONS AND RELEVANCE

A health care professional communication intervention significantly improved HPV vaccine series initiation and completion among adolescent patients.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02456077.