Human Papillomavirus Vaccinations During the COVID-19 Pandemic in Middle Schools in the Rio Grande Valley of Texas

Multilevel perspectives on school-based opportunities to improve HPV vaccination among medically underserved adolescents: Beyond school entry mandates

School-based HPV vaccination programs have improved vaccine uptake among adolescents globally. However, school-based HPV vaccination strategies in the United States (US) have mainly focused on school-entry mandates for vaccination, which have passed in only five states/jurisdictions. Many schools and school-based health centers (SBHCs) already provide health services to medically underserved adolescents and opportunities to improve disparities in HPV vaccine education and uptake are underexplored. This qualitative study of clinic and community members assessed potential opportunities within and outside schools to increase HPV vaccination. Data were generated from a larger mixed-methods study designed to understand experiences with HPV vaccination evidence-based strategies in medically underserved communities. The parent study included interviews and focus groups conducted with clinic (providers, clinic leaders, staff) and community (racial/ethnic minority parents, advocates, payers, policy representatives) members in Los Angeles and New Jersey between December 2020-January 2022. We created a reduced dataset of text related to schools/SBHCs (30 in-depth interviews, 7 focus groups) and conducted a directed content analysis. Participants indicated that schools and SBHCs are ideal venues for reaching medically underserved adolescents experiencing barriers to primary care access. Parents/providers expressed mutual interest in HPV vaccine administration/education in schools, but some advocates/policy participants experienced challenges due to increasing politicization of vaccines. Participants highlighted policies for expanding HPV vaccine education and administration in schools, including minor consent and increasing SBHC funding for HPV vaccines. More research is needed to explore existing infrastructure, partner motivation, and opportunities to improve HPV vaccination among medically underserved adolescents within schools beyond vaccine mandates.

Lessons Learned from All for Them: Best Practices for a Cross-Collaboration Approach to HPV Vaccination in Public Schools

The Community Preventive Services Task Force endorses vaccination programs in schools to increase access to vaccinations. However, implementing a school-based approach requires substantial coordination, planning, and resources. All for Them (AFT) is a multilevel, multicomponent approach to increase HPV vaccination among adolescents attending public schools in medically underserved areas in Texas. AFT comprised a social marketing campaign, school-based vaccination clinics, and school nurse continuing education. Process evaluation metrics and key informant interviews to understand experiences with AFT program implementation informed lessons learned. Lessons emerged in six domains: strong champion, school-level support, tailored and cost-effective marketing approaches, mobile provider collaboration, community presence, and crisis management. Strong support at district and school levels is vital for gaining principal and school nurse buy-in. Social marketing strategies are integral to program implementation and should be adjusted to maximize their effectiveness in motivating parents to vaccinate children against HPV, which also can be achieved through increased community presence of the project team. Preparing contingency plans and flexibility within the program can facilitate appropriate responses to provider restrictions in mobile clinics or in the event of unforeseen crises. These important lessons can offer useful guidelines for the development of prospective school-based vaccination programs.

Human Papillomavirus Vaccination Uptake in the Rio Grande Valley: Results from a Pilot Community-Based Educational and School-Based Vaccination Program and Its Expansion

Human papillomavirus (HPV) vaccine is a safe and effective strategy for reducing HPV morbidity and mortality. Schools have become an increasingly attractive setting for delivering vaccinations and supporting vaccination health literacy and decisional support. This study assesses the effectiveness of a community-based, physician-led HPV education campaign (starting in 2016) and onsite middle school-based HPV vaccination program across six school districts (2017, 2019, 2020) in a rural, medically underserved Texas area (Rio Grande Valley). Pre- and post-intervention HPV vaccination rates were tracked against the 2016 National Immunization Survey-Teen target rates (initiation: 49.3%; completion: 32.9%). Summary statistics were stratified by gender, school district, and grade level. The study reached 19,951 students who received HPV vaccines directly or indirectly through our program (10,289 females; 9662 males) (August 2016-August 2022). Of those, 2145 students (1074 females; 1071 males) were vaccinated directly through our program. The overall HPV up-to-date (UTD) rates were 58.8%. The overall median age at HPV vaccine initiation and HPV-UTD (range) was 11 years (9-21) and 12 years (9-20). The overall median interval between HPV vaccine doses (range) was 291 days (146-2968). Recommending HPV vaccine initiation at younger ages increases HPV vaccine completion and providing access to HPV vaccines encourages on-time vaccination and completion.

Human papillomavirus vaccinations at recommended ages: How a middle school-based educational and vaccination program increased uptake in the Rio Grande Valley

Human papillomavirus (HPV) vaccination is recommended for U.S. adolescents at ages 11-12 requiring two or three doses depending on if the vaccine series started before age 15. The objective was to compare HPV vaccination rates among medically underserved, economically disadvantaged, students in rural middle school districts (Rio Grande Valley [RGV], Texas) by age of initiation (≤ age 11 years vs. age 12 years and older). This quasi-experimental study included 1,766 students (884 females; 882 males) who received at least one HPV vaccine dose through our school-based vaccination program between 08/2016-06/2022. Summary statistics were stratified by age at initiation and gender. The overall HPV up-to-date (UTD) rate was 59.7% (95% Confidence Interval: 57.4-62.0%). The median age at HPV UTD (range) was 12 years (9-19) and median interval between HPV vaccine doses (range) was 316 days (150-2,855). Most students received the HPV vaccine bundled with other vaccinations (72.4%, 1,279/1,766). There was a higher HPV UTD rate among students who initiated the HPV vaccine on or before age 11 than those who initiated on or after age 12 (73.6% versus 45.1%, respectively). The median age of HPV UTD was age 12 for those initiating on or before 11 years versus age 13 for those initiating on or after 12 years of age. Initiating the HPV vaccine at age ≤11 years increased completion of the HPV vaccine series. Improving HPV vaccine coverage and introduction of pan-gender vaccination programs will significantly decrease HPV-related diseases in the RGV.