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Isher-Witt J, Foley S, Hassan A, Sloan A, Nkonga J, Fisher-Borne M. Age nine is possible: Improving age 9 HPV initiation through a national quality improvement initiative during the COVID-19 pandemic. Hum Vaccin Immunother 2023; 19:2284359. [PMID: 37994120 PMCID: PMC10760390 DOI: 10.1080/21645515.2023.2284359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 11/13/2023] [Indexed: 11/24/2023] Open
Abstract
The American Cancer Society collaborated with a range of healthcare partners in 2020-2022 to implement quality improvement clinical interventions with the goal of improving HPV vaccination rates among adolescents' ages 9-13. 2020 was the first cohort for which partners had been asked to submit HPV rate data for patients' ages 9-12. At least 80% of the partners across all reported project years were able and willing to report HPV rates for these ages. Partners submitted HPV initiation rates at the beginning and end of the 12-month project year along with project activities, including evidence-based interventions (EBIs) implemented. Mean initiation rates for ages 9-10 significantly increased 4.1% during 2020 compared to non-significant rate increases of 2.6% and 2.0% for ages 11-12 and age 13, respectively. In 2021, ages 9-10 initiation saw a non-significant increase of 2.2%, whereas ages 11-12 and age 13 decreased non-significantly by 0.3% and 0.1%, respectively. The 2022 cohort saw significant initiation rate increases of at least 4% across all ages, potentially a promising result of the myriad back on track HPV vaccination campaigns designed to reverse the damage of the COVID-19 pandemic on adolescent immunizations. These findings demonstrate an effective adaptation of quality improvement in increasing HPV vaccination coverage among younger ages even during a national pandemic.
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Affiliation(s)
- Jennifer Isher-Witt
- Interventions and Implementation, American Cancer Society, Kennesaw, GA, USA
| | - Shaylen Foley
- Interventions and Implementation, American Cancer Society, Kennesaw, GA, USA
| | - Anna Hassan
- Interventions and Implementation, American Cancer Society, Kennesaw, GA, USA
| | - Amelia Sloan
- Interventions and Implementation, American Cancer Society, Kennesaw, GA, USA
| | - Jennifer Nkonga
- Interventions and Implementation, American Cancer Society, Kennesaw, GA, USA
| | - Marcie Fisher-Borne
- Interventions and Implementation, American Cancer Society, Kennesaw, GA, USA
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Balogun FM, Omotade OO. Facilitators and barriers of healthcare workers' recommendation of HPV vaccine for adolescents in Nigeria: views through the lens of theoretical domains framework. BMC Health Serv Res 2022; 22:824. [PMID: 35752809 PMCID: PMC9233785 DOI: 10.1186/s12913-022-08224-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 06/16/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The human Papillomavirus (HPV) vaccine has demonstrated efficacy in the prevention of cervical cancer when given in early adolescence. The recommendation of the vaccine by health care workers (HCW) is crucial to the uptake of the vaccine by adolescents and the process of this recommendation is important as it determines subsequent uptake of the vaccine. Understanding of the facilitators and barriers of recommendation of this vaccine can help in the development of strategies to improve its recommendation rates and uptake. This study therefore explored the facilitators and barriers for the recommendation of HPV vaccine for adolescents by HCW in Ibadan, Nigeria using the Theoretical Domain Framework (TDF). METHODS Key informant interviews were conducted with 14 purposively selected HCW who were in charge of vaccination. Content analysis was used after deductive coding of the data using the domains of the TDF. Relevant concepts for facilitators and barriers of HPV vaccine recommendation and quotes were then identified. RESULTS Mean age of the HCW was 47.7 ± 6.5 years and they consisted of eight nurses, four medical doctors, one medical social worker and one health visitor. Ten domains of the TDF were represented among the facilitators and barriers against the recommendation of HPV vaccination by the HCW, except the goals; memory, attention, decision process; emotion; and behavioral regulation domains. The domains with the highest frequency of concepts were: knowledge, skills, social/professional role and identity, beliefs about capabilities, beliefs about consequences, intention and environmental context and resources. Domains with conflicting statements in the concept were: environmental context and resources, and beliefs about consequences. While those with perceived strength of concept were: social influences, reinforcement and optimism. CONCLUSION All the 10 identified domains of the TDF are potential areas of focus for strategies for improving the recommendation of HPV vaccine for adolescents by health care workers in Nigeria and other countries with similar sociocultural settings.
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Affiliation(s)
- Folusho M Balogun
- Institute of Child Health, College of Medicine, University of Ibadan, PMB 5116, Oyo, 200001, Ibadan, Nigeria. .,Institute of Child Health, University College Hospital, Ibadan, Nigeria.
| | - Olayemi O Omotade
- Institute of Child Health, College of Medicine, University of Ibadan, PMB 5116, Oyo, 200001, Ibadan, Nigeria.,Institute of Child Health, University College Hospital, Ibadan, Nigeria
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Anyiwe K, Richardson M, Brophy J, Sander B. Assessing adolescent immunization options for pertussis in Canada: A cost-utility analysis. Vaccine 2019; 38:1825-1833. [PMID: 31889607 DOI: 10.1016/j.vaccine.2019.12.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/07/2019] [Accepted: 12/10/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Adolescent tetanus, diphtheria and pertussis (Tdap) immunization helps prevent pertussis infection. Timing of Tdap receipt represents an important facet of successful adolescent pertussis immunization. Potential strategies for timing of vaccine administration are each associated with different benefits - including disease prevention - and costs. The objective of this study was to assess the cost-utility of adolescent pertussis immunization strategies in Canada. METHODS A cost-utility analysis was conducted using a pertussis disease history-simulating Markov model, with adolescents (beginning at age 10 years) as the cohort of interest. The model assessed three Tdap vaccination strategies: (1) immunization of 10 year olds, (2) removal of adolescent vaccination, and (3) immunization of 14 year olds (status quo). The analysis was conducted from a healthcare payer perspective and used a lifetime time horizon. Primary outcomes included life years, quality-adjusted life years (QALYs), health system costs, and an incremental cost-effectiveness ratio (ICER). Costs and outcomes were discounted at 1.5 percent annually. Deterministic and probabilistic sensitivity analyses were performed to assess parameter uncertainty. RESULTS The current recommended adolescent immunization strategy (at age 14) resulted in an average of 40.4432 expected QALYs and $26.28 per individual. This strategy was dominated by immunization at 10 years and no immunization. Compared to no immunization, immunizing adolescents at age 10 had an ICER of $74,899 per QALY. Results were most sensitive to the incidence of pertussis and the utility of moderate or severe pertussis. At a cost-effectiveness threshold of $50,000/QALY, removal of adolescent vaccination represented the most cost-effective strategy in 78% of simulations. CONCLUSION Analysis assumes a policy context where immunization of pregnant women is recommended. Findings suggest that alternate adolescent Tdap vaccine strategies - either immunization of 10 year olds, or removal of the adolescent vaccine - are more cost-effective than the current practice of immunizing 14 year olds.
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Affiliation(s)
- Kika Anyiwe
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto, ON M5T 3M6, Canada; Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada.
| | - Marina Richardson
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto, ON M5T 3M6, Canada; Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
| | - Jason Brophy
- Department of Pediatrics, University of Ottawa, 451 Smyth Road, Ottawa, ON K1H 8M5, Canada; Division of Infectious Diseases, Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, ON K1H 8L1, Canada
| | - Beate Sander
- Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto, ON M5T 3M6, Canada; Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto General Hospital, University Health Network, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada; ICES, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada; Public Health Ontario, 480 University Avenue, Suite 300, Toronto, ON M5G 1V2, Canada
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Caskey R, Sherman EG, Beskin K, Rapport R, Xia Y, Schwartz A. A Behavioral Economic Approach to Improving Human Papillomavirus Vaccination. J Adolesc Health 2017; 61:755-760. [PMID: 29037471 DOI: 10.1016/j.jadohealth.2017.07.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 06/22/2017] [Accepted: 07/20/2017] [Indexed: 01/01/2023]
Abstract
PURPOSE The objectives of this study were to measure the impact of a behavioral economic intervention on human papillomavirus (HPV) vaccine initiation and series completion rates for adolescents and to measure the impact of the intervention on the receipt of a nonincentivized influenza vaccine. METHODS We conducted a quasi-randomized trial to compare the impact of an escalating delayed cash incentive (intervention), compared with usual care (control), on HPV vaccination initiation and series completion rates among adolescents (11-17 years) at an urban medical center. We measured HPV vaccine initiation and completion rates during the 12 months after enrollment and subsequent influenza vaccination rates for 24 months after enrollment. RESULTS A total of 85 participants were actively enrolled in the intervention arm and 103 were passively enrolled in the control arm. Participants were predominantly publically insured African-American and Hispanic adolescents. The majority (75%) of the intervention group received one or more doses of the HPV vaccine, with 36% completing the three-dose series, compared with 47% of the control group receiving one or more doses and only 13% completing the series. The odds of HPV p-value vaccine initiation (odds ratio 4.19 [95% confidence interval 1.84-10.10], p < .01) and HPV vaccine series completion (OR 4.16 [95% confidence interval 1.64-11.28], p < .01) were greater among the intervention group compared with the control group. There was no difference in influenza vaccination rates between the intervention group and the control group during the 2013-2014 season (p = .138) and during the 2014-2015 influenza season (p value .683). CONCLUSIONS An incentive-based approach to HPV vaccination was effective in increasing vaccine initiation and series dose completion.
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Affiliation(s)
- Rachel Caskey
- Department of Pediatrics, University of Illinois at Chicago, Chicago, Illinois; Department of Medicine, University of Illinois at Chicago, Chicago, Illinois.
| | - E Grace Sherman
- School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Kera Beskin
- School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Rebecca Rapport
- School of Public Health, University of Illinois at Chicago, Chicago, Illinois
| | - Yinglin Xia
- Department of Medicine, University of Illinois at Chicago, Chicago, Illinois
| | - Alan Schwartz
- Department of Medical Education, University of Illinois at Chicago, Chicago, Illinois
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Westrick SC, Hohmann LA, McFarland SJ, Teeter BS, White KK, Hastings TJ. Parental acceptance of human papillomavirus vaccinations and community pharmacies as vaccination settings: A qualitative study in Alabama. Papillomavirus Res 2016; 3:24-29. [PMID: 28720453 PMCID: PMC5883249 DOI: 10.1016/j.pvr.2016.12.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 10/10/2016] [Accepted: 12/21/2016] [Indexed: 11/19/2022]
Abstract
Purpose To determine parents’ knowledge and attitudes regarding human papillomavirus (HPV) vaccinations in their adolescent children and to describe parents’ perceptions of adolescent vaccinations in community pharmacies. Methods In-depth interviews were completed with parents or guardians of children ages 11–17 years from Alabama's Lee and Macon counties. One-hour long, open-ended telephonic or in-person interviews were conducted until the saturation point was reached. Using ATLAS.ti software and thematic analysis, interview transcripts were coded to identify themes. Results Twenty-six parents were interviewed, most of whom were female (80.8%) and white (50%). A total of 12 themes were identified. First, two themes emerged regarding elements facilitating children's HPV vaccination, the most common being positive perception of the HPV vaccine. Second, elements hindering children's vaccination contained seven themes, the top one being lack of correct or complete information about the HPV vaccine. The last topic involved acceptance/rejection of community pharmacies as vaccination settings, and the most frequently cited theme was concern about pharmacists’ clinical training. Conclusions Physician-to-parent vaccine education is important, and assurances of adequate pharmacy immunization training will ease parents’ fears and allow pharmacists to better serve adolescents, especially those who do not see physicians regularly. Physicians play a crucial role in parents’ HPV vaccination decisions. Parents are reluctant to use pharmacists as HPV vaccine providers. Parents are concerned about pharmacists’ training and pharmacy infrastructure. Community pharmacists must work in conjunction with physicians.
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Affiliation(s)
- Salisa C Westrick
- Health Outcomes Research and Policy, Harrison School of Pharmacy Auburn University, 020 James E. Foy Hall, Aub urn University, AL 36849, USA.
| | - Lindsey A Hohmann
- Health Outcomes Research and Policy, Harrison School of Pharmacy Auburn University, 020 James E. Foy Hall, Aub urn University, AL 36849, USA.
| | - Stuart J McFarland
- Health Outcomes Research and Policy, Harrison School of Pharmacy Auburn University, 020 James E. Foy Hall, Aub urn University, AL 36849, USA.
| | - Benjamin S Teeter
- University of Arkansas for Medical Sciences, 4301 W Markham St, Little Rock, AR 72205, USA.
| | - Kara K White
- Health Outcomes Research and Policy, Harrison School of Pharmacy Auburn University, 020 James E. Foy Hall, Aub urn University, AL 36849, USA.
| | - Tessa J Hastings
- Health Outcomes Research and Policy, Harrison School of Pharmacy Auburn University, 020 James E. Foy Hall, Aub urn University, AL 36849, USA.
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Salam RA, Das JK, Lassi ZS, Bhutta ZA. Adolescent Health Interventions: Conclusions, Evidence Gaps, and Research Priorities. J Adolesc Health 2016; 59:S88-S92. [PMID: 27664599 PMCID: PMC5026678 DOI: 10.1016/j.jadohealth.2016.05.006] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 04/14/2016] [Accepted: 05/03/2016] [Indexed: 12/02/2022]
Abstract
Adolescent health care is challenging compared to that of children and adults, due to their rapidly evolving physical, intellectual, and emotional development. This paper is the concluding paper for a series of reviews to evaluate the effectiveness of interventions for improving adolescent health and well-being. In this paper, we summarize the evidence evaluated in the previous papers and suggest areas where there is enough existing evidence to recommend implementation and areas where further research is needed to reach consensus. Potentially effective interventions for adolescent health and well-being include interventions for adolescent sexual and reproductive health, micronutrient supplementation, nutrition interventions for pregnant adolescents, interventions to improve vaccine uptake among adolescents, and interventions for substance abuse. Majority of the evidence for improving immunization coverage, substance abuse, mental health, and accidents and injury prevention comes from high-income countries. Future studies should specifically be targeted toward the low- and middle-income countries with long term follow-up and standardized and validated measurement instruments to maximize comparability of results. Assessment of effects by gender and socioeconomic status is also important as there may be differences in the effectiveness of certain interventions. It is also important to recognize ideal delivery platforms that can augment the coverage of proven adolescent health-specific interventions and provide an opportunity to reach hard-to-reach and disadvantaged population groups.
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Affiliation(s)
- Rehana A. Salam
- Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Jai K. Das
- Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Zohra S. Lassi
- Robinson Research Institute, University of Adelaide, Adelaide, Australia
| | - Zulfiqar A. Bhutta
- Centre for Global Child Health, The Hospital for Sick Children, Toronto, Ontario, Canada,Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan,Address correspondence to: Zulfiqar A. Bhutta, Ph.D., Centre for Global Child Health, The Hospital for Sick Children, 686 Bay Street, Toronto, Ontario M6S 1S6, Canada.Centre for Global Child Health, The Hospital for Sick Children686 Bay StreetTorontoOntarioM6S 1S6Canada
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Seib K, Underwood NL, Gargano LM, Sales JM, Morfaw C, Weiss P, Murray D, Vogt TM, DiClemente RJ, Hughes JM. Preexisting Chronic Health Conditions and Health Insurance Status Associated With Vaccine Receipt Among Adolescents. J Adolesc Health 2016; 58:148-53. [PMID: 26683985 DOI: 10.1016/j.jadohealth.2015.10.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Revised: 10/15/2015] [Accepted: 10/15/2015] [Indexed: 11/17/2022]
Abstract
PURPOSE Four vaccines are routinely recommended for adolescents: tetanus, diphtheria, and acellular pertussis (Tdap); human papillomavirus (HPV); meningococcal-conjugate (MCV4); and a yearly seasonal influenza vaccine. Vaccination promotion and outreach approaches may need to be tailored to certain populations, such as those with chronic health conditions or without health insurance. METHODS In a controlled trial among middle and high school students in Georgia, 11 schools were randomized to one of three arms: no intervention, parent education brochure, or parent education brochure plus a student curriculum on the four recommended vaccines. Parents in all arms were surveyed regarding their adolescent's vaccine receipt, chronic health conditions, and health insurance status. RESULTS Of the 686 parents, most (91%) reported their adolescent had received at least one of the four vaccines: Tdap (82%), MCV4 (59%), current influenza vaccine (53%) and HPV (48%). Twenty-three percent of parents reported that their adolescent had asthma. Most parents reported that their adolescent's insurance was Medicaid (60%) or private insurance (34%), and 6% reported no insurance. More adolescents with a chronic health condition received any adolescent vaccine than adolescents without a chronic health condition (p < .0001). Among those with no insurance, fewer had received any adolescent vaccine than those with Medicaid or private insurance (p < .0001). CONCLUSIONS The federal Vaccines for Children program offers recommended vaccines free to eligible children (including those without health insurance). Our findings suggest that parents may not be aware of this program or eligibility for it, thus revealing a need for education or other fixes.
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Affiliation(s)
- Katherine Seib
- Division of Infectious Diseases, School of Medicine, Emory University, Atlanta, Georgia.
| | - Natasha L Underwood
- Division of Infectious Diseases, School of Medicine, Emory University, Atlanta, Georgia
| | - Lisa M Gargano
- Division of Infectious Diseases, School of Medicine, Emory University, Atlanta, Georgia
| | - Jessica M Sales
- Rollins School of Public Health, Department of Behavioral Sciences and Health Education, Emory University, Atlanta, Georgia
| | - Christopher Morfaw
- East Central Health District, Georgia Department of Public Health, Augusta, Georgia
| | - Paul Weiss
- Rollins School of Public Health, Department of Biostatistics and Bioinformatics, Emory University, Atlanta, Georgia
| | - Dennis Murray
- Department of Pediatrics, School of Medicine, Georgia Regents University, Augusta, Georgia
| | - Tara M Vogt
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ralph J DiClemente
- Rollins School of Public Health, Department of Behavioral Sciences and Health Education, Emory University, Atlanta, Georgia
| | - James M Hughes
- Division of Infectious Diseases, School of Medicine, Emory University, Atlanta, Georgia
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Cates JR, Diehl SJ, Crandell JL, Coyne-Beasley T. Intervention effects from a social marketing campaign to promote HPV vaccination in preteen boys. Vaccine 2014; 32:4171-8. [PMID: 24886960 DOI: 10.1016/j.vaccine.2014.05.044] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 05/01/2014] [Accepted: 05/07/2014] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Adoption of human papillomavirus (HPV) vaccination in the US has been slow. In 2011, HPV vaccination of boys was recommended by CDC for routine use at ages 11-12. We conducted and evaluated a social marketing intervention with parents and providers to stimulate HPV vaccination among preteen boys. METHODS We targeted parents and providers of 9-13 year old boys in a 13 county NC region. The 3-month intervention included distribution of HPV vaccination posters and brochures to all county health departments plus 194 enrolled providers; two radio PSAs; and an online CME training. A Cox proportional hazards model was fit using NC immunization registry data to examine whether vaccination rates in 9-13 year old boys increased during the intervention period in targeted counties compared to control counties (n=15) with similar demographics. To compare with other adolescent vaccines, similar models were fit for HPV vaccination in girls and meningococcal and Tdap vaccination of boys in the same age range. Moderating effects of age, race, and Vaccines for Children (VFC) eligibility on the intervention were considered. RESULTS The Cox model showed an intervention effect (β=0.29, HR=1.34, p=.0024), indicating that during the intervention the probability of vaccination increased by 34% in the intervention counties relative to the control counties. Comparisons with HPV vaccination in girls and Tdap and meningococcal vaccination in boys suggest a unique boost for HPV vaccination in boys during the intervention. Model covariates of age, race and VFC eligibility were all significantly associated with vaccination rates (p<.0001 for all). HPV vaccination rates were highest in the 11-12 year old boys. Overall, three of every four clinic visits for Tdap and meningococcal vaccines for preteen boys were missed opportunities to administer HPV vaccination simultaneously. CONCLUSIONS Social marketing techniques can encourage parents and health care providers to vaccinate preteen boys against HPV.
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Affiliation(s)
- Joan R Cates
- School of Journalism and Mass Communication, University of North Carolina at Chapel Hill, Campus Box 3365, Chapel Hill, NC 27599-3365, United States.
| | - Sandra J Diehl
- NC TraCS Institute, Community Academic Resources for Engaged Scholarship (CARES), Home of the UNC Clinical and Translational Science Awards (CTSA), University of North Carolina at Chapel Hill, CB# 7064, Chapel Hill, NC 27599-7064, United States.
| | - Jamie L Crandell
- School of Nursing and Department of Biostatistics, University of North Carolina at Chapel Hill, 2011 Carrington Hall, Campus Box 7460, Chapel Hill, NC 27599-7460, United States.
| | - Tamera Coyne-Beasley
- NC Child Health Research Network, Community Engagement NC TraCS Institute - Child Health Core Home of the UNC-CH Clinical and Translational Science Awards (CTSA), United States; Division of General Pediatrics and Adolescent Medicine, University of North Carolina at Chapel Hill, CB # 7225, 231 MacNider, Chapel Hill, NC 27599, United States.
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