Intervention effects from a social marketing campaign to promote HPV vaccination in preteen boys

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.     

Effectiveness of a provider-focused intervention to improve HPV vaccination rates in boys and girls

BackgroundHPV vaccination is universally recommended for boys and girls, yet vaccination rates remain low nationwide.MethodsWe conducted a provider-focused intervention that included repeated contacts, education, individualized feedback, and strong quality improvement incentives to raise HPV vaccination rates at two federally qualified community health centers. To estimate the effectiveness of the intervention, rates of initiation of vaccination, and completion of the next needed HPV vaccination (dose 1, 2 or 3) among boys and girls ages 11–21 were compared at baseline and two follow-up periods in two intervention health centers (n  4093 patients) and six control health centers (n  9025 patients). We conducted multivariable logistic regression accounting for clustering by practice.ResultsGirls and boys in intervention practices significantly increased HPV vaccine initiation during the active intervention period relative to control practices (girls OR 1.6, boys OR 11; p < 0.001 for both). Boys at intervention practices were also more likely to continue to initiate vaccination during the post-intervention/maintenance period (OR 8.5; p < 0.01). Girls and boys at intervention practices were more also likely to complete their next needed HPV vaccination (dose 1, 2 or 3) than those at control practices (girls OR 1.4, boys OR 23; p < 0.05 for both). These improvements were sustained for both boys and girls in the post-intervention/maintenance period (girls OR 1.6, boys OR 25; p < 0.05 for both).ConclusionsProvider-focused interventions including repeated contacts, education, individualized feedback, and strong quality improvement incentives have the potential to produce sustained improvements in HPV vaccination rates.     

HPV vaccination among adolescent males: Results from the National Immunization Survey-Teen

US guidelines provided a permissive recommendation for HPV vaccine for males in 2009, with an updated recommendation for routine vaccination in 2011. Data on vaccine uptake among males, however, remain sparse. We analyzed 2010–2011 data (collected mostly prior to the recommendation for routine vaccination) from the National Immunization Survey-Teen for a nationally representative sample of adolescent males ages 13–17 (n = 22,365). We examined HPV vaccine initiation (receipt of at least one dose based on healthcare provider records) as the primary outcome. Analyses used weighted logistic regression. HPV vaccine initiation increased from 1.4% in 2010 to 8.3% in 2011. Parents who reported receiving a healthcare provider recommendation to get their sons HPV vaccine were much more likely to have vaccinated sons (OR = 19.02, 95% CI: 14.36–25.19). Initiation was also higher among sons who were Hispanic (OR = 1.83, 95% CI: 1.24–2.71) or who were eligible for the Vaccines for Children program (OR = 1.53, 95% CI: 1.01–2.31). Only 31.0% of parents with unvaccinated sons indicated their sons were “somewhat likely” or “very likely” to receive HPV vaccine in the next year. The most common main reasons for parents not intending to vaccinate were believing vaccination is not needed or not necessary (24.5%), not having received a provider recommendation (22.1%), and lack of knowledge (15.9%). HPV vaccination is low among adolescent males in the US, and provider recommendation for vaccination is likely key to improving vaccine uptake. Given the updated recommendation for routine vaccination and the changes in health insurance coverage that are likely to follow, continued efforts are needed to monitor HPV vaccination among males.     

Immunization stress-related responses presenting as psychogenic non-epileptic seizures following HPV vaccination in Rio Branco,Brazil

ImportanceThe absence of a positive diagnosis of psychogenic non-epileptic seizures (PNES) in immunization stress-related response (ISRR) clusters may have not only a direct impact on affected patients’ health but may also reduce compliance to national vaccination programs. It is therefore crucial to develop efficient diagnostic tools and a feasible proposal for proper communication and treatment of ISRR.PurposeTo explore the psychogenic nature of patients’ convulsive seizures in a suspected outbreak of an ISRR cluster following human papillomavirus vaccination in Rio Branco, Brazil.MethodsTwelve patients with convulsive seizures were submitted to prolonged intensive video-electroencephalography monitoring, brain magnetic resonance imaging, cerebrospinal fluid diagnostic testing, laboratory subsidiary examinations, and complete neurological and psychiatric evaluations.ResultsTen patients received the positive diagnosis of PNES, and two patients received the diagnosis of idiopathic generalized epilepsy. No biological association was found between the HPV vaccine and the clinical problems presented by the patients.ConclusionsProlonged VEEG monitoring can contribute significantly to the positive diagnosis of PNES in ISRR clusters and to avoid hesitancy to vaccinate.     

Outsmart HPV: Acceptability and short-term effects of a web-based HPV vaccination intervention for young adult gay and bisexual men

BackgroundEffective interventions to promote human papillomavirus (HPV) vaccination are needed, particularly among populations at increased risk of HPV-related disease. We developed and pilot tested a web-based intervention, Outsmart HPV, to promote HPV vaccination among young gay and bisexual men (YGBM).MethodsIn 2016, we recruited a national sample (n = 150) of YGBM ages 18–25 in the United States who had not received any doses of HPV vaccine. Participants were randomized to receive either standard HPV vaccination information (control) or population-targeted, individually-tailored content (Outsmart HPV intervention). We assessed between group differences in HPV vaccination attitudes and beliefs immediately following the intervention using multiple linear regression.ResultsThere were no differences in HPV vaccination attitudes, beliefs and intentions between groups at baseline. Compared to participants in the control group, intervention participants reported: greater perception that men who have sex with men are at higher risk for anal cancer relative to other men (b = 0.34); greater HPV vaccination self-efficacy (b = 0.15); and fewer perceived harms of HPV vaccine (b = −0.34) on posttest surveys (all p < .05). Overall, intervention participants reported high levels of acceptability and satisfaction with the Outsmart HPV intervention (all > 4.4 on a 5-point scale).ConclusionsFindings from this study provide preliminary support for a brief, tailored web-based intervention in improving HPV vaccination attitudes and beliefs among YGBM. An important next step is to determine the effects of Outsmart HPV on HPV vaccine uptake.Clinical trials registrationClinicalTrials.gov identifier NCT02835755.     

Factors associated with continued adherence to influenza vaccination in the elderly

Objective

We aimed to analyze the factors influencing continued adherence to influenza vaccination in elderly persons vaccinated in the preceding season.

Methods

Using a population-based vaccination registry, we evaluated the proportion of persons vaccinated against influenza in Navarre, Spain, in the 2010-11 season among non-institutionalized persons aged 65 years or over who had been vaccinated in the 2009-10 season. Logistic regression was used to analyze the influence of sociodemographic, clinical and health care factors.

Results

Of the 64,245 persons vaccinated against influenza in the 2009-10 season, 87% were vaccinated in the 2010-11 season. Continued adherence to vaccination increased with the number of physician visits per year. It was lower in women, in the 65-69 and ≥ 95 year age-groups, in those hospitalized or diagnosed with any major chronic condition in the previous year, and in persons with hematological cancer or dementia. Health districts and physicians with higher coverage in the previous season continued to have higher adherence in the following season.

Conclusions

People vaccinated against influenza in one season tend to be vaccinated in the following one. Sociodemographic, clinical and health care factors have a moderate effect on the continuity of vaccination, with the most important factor being the treating physician.     

County-level correlates of missed opportunities for HPV vaccination in Indiana: An environmental scan

BackgroundThe goal of this study was to examine variability across the 92 Indiana counties in missed opportunities for HPV vaccination and to assess county-level correlates of missed opportunities.MethodsThe Indiana immunization registry provided county level data on 2017 missed opportunity rates for adolescents ages 11–18. A missed opportunity was an encounter when a patient eligible for HPV vaccination received one or more other recommended vaccines, but not HPV. Potential county-level correlates of missed opportunities included race, income, population density, education, primary care providers per capita, smoking rates, mammography screening, diabetes monitoring, and Pap testing.ResultsThe missed opportunity rate ranged from 31% to 85% across Indiana counties. Higher population density, mammography screening, income inequality, and diabetes monitoring were associated with fewer missed opportunities.ConclusionsWe found wide variability in missed opportunities across counties, which were associated with population density and county-level participation in other health-related behaviors.Sources of supportThis study was supported by the National Cancer Institute under Award Number P30 CA082709-18S4.     

Provider communication and HPV vaccination: The impact of recommendation quality

BackgroundReceiving a healthcare provider's recommendation is a strong predictor of HPV vaccination, but little is known empirically about which types of recommendation are most influential. Thus, we sought to investigate the relationship between recommendation quality and HPV vaccination among U.S. adolescents.MethodsIn 2014, we conducted a national, online survey of 1495 parents of 11–17-year-old adolescents. Parents reported whether providers endorsed HPV vaccination strongly, encouraged same-day vaccination, and discussed cancer prevention. Using an index of these quality indicators, we categorized parents as having received no, low-quality, or high-quality recommendations for HPV vaccination. Separate multivariable logistic regression models assessed associations between recommendation quality and HPV vaccine initiation (≥1 dose), follow through (3 doses, among initiators), refusal, and delay.ResultsAlmost half (48%) of parents reported no provider recommendation for HPV vaccination, while 16% received low-quality recommendations and 36% received high-quality recommendations. Compared to no recommendation, high-quality recommendations were associated with over nine times the odds of HPV vaccine initiation (23% vs. 74%, OR = 9.31, 95% CI, 7.10–12.22) and over three times the odds of follow through (17% vs. 44%, OR = 3.82, 95% CI, 2.39–6.11). Low-quality recommendations were more modestly associated with initiation (OR = 4.13, 95% CI, 2.99–5.70), but not follow through. Parents who received high- versus low-quality recommendations less often reported HPV vaccine refusal or delay.ConclusionsHigh-quality recommendations were strongly associated with HPV vaccination behavior, but only about one-third of parents received them. Interventions are needed to improve not only whether, but how providers recommend HPV vaccination for adolescents.     

Prevention of cervical cancer in rural China: evaluation of HPV vaccination and primary HPV screening strategies

Comprehensive evaluation of the cost-effectiveness of HPV vaccination in China has not previously been performed. The objective of this study was to evaluate vaccination as an alternative or addition to primary HPV screening with careHPV (Qiagen, Gaithersburg, USA), and to assess the threshold total cost per vaccinated girl (CVG) at which strategies involving vaccination would become viable compared to screening-only strategies in rural China. We used data from field studies in Shanxi Province to support modelling of HPV vaccination and screening, including local information on sexual behaviour, HPV prevalence, test accuracy, treatment protocols and costs. We evaluated several strategies involving screening once or twice per lifetime or at regular 5-yearly intervals, with or without vaccination of young females at age 15 years, assuming 70% coverage for both screening and vaccination. We also predicted cross-sectional cancer incidence each year to the year 2050 for a range of strategies. We found that strategies involving vaccination would be cost-effective at CVGs of US$50-54 or less, but at CVGs >$54, screening-only strategies would be more cost-effective. If vaccination of young cohorts is combined with two rounds of careHPV screening for women aged 30-59 years in 2012 and 2027, a predicted indicative 33% reduction in cervical cancer incidence by 2030 would be sustained until 2050, with incidence rates decreasing thereafter. In conclusion, taking into account estimated vaccine delivery costs (for 3 doses), a per-dose HPV vaccine cost of approximately <$9-14 would be required for strategies involving vaccination to be cost-effective. Overall, combined screening and vaccination approaches are required to maximise outcomes in rural China.     

How acceptable is adolescent self-consent for the HPV vaccination: Findings from a qualitative study in south-west England

BackgroundHuman Papillomavirus (HPV) vaccination programmes have the potential to reduce the incidence of cervical cancer. The preferred age for HPV vaccination is 12–13 years for optimal benefit. The legal framework in England allows adolescents to be vaccinated without parental consent if they are assessed as competent. A ‘South West Template Pathway on Self Consent for School Aged Immunisations’ was developed to improve uptake of immunisations in south-west England.Study aimTo examine how acceptable the new procedures are to the young women, parents and carers, school staff and immunisation nurses involved.MethodsThe research was undertaken in two local authorities in south-west England during the 2017/18 and 2018/19 programme years. Semi-structured digitally recorded interviews were undertaken with 53 participants: one health service manager, three immunisation nurses, five staff at alternative education providers, three staff at mainstream schools, 19 young women and 22 parents. All recordings were transcribed verbatim and thematic analysis was undertaken, assisted by NVivo software.ResultsMost participants were not fully aware of the legal framework that enables a young person to self-consent to vaccination. There was a strong presumption that parents should make decisions affecting the health of their children. The preferred age at which the HPV vaccination is administered (12–13 years) contributed to reluctance in endorsing self-consent which was thought to have the potential to break down trust between parents and school staff, and within families. In practice, formal self-consent was rare.ConclusionUnresolved issues in relation to adolescent self-consent include public and professional perceptions of young people’s rights and abilities to take responsibility for decisions affecting their health, and concerns about the impact of self-consent on relationships both within families and between professionals and the families they serve.     

Identifying human papillomavirus vaccination practices among primary care providers of minority,low-income and immigrant patient populations

Objective

Minority populations in the United States are disproportionally affected by human papillomavirus (HPV) infection and HPV-related cancer. We sought to understand physician practices, knowledge and beliefs that affect utilization of the HPV vaccine in primary care settings serving large minority populations in areas with increased rates of HPV-related cancer.

Study design

Cross-sectional survey of randomly selected primary care providers, including pediatricians, family practice physicians and internists, serving large minority populations in Brooklyn, N.Y. and in areas with higher than average cervical cancer rates.

Results

Of 156 physicians randomly selected, 121 eligible providers responded to the survey; 64% were pediatricians, 19% were internists and 17% were family practitioners. Thirty-four percent of respondents reported that they routinely offered HPV vaccine to their eligible patients. Seventy percent of physicians reported that the lack of preventive care visits for patients in the eligible age group limited their ability to recommend the HPV vaccine and 70% of those who reported this barrier do not routinely recommend HPV vaccine. The lack of time to educate parents about the HPV vaccine and cost of the vaccine to their patients were two commonly reported barriers that affected whether providers offered the vaccine.

Conclusions

Our study found that the majority of providers serving the highest risk populations for HPV infection and HPV-related cancers are not routinely recommending the HPV vaccine to their patients. Reasons for providers’ failure to recommend the HPV vaccine routinely are identified and possible areas for targeted interventions to increase HPV vaccination rates are discussed.     

Strategies to vaccinate against cancer of the cervix: feasibility of a school-based HPV vaccination program in Peru

Operational research using a mixed method, cross-sectional, case-study approach assessed the feasibility and health system impact of large-scale implementation of human papillomavirus (HPV) vaccination into routine vaccine delivery by the Ministry of Health in Peru. The strategy was school-based vaccination of fifth grade girls in 527 primary schools in Piura region. Our evaluation showed that school-based HPV vaccination is feasible without major changes in existing health systems. This was reflected in the opinions of health personnel, the lack of impact on other vaccine coverage, and the high HPV vaccine coverage documented in routine records and by an independent community-based survey.     

Changing the default to promote influenza vaccination among health care workers

BackgroundThe prevention of health care acquired infections is an important objective for patient safety and infection control in all health care settings. Influenza vaccination uptake among health care workers (HCWs) is the most effective method to prevent transmission to patients, but vaccination coverage rates are low among HCWs. Several educational campaigns have been developed to increase the influenza vaccination coverage rates of HCWs, but showed only small effects. The aim of this study was to test an opt-out strategy in promoting uptake among HCWs in a tertiary care center for patients with complex chronic organ failure.MethodsHCWs were randomly assigned to one of two conditions. In the opt-out condition (N = 61), participants received an e-mail with a pre-scheduled appointment for influenza vaccination, which could be changed or canceled. In the opt-in condition (N = 61), participants received an e-mail explaining that they had to schedule an appointment if they wanted to get vaccinated.ResultsThe findings show no statistically detectable effect of condition on being vaccinated against influenza. However, HCWs in the opt-out condition were more likely to have an appointment for influenza vaccination, which in turn increased the probability of getting vaccinated.ConclusionTo change the default to promote influenza vaccination among HCWs might be an easy and cost-effective alternative to the complex vaccination campaigns that have been proposed in recent years.     

A multilevel analysis of factors influencing the inaccuracy of parental reports of adolescent HPV vaccination status

Background

Parental reports are commonly used for adolescent HPV vaccination status but may be subjected to bias. Guided by the Socioecological Framework, our study explores potential multilevel factors influencing the inaccuracy of parental reports of adolescent HPV vaccination status.

Contribution of primary care to health systems and health

Evidence of the health-promoting influence of primary care has been accumulating ever since researchers have been able to distinguish primary care from other aspects of the health services delivery system. This evidence shows that primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care. The evidence also shows that primary care (in contrast to specialty care) is associated with a more equitable distribution of health in populations, a finding that holds in both cross-national and within-national studies. The means by which primary care improves health have been identified, thus suggesting ways to improve overall health and reduce differences in health across major population subgroups.     

A qualitative study of parental views of HPV vaccination in Ireland

BackgroundDespite significant evidence supporting the Human Papillomavirus (HPV) vaccine in the prevention of cervical cancer, uptake of this vaccine is below target in many countries. HPV uptake in Ireland has declined from 87% in 2014–15 to 51% in 2016–17 and currently remains suboptimal at 64.1% in 2017–18.ObjectivesThis study aimed to explore parental views of the HPV vaccine; elucidate specific concerns relating to this vaccine and to identify relevant influences on the decision to vaccinate against HPV to inform strategies to optimise uptake.MethodsAn in-depth qualitative study, using semi-structured interviews was conducted among parents of 11–13-year-old girls (n = 18) who had not yet been offered the HPV vaccine. Convenience sampling was used. Interviews, conducted in the Republic of Ireland over six-months in 2018, were audio-recorded, transcribed, and analysed by thematic analysis.ResultsEighteen interviews were conducted (14 female and 4 male participants). Parents favoured HPV vaccination to protect their daughters and prevent disease. Barriers to vaccination included; the fear of long-term side effects, lack of knowledge and the risk versus benefit ratio. General practitioners (GPs) were identified as having a strong influence over parental vaccination decisions, as did media reports and the recent cervical screening programme controversy in Ireland.ConclusionThis study suggests that significant parental concerns remain to the HPV vaccine. More comprehensive information on the research surrounding this vaccine’s safety profile is required. GP’s may play a pivotal role in HPV vaccination going forward.     

How to screen for cervical cancer after HPV16/18 vaccination in The Netherlands

In The Netherlands, vaccination against HPV16/18 has been recommended for all 12-year-old girls. Because screening of vaccinated women remains important, we evaluated the model-based cost-effectiveness of cervical cancer screening strategies. We considered cytology and the HPV DNA test as primary screening instrument, varied the number of screening rounds from 7 to 4, and set the screening starting age at 30 and 35 years. Our model predicted reductions in cervical cancer mortality between 60 and 81% (from 199 deaths to 37–79) when adding screening to vaccination (assumptions for vaccination: 95% efficacy, 100% compliance, lifelong protection). Screening 5 times with HPV DNA (€11,133/QALY) or 7 times with cytology (€17,627/QALY) were scenarios with comparable costs and effects and incremental cost-effectiveness ratios below the threshold in The Netherlands (€20,000 per QALY).