CE/CME

How to Increase HPV Vaccination Rates

Clinician Reviews. 2017 September;27(9):40-46

References

1. Juckett G, Hartsman-Adams H. Human papillomavirus: clinical manifestations and prevention. Am Fam Physician. 2010;82(10):1209-1213.
2. Markowitz LE, Dunne EF, Saraiya M, et al. Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2014;63(RR-05):1-30.
3. Viens LJ, Henley SJ, Watson M, et al. Human papillomavirus-associated cancers—United States, 2008-2012. MMWR Morb Mortal Wkly Rep. 2016;65(26):661-666.
4. American Cancer Society. Cancer facts and figures 2016. Atlanta: American Cancer Society; 2016.
5. Holman DM, Benard V, Roland KB, et al. Barriers to the human papillomavirus vaccination among US adolescents: a systematic review of the literature. JAMA Pediatr. 2014;168(1):76-82.
6. American College of Obstetricians and Gynecologists. Human papillomavirus vaccination. Committee Opinion. Number 704. June 2017. www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/Human-Papillomavirus-Vaccination. Accessed August 17, 2017.
7. Meites E, Kempe A, Markowitz LE. Use of a 2-dose schedule for human papillomavirus vaccination—updated recommendation of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2016;65(49):1405-1408.
8. Mulcahy N. GSK’s HPV vaccine, Cervarix, no longer available in the US. Medscape Medical News. October 26, 2016. www.medscape.com/viewarticle/870853. Accessed June 11, 2017.
9. Reagan-Steiner S, Yankey D, Jeyarajah J, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years—United States, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(29):784-792.
10. Muncie HL, Lebato AL. HPV vaccination: overcoming parental and physician impediments. Am Fam Physician. 2015;92(6):449-454.
11. Bratic JS, Seyferth ER, Bocchini JA Jr. Update on barriers to human papillomavirus vaccination and effective strategies to promote vaccine acceptance. Curr Opin Pediatr. 2016;28(3):407-412.
12. Rahman M, Laz TH, McGrath CJ, Berenson AB. Provider recommendation mediates the relationship between parental human papillomavirus (HPV) vaccine awareness and HPV vaccine initiation and completion among 13- to 17-year-old US adolescent children. Clin Pediatr. 2015;54(4):371-375.
13. Sussman AL, Helitzer D, Bennett A, et al. Catching up with the HPV vaccine: challenges and opportunities in primary care. Ann Fam Med. 2015;13(4):354-360.
14. Clark SJ, Cowan AE, Filipp SL, et al. Parent perception of provider interactions influences HPV vaccination status of adolescent females. Clin Pediatr. 2016;55(8):701-706.
15. Ackerman LK, Serrano JL. Update on routine childhood and adolescent immunizations. Am Fam Physician. 2015;92(6):460-468.
16. Tom A, Robinett H, Buenconsejo-Lum L, et al. Promoting and providing the HPV vaccination in Hawaii: barriers faced by health providers. J Community Health. 2016;41(5):1069-1077.
17. Young JL, Bernheim RG, Korte JE, et al. Human papillomavirus vaccination recommendation may be linked to reimbursement: A survey of Virginia family practitioners and gynecologists. J Pediat Adolesc Gynecol. 2011;24(6):380-385.
18. Thomas R, Higgins L, Ding L, et al. Factors associated with HPV vaccine initiation, vaccine completion, and accuracy of self-reported vaccination status among 13- to 26-year-old men. Am J Mens Health. 2016;1-9.
19. Laz TH, Rahman M, Berenson AB. Human papillomavirus vaccine uptake among 9-17 year old males in the United States: the National Health Interview Survey, 2010. Hum Vaccin Immunother. 2013;9(4):874-878.
20. Perkins RB, Zisblatt L, Legler A, et al. Effectiveness of a provider-focused intervention to improve HPV vaccination rates in boys and girls. Vaccine. 2015;33:1223-1229.
21. Smulian EA, Mitchell KR, Stokley S. Interventions to increase HPV vaccination coverage: a systematic review. Hum Vaccin Immunother. 2016;12:1566-1588.
22. Walling EB, Benzoni N, Dornfeld J, et al. Interventions to improve HPV vaccine uptake: a systematic review. Pediatrics. 2016;138(1).
23. CDC. Overview of AFIX. www.cdc.gov/vaccines/programs/afix/index.html. Accessed August 17, 2017.
24. CDC. Human papillomavirus (HPV). www.cdc.gov/hpv/. Accessed August 17, 2017.
25. Fu LY, Bonhomme LA, Cooper SC, et al. Educational interventions to increase HPV vaccination acceptance: a systematic review. Vaccine. 2014;32(17):1901-1920.
26. Kennedy A, Sapsis KF, Stokley S, et al. Parental attitudes toward human papillomavirus vaccination: evaluation of an educational intervention, 2008. J Health Commun. 2011;16(3):300-313.
27. Spleen AM, Kluhsman BC, Clark AD, et al; ACTION Health Cancer Task Force. An increase in HPV-related knowledge and vaccination intent among parental and non-parental caregivers of adolescent girls, ages 9-17 years, in Appalachian Pennsylvania. J Cancer Educ. 2012;27(2):312-319.
28. Conroy K, Rosenthal SL, Zimet GD, et al. Human papillomavirus vaccine uptake, predictors of vaccination, and self-reported barriers to vaccination. J Womens Health (Larchmt). 2009;18(10):1679-1686.
29. National Vaccine Advisory Committee. Overcoming barriers to low HPV vaccine uptake in the United States: recommendations from the National Vaccine Advisory Committee. Public Health Rep. 2016;131(1):17-25.
30. Aragones A, Bruno DM, Ehrenberg M, et al. Parental education and text messaging reminders as effective community based tools to increase HPV vaccination rates among Mexican American children. Prev Med Rep. 2015;2:554-558.
31. Chao C, Preciado M, Slezak J, Xu L. A randomized intervention of reminder letter for human papillomavirus vaccine series completion. J Adolesc Health. 2015;56(1):85-90.
32. Community Preventive Services Task Force. The community guide—guide to community preventive services: increasing appropriate vaccinations. Atlanta, GA: Community Preventive Services Task Force; 2016
33. Kelminson K, Saville A, Seewald L, et al. Parental views of school-located delivery of adolescent vaccines. J Adolesc Health. 2012;51(2):190-196.

Health care provider interventions

Evidence supports a number of provider-level strategies to increase HPV vaccination rates (see Table 3). An improvement in vaccination acceptance was observed when providers promoted the vaccine as a safe, effective way to prevent cancer, rather than as a means to prevent a sexually transmitted infection.^10,11,20

Some primary care providers found that encouraging the HPV vaccine at the same time as the meningococcal and Tdap vaccinations, which are also recommended at age 11 to 12 years, increased vaccination rates as well.^13,20 Another successful strategy is reviewing vaccination history at every visit, whether the visit is for an acute event or an annual well exam.^10,13,20 These tactics are most useful when providers practice them consistently, which may require them to change or adapt their way of practice.

Provider-based trainings that educate and prepare them to consistently recommend the vaccine have demonstrated success in increasing HPV vaccination uptake.^21,22 The CDC’s Assessment/Feedback/Incentive/eXchange (AFIX) quality improvement program to increase vaccination rates, which includes Web-based or in-person consults, has been shown to increase HPV vaccination rates.^20-23 The Assessment phase of the AFIX program determines a practice’s current immunization practices and rates, while the Feedback portion provides strategies for increasing vaccination rates.²³ A study by Perkins and colleagues utilized AFIX strategies, specifically for the HPV vaccine, such as focusing provider education on HPV-related cancers and vaccine efficacy, as well as preparing providers to discuss and answer questions through basic motivational interviewing tactics.²⁰

The CDC also offers PowerPoint presentations, flyers, posters, videos, and other informational resources to guide and educate providers, parents, and patients about the HPV vaccine.²⁴ Educational resources, such as pamphlets, flyers, or fact sheets given to parents and patients, have been shown to improve intent to vaccinate as well as awareness of the vaccine.^25-27

Although Fu and colleagues in a systematic review concluded that there was insufficient data to support a specific educational intervention for widespread use, the authors did recommend utilizing educational pieces and adapting them to specific populations.²⁵ These simple interventions help increase awareness and can be implemented with other interventions in health care offices by providers and other staff.

System-level interventions

The use of systems that track patients for necessary vaccines and remind providers, parents, and patients about vaccine appointments have increased vaccination rates.^13,28 Facility-based interventions, such as electronic medical records (EMR) that track patients for scheduled vaccines and remind providers when patients are due for vaccinations, will help increase provider recommendations and completion of the entire vaccination series.¹³

The National Vaccine Advisory Committee (NVAC) suggests that provider offices implement reminder-recall systems and provide educational material for parents and patients to increase vaccination rates.²⁹ One specific study using both educational material and text-message reminders for parents found that these interventions significantly increased vaccination rates.³⁰ Health care facilities could also incorporate reminder letters mailed to patients and parents to promote vaccine initiation and completion.³¹ The evidence supports the use of reminder alerts and EMR tracking systems to increase rates, but more research is warranted to determine the most cost-effective approach.

National programs, committees, and organizations have provided recommendations for overcoming system-related barriers to HPV vaccination, such as access and cost.^29,32 The NVAC recommends incorporating alternative venues for vaccination delivery, such as pharmacies, schools, and health clinics, to increase availability to the adolescent population, especially to those who do not have primary care providers.²⁹ One study that addressed parental opinions of vaccination administration in schools found that the majority of parents were in favor of this type of program.³³ Although these recommendations seem promising and are accepted by parents, logistical barriers such as reimbursement to the pharmacies, schools, and clinics and accurate documentation of the doses received need to be addressed.²⁹ The NVAC recommends continued evaluation and efforts to develop these programs in the future.²⁹

In addition to school-based interventions, providing home visits for vaccination and implementing standing orders are other suggestions to overcome access and cost barriers for vaccinations, including HPV.³² Standing orders allow for individuals to receive a vaccine by a health care professional in an approved institution, where allowed by state law.³² This provides easier access to vaccinations, especially for those who do not see a primary care provider.

Although some of the system-level interventions mentioned in this article are outside the realm of what providers can do in the office, understanding and advocating for these advancements will promote vaccine uptake.

CONCLUSION

Lack of provider recommendation, coupled with poor or no parental knowledge about the HPV vaccine, are significant factors affecting vaccination uptake. Evidence supports the use of multifaceted interventions that promote and support provider recommendation and parent/patient education. Studies of interventions that incorporated educational resources and alert systems for both providers and patients or their caregivers have shown these strategies to be effective in increasing vaccination uptake and completion.

In addition to recommending the HPV vaccine, providers must educate parents/caregivers and patients about it, particularly by presenting the vaccine as a means of cancer prevention. Primary care facilities should implement reminder plans and provide educational literature to promote vaccine uptake. Although the interventions highlighted here have increased HPV vaccination rates, further research is warranted to evaluate more effective strategies for overcoming barriers and to determine which strategies are most cost-effective.

How to Increase HPV Vaccination Rates

References

Health care provider interventions

System-level interventions

CONCLUSION

Pages

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