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Abstract

Background: Despite continued public health efforts to increase human papillomavirus (HPV) vaccination among adolescents, initiation remains below the level needed to reach the Healthy People 2020 goal of 80% series completion by age 13.

Methods: We developed, implemented, and evaluated a multi-component program that used evidence-based strategies to increase HPV vaccine initiation in a network of 51 pediatric clinics in Houston, Texas. Our target populations were the clinic network, healthcare providers, male and female patients ages 11-17, and their parents. The program, called the Adolescent Vaccination Program (AVP), was conducted from March 2016 through March 2019 and contained strategies to increase vaccination including: HPV immunization champions; provider assessment and feedback; provider continuing education; provider reminders; and patient reminders. We used a single group pre/post design with an external comparison – NIS-Teen. Our primary outcome was initiation of the HPV vaccine based on the electronic health record. We used interrupted time series analysis (ITSA) to measure change in initiation over time. We calculated monthly, quarterly, and annual rates of initiation for each physician, clinic, and the network. We examined patterns of initiation by patient age, sex, race/ethnicity, and type of insurance.

Results: By the end of the project, the 51 clinics averaged 77.4% initiation. Rates increased annually from September 2015 through March 2019. ITSA analysis over 75 months showed an increase in vaccine initiation of 0.396% per month from the introduction of the program in March 2016. Average individual clinic improvement was 0.37% per month ranging from -0.04% to 0.68% through March 2019. Data for the 11-12 year olds, the target age group for initiating the vaccine, showed a greater percentage increase (54.2%) compared with the 13-17 year olds (29.6%). Hispanics and African Americans had the highest initiation rates in all years while non-Hispanic whites had the lowest. Families without insurance had the lowest rates while those with Medicaid/Medicare had the highest.

Conclusions: We observed a secular trend upward in both the network and NIS-Teen data; however, the network showed a steeper increase. The AVP is a promising program of strategies to increase HPV vaccination in a clinic setting.

Key Take Away Points

  • We developed, implemented, and evaluated a multi-component program that used evidence-based strategies to increase HPV vaccine initiation in a network of 51 pediatric clinics in Houston, Texas.
  • The Adolescent Vaccination Program contained evidence-based strategies for HPV vaccination including HPV immunization champions, provider assessment and feedback, provider continuing education, provider reminders, and patient reminders.
  • We observed a secular trend upward in HPV vaccine initiation in both the network and NIS-Teen data; however, the network showed a steeper increase.
  • The Adolescent Vaccination Program is a successful theory- and empirically-based multi-component systems-based approach, mediated by clinic AVP champions.

Author Biography

Sally W. Vernon, MA, PhD is Professor of Epidemiology and Behavioral Sciences at the University of Texas Health Science Center at Houston (UTHealth) School of Public Health. Lara Savas, PhD is Associate Professor of Behavioral Sciences at UTHealth School of Public Health. Ross Shegog, PhD is Professor of Behavioral Sciences at UTHealth School of Public Health. Mary Healy, MD is Associate Professor of Pediatrics, Infectious Diseases, at Baylor College of Medicine and Texas Children’s Hospital. Erica L. Frost, MPH is a Program Manager at the UTHealth School of Public Health. Sharon P. Coan, MS is a Statistician at UTHealth School of Public Health. Efrat K. Gabay, MPH is a Research Coordinator at UTHealth School of Public Health. Sharice M. Preston, PhD is a post-doctoral fellow at UTHealth School of Public Health on a National Cancer Institute training grant (NCI/NIH Grant T32/CA057712). Claire A. Crawford, LMSW is a Doctoral Student at UTHealth School of Public Health and a Palliative Care Social Worker at Texas Children's Hospital. Stanley W. Spinner, MD, FAAP is the Chief Medical Officer/Vice President of Texas Children’s Pediatrics and Texas Children’s Urgent Care and Associate Clinical Professor at Baylor College of Medicine. Matthew A. Wilber, MD, FAAP is a Pediatrician at Texas Children’s Pediatrics Pearland.

Acknowledgements

The project was funded by the Prevention Program of the Cancer Prevention and Research Institute of Texas (PP140183 Drs. Vernon and Savas). The project was approved by the Institutional Review Board at the University of Texas Health Sciences Center at Houston (HSC-SPH-14-0725). Dr. Preston was the recipient of a post-doctoral fellowship from the University of Texas Health Science Center at Houston School of Public Health Cancer Education and Career Development Program – National Cancer Institute/NIH Grant T32/CA057712. Disclaimer: The content is solely the responsibility of the authors and does not necessary represent the official views of the National Cancer Institute or the National Institutes of Health.

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