An Electronic Medical Record Alert Intervention to Improve HPV Vaccination Among Eligible Male College Students at a University Student Health Center

Integrating HPV Vaccination Within PrEP care Delivery for Underserved Populations: A Mixed Methods Feasibility Study

Human Papillomavirus (HPV) vaccination is effective at preventing anal cancer, which disproportionally impacts gay/bisexual men (GBM) and transgender women (TGW). Vaccine coverage among GBM/TGW is insufficient to reduce anal cancer disparities. Federally qualified health centers (FQHCs) can increase reach and uptake of HPV vaccination by integrating and promoting HPV vaccination in ongoing HIV preventive care (e.g., Pre-exposure Prophylaxis [PrEP]). The purpose of the current study was to assess the feasibility and potential impact of integrating HPV vaccination with PrEP care. We conducted a mixed methods study of PrEP providers and staff (qualitative interviews, N = 9) and PrEP patients (quantitative survey, N = 88) at an FQHC in Philadelphia, Pennsylvania. Qualitative thematic analysis of PrEP provider/staff interviews was informed by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework to identify and describe barriers and facilitators to HPV vaccination implementation. Quantitative analysis of PrEP patient survey was informed by the Information-Motivation-Behavioral Skills Model. Quantitative interviews resulted in 16 themes related to characteristics of the inner and outer clinic context. Barriers among providers included lack of focus on HPV in PrEP management guidelines, in metrics mandated by funding agencies, and in electronic medical record templates. Lack of anal cancer specific knowledge and motivation was identified in both PrEP patients and providers/staff. Providing HPV vaccination during routine PrEP visits was highly acceptable to both patients and providers. Based on these findings, we recommend several multi-level strategies to increase HPV vaccine uptake among PrEP patients.

Integrated Health Maintenance Reminders for Improved HPV Vaccine Administration: Toward Improvements in Completion Disparities

OBJECTIVE

To evaluate the effect of a health maintenance reminder (HMR) on human papillomavirus (HPV) vaccine administration and completion across different age, insurance, and race cohorts.

STUDY DESIGN

Retrospective pre-post analysis.

SETTING

Academic primary care.

METHODS

Patients aged 9 to 26 who had initiated the HPV vaccine series from 2016 to 2021 were analyzed, based on current age-based standards. The cohort was divided based on vaccine uptake before and after the implementation of the HMR program in February 2020. The multivariate analysis estimated the odds of vaccine completion based on sociodemographic factors, and variable interactions were investigated to determine independent associations between sociodemographic factors and HMR implementation.

RESULTS

There were 7654 individual patients (mean age was 15.8 years; 46.7 were males; and 50.7% were white). HPV vaccine completion rates increased post-HMR implementation by 59.2% (37% pre-, and 58.9% post-HMR; p < .001) in the entire cohort. Overall, black patients (adjusted odds ratio [aOR] = 0.68; 95% confidence interval [CI]: 0.60, 0.70) and patients ≥18 years (aOR = 0.13; 95% CI: 0.11, 0.15) were significantly less likely to complete their vaccine series; however, this improved significantly following HMR in these groups (p < .001). Post-HMR, race, and insurance status were not independently associated with disparate vaccine completion rates, however, age was, and patients ≤14 or younger had higher odds of vaccine completion (aOR = 3.54; 95% CI: 2.91, 4.32).

CONCLUSION

The implementation of an HMR was associated with increased HPV vaccine uptake across age and race groups in this single-institution study. Future research should explore barriers to implementing HMRs in different healthcare settings.

The Male Domain-Digital Game-Based Learning for Human Papillomavirus Vaccination Among Young Males

Background: Human papillomavirus (HPV) is the most common sexually transmitted disease, with the highest infection rates among those sexually active under 25. Although vaccination can reduce HPV cancers among men, public health interventions have primarily targeted females. Increased gaming rates among men provide innovative opportunities to motivate behavior change. This study sought to explore which game development and design strategies are most effective in a game for sexual health, specifically focused on HPV. We also sought to capture information relevant to preferred gaming platforms and game mechanics (health messages, avatars, and visual imagery). Materials and Methods: Twenty-two (n = 22) qualitative interviews were conducted with experts. Using grounded theory, interview data was coded, and emergent themes were identified. Results: Game mechanics most mentioned included simulation/role-playing, social interaction, narrative, and rewards. Experts felt it was important to keep the game in the context of the target audience and integrate the game into an existing game/game scenario or application. Experts also felt the game should link to external resources and enlist partnerships or collaborations with external health agencies. Moreover, while there are benefits to each gaming platform, games on mobile phones and tablets are most appropriate. Conclusion: Digital games are a nonconfrontational approach to discussing HPV and can increase knowledge/awareness and positively influence behavior change toward vaccine uptake. Digital games present a safe environment for role-playing through simulated activities without real-world consequences.

mHealth video gaming for human papillomavirus vaccination among college men-qualitative inquiry for development

BACKGROUND

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. Persistent infection with HPV can cause various cancers; however, HPV vaccination can prevent infections associated with high risk, cancerous strains of the virus. As it relates to HPV, college age men have been identified as one of the catch-up vaccination groups. Among college age men, gaming is an extremely popular extracurricular activity. Further, video games have emerged as a popular public health intervention tool. Therefore, this study aims to collect qualitative data on how to develop, implement and evaluate the effectiveness of a gaming intervention to increase HPV risk perceptions, improve self-efficacy and increase intention to receive the HPV vaccine among male college students (18-26 years old).

METHODS

Four focus group sessions ranging from eight to ten individuals were conducted among male college students from one large research-intensive university in the South. Using grounded theory, data from focus group interviews were coded using NVivo software to identify emergent themes.

RESULTS

Participants emphasized that although customization was not viewed as important by college aged males, the ability to tailor in game experiences or experience different things each time they played (creative freedom) was more important. They encouraged that the digital game be created on a mobile platform, incorporate health messages, and be informative to reach their population. Furthermore, they suggested innovative way to disseminate the game, which included having health department/health care providers prescribe the game to patients as an end of clinical interaction strategy.

CONCLUSIONS

College age men, are natural avid gamers, enjoy game play, and can engage in learning online or offline. While platform preference varies among gamer type, college age men in our study emphasized that mobile based gaming is the most advantageous way to increase knowledge/awareness and encourage positive in game behavior which can impact out of game behaviors such as vaccination. Because of the level of access and natural disposition of mHealth technology seen as an "extension of the self", games for health developers should consider the mobile platform as the ideal for the target demographic.

"I don't think I have a chance to get it": International university student HPV knowledge and preventive behaviors

Objective: Half of new human papilloma virus ( (HPV)) infections occur between the ages of 15 and 24. As preventive measures are underutilized globally; international university students are at particular risk for HPV infection and sequelae. The study aim was to explore HPV knowledge and preventive behaviors in this population. Participants: Eighty-one undergraduate and graduate international university students (49 females, 32 males) at a southeastern university. Methods: Exploratory sequential mixed methods guided by the Health Belief Model. Results: Integrated qualitative/quantitative data revealed four themes mapped to relevant HBM constructs: Perceived susceptibility to HPV; Perceived benefits/Perceived barriers to HPV prevention; Cues to Action; and Likelihood of Engaging in Health-Promoting Behavior. Over half believed they were not at risk for HPV/sequelae. Only a quarter had received HPV vaccination. Conclusions: International university students represent an important catch-up population for HPV screening/vaccination. Results can be used to design and tailor interventions for this vulnerable population.

Effect of Electronic Health Record Reminders for Routine Immunizations and Immunizations Needed for Chronic Medical Conditions

BACKGROUND

 Immunization reminders in electronic health records (EHR) provide clinical decision support (CDS) that can reduce missed immunization opportunities. Little is known about using CDS rules from a regional immunization information system (IIS) to power local EHR immunization reminders.

OBJECTIVE

 This study aimed to assess the impact of EHR reminders using regional IIS CDS-provided rules on receipt of immunizations in a low-income, urban population for both routine immunizations and those recommended for patients with chronic medical conditions (CMCs).

METHODS

 We built an EHR-based immunization reminder using the open-source resource used by the New York City IIS in which we overlaid logic regarding immunizations needed for CMCs. Using a randomized cluster-cross-over pragmatic clinical trial in four academic-affiliated clinics, we compared captured immunization opportunities during patient visits when the reminder was "on" versus "off" for the primary immunization series, school-age boosters, and adolescents. We also assessed coverage of CMC-specific immunizations. Up-to-date immunization was measured by end of quarter. Rates were compared using chi square tests.

RESULTS

 Overall, 15,343 unique patients were seen for 26,647 visits. The alert significantly impacted captured opportunities to complete the primary series in both well-child and acute care visits (57.6% on vs. 54.3% off, p = 0.001, and 15.3% on vs. 10.1% off, p = 0.02, respectively), among most age groups, and several immunization types. Captured opportunities for CMC-specific immunizations remained low regardless of alert status. The alert did not have an effect on up-to-date immunization overall (89.1 vs. 88.3%).

CONCLUSION

 CDS in this population improved captured immunization opportunities. Baseline high rates may have blunted an up-to-date population effect. Converting Centers for Disease Control and Prevention (CDC) rules to generate sufficiently sensitive and specific alerts for CMC-specific immunizations proved challenging, and the alert did not have an impact on CMC-specific immunizations, potentially highlighting need for more work in this area.

Increasing Human Papillomavirus Vaccination in a Federally Qualified Health Center Organization Using a Systems-Based Intervention Integrating EHR and Statewide Immunization Information System

Public acceptance of the HPV vaccine has not matched that of other common adolescent vaccines, and HPV vaccination rates remain below the Healthy People 2020 target of 80% compliance. The purpose of this study was to evaluate the capacity of nine pediatric clinics in a Federally Qualified Health Center organization to implement a systems-based intervention targeting office staff and providers using EHRs and a statewide immunization information system to increase HPV vaccination rates in girls and boys, ages 11 to 16 over a 16-month period. System changes included automated HPV prompts to staff, postcard reminders to parents when youths turned 11 or 12 years old, and monthly assessment of provider vaccination rates.

During the intervention, 8960 patients (11–16 yo) were followed, with 48.8% girls (n = 4370) and 51.2% boys (n = 4590). For this study period, 80.5% of total patients received the first dose of the HPV vaccine and 47% received the second dose. For the first dose, 55.5% of 11 year old girls and 54.3% of 11 year old boys were vaccinated. For ages 12 to 16, first dose vaccination rates ranged from the lowest rate of 84.5% for 14 yo girls up to the highest rate of 90.5% for 13 yo boys. Logistic regression showed age was highly significantly associated with first dose completion (OR 1.565, 95% CI 1.501, 1.631) while males did not have a significant association with first dose completion compared to females. The intervention increased overall counts of first and second HPV vaccination rates.

Self-efficacy and HPV Vaccine Attitudes Mediate the Relationship Between Social Norms and Intentions to Receive the HPV Vaccine Among College Students

Human papillomavirus (HPV) has been linked to genital warts and multiple cancers affecting both men and women. Despite college students' high risk for HPV, their vaccination rates remain suboptimal. The current observational study examined the relationship between social norms and HPV vaccine intentions and potential mechanisms underlying this relationship among undergraduates. Participants (N = 190; 66.8% female) completed a survey assessing HPV vaccine social norms, attitudes, self-efficacy, and intentions. Three mediation analyses were conducted to examine whether self-efficacy and attitudes mediated the relationship between social norms (i.e., parents, friends, doctor) and intentions, controlling for demographic and health care covariates. Social norms were indirectly related to intentions through self-efficacy and attitudes in multiple models (ps < .05). Specifically, perceiving greater support for HPV vaccination from one's friends, parents, and doctor was related to greater HPV vaccine self-efficacy, which, in turn, was related to increased vaccine intentions. In addition, perceiving greater parental and doctor support for HPV vaccination was related to more favorable attitudes towards the vaccine, which, in turn, were related to increased vaccine intentions. Findings suggest potential targets for future interventions to promote HPV vaccination among young adults.

Utilizing Theories and Evaluation in Digital Gaming Interventions to Increase Human Papillomavirus Vaccination Among Young Males: Qualitative Study

BACKGROUND

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. HPV attributes to most cancers including anal, oral, cervical, and penile. Despite infection rates in the United States, recommendations and communication campaigns have traditionally focused on females. Because of this, males lack knowledge about reasons for vaccination, the benefits of being vaccinated, and their HPV risk, overall. Gaming as a health education strategy can be beneficial as mechanism that can promote behavior change for this key demographic because of the popularity of gaming.

OBJECTIVE

We sought to explore the relationship between gamification and HPV vaccine uptake.

METHODS

Interviews were conducted with experts (n=22) in the fields of cancer prevention, sexual and reproductive health, public health, game design, technology, and health communication on how a game should be developed to increase HPV vaccination rates among males.

RESULTS

Overwhelmingly, theoretical models such as the health belief model were identified with key constructs such as self-efficacy and risk perception. Experts also suggested using intervention mapping and logic models as planning tools for health promotion interventions utilizing a digital game as a medium. In game and out of game measures were discussed as assessments for quality and impact by our expert panel.

CONCLUSIONS

This study shows that interventions should focus on whether greater utilization of serious games, and the incorporation of theory and standardized methods, can encourage young men to get vaccinated and to complete the series of HPV vaccinations.

HPV vaccine uptake among daughters of Latinx immigrant mothers: Findings from a cluster randomized controlled trial of a community-based, culturally relevant intervention

OBJECTIVE

We examined the efficacy of a culturally relevant, community-based HPV vaccination intervention among Latinx immigrant mothers with daughters aged 9-12 in Alabama.

METHODS

We conducted a cluster-randomized controlled trial with "place of residence" (e.g., apartment complexes, trailer parks) as the unit of randomization that evaluated two interventions: 1) promotion of HPV vaccination and 2) promotion of healthy eating and appropriate nutrition label interpretation. Identical baseline/post/7-month follow up questionnaires were completed by all participants and both interventions consisted of four group sessions and one individual session. A total of 40 locations were randomized with 317 mother-daughter dyads enrolled in the study between May 2013 and October 2017.

RESULTS

A total of 278 mother-daughter dyads met full eligibility and initiated the intervention/control participation. Retention rate overall was 93.2% (92.6% for the intervention arm and 93.7% for the control arm). Daughters in the intervention arm were significantly more likely to receive one, two, and three doses of HPV vaccine than daughters in the control arm p < 0.001). In multivariate analyses, mothers in the intervention arm had a six times greater odds of vaccinating daughters with the first dose (OR = 5.96, 95% CI: 3.38, 10.49), eight times greater odds of vaccinating daughters with the second dose (OR = 8.09, 95% CI: 4.0, 16.35), and more than 16 times greater odds of completing the three-dose HPV vaccine series than mothers in the control arm after adjusting for mother's age, time in the U.S., income, and daughter's health insurance status (OR = 16.5, 95% CI: 5.73, 47.48). Only perceived risk of their daughters' future HPV infection remained significant as a predictor of three-dose HPV vaccination completion (OR = 0.69, 95% CI: 0.23, 2.1).

CONCLUSIONS

A theory-driven, culturally-relevant intervention developed through extensive formative assessments in collaboration with community members can effectively promote HPV vaccination among 9-12 years of age daughters of Latina immigrants.

A significant portion of college students are not aware of HPV disease and HPV vaccine recommendations

There is limited data on the HPV immunization status of Latino/Hispanic youth in the USA. In Los Angeles County in 2015, 54,973 (34.3%) college students were of Latino/Hispanic background. We examined Los Angeles County college students’ awareness of HPV and HPV-related disease, HPV vaccine recommendations, and their vaccination status. This study surveyed 212 Los Angeles college students from January to April 2018. In a convenience sampling study, a 31-question, IRB-approved survey was administered face-to-face to college students 18 years and older at California State University settings in Los Angeles County. Almost two-thirds of the male (65%) and half of the female (51.6%) respondents did not know that the HPV vaccine is recommended through 26 years of age, and 47.6% did not know they can get the HPV vaccine at the college student health center or youth-friendly clinics. Ethnicity, family income, and the highest level of education in the family had a significant impact on immunization rates. Self-reported and actual HPV knowledge levels were significantly associated with vaccination status. Educational strategies focusing on the logistics of receiving the HPV vaccine and HPV vaccine catch-up eligibility for college students may be effective in decreasing racial disparities in vaccine receipt.

The use of technology to promote vaccination: A social ecological model based framework

Vaccinations are an important and effective cornerstone of preventive medical care. Growing technologic capabilities and use by both patients and providers present critical opportunities to leverage these tools to improve vaccination rates and public health. We propose the Social Ecological Model as a useful theoretical framework to identify areas in which technology has been or may be leveraged to target undervaccination across the individual, interpersonal, organizational, community, and society levels and the ways in which these levels interact.