Evaluation of Educational Interventions to Enhance Adolescent Specific Vaccination Coverage

Multilevel Targets for Promoting Pediatric HPV Vaccination: A Systematic Review of Parent-Centered, Provider-Centered, and Practice-Centered Interventions in HIC and LMIC Settings

BACKGROUND/OBJECTIVES

Human papillomavirus (HPV) is a predominant cause of cervical cancer globally in women. HPV-related cancers in men are also on the rise. Immunization against HPV infection is a highly effective preventative against these cancers. However, HPV vaccine programs are not easily implemented globally. The objective of this systematic review was to identify multilevel strategies associated with improved pediatric HPV vaccination in high-income countries (HICs) and low- and middle-income countries (LMICs) that target parent, provider, and practice points of interventions.

METHODS

Through a systematic search of electronic databases, we identified 159 peer-reviewed articles published between the years 2011 and 2023.

RESULTS

Ninety-five percent of the included studies were conducted in HICs. Just eight studies were set in LMICs. A variety of HPV vaccination outcomes were assessed including uptake, initiation of the series, continuation of the series, missed opportunities, time, and refusal. Eighty percent of studies reported improved pediatric HPV vaccination, including a third of studies with mixed findings. Parent-centered strategies included education programs and reminder/recall procedures. Provider-centered strategies also included education programs and training in communication. Practice-centered strategies included vaccine access programs, vaccine bundling protocols, provider prompts, standing orders, vaccine messaging, and lowering the initiation age to 9 years. Multilevel, multi-component programs were highly effective.

CONCLUSIONS

Multilevel strategies can be adopted in a variety of settings to promote HPV vaccination among youth globally. However, this research is disproportionately conducted in high resource environments. Further work is needed in LMIC settings as more countries begin to adopt HPV immunization programs.

Opportunities for HPV vaccine education in school-based immunization programs in British Columbia, Canada: A qualitative study

Despite the availability of school-based immunization programs (SBIPs) in Canada, human papillomavirus (HPV) vaccine uptake remains suboptimal. Vaccine education may improve vaccine uptake among adolescents. The objective of this qualitative study was to identify opportunities for HPV vaccine education in British Columbia, Canada, by exploring the perspectives of students, parents, school staff, and public health nurses on the current SBIP. Individual semi-structured interviews were conducted with adult participants and focus groups were conducted with grade 6 students between November 2019 and May 2020. The interviews and focus groups were transcribed and then analyzed using reflexive thematic analysis. Opportunities for HPV vaccine education were identified in three themes: 1) making SBIPs student-centered; 2) adopting a collaborative and interdisciplinary approach to vaccine education; and 3) actualizing parent education opportunities. Broad support existed for a formal, collaborative HPV grade 6 vaccine curriculum delivered by teachers and public health nurses to provide evidence-based health information. Participants voiced that the curriculum should integrate students' perspectives on topics of interest and address needle associated pain and anxiety. Parents were identified as the primary vaccine decisionmakers, therefore, participants stated it was crucial to also provide parent-directed vaccine education as part of SBIP. Our findings support the development of a collaborative HPV vaccine curriculum directed to and informed by students and parents to buttress current SBIPs in British Columbia.

Increasing vaccinations through an on-site school-based education and vaccination program: A city-wide cluster randomized controlled trial

Vaccination rates for mumps, measles, and rubella (MMR) and tetanus, diphtheria, pertussis, and polio (Tdap-IPV) fall short of global targets, highlighting the need for vaccination interventions. This study examines the effectiveness of a city-wide school-based educational vaccination intervention as part of an on-site vaccination program aimed at increasing MMR and Tdap-IPV vaccination rates versus on-site vaccination alone among sociodemographically diverse students from Berlin, Germany. The study was a 1:1 two-arm cluster randomized controlled trial, with schools randomly assigned to either the Educational Class Condition (ECC) or the Low-Intensity Information Condition (LIIC). Both received an on-site vaccination program, while students in the ECC received an additional educational unit. Primary outcomes were MMR and Tdap-IPV vaccination rates. In total, 6512 students from 25 randomly selected urban area secondary schools participated. For students providing their vaccination documents on the day of the intervention (2273, 34.9%), adjusted Poisson mixed models revealed significant between-group differences in favor of the ECC (MMR: logRR = 0.47, 95%CI [0.01,0.92], RR = 1.59; Tdap-IPV: logRR = 0.28, 95%CI [0.10,0.47], RR = 1.32). When adjusting for socioeconomic and migration background, between-group differences became non-significant for MMR but remained significant for Tdap-IPV. Findings suggest that educational, school-based on-site vaccination appears to be a promising strategy for increasing vaccination uptake in adolescents.

Sense of safety and opinions about COVID-19 vaccinations in Polish school teachers: the role of conspiracy theories belief and fear of COVID-19

The co-occurrence of COVID-19 conspiracy theories (CCT) and fear of the coronavirus (FCV) can be linked to how safe people feel and how much they endorse vaccinations. School teachers were one of the vaccination priority groups in Poland. We conducted three cross-sectional studies (N1 = 1006; N2 = 1689; N3 = 627) to find out the potential interaction effects of CCT belief and FCV in predicting sense of safety (SoS; Studies 1-3), opinions about vaccinations efficacy (Studies 2-3) and endorsement of vaccinations of children (Study 3) among school teachers. In all three studies, the belief in CCT was related to lower SoS only when FCV was low. For low CCT belief, although the belief in vaccination efficacy was higher than for CCT endorsers, it was unrelated to FCV. However, for high and average CCT belief, FCV was linked to belief in vaccination efficacy. FCV was positively related to acceptance of vaccinating children on all levels of CCT endorsement. The results are discussed in light of the available literature and their potential use in public health.

School-Based Interventions to Increase Student COVID-19 Vaccination Coverage in Public School Populations with Low Coverage - Seattle, Washington, December 2021-June 2022

COVID-19 can lead to severe outcomes in children (1). Vaccination decreases risk for COVID-19 illness, severe disease, and death (2). On December 13, 2020, CDC recommended COVID-19 vaccination for persons aged ≥16 years, with expansion on May 12, 2021, to children and adolescents (children) aged 12-15 years, and on November 2, 2021, to children aged 5-11 years (3). As of March 8, 2023, COVID-19 vaccination coverage among school-aged children remained low nationwide, with 61.7% of children aged 12-17 years and approximately one third (32.7%) of those aged 5-11 years having completed the primary series (3). Intention to receive COVID-19 vaccine and vaccination coverage vary by demographic characteristics, including race and ethnicity and socioeconomic status (4-6). Seattle Public Schools (SPS) implemented a program to increase COVID-19 vaccination coverage during the 2021-22 school year, focusing on children aged 5-11 years during November 2021-June 2022, with an added focus on populations with low vaccine coverage during January 2022-June 2022.^† The program included strategic messaging, school-located vaccination clinics, and school-led community engagement. Vaccination data from the Washington State Immunization Information System (WAIIS) were analyzed to examine disparities in COVID-19 vaccination by demographic and school characteristics and trends over time. In December 2021, 56.5% of all SPS students, 33.7% of children aged 5-11 years, and 81.3% of children aged 12-18 years had completed a COVID-19 primary vaccination series. By June 2022, overall series completion had increased to 80.3% and was 74.0% and 86.6% among children aged 5-11 years and 12-18 years, respectively. School-led vaccination programs can leverage community partnerships and relationships with families to improve COVID-19 vaccine access and coverage.

Health behavior and health needs of first-year medical and health sciences students

Objective: The aim of this study is to evaluate the health behavior and health needs of medical and health sciences students in order to identify areas that need intervention. Materials and Methods: This descriptive study was conducted with 770 first-year university students. The data were collected with a sociodemographic questionnaire, the Youth Risk Behavior Survey and the Eating Attitudes Test. Body mass index was calculated. Results: Although, only 12.7% of the students were overweight or obese, 25.6% of the students perceived themselves to be overweight or obese. The students said that in the last week, 20.9% had breakfast 1 or 3 times, 5.7% ate no fruits at all, and 11.6% ate no vegetables at all. 48.1% of the students did not engage in any physical activity, and 83.2% spent more than 2 hours inactively in front of a screen. It was observed that 22.3% were current smokers. A propensity for eating behaviors disorder was found in 9.0%. Drinking energyboosting sports drinks 1-6 times in the last week (β: 3.286), smoking (β: 1.875) and eating few vegetable dishes in the last week (β: 0.484) were identified as factors that could be associated with a “tendency for eating behavior disorder.” Conclusion: We can conclude that nutritional issues, negative body weight perception, use of tobacco, and sedentary lifestyle are the main intervention and counselling areas for our study group.

Healthcare University Courses Fail to Improve Opinions, Knowledge, and Attitudes toward Vaccines among Healthcare Students: A Southern Italy Cross-Sectional Study

(1) Background: Healthcare providers have a crucial role in contrasting vaccine hesitancy (VH). We aimed to investigate opinions, knowledge, and attitudes toward vaccines in healthcare students (HS) at the University of Catania (Italy). (2) Methods: A survey was conducted from 1 October 2019 to 31 January 2020. Data on the opinions, knowledge, and attitudes of HS toward vaccinations were collected using an anonymous self-administered questionnaire. The opinion answers were added to calculate the VH index (<18 = low, 19−22 = medium, >23 = high). Data were summarized by the VH index, degree, year of study, and sex differences, using descriptive statistics. (3) Results: A total of 1275 students (53.7% females) participated in the study, with a median (IQR) age of 21 (19−22) years. The median level of VH was 20 (17−23), with slightly higher values in males. We found an inverse trend between VH and opinions, knowledge, and attitudes toward vaccines. The same trend was confirmed in all study courses. Furthermore, the comparison between sexes revealed a higher level of knowledge in women. (4) Conclusions: The results highlight a lack of knowledge about vaccines, as well as contrasting opinions and attitudes among future health professionals. Therefore, future interventions on these topics in the preparation of future healthcare providers are needed.

Insights on COVID-19 Vaccination in Portugal: A Qualitative Study among Health Professionals and Teachers

BACKGROUND

Vaccination against COVID-19 has had a major impact over the course of the pandemic, leading to a reduced number of hospitalizations and deaths. However, the mass vaccination process has been accompanied by skepticism and hesitancy since its beginning. As health professionals and teachers are important public health actors who can strongly intervene to reduce vaccination hesitancy among their patients and students, respectively, this study aimed to assess their main perceptions towards COVID-19 vaccination.

METHODS

Two focus group sessions, one with health professionals and the other with teachers, were conducted according to the COREQ checklist. Qualitative data were analyzed through theoretical thematic analysis.

RESULTS

In general, none of the groups showed vaccine hesitancy, although both groups had concerns regarding the safety and efficacy of the vaccines. The main concerns of health professionals were mostly related to the long-term impact of the COVID-19 pandemic, while teachers were more worried about the lack of access to reliable information about the COVID-19 vaccination.

CONCLUSIONS

It is plausible to conclude that it is imperative to provide clear and accurate information for the population in order to avoid vaccination hesitancy.

Unravelling the drivers behind COVID-19 vaccination hesitancy and refusal among teachers: A nationwide study

This study aims to assess the determinants of the coronavirus disease 2019 (COVID-19) vaccination hesitancy and refusal (VHR) among teachers, from pre-school to higher education, through an online survey. A logistic regression analysis was used to determine the adjusted odds ratio (OR) of the independent variables (perceptions, knowledge, and attitudes) per 1-point increase in the Likert scale, and VHR.

Concerns about the vaccines’ efficacy and safety increase the risk of VHR (OR = 6.97, 95 %CI: 4.82–10.09 and OR = 8.71, 95 %CI: 5.52–13.73, respectively). Higher risk perceptions of getting infected (1/OR = 3.94, 95 %CI: 2.93–5.29), trust in the effectiveness of vaccines in reducing this risk or protecting against suffering complications (OR = 3.52, 95 %CI: 2.72–4.55 and OR = 10.94, 95 %CI: 7.16–16.68, respectively), and higher trust levels on the information transmitted regarding COVID-19 vaccination, are associated to lower VHR.

As VHR appears to be highly influenced by perceptions, knowledge, and attitudes, it is crucial to promote and design interventions targeted to transforming these determinants.

Interventions to Improve Immunization Coverage Among Children and Adolescents: A Meta-analysis

BACKGROUND AND OBJECTIVES

Vaccinations are recognized as a feasible, cost-effective public health intervention for reducing the burden and associated mortality of many infectious diseases. The purpose of this study was to evaluate the effectiveness of potential interventions to improve the uptake of vaccines among children and adolescents.

METHODS

We performed a literature search until December 2020. Eligible studies were identified using Cochrane Central Register of Controlled Trials, MEDLINE, PubMed, and other sources. We included studies conducted on children and adolescents aged 5 to 19 years. Studies comprised of hospitalized children and those with comorbid conditions were excluded. Two authors independently performed the meta-analysis.

RESULTS

Findings from 120 studies (123 articles), of which 95 were meta-analyzed, reveal that vaccination education may increase overall vaccination coverage by 19% (risk ratio [RR], 1.19; 95% confidence interval [CI], 1.12-1.26), reminders by 15% (RR, 1.15; 95% CI, 1.11-1.18), interventions for providers by 13% (RR, 1.13; 95% CI, 1.07-1.19), financial incentives by 67% (RR, 1.67; 95% CI, 1.40-1.99), and multilevel interventions by 25% (RR, 1.25; 95% CI, 1.10-1.41). The impact of school-based clinics and policy and legislation on overall vaccination coverage is still uncertain, and no impact of a multicomponent intervention on overall vaccination coverage was found.

CONCLUSIONS

Educational interventions, reminders, provider-directed interventions, financial incentives, and multilevel interventions may improve vaccination coverage among school-aged children and adolescents.

A school-based educational on-site vaccination intervention for adolescents in an urban area in Germany: feasibility and psychometric properties of instruments in a pilot study

Background

Vaccination rates for measles, mumps, and rubella (MMR) and diphtheria, tetanus, pertussis, and polio (Tdap-IPV) are not optimal among German adolescents. Education in combination with easy access to vaccination may be a promising approach to improve vaccination rates. The present paper describes a pilot study of a planned cluster randomized controlled trial (cRCT) in which we aim to improve MMR and Tdap-IPV vaccination rates together with knowledge and self-efficacy in a school setting.

Methods

The study covered 863 students from 41 classes of four schools. The optimization and feasibility of access to schools, recruitment strategies, intervention, and assessment procedures were examined. The course and content of the educational unit were evaluated with a mixed-methods approach. A pre-post measurement design was tested for the vaccination rate in all schools. Additionally, at two schools, improvement in vaccination-related knowledge and perceived self-efficacy were measured by questionnaire pre-educational unit (n=287) and post-educational unit (n=293). The remaining two schools provided only postintervention data. Finally, we evaluated the psychometric properties (i.e., reliability, retest reliability, and change rates) of the questionnaire, applying Cronbach’s alpha, factor analyses, generalized estimating equations and linear mixed models.

Results

The findings of the pilot study indicated good feasibility. Of the total sample, 437 students (50.9%) brought their vaccination cards to school, 68 students received Tdap-IPV vaccinations, and 11 received MMR vaccinations. Out of six knowledge questions, on average, the students had M=2.84 (95% CI [2.69, 3.10]) correct answers before and M=4.45 (95% CI [4.26, 4.64]) after the class. Ranging from 1 to 4, the self-efficacy scale changed by 0.3 points (p <.001); Cronbach’s alpha was 0.67 and 0.76 pre- and post-educational unit, respectively, and a one-factor solution was found. Content analysis of the five semistructured group interviews (n=12, 58.3% female) showed that all students found the length of the intervention to be appropriate. The teaching methods, including interactive and social media components, were perceived as very good.

Conclusions

A school-based educational and on-site vaccination intervention appears to be feasible in terms of procedures and the adequacy of the instruments for the adolescent target group.

Trial registration

ISRCTN, ISRCTN18026662. Pilot study for main trial registered 8 December 2017.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12443-8.

Understanding the determinants of vaccine hesitancy and vaccine confidence among adolescents: a systematic review

Vaccine hesitancy (VH) in the age of adolescence is a major public health issue, though it has not been widely examined in the scientific literature. This systematic review aims to address the determinants of VH among adolescents aged 10-19. PubMed, Scopus, and Web of Science were searched from the inception until 11 December 2020. Articles in English, assessing adolescents' attitudes toward vaccination in terms of hesitancy and/or confidence were considered eligible. Out of 14,704 articles, 20 studies were included in the qualitative analysis. Quality assessment was performed through the Appraisal tool for Cross-Sectional Studies (AXIS). A better knowledge of vaccine-preventable diseases, a higher confidence in vaccines, as well as an active involvement in the decision-making process showed a positive relationship with adolescents' vaccine uptake. These aspects should be considered to plan tailored interventions for the promotion of vaccination among adolescents and to reduce VH. Major limitations of this review are represented by the high heterogeneity of the tools used in the primary studies and the lack of standardization in outcomes definitions. Future research is needed to disentangle the interrelationship among the different determinants of VH in this age group.

A Systematic Review of Interventions to Improve HPV Vaccination Coverage

Human papillomavirus (HPV) infection is the most common sexually transmitted infection worldwide. Although most HPV infections are transient and asymptomatic, persistent infection with high-risk HPV types may results in diseases. Although there are currently three effective and safe prophylactic HPV vaccines that are used across the world, HPV vaccination coverage remains low. This review evaluates the effects of the interventions to improve HPV vaccination coverage. We searched the Cochrane Central Register of Controlled Trials, PubMed, Web of Science, Scopus, and the World Health Organization International Clinical Trials Registry Platform and checked the reference lists of relevant articles for eligible studies. Thirty-five studies met inclusion criteria. Our review found that various evaluated interventions have improved HPV vaccination coverage, including narrative education, outreach plus reminders, reminders, financial incentives plus reminders, brief motivational behavioral interventions, provider prompts, training, training plus assessment and feedback, consultation, funding, and multicomponent interventions. However, the evaluation of these intervention was conducted in high-income countries, mainly the United States of America. There is, therefore, a need for studies to evaluate the effect of these interventions in low-and middle-income countries, where there is a high burden of HPV and limited HPV vaccination programs.

Multi-component cancer prevention awareness program to improve adolescent HPV vaccine uptake

OBJECTIVE

We introduced a multi-component cancer prevention awareness program to primary care practices across New York State to evaluate its impact on adolescent human papillomavirus (HPV) vaccination rates.

METHODS

Eight pediatric and three family medicine practices were recruited to participate in this program. On-site training sessions were provided for all practice providers and staff to discuss the importance of HPV vaccine and cancer prevention and teach strategies for delivering a strong vaccine recommendation. Each practice received a study-specific booklet that included HPV vaccine information and other commonly provided cancer prevention guidance. These booklets were distributed to all adolescents and their parents during well visits over a one-year period. Practice specific and county-wide HPV vaccination rates were assessed before and 12 months after the program training session.

RESULTS

One year after program initiation, aggregate data show statistically higher vaccine series initiation rates among 11-12 and 13-18-year-olds and higher vaccine series completion rates among 13-18-year-olds. The greatest and most consistent improvements were seen in vaccine initiation rates for the 11-12-year-old cohort. Disparities in vaccine uptake were observed by gender and medical specialty.

CONCLUSION

Cancer prevention education targeting providers, office staff, patients, and parents, improved adolescent HPV vaccine series initiation rates.

Calling the Shots? Adolescents' Influence on Human Papillomavirus Vaccine Decision-Making During Clinical Encounters

PURPOSE

The aim of the study was to examine adolescents' influence on human papillomavirus (HPV) vaccine decision-making and receipt during clinical visits.

METHODS

We recruited English- and/or Spanish-speaking parents and their adolescent children aged 9-17 years who were eligible for the first HPV vaccine dose and seeking routine care at pediatric and family medicine clinics in the Greater Boston area enrolled in a multilevel intervention to improve HPV vaccination coverage. Parents completed previsit surveys that included parental intention to vaccinate. We coded transcripts of adolescents' clinical encounters to define adolescents' participation in vaccine discussions and cooperation with immunization. Adolescents' influence on vaccine decision-making was determined based on analyses of their participation in discussions and parents' previsit vaccine intentions.

RESULTS

A total of 113 adolescents and their parents participated. Eighty-seven percent of adolescents received their first HPV vaccine dose during the visit. Most reactions were negative (23% mild, 23% moderate, and 10% extreme); nearly all objections were concerns related to the pain of injection rather than specific to HPV vaccination. A minority of reactions were positive (12%), 33% were neutral, and 12% did not participate in vaccine discussions. All adolescents with positive or neutral reactions received vaccination, as did 91% of those with negative reactions. After accounting for parents' previsit vaccine intentions and analyzing discussions during clinical encounters, only 5% of adolescents appeared to influence vaccination either positively (n = 3) or negatively (n = 3).

CONCLUSIONS

In this study, adolescents rarely influenced parents' vaccine decision-making, although many exhibited distress over the pain of injections. This suggests that increasing adolescents' involvement in vaccine discussions may have limited effects on vaccination rates.