Sally W. Vernon

Introduction: HPV vaccination rates for adolescents in the United States are below recommended levels. The Adolescent Vaccination Program (AVP) guides pediatric clinics on how to implement evidence-based strategies to increase HPV vaccination rates. These strategies comprise the adoption of (1) immunization champions, (2) provider assessment and feedback, (3) continuing education, and (4) prompts, (5) parent reminders, and (6) parent education. The AVP systems-based intervention has demonstrated increased HPV vaccination rates in large urban pediatric clinic networks. The purpose of this study was to assess the feasibility of using an online decision support tool, the AVP Implementation Tool (AVP-IT), to implement AVP strategies in safety-net clinics to improve healthcare for the medically underserved in Texas. Methods: AVP immunization clinic staff champions in four urban safety-net clinics completed tailored Action Plans within the AVP-IT to guide strategy implementation, received webinar training from the research team commensurate to each AVP strategy, and participated in monthly monitoring calls with AVP-IT project staff over a 33-month period from 2022 to 2024. Results: All clinics made progress toward full implementation of AVP strategies. Interrupted time series (ITS) trend analysis demonstrated that AVP-IT implementation was associated with an immediate boost in HPV vaccine initiation rates (p < 0.001) and that long-term trends (ITS slopes) were significant for HPV, MCV4, and Tdap vaccines despite low post-COVID-19 pandemic rates (p < 0.001). Vaccination rates using raw data (mean differences) were not longitudinally significant except for older youth aged 13–17 years. Conclusions: The AVP-IT promises accessible and practical decision support to implement strategies to increase HPV vaccination rates in safety-net clinics. Scale-up in these clinics will require leadership support, technical assistance, and EHR optimization.

Background/objectives: Pediatrician recommendations are highly influential in parents’ decisions to vaccinate their children against HPV. Unqualified, presumptive, and bundled recommendations (UPBRs) are associated with increased HPV vaccine uptake and are considered best practice. This study analyzes pediatricians’ self-reported data to assess changes in UPBR use and the psychosocial determinants of UPBR use as a result of the implementation of a multi-level intervention, the Adolescent Vaccination Program (AVP). Methods: We surveyed pediatricians across 51 clinics in the Houston area. Baseline surveys (n = 137) were distributed in 2015, and follow-ups (n = 120) in 2019. Results: Pediatrician UPBR use significantly increased as a result of AVP implementation. Change in the provider belief that it is necessary to tell parents that HPV vaccination is not required for public school attendance significantly predicted UPBR use at follow up. This belief was also a significant mediator of increased use of UPBRs at follow-up. Conclusions: AVP was successful in increasing pediatricians’ use of UPBRs. Change in UPBR use is related to one critical psychosocial determinant: beliefs about communication regarding the non-mandatory nature of HPV vaccination for school enrollment. HPV vaccine promotion efforts should devote focus to changing pediatricians’ beliefs about the necessity of disclosing the non-mandatory nature of HPV vaccination for school attendance.

Despite clear evidence of the public health benefits of the human papillomavirus (HPV) vaccine in preventing HPV-related cancers and genital warts, underutilization of HPV vaccination in the United States persists. Interventions targeting multi-level determinants of vaccination behavior are crucial for improving HPV vaccination rates. The study’s purpose was to implement and evaluate the adapted Adolescent Vaccination Program (AVP), a clinic-based, multi-level, multi-component intervention aimed at increasing HPV vaccine initiation and completion rates in a five-clinic pediatric network in Bexar County, Texas. The adaptation process was guided by established frameworks and involved formative work with clinic stakeholders. The study utilized a quasi-experimental single group pre- and post- study design, with an external comparison data using the National Immunization Survey-Teen (NIS-Teen) datasets for the same time period to examine the AVP’s effect on HPV vaccination initiation and completion. A series of interrupted time series analyses (ITSA) compared the clinic system patient outcomes (HPV vaccination initiation and completion rates) in the post-intervention to the general adolescent population (NIS-Teen). Of the 6438 patients (11–17 years) with clinic visits during the 3-year study period, HPV vaccination initiation rates increased from 64.7% to 80.2% (p < 0.05) and completion rates increased from 43.2% to 60.2% (p < 0.05). The AVP was effective across various demographic and economic subgroups, demonstrating its generalizability. ITSA findings indicated the AVP improved HPV vaccination initiation and completion rates in clinic settings and that AVP strategies facilitated resilience during the pandemic. The minimal adaptation required for implementation in a new clinic system underscores its feasibility and potential for widespread adoption.

Human papilloma virus (HPV) vaccination rates remain below national goals in the United States despite the availability of evidence-based strategies to increase rates. The Adolescent Vaccination Program (AVP) is a multi-component intervention demonstrated to increase HPV vaccination rates in pediatric clinics through the implementation of six evidence-based strategies. The purpose of this study, conducted in Houston, Texas, from 2019–2021, was to adapt the AVP into an online decision support implementation tool for standalone use and to evaluate its feasibility for use in community clinics. Phase 1 (Adaptation) comprised clinic interviews (n = 23), literature review, Adolescent Vaccination Program Implementation Tool (AVP-IT) design documentation, and AVP-IT development. Phase 2 (Evaluation) comprised usability testing with healthcare providers (HCPs) (n = 5) and feasibility testing in community-based clinics (n = 2). AVP-IT decision support provides an Action Plan with tailored guidance on implementing six evidence-based strategies (immunization champions, assessment and feedback, continuing education, provider prompts, parent reminders, and parent education). HCPs rated the AVP-IT as acceptable, credible, easy, helpful, impactful, and appealing (≥80% agreement). They rated AVP-IT supported implementation as easier and more effective compared to usual practice (p ≤ 0.05). The clinic-based AVP-IT uses facilitated strategy implementation by 3-month follow-up. The AVP-IT promises accessible, utilitarian, and scalable decision support on strategies to increase HPV vaccination rates in pediatric clinic settings. Further feasibility and efficacy testing is indicated.

The Community Preventive Services Task Force endorses vaccination programs in schools to increase access to vaccinations. However, implementing a school-based approach requires substantial coordination, planning, and resources. All for Them (AFT) is a multilevel, multicomponent approach to increase HPV vaccination among adolescents attending public schools in medically underserved areas in Texas. AFT comprised a social marketing campaign, school-based vaccination clinics, and school nurse continuing education. Process evaluation metrics and key informant interviews to understand experiences with AFT program implementation informed lessons learned. Lessons emerged in six domains: strong champion, school-level support, tailored and cost-effective marketing approaches, mobile provider collaboration, community presence, and crisis management. Strong support at district and school levels is vital for gaining principal and school nurse buy-in. Social marketing strategies are integral to program implementation and should be adjusted to maximize their effectiveness in motivating parents to vaccinate children against HPV, which also can be achieved through increased community presence of the project team. Preparing contingency plans and flexibility within the program can facilitate appropriate responses to provider restrictions in mobile clinics or in the event of unforeseen crises. These important lessons can offer useful guidelines for the development of prospective school-based vaccination programs.

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.

Accurate and valid measures for implementation constructs are critical to advance research and guide implementation efforts. However, there is a continued need for valid and reliable measures for implementation research. The purpose of this study was to assess the psychometric properties of measures for the Inner Setting domain of the Consolidated Framework for Implementation Research (CFIR) in a network of pediatric clinics. This study used cross-sectional survey data collected from physicians, advanced practice providers, clinic managers, and clinical staff (n = 546) working in a pediatric clinic network (n = 51). Surveys included measures assessing Inner Setting constructs from CFIR (culture, learning climate, leadership engagement, and available resources). We used a series multilevel confirmatory factor analysis (CFA) models to assess factorial validity. We also examined measure correlations to test discriminant validity and intraclass correlation coefficients, ICC(1) and ICC(2), to assess inter-rater reliability. Factor loadings were high (≥0.60) for all but one of the measurement items. Most CFA models for respective constructs demonstrated adequate or good model fit (CFI > 0.90, TLI > 0.90, RMSEA< 0.08, and SRMR< 0.08). The measures also demonstrated good discriminant validity (correlations< 0.90) aside from some evidence of overlap between leadership engagement and learning climate at the clinic level (0.91). The ICC(1) values ranged from 0.05–0.16 while the ICC(2) values ranged from 0.34–0.67. The measures demonstrated good validity and adequate reliability with the exception of available resources, which had some evidence of lower than desired reliability and validity at the clinic level. Our findings extend previous work by providing additional psychometric evidence to support the use of these Inner Setting measures in pediatric clinics implementing human papillomavirus programs.