DOSE HPV: Development of Systems and Education for HPV Vaccination

In the United States, approximately 79 million people are infected with the human papillomavirus (HPV). HPV can lead to health complications including cancers of the cervix, tongue, tonsils, penis, vulva, and vagina; pre-cancerous lesions that require treatment; and genital warts. Each year, nearly 3 million men and women seek medical care related to HPV and more than 30,000 are diagnosed with a cancer caused by HPV. The most dangerous forms of HPV infection can be prevented by receiving the HPV vaccination series. The Centers for Disease Control and Prevention recommends that all adolescents receive the HPV vaccine series, which is approved for 9- to 26-year-olds. Because early vaccination is more effective, recommendations include initiating the series by age 12 and completing the series by age 13. Healthy People 2020 goals are to fully vaccinate 80% of boys and girls, because countries where this has been achieved have already documented decreases in rates of cervical cancer, cervical dysplasia, and genital warts. Current vaccination rates in the United States are less than 80%, however, so interventions are needed to increase HPV vaccination among adolescents and young adults to protect them from diseases and cancers caused by HPV.

DOSE HPV: Development of Systems and Education for HPV Vaccination is a multi-component intervention that educates the medical providers of adolescents and young adults about HPV, the HPV vaccine, and communicating with parents about the importance of the vaccine with the aim of increasing HPV vaccination rates. The intervention combines standardized HPV education, training in a focused motivational interviewing technique, and quality improvement techniques to improve clinician-parent communication about the vaccine and decrease missed opportunities for vaccination.

The 12-month intervention consists of six to eight sessions of approximately 60 minutes held about every 4 to 6 weeks. For the first 6 months, the transition period, an HPV physician-educator and administrative personnel meet with medical providers at their practice to educate them on HPV morbidity and mortality, vaccine safety, vaccine efficacy, and motivational interviewing techniques they can use when talking with parents who are hesitant about getting their child vaccinated. These sessions aim to establish a relationship of trust between the physician-educator and providers, convey the importance of HPV vaccination, create discussion around HPV vaccination, and help the providers better communicate with parents about the vaccine. For the next 6 months, the active period, the physician-educator gives the providers individualized feedback on their patient vaccination rates, as well as at the practice, state, and national level, so the providers can compare the vaccination rates of their patients with those of other providers. Each participant receives individual reports that show his or her patients' HPV rates by gender, age, and number of doses given. Using these data, providers may revise their practice's clinical action plans and make other practice-wide changes to increase HPV vaccination rates (e.g., making a strong recommendation to all 11-year-old patients, placing posters about the vaccination in exam rooms, using enhanced reminder and recall methods), and they receive feedback on their behaviors after implementation of their action plans.

Following the implementation plan outlined in this manual, providers can submit this project with confidence for approval for MOC Part IV credit through the ABP or the ABFM application system. These credits help fulfill board certification requirements for pediatrics.

Approximately 60 minutes for each of six to eight educational sessions

The intervention is intended for medical providers who treat males and females ages 9‒26.

The intervention is suitable for implementation in clinical/medical settings in urban/inner-city, suburban, and rural areas.

Required resources to implement the program include the following:

-- DOSE HPV Implementation Guide
-- DOSE HPV Session 1 PowerPoint presentation
-- DOSE HPV Session 2 PowerPoint presentation
-- DOSE HPV Session 3 PowerPoint presentation
-- DOSE HPV Session 4 PowerPoint presentation
-- Session 4 (Action Plan) discussion guide
-- Sessions 5-7 sample PDSA cycles
-- Sample data collection spreadsheet
-- Sample individual provider feedback form
-- Sample session evaluation forms
-- Three posters
-- Intervention Fidelity checklist
-- HPV Vaccination Is Cancer Prevention video

For costs associated with this program, please contact the developers, Rebecca Perkins and Emma Trucks. (See products page on the EBCCP website for developer contact information.)

The study included one urban academic medical center and seven federally qualified community health centers, all of which had separate staff and facilities. Two community health centers were assigned to the intervention group, and the remainder were assigned to the control group. All medical professionals employed within an intervention practice were eligible to participate in the intervention. However, only physicians, nurse practitioners, and physician assistants who provided care for patients were able to receive personalized data showing their vaccination rates.

Patients enrolled in the study were males (7,332) and females (5,786) aged 11-21 who were current primary care patients at one of the study's practices. Patients were excluded from the study if they had not had one or more well visits over the past 2 years, had already completed the HPV vaccine series, were pregnant during the study period, or had received care at both an intervention and control practice.

Of the 13,118 total eligible patients seen during the study periods (2,344 males and 1,749 females in the intervention group and 4,988 males and 4,037 females in the control group), 92% were from racial and ethnic minority populations, 39% did not speak English as their primary language, and 56% had Medicaid insurance.

The study's primary outcomes were initiation of HPV vaccination (receipt of dose 1 only) and receipt of the next needed dose of HPV vaccination (dose 1, 2, or 3). The vaccination rates of presenting patients at intervention and control practices were compared at baseline (the 6-month period before the intervention), during the 6-month transition period, during the 6-month active period, and for 6 months after the intervention, with males and females analyzed separately. Outcomes were measured by review of electronic medical records. Patients who had previously initiated the HPV vaccination were excluded from the analysis of vaccine initiation but were included in the analysis of receipt of next needed dose.

• Both males and females in intervention practices were more likely than those in control practices to receive an initiation dose during the active period (p<.01 for both analyses), and males in intervention practices were more likely than their control group peers to receive the initiation dose during the transition and post-intervention period (p<.01 for both analyses). 

• Males in intervention practices were more likely than those in control group practices to receive the next needed dose during the transition period (p<.01). Both males and females in the intervention practices were more likely than their control group peers to receive the next needed dose during the active period and post-intervention period (p<.01 for males at both time points, p<.05 for females at both time points).

Additional Findings
 

• Multiple factors were associated with receiving the initiation dose and/or next needed dose. For males, these factors were having subsidized insurance (initiation only); being Hispanic or Asian (next dose only); and being older than 15 years, receiving other vaccines, having a history of a sexually transmitted infection, and having more clinic visits. For females, these factors were being less than 15 years and having subsidized insurance (initiation only); being Asian (next dose only); and being Hispanic, having a primary language other than English, receiving other vaccines, and having more clinic visits.