New Hampshire and Vermont Barriers and Facilitators to HPV Vaccination

Problem: Uptake of the human papillomavirus (HPV) vaccine is much lower than the uptake of other vaccines given at ages 11 and 121. Within New Hampshire and Vermont, the HPV vaccination rates are much higher than in other parts of the U.S., but rates had plateaued at the time of this initiative.¹ 

¹Walker, T. Y., Elam-Evans, L. D., Yankey, D., Markowitz, L. E., Williams, C. L., Mbaeyi, S. A., . . . Stokley, S. (2018). National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years — United States, 2017. Morbidity and Mortality Weekly Report, 67(33), 909-917. 

PSE Change Solution: The catchment area of the Dartmouth-Hitchcock Norris Cotton Cancer Center (Norris Cotton), located in Lebanon, New Hampshire, includes New Hampshire and Vermont. A research team² conducted an environmental scan focused on understanding the barriers and facilitators to adolescent HPV vaccination in these two states. The scan identified vaccination facilitators, including strong partnerships among partners , and the availability of the vaccine at no cost. Vaccination barriers included limited clinician/staff preparedness to provide a strong recommendation for the vaccine, and lack of parent/child awareness/knowledge about HPV and the vaccine. Common themes related to parents’  attitudes and beliefs about the HPV vaccine were also identified. 

Since the completion of the environmental scan, Norris Cotton has been working to disseminate the results to stakeholders throughout New Hampshire and Vermont. Results have been shared with both states’ HPV vaccine coalitions, and Norris Cotton co-hosted a Summit where the findings of the environmental scan were shared and discussed for future collaborative interventions. In addition, Norris Cotton is working to address the findings about parents’ attitudes and beliefs toward the HPV vaccine. 

²Sunny Jung Kim, Virginia Commonwealth University, was the co-investigator on this project. 

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Problem 

The human papillomavirus (HPV) vaccine is effective in preventing HPV-related cancers, and it’s recommended that the vaccine be given at ages 11 and 12 years old (Centers for Disease Control and Prevention [CDC], 2017). Unfortunately, uptake of the HPV vaccine is much lower than the uptake of other vaccines given at these same ages (Walker et al., 2018). Within New Hampshire and Vermont, the HPV vaccination rates are much higher than in other parts of the U.S., but rates have plateaued in recent years (Walker et al., 2018). 

PSE Solution 

The catchment area of the Dartmouth-Hitchcock Norris Cotton Cancer Center (Norris Cotton), located in Lebanon, New Hampshire, includes New Hampshire and Vermont. A research team,¹ comprised of an investigator from the Cancer Population Sciences Research Program and members of the cancer center’s Community Outreach and Engagement team, conducted an environmental scan focused on understanding the barriers and facilitators to adolescent HPV vaccination in these two states. Findings from the environmental scan presented several opportunities for public health and clinical interventions to address barriers to HPV vaccination. 

¹Sunny Jung Kim, Virginia Commonwealth University, was the co-investigator on this project. 

Actions/Results 

Actions 

The environmental scan involved the following actions: 

• Conducted interviews with HPV vaccine stakeholders (e.g., healthcare providers; representatives from healthcare organizations, oral health organizations, and cancer centers; cancer survivors and advocates; public health officials) across New Hampshire and Vermont to understand their perspectives on facilitators and barriers to HPV vaccination; 

• Administered a survey of primary care and pediatric clinicians to understand the circumstances under which they recommend the HPV vaccine and how they deliver the recommendation to patients and parents; and 

• Held two in-person focus groups and five social media discussion forums with parents of adolescents (9-to-14-year-olds) to describe their attitudes and beliefs related to HPV vaccination. 

Results 

From the interviews with 32 HPV vaccination stakeholders, the following emerged as some of the top facilitators of HPV vaccination: 

• Strong partnerships among stakeholders – for example, interviewees spoke of the importance of having a strong coalition or work group that engages stakeholders around HPV vaccination; 

• The vaccine being available at no cost; 

• Clinicians receiving continuing education about HPV vaccination; and 

• Messaging the vaccine as a cancer prevention vaccine. 

Some of the top barriers identified were: 

• Limited clinician/staff preparedness to provide a strong recommendation for the vaccine; 

• Lack of parent/child awareness/knowledge about HPV and the vaccine; 

• Parents’ fears about the safety of the vaccine; 

• Lack of media campaigns about the vaccine; 

• Lack of access to the vaccine (e.g., in non-traditional settings); and 

• A sexual activity stigma associated with the vaccine. 

Findings from the survey of 219 clinicians demonstrate that about half of the clinicians strongly recommend the HPV vaccination across different patient and clinical visit scenarios; preventive visits were the most common type of visit during which the HPV vaccine is recommended (71%), in comparison to visits for febrile/infection issues, where very few clinicians (3%) recommend the HPV vaccine. When presented with different patient scenarios, 29-35% of clinicians adjusted their vaccine recommendation based on their expectation of whether the patient would be sexually active in the next two years. Similar findings have been reported in the literature (Allison et al., 2016; Holman et al., 2014). In each scenario, nurse practitioners were significantly more likely than physicians to vary their recommendation based on perceived risk of sexual activity. Regarding clinicians’ messaging about timing of vaccination, pediatricians were more likely to mention the importance of vaccinating at a younger age because of the stronger antibody response developed, in comparison with family physicians and nurse practitioners. 

Finally, the two in-person parent focus groups and five social media discussion forums identified five common themes related to parents’ attitudes and beliefs about the HPV vaccine: 

1. Concerns about the vaccine’s safety (e.g., ingredients, side effects) 

2. Distrust of the vaccine/health care system (e.g., FDA, doctors, pharmaceutical companies) 

3. Concerns about the vaccine’s effectiveness (e.g., it doesn’t prevent cancer, it only prevents a few HPV types) 

4. Connection to sexual activity (e.g., belief that only sexually active children need the vaccine) 

5. General misinformation and/or misstatement of information (e.g., incorrect information about the vaccine recommendation) 

Success Factors and Key Questions Addressed 

What was the ultimate purpose of the PSE change? What was your “ask”? 

The ultimate purpose of the environmental scan was to understand the reasons why HPV vaccination rates are not as high as the rates for other vaccinations in New Hampshire and Vermont and to identify opportunities to engage stakeholders to increase vaccination rates. 

What level of PSE change was necessary (local, state, federal or institutional)? 

Because the Norris Cotton catchment area is comprised of Vermont and New Hampshire, the environmental scan focused on both states. 

Who was already attempting PSE change efforts around the health issue? 

The National Cancer Institute (NCI) has provided funding for many of the NCI-designated cancer centers throughout the U.S.—including Norris Cotton—to (1) conduct local environmental scans focused on understanding barriers and facilitators related to HPV vaccination, and (2) collaborate with coalitions and immunization programs regarding pediatric HPV vaccine uptake. The NCI’s goal is for cancer centers to use these collaborations to develop applied research to increase vaccination (NOVA Research Company, 2016). 

Was the environment conducive to the PSE change? What challenges did the scan reveal (economic, political, social, legal etc.)? 

While the environment was generally conducive to conducting an environmental scan about HPV vaccination, there were a few lessons learned about method selection that may be instructive for other programs/coalitions. 

Because HPV vaccination is a relatively contentious public health topic, stakeholders conducting environmental scans in their communities should give great consideration to the methods they employ to collect data from their communities. There are two main reasons for this. First, some methods will elicit more useful data than others. For example, if stakeholders want to understand how to increase parent acceptance of the vaccine, the target audience would likely be parents who do not have strongly formed opinions about the vaccine; therefore, materials promoting a survey or focus group for parents may best be framed as being about “adolescent health” or “health”, rather than being about “HPV vaccine” or “vaccination.” Second, while it may be ideal to conduct a comprehensive environmental scan that includes all perspectives on the topic, this has the potential to cause harm if not conducted carefully. For example, based on discussions with the research team, it was recommended not to engage anti-vaccine representatives in key informant interviews since including their perspective may elevate their concerns and, ultimately, limit the ability to conduct the environmental scan and future HPV vaccine promotion activities. 

Next Steps 

Since the completion of the environmental scan, Norris Cotton has been working to disseminate the results to stakeholders throughout New Hampshire and Vermont. Results have been shared with both states’ HPV vaccine coalitions, and Norris Cotton co-hosted a Summit where the findings of the environmental scan were shared and discussed for future collaborative interventions (Step 5: Promote). 

In addition, Norris Cotton is working to address the findings about parents’ attitudes and beliefs toward the HPV vaccine. Since completing the focus groups and online discussions, Norris Cotton has developed messages that target the top five themes that emerged during the focus groups (i.e., safety concerns, effectiveness concerns, distrust of the vaccine/healthcare system, misinformation/misstatement of facts, and connection to sexual activity), and these messages have been tested with parents to identify messages that are effective in changing parents’ attitudes toward the vaccine and their intent to vaccinate their children against HPV. These effective messages are being used in a social media campaign targeting parents throughout Vermont and New Hampshire (Step 6: Implement). After the campaign is evaluated (Step 7: Evaluate), Norris Cotton will share the messages and the results of the campaign with stakeholders, enabling them to also deploy these messages with the parents they reach. 

Related Resources 

See the George Washington University Cancer Center’s HPV Cancer and Prevention Profiles for state-specific snapshots of HPV-associated cancers and vaccination rates. (Contact the GW Cancer Center to access the HPV Cancer and Prevention Profiles). Additional information is available through resources of the National HPV Vaccination Roundtable, including a toolkit on health systems change and a coalition guide. 

REFERENCES 

Allison, M. A., Hurley, L. P., Markowitz, L., Crane, L. A., Brtnikova, M., Beaty, B. L., . . . Kempe, A. (2016). Primary care physicians’ perspectives about HPV vaccine. Pediatrics, 137(2), e20152488. doi: 10.1542/peds.2015-2488 

Centers for Disease Control and Prevention. (2017). Human Papillomavirus (HPV). Genital HPV Infection – Fact Sheet. Retrieved from https://www.cdc.gov/std/hpv/stdfact-hpv.htm. 

Holman, D. M., Benard, V., Roland, K. B., Watson, M., Liddon, N., & Stokley, S. (2014). Barriers to human papillomavirus vaccination among US adolescents: A systematic review of the literature. JAMA Pediatrics, (168)1, 76-82. doi: 10.1001/jamapediatrics.2013.2752 

NOVA Research Company. (2016). Administrative supplements for NCI-designated cancer centers to support collaborations to enhance HPV vaccination in pediatric settings: A summary report. Retrieved from https://healthcaredelivery.cancer.gov/hpvuptake/DCCPS_HPVvax-report_FINAL_508compliant.pdf. 

Walker, T. Y., Elam-Evans, L. D., Yankey, D., Markowitz, L. E., Williams, C. L., Mbaeyi, S. A., . . . Stokley, S. (2018). National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years — United States, 2017. Morbidity and Mortality Weekly Report, 67(33), 909-917.