The Importance of Increasing Hpv Vaccination in Children

Introduction

The Human Papillomavirus (HPV) is a sexually transmitted disease that causes not only cervical cancer, but also other cancers and genital warts. The Advisory Committee on Immunization Practices (ACIP) recommends that adolescents aged eleven to twelve years routinely receive vaccines to prevent diseases, including HPV associated cancers. The current recommendation is two doses with the second dose being administered six to twelve months after the initial dose.

Ethnicity plays a part in the epidemiology of cervical cancer with twice as many African American women dying when compared to white women. Hispanic women have a high mortality rate as well when compared to white women.

The problem is the low HPV vaccine uptake amongst adolescents within the targeted population (minority 9th graders at Washington High). Currently, about 40% of the 9th graders have at least the first dose of the HPV vaccine. The objective is to increase that number by about 20-25% and to increase HPV uptake amongst adolescents within this population by implementing evidence-based tactics.

Background and Significance

There is a gap when it comes to children being vaccinated appropriately for the HPV vaccine. According to research, barriers include parental fears, lack of physician communication with parents, religious beliefs and the perceived stigma that accompanies the vaccine all contribute to the low uptake of the vaccine. The key to increasing uptake includes addressing those barriers and implementing sustainable interventions.

In the United States, the current rates are 39.7% for girls and 21.6% for boys aged 13 to 17 for completing the three-dose vaccine series. During 2014–2015, coverage among adolescents aged 13–17 years increased for each HPV vaccine dose among males, (from 41.7% to 49.8%), and increased modestly for females (from 60.0% to 62.8%).

Per Reagan Steiner (2016), in 2015, nationally, all adolescent HPV vaccination coverages with ≥1 dose was 56.1% (95% CI = 54.9%–57.4%), with ≥2 doses was 45.4% (95% CI = 44.2-3we4z%–46.7%), and with ≥3 doses was 34.9% (95% CI = 33.7%–36.1%). The HPV vaccine is not being routinely administered at visits when other recommended vaccines are given, and demonstrates ongoing missed opportunities for the prevention of HPV-associated outcomes, including cancers.

According to the Center for Disease Control and Prevention (CDC) (2016), the HPV Vaccination and Texas 2015 Immunization Survey showed that about 66% of girls received the first dose of the vaccine in Houston. The survey revealed that about 58.1% of girls received second dose and about 42.8% received the 3rd dose. The survey revealed that boys in Houston were vaccinated less than girls in 2015 with only about 58.6% of boys getting the first vaccine followed by 46.4% and 22.7% vaccinated with the second and third doses.

Problem Statement

Parents of adolescent children are receptive and look for advice from their medical providers. Improving communication between parents and providers could increase the HPV vaccine uptake. In addition, addressing parental fears and implementing school-based interventions could be effective as well. It is important to address and understand current barriers with increasing HPV uptake before strategies can be successfully implemented. Medical providers should gain a deeper understanding of their parent’s personal beliefs and feelings. The link between HPV and cancer should be reiterated and discussed thoroughly. Technology is on the rise and using it to educate adolescents on the importance of the vaccine could be beneficial. It is important to design and test context-specific strategies to improve adolescent vaccine uptake and dose completion rates.

Potential recommendations include requiring an integrated approach ranging from mass availability of vaccines at the national level to targeting adolescents in school and during health care visits to enhance the effectiveness of immunization programs. Further research is recommended to explore why missed vaccination opportunities exist and to develop evidence-based strategies to lower the number of missed chances and improve adolescent vaccination coverage.

The decrease in adolescent HPV vaccination in recent years, especially among adolescent girls, can be addressed by improving communication between care providers and parents, who often ignore medical advice or refuse to allow their children to be vaccinated based on misconceptions that could easily be dispelled with clear information and evidence. Information and education are common threads running through the issue, providing the means of reinforcing public and medical assets, and developing multifaceted approaches to the situation that communicate effectively to key stakeholders, such as health care providers and parents.

Economically, it is important to consider closing the gap on underserved or minority populations as it relates to vaccinations. The cost to vaccinate in hopes of eliminating the risk of acquiring HPV is more economically advantageous versus the cost of treating HPV itself. According to Richardson (2007), priorities should include investing in health as a mean to increase the chance the child will grow into a healthy adult and maximize their intellectual potential versus becoming a drain on social systems.

HPV vaccines can be highly efficacious and potentially lifesaving if administered to adolescents per clinical studies. These studies also show “HPV vaccination can be cost-effective with an incremental cost-effectiveness ratio (ICER) of $100,000 or less per quality adjusted life year (QALY) gained if administered to females aged 12 years in the context of cervical screening intervals, typically greater than 1 year”. Playing “catch-up” and being vaccinated through 21 years of age will increase the cost per QALY to more than $100,000, which can strain an economy (Armstrong, 2010) especially when the population is already underserved.

Assessment Approach

The researcher identified various types of assessment data and methods for data collection based on the barriers from the literature (parental fears, lack of communication by the provider during the clinic visit, lack of knowledge on the vaccine by parent, efficacy concerns, lack of knowledge by school nurse). According Rosen et al., (2015) school nurses can enhance their influence on parents regarding the HPV vaccine by focusing on increasing positive attitudes towards the vaccine and strengthening perceptions of their role as opinion leaders. Provider-focused interventions such as educating the parent and providing individualized feedback also produced sustained improvements in HPV vaccination rates (Perkins et al., 2015). Beavis & Levinson (2016) reported that physicians located in the South were less likely to offer the vaccine when compared to physicians in other regions. It is important to understand the targeted audience and communities because each group has different cultural needs when it comes to learning and retaining information. Systems for parents such as telephone calls, letters, outreach visits, focus groups, and text messages are interventions that have proven effective and have increased the uptake of the HPV vaccine.

Description of the Organization

Houston Independent School District is the largest public school system in the State of Texas with two hundred and eighty seven schools collectively. There are about 215,000 students with about 62.1% Hispanic, 24.5% African-American, 3.7% Asian, 8.4% White and is about 75.5% economically disadvantaged.

Booker T. Washington High School has about 700 registered students. It is located in the Independence Heights community in Houston, Texas. About 56% of the students are African American, 40% Hispanic and 3% are White. Approximately 69% of the students are from low-income families, therefore, this is a Title 1 school. The per-capita household income for 77018 is $41. Most of the students who attend the school have no medical insurance or they have a form of Medicaid. Health and Medical Services assigned Washington High to me for this project.

Using the high school for the pilot study will support the project’s design and implementation. It allows access to the adolescent’s parents, school immunization records, access to name of primary care doctors, and access to hold focus groups. In addition, it allows for observation of immunization suggestions during 9th grade registration by the school nurse, is a beneficial avenue to distribute and receive questionnaires, and most importantly allows for an opportunity to build a relationship with students and parents.

Stakeholders include the manager of Houston Independent School’s District Health and Medical Services (HMS), community physicians, school nurses and school principals. These individuals were chosen because they have a genuine interest and concern as it relates to HPV and its effect on adolescents. The inter-professional team consists of the manager of the districts HMS department and a nurse directly under her, will facilitate and ensure that there is access to the vaccination data reported to the state. They are also responsible for choosing the schools that are willing to allow the project to take place. The principal at Washington High is also a member of the team as they allow collection and distribution of the questionnaires, facilitate the focus groups and allow a place for dialogue between parents and the nurses.

Macrosystem

For the purpose of this project, the macrosystem is described as the Houston Independent School district (HISD). The district sets policy guidelines and monitors change through data collection. HISD is composed is students from varying social, economic, and racial backgrounds. The culture within HISD is to maintain a sense of safety at each campus and to propel each child academically to their fullest potential. The child’s macrosystem is also impacted by the family’s socio-economic status, political views, religion and gender. It is important to keep that in mind that when considering how a child will interpret experiences and what a child will experience and those factors should be considered. Parental beliefs including life experiences and cultural influences will have an effect on whether a parent chooses to vaccinate their child. In this system, filtering what one saw or heard will contribute to one’s interpretation and ultimately their decision.

Mesosystem

The mesosystem “produces the connections between the child microsystems, i.e. connections between the child´s teacher and the parents or the child´s church, school and the neighborhood (Paquette & Ryan 2001)”. For this project, the mesosystem can be described as the actually campus or school. The mesosystem is also where collaboration such as education between the school (including the school nurse), the primary care physician and the adolescent’s family would fall under.

Microsystem

Microsystems can be defined as the smaller teams of professionals who collaborate frequently to ensure that the students are meeting their goals. Teachers, dietary staff, custodians, counselors, and the administrative team, all work together cohesively to achieve similar goals. The school nurses within HISD also work together to make sure state guidelines are being met and that each campus is operating effectively and per policy.

Potential barriers

Potential barriers include lack of knowledge management skills and infrastructure by decision makers. Key stakeholders may face barriers such as lack of access to research evidence or they may not fully understand the research evidence. Other barriers include obtaining and administering the HPV vaccine to the students. Insurance issues, parent waivers and securing an organization to actually supply the vaccinations is a challenge. Parents of adolescent children are receptive and look for advice from their medical providers. Therefore, improving communication between parents and providers could increase the HPV vaccine uptake. In addition, addressing parental fears and implementing school-based interventions could be effective as well.

It is also important to address and understand current barriers with increasing HPV uptake before strategies can be successfully implemented. Medical providers should gain a deeper understanding of the parent’s personal beliefs and feelings and address vaccine safety or efficacy concerns. The link between HPV and cancer should be reiterated and discussed thoroughly. Technology is on the rise and using it to educate adolescents on the importance of the vaccine could be beneficial. It is important to design and test context-specific strategies to improve adolescent vaccine uptake and dose completion rates.

Although barriers exist, it is important to close the knowledge-to-practice gaps. Effective knowledge translation interventions will improve health outcomes and these initiatives should include all aspects of care. Also a multifaceted approach is vital to break down the barriers to HPV vaccination.

Opportunities for Assessment

Although education is key, education alone will not increase the uptake of the vaccine. School-based vaccine methods have continuously been a successful option, however, the approach should be multifaceted. By using assessment tools such as focus groups, phone interviews, surveys, Chancery (district vaccine database), and face-to-face interviews, this writer will be able to assess values, attitudes, educational outcomes, and perceived learning from parents, enrolled students, and providers. As a result, the opportunity for improvement can be identified.