Outreach increases completion of HPV vaccination series by adolescent girls

"Delivery of the HPV vaccine in safety-net settings is critically important because uninsured African-American and Hispanic women have higher rates of cervical cancer," said Dr. Jasmin Tiro, Associate Professor of Clinical Sciences at UT Southwestern, who led the study.

According to the National Cancer Institute (NCI), HPVs are the most common types of sexually transmitted infections in the United States and can be spread by vaginal, anal, or oral sex. Completing the HPV vaccine series before beginning sexual activity reduces risk of infection from the HPV types targeted by the vaccine. HPV infection can cause cervical, head and neck, and anal cancers, plus genital warts.

Despite the HPV vaccine being available since 2006, challenges remain in persuading parents and their teenage children to complete the vaccine series.

"Teens should receive all three recommended doses to protect against HPV infections that can persist and lead to cervical cancer," added Dr. Tiro, also Co-Leader of the Cancer Control and Population Science Program at UT Southwestern's Harold C. Simmons Comprehensive Cancer Center.

Published in the journal Pediatrics, this study is the first to compare effectiveness in safety-net populations of HPV-specific information and follow-up calls to those overdue for later doses of the vaccine versus more traditional general vaccine information. The work was funded by the Cancer Prevention and Research Institute of Texas.

The study was conducted at Parkland, the public health system for Dallas County, the ninth largest county by population and one of the most ethnically diverse counties in the U.S. From Parkland's system of 10 neighborhood-based pediatric clinics, researchers identified four clinics with the largest volume of patients aged 11 to 18. All of the clinics use electronic health records. At the time of this study (2010-2011), the vaccine was only recommended for girls. Since then, the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices has recommended that boys also receive the vaccine.

The 814 girls in the study were randomly assigned to one of two groups. Those in one group received a general adolescent vaccine brochure. Members of the other group received an HPV vaccine-specific brochure, plus telephone calls to parents who declined, and reminder calls to patients overdue for the second and third doses of the vaccine. One year later, HPV one-dose and three-dose coverage rates were assessed via electronic health records. Study participants were diverse -- 68 percent Hispanic and 28 percent African-American.

The HPV vaccine-specific educational brochure, designed to motivate parents to start the series, had mixed results by race/ethnicity. Developed with feedback from Parkland parents to explain the value of the cancer-fighting HPV vaccine in a culturally sensitive manner, the brochure was effective for Hispanic parents only.

"Our study shows that one brochure does not work for all parents at Parkland. Parents have different information needs, and different messages will motivate them to start the series. As a follow-up to this study, our current grant from the NCI supports testing a tablet-based self-persuasion intervention to address the needs of different subpopulations at Parkland -- adolescent girls and boys, Hispanics, and African-Americans," said Dr. Tiro.

The senior author of the study is Dr. Donna Persaud, Parkland's Chief of Pediatric & Adolescent Medicine, Population Health Division.

"As a result of this research partnership, Parkland has focused on improving vaccine outreach, education, and parent-provider discussions with African-American families," said Dr. Persaud. "We are implementing a quality improvement program funded by the state's Delivery System Reform Incentive Payment (DSRIP) Program. Preliminary results show a small, steady increase in HPV vaccine completion among African-American girls by their 13th birthday. The rate increased from 14.8 percent to 21.1 percent during the period October 2014 through September 2015."

"HPV vaccine delivery is challenging because of the dosing schedule and parental hesitation about vaccines," said contributing author Dr. Celette Sugg Skinner, Interim Chair of the Department of Clinical Sciences, Associate Director for Population Research at the Simmons Cancer Center, and holder of the Parkland Community Medicine Professorship at UT Southwestern. "Given these challenges, we must offer both education and vaccine opportunities at all health care visits. UT Southwestern and Parkland are committed to eliminating health care disparities and improving cancer prevention services."

The authors recommend that future research test mechanisms that may mediate intervention effects for different racial/ethnic groups, such as different informational needs, experiences, norms, or cultural beliefs.