Amy B. Middleman

The Role of Schools in Strengthening Delivery of New Adolescent Vaccinations

Schools offer an opportunity to deliver new vaccines to adolescents who may not receive them in their medical home. However, school budgets and health priorities are set at the local level; consequently resources devoted to health-related activities vary widely. Partnering with schools requires soliciting buy-in from stakeholders at district and school levels and providing added value to schools. With appropriate resources and partnerships, schools could carry out vaccination-related activities from educating students, parents, and communities to developing policies supporting vaccination, providing vaccines, or serving as the site at which partners administer vaccines. Activities will vary among schools, but every school has the potential to use some strategies that promote adolescent vaccination.

Adolescent sexuality and sexual behavior

Purpose of review Adolescence is a time of self-discovery and physical, as well as cognitive, development. It is within this context that adolescent sexual development and sexual behavior occur. While curiosity and experimentation are normal, sexual behaviors, both coital and non-coital, place adolescents at risk for undesired consequences including sexually transmitted disease acquisition and pregnancy. Trends in adolescent sexual behavior are changing, and health care professionals must be aware of these trends to provide necessary medical care and education to this population. Recent findings While the sexual activity of teenagers garners much attention, attention must also be directed at non-coital activities such as masturbation, mutual masturbation and oral sex, as the riskier of these behaviors appear to be increasing. The trends in sexual activity and contraceptive use are encouraging with a decrease in the proportion of adolescents reporting sexual activity, and an increase in the proportion reporting using contraception. These trends, however, are not shared equally among racial groups with the greatest decline reported in the in lowest risk groups. Sexual minority youth continue to report a higher prevalence of high-risk behaviors, both sexual and non-sexual, as compared to their heterosexual peers. Summary These findings highlight the multiple roles health care professionals can play in caring for this unique population: firstly as health care providers, offering age appropriate, confidential health care; secondly, as reproductive health care educators providing factual, balanced, and realistic information to both teenagers and the community; and thirdly, as advocates lobbying for greater education and services for this at-risk population.

Effect of Needle Length When Immunizing Obese Adolescents With Hepatitis B Vaccine

OBJECTIVE: Several studies have noted that obese adolescents and adults achieve lower titers of antibody in response to vaccines such as hepatitis B virus (HBV) vaccine. The objective of this study was to determine whether use of a longer (1.5-in) rather than a standard (1-in) needle to penetrate the thicker deltoid fat pad among obese youth would result in higher antibody titers after immunization against HBV. METHODS: Obese adolescents from a large metropolitan area who had not previously received the HBV vaccine were randomly assigned to be immunized with HBV vaccine by using either a 1-inch or a 1.5-inch needle. RESULTS: Those who were immunized with a 1.5-inch needle achieved significantly higher antibody titers to hepatitis B surface antigen (median titers: 1-inch = 189.8 mIU/mL, 1.5-inch = 345.4 mIU/mL; P = .03). CONCLUSIONS: This finding supports the hypothesis that needle length accounts for a significant portion of the discrepancy in immune response to HBV vaccine that is seen among those with obesity.

Low prevalence of antibody to hepatitis C virus in an urban adolescent population

We tested 869 subjects attending either an urban adolescent medicine clinic or a school-based clinic for antibody to hepatitis C virus. Demographic data indicated a representative study sample, and behaviors associated with hepatitis C virus transmission. One subject (0.1%) was seropositive for antibody to hepatitis C virus, indicating a very low prevalence of hepatitis C virus exposure in adolescents.

Urban Middle School Parent Perspectives: The Vaccines They Are Willing to Have Their Children Receive Using School-Based Immunization Programs

PURPOSE With new vaccination recommendations for adolescents, school-based immunization programs become a valuable alternative site for immunization. This study seeks to determine factors associated with parental willingness to utilize school-based programs for immunizations. METHODS A questionnaire was distributed to the parents of 11-14-year-olds attending 7 middle schools in a large, urban public school district. Participants were asked multiple questions including medical home enrollment, primary language spoken at home, site of last immunization, and comfort with their child receiving specific vaccines during school hours. Frequencies, chi-square analyses, and logistic regression analyses were performed using SPSS 17.0. RESULTS A total of 615 parent questionnaires were included in the analyses; 81% of parents were Hispanic, 16% black, 39% spoke primarily English at home, and 77% indicated that they had a medical home for their child. Regarding specific vaccines, the largest percentage of parents were willing to have their child receive influenza vaccine (57%) and the smallest percentage were willing to have the human papillomavirus vaccine (27%) at school during school hours. Parents who had used a school-based clinic for their childs last immunization were more willing to receive each vaccine at school. CONCLUSIONS This study indicates that there is significant interest and willingness among predominantly lower income, Hispanic middle school parents to have their children receive specific vaccines during school hours through school-based immunization programs. More study is needed among a more diverse population of parents to help target the various needs of parents and adolescents and ultimately increase adolescent immunization rates.

At what sites are parents willing to have their 11 through 14-year-old adolescents immunized?

INTRODUCTION Parental preferences of alternative immunization sites for adolescents must be evaluated to determine optimal delivery strategies. METHODS Analyses were performed on data from middle-school parent questionnaires in low income areas. RESULTS 1838 questionnaires were returned; 86.5% of the participants were Hispanic, 65% spoke primarily Spanish at home. Among those with a medical home, 32% had the last immunization at an alternative location. When checking all that apply, 65% of parents selected the medical home as a desirable location for immunization; 41% selected a school-based program. CONCLUSIONS Despite lack of exposure to school-based immunization programs, school-based programs are a desirable immunization site among middle-school parents.

School-located immunization programs: Do parental preferences predict behavior? ☆

BACKGROUND Little is known about parental attitudes regarding school-located immunization programs and their effect on program participation behaviors. OBJECTIVE To determine the relationship between attitudes of middle school parents regarding school-located immunization programs and subsequent consent behaviors when such a program becomes available. METHODS Primarily Hispanic, middle school parents completed questionnaires about school-located immunization programs. After questionnaire collection, immunization consent/refusal packets (English/Spanish) for a program providing Tdap and MCV4 vaccines were distributed at five Houston middle schools in low-income, urban areas. Responses regarding demographics, enrollment in a medical home, immunization location preferences, and knowledge of immunization recommendations were analyzed from questionnaires returned by those who later returned consent or refusal forms for school-located program participation. Frequency and chi square statistics were calculated using SPSS 18.0. RESULTS Of 475 parents who completed the questionnaire and later sent a consent or refusal form, 289 (61%) consented to ≥1 vaccines for their child. Among those who consented: 71% were enrolled in a medical home; 42% had previously indicated that they did NOT prefer school as an immunization location; 32% had stated that they wanted to be present for their childs shots. Of those who sent refusal forms indicating they would access the vaccines from their own providers, 70% stated they wanted to be present for their childs vaccination. CONCLUSIONS A significant proportion of Hispanic, low-income middle school parents participating in a school-located immunization program had previously indicated that schools were not a preferred immunization site. Despite the availability of a medical home, a lack of preference for schools as a site, and the desire to be present during their childs injections when asked prior to program availability, these parents participated in the program when it was made available. Preferences noted in pre-program questionnaires may not predict parental consent behaviors for school-located immunizations.

Use of hormonal methods of birth control among sexually active adolescent girls.

OBJECTIVE To identify factors associated with the use of various birth control methods among sexually active adolescent girls. DESIGN A survey distributed as part of a larger study measuring compliance with hepatitis B vaccination. SETTING A hospital-based and a school-based clinic. MEASURES Demographic and health behavior data including sexual activity, contraceptive method, substance use, condom use, and history of sexually transmitted diseases (STDs) were collected. Birth control method was confirmed by medical record review. Associations with the outcome variable of birth control method were analyzed using chi square, Kruskal-Wallis analyses of variance, and t-tests, followed by logistic regression analysis. RESULTS Among sexually experienced girls, 39% (n = 123) reported using oral contraceptive pills (OCPs), 5.4% (n = 17) used Depo-Provera (medroxyprogesterone acetate) or Norplant (levonorgestrel), and 55.6% (n = 175) used no hormonal method. Logistic regression analysis revealed that the factors most significantly associated with the use of hormonal methods were older age (odds ratio [OR] = 1.19; 95% confidence interval [CI], 1.07-1.33), not using a condom at last intercourse (OR = 0.55; CI, 0.34-0.90), and having had a well visit within 1 year (OR = 2.11; CI, 1.12-3.70). OCP users were less likely than Depo-Provera or Norplant users to have used alcohol (p = 0.041), cigarettes (p = 0.002), or marijuana (p = 0.018) in the past 30 days. OCP users were less likely than nonusers of hormonal methods to have smoked cigarettes (p = 0.034) or marijuana (p = 0.052). The school-based clinic had a greater proportion of subjects using long-acting progestins (p < 0.001). CONCLUSIONS The decreased rate of condom use among those who used hormonal birth control methods and the different rates of health risk behaviors among users of various methods require targeted counseling efforts to decrease pregnancy and STD rates among young women.

School-located influenza immunization programs: Factors important to parents and students ☆

PURPOSE To describe both parent and student perspectives on the importance of various programmatic factors when deciding to participate in a school-located immunizations program (SLIP) for influenza vaccine. METHODS Questionnaires were distributed to middle- and high-school students and their parents; the document assessed demographic data, influenza vaccination history, and the importance of various factors in their decision to participate in a potential SLIP for influenza vaccine. Factor analysis created six primary factors of importance related to programming: (1) safety/trust; (2) outbreaks (representing imminent threat of disease, an environmental factor associated with program timing); (3) issues of site implementation; (4) public health benefits; (5) record-keeping; (6) medical/emotional support. RESULTS Participants included 621 students and 579 parents; 566 student/parent dyads were included. Most respondents were female, felt it is important to be immunized against the flu, and received the influenza vaccine in the past. Fewer than 50% had received the intranasal vaccine. More parents (67%) than students (46%) expressed a general willingness to consent to utilizing a SLIP. The programmatic factors associated with public health were second only to safety/trust factors as the most important to parents and students when considering participation in a SLIP. Demographic variables were found to be associated with the importance ratings of program factors associated with participation in a SLIP. CONCLUSIONS When considering possible participation in SLIPs, parents and students consider programmatic factors associated with safety/trust and public health benefits to be of the greatest importance. Further study will be needed to develop effective and culturally sensitive messaging that targets and emphasizes these factors to potentially increase participation in SLIPS.

Human Papillomavirus Vaccination in Female Pediatric Cancer Survivors

STUDY OBJECTIVE Survivors of childhood malignancy may be at increased risk for HPV infection for biological and cognitive/behavioral reasons. HPV vaccination is currently recommended for females 11-12 years old with catch up vaccination up to age 26 years. The objective of this cross-sectional study was to determine the prevalence of HPV vaccination among female pediatric cancer survivors, age 11-18 years, at Texas Childrens Hospital. STUDY DESIGN, SETTING, AND PARTICIPANTS: A 42-question survey was distributed to parents/guardians of 172 long-term cancer survivors from August-November of 2010. Data were analyzed using frequencies, t-tests, and chi-square analyses. MAIN OUTCOME MEASURES Prevalence of HPV vaccination (intention and completion). RESULTS Sixty-six persons (38%) responded. The median current age of survivors was 14 years. Most were white/non-Hispanic (48%) or white/Hispanic (37%). Seventy-one percent had discussed HPV vaccination with a healthcare provider. The overall rate of HPV vaccination (≥ 1 dose) was 32%, including 5% of those age 11-12 years (n = 1 of 21), 36% of those age 13-17 years (n = 13 of 36), and 78% of those age 18 years (n = 7 of 9). Of those whose children had not been immunized, 36% intended to do so in the future. Factors associated with HPV vaccination included age ≥13 years, report of sexual activity, and report of having discussed HPV vaccination with a healthcare provider. CONCLUSION The rate of HPV vaccination among female pediatric cancer survivors is not appreciably different than that seen in the general population.