Melissa B. Gilkey

Longitudinal Predictors of Human Papillomavirus Vaccination Among a National Sample of Adolescent Males

OBJECTIVES We conducted a longitudinal study to examine human papillomavirus (HPV) vaccine uptake among male adolescents and to identify vaccination predictors. METHODS In fall 2010 and 2011, a national sample of parents with sons aged 11 to 17 years (n = 327) and their sons (n = 228) completed online surveys. We used logistic regression to identify predictors of HPV vaccination that occurred between baseline and follow-up. RESULTS Only 2% of sons had received any doses of HPV vaccine at baseline, with an increase to 8% by follow-up. About 55% of parents who had ever received a doctors recommendation to get their sons HPV vaccine did vaccinate between baseline and follow-up, compared with only 1% of parents without a recommendation. Fathers (odds ratio = 0.29; 95% confidence interval = 0.09, 0.80) and non-Hispanic White parents (odds ratio = 0.29; 95% confidence interval = 0.11, 0.76) were less likely to have vaccinated sons. Willingness to get sons HPV vaccine decreased from baseline to follow-up among parents (P < .001) and sons (P = .003). CONCLUSIONS Vaccination against HPV remained low in our study and willingness to vaccinate may be decreasing. Physician recommendation and education about HPV vaccine for males may be key strategies for improving vaccination.

Do correlates of HPV vaccine initiation differ between adolescent boys and girls

BACKGROUND Guidelines now recommend that adolescents routinely receive human papillomavirus (HPV) vaccine. Because little is known about uptake among boys, we assessed HPV vaccine initiation in a population-based sample of adolescent boys and girls. METHODS We analyzed weighted data from 751 parents who reported on an 11- to 17-year-old son or daughter for the 2010 North Carolina Child Health Assessment and Monitoring Program survey. Stratified multivariate logistic regression analyses identified correlates of HPV vaccine initiation separately for boys and girls. RESULTS Only 14% of sons had received one or more doses of HPV vaccine compared to 44% of daughters (p<0.01). For both sons and daughters, vaccine initiation correlated with age and having received meningococcal vaccine. Among sons, initiation of HPV vaccine was lower for those living in high income households (odds ratio [OR]=0.22, 95% CI, 0.09-0.53) and higher for those whose race was neither white nor black (OR=3.26, 95% CI, 1.06-10.04). When asked to give the main reason for not vaccinating their child against HPV, parents of unvaccinated sons were more likely than those of daughters to report not getting a providers recommendation or not being aware that the vaccine was available for their child, but less likely to report concern about safety (p<0.01). At least 86% of unvaccinated children had missed an opportunity to receive HPV vaccine. CONCLUSIONS HPV vaccine correlates and concerns varied for parents of boys and girls. To improve very low levels of uptake among boys, providers should recommend HPV vaccine concomitant with other adolescent vaccines.

Provider communication and HPV vaccination: The impact of recommendation quality

BACKGROUND Receiving a healthcare providers recommendation is a strong predictor of HPV vaccination, but little is known empirically about which types of recommendation are most influential. Thus, we sought to investigate the relationship between recommendation quality and HPV vaccination among U.S. adolescents. METHODS In 2014, we conducted a national, online survey of 1495 parents of 11-17-year-old adolescents. Parents reported whether providers endorsed HPV vaccination strongly, encouraged same-day vaccination, and discussed cancer prevention. Using an index of these quality indicators, we categorized parents as having received no, low-quality, or high-quality recommendations for HPV vaccination. Separate multivariable logistic regression models assessed associations between recommendation quality and HPV vaccine initiation (≥ 1 dose), follow through (3 doses, among initiators), refusal, and delay. RESULTS Almost half (48%) of parents reported no provider recommendation for HPV vaccination, while 16% received low-quality recommendations and 36% received high-quality recommendations. Compared to no recommendation, high-quality recommendations were associated with over nine times the odds of HPV vaccine initiation (23% vs. 74%, OR=9.31, 95% CI, 7.10-12.22) and over three times the odds of follow through (17% vs. 44%, OR=3.82, 95% CI, 2.39-6.11). Low-quality recommendations were more modestly associated with initiation (OR=4.13, 95% CI, 2.99-5.70), but not follow through. Parents who received high- versus low-quality recommendations less often reported HPV vaccine refusal or delay. CONCLUSIONS High-quality recommendations were strongly associated with HPV vaccination behavior, but only about one-third of parents received them. Interventions are needed to improve not only whether, but how providers recommend HPV vaccination for adolescents.

Announcements Versus Conversations to Improve HPV Vaccination Coverage: A Randomized Trial

OBJECTIVE: Improving provider recommendations is critical to addressing low human papillomavirus (HPV) vaccination coverage. Thus, we sought to determine the effectiveness of training providers to improve their recommendations using either presumptive “announcements” or participatory “conversations.” METHODS: In 2015, we conducted a parallel-group randomized clinical trial with 30 pediatric and family medicine clinics in central North Carolina. We randomized clinics to receive no training (control), announcement training, or conversation training. Announcements are brief statements that assume parents are ready to vaccinate, whereas conversations engage parents in open-ended discussions. A physician led the 1-hour, in-clinic training. The North Carolina Immunization Registry provided data on the primary trial outcome: 6-month coverage change in HPV vaccine initiation (≥1 dose) for adolescents aged 11 or 12 years. RESULTS: The immunization registry attributed 17 173 adolescents aged 11 or 12 to the 29 clinics still open at 6-months posttraining. Six-month increases in HPV vaccination coverage were larger for patients in clinics that received announcement training versus those in control clinics (5.4% difference, 95% confidence interval: 1.1%–9.7%). Stratified analyses showed increases for both girls (4.6% difference) and boys (6.2% difference). Patients in clinics receiving conversation training did not differ from those in control clinics with respect to changes in HPV vaccination coverage. Neither training was effective for changing coverage for other vaccination outcomes or for adolescents aged 13 through 17 (n = 37 796). CONCLUSIONS: Training providers to use announcements resulted in a clinically meaningful increase in HPV vaccine initiation among young adolescents.

Forgone vaccination during childhood and adolescence: Findings of a statewide survey of parents

OBJECTIVE Widespread immunization confers both individual- and community-level protection against vaccine-preventable diseases. To better understand vaccine hesitancy, we assessed correlates of forgone vaccination for children and adolescents. METHOD We analyzed weighted data from the 2010 Child Health Assessment and Monitoring Program survey of North Carolina parents (n=1,847) of children ages 1-17. RESULTS Overall, 12% of parents reported having refused or delayed a vaccine for their child. Forgone vaccination was more common for young children than for teenagers (16% versus 8%) and for children born before rather than on/after their due dates (16% versus 10%). Parents with high (versus low) scores on an index of healthy feeding practices were also more likely to report forgone vaccination (17% versus 5%). The most common reason for forgoing vaccines was concern about safety (34%). Other reasons included believing the child did not need (18%) or was too young (13%) for the vaccine, or that the child was sick (10%). CONCLUSION Forgoing vaccines is more common among parents who are socially advantaged and highly attentive to their childrens health in other areas such as nutrition. Providers should reassure parents of premature or sick children that such circumstances are not typically contraindications to vaccination.

Promising alternative settings for HPV vaccination of US adolescents

Vaccination in alternative settings, defined here as being outside of traditional primary care, can help address the pressing public health problem of low human papillomavirus vaccine coverage among adolescents in the United States. Pharmacies are promising because they are highly accessible and have well established immunization practices. However, pharmacies currently face policy and reimbursement challenges. School-located mass vaccination programs are also promising because of their high reach and demonstrated success in providing other vaccines, but control by local policymakers and challenges in establishing community partnerships complicate widespread implementation. Health centers in schools are currently too few to greatly increase access to human papillomavirus vaccine. Specialty clinics have experience with vaccination, but the older age of their patient populations limits their reach. Future steps to making alternative settings a success include expanding their use of statewide vaccine registries and improving their coordination with primary care providers.

Increasing Provision of Adolescent Vaccines in Primary Care: A Randomized Controlled Trial

OBJECTIVES: To assess the effectiveness of in-person and webinar-delivered AFIX (Assessment, Feedback, Incentives, and eXchange) consultations for increasing adolescent vaccine coverage. METHODS: We randomly assigned 91 primary care clinics in North Carolina, serving 107 443 adolescents, to receive no consultation or an in-person or webinar AFIX consultation. We delivered in-person consultations in April through May 2011 and webinar consultations in May through August 2011. The states immunization registry provided vaccine coverage data for younger patients (ages 11–12 years) and older patients (ages 13–18 years) for 3 adolescent vaccines: tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap); meningococcal; and human papillomavirus (HPV) vaccines (≥1 dose, females only). RESULTS: At the 5-month follow-up, AFIX consultations increased vaccine coverage among younger adolescents. Patients in the in-person arm experienced coverage changes that exceeded those in the control arm for Tdap (3.4% [95% confidence interval (CI): 2.2 to 4.6]), meningococcal (4.7% [95% CI: 2.3 to 7.2], and HPV (1.5% [95% CI: 0.3 to 2.7]) vaccines. Patients in the webinar versus control arm also experienced larger changes for these vaccines. AFIX did little to improve coverage among older adolescents. At 1 year, the 3 arms showed similar coverage changes. The effectiveness of in-person and webinar consultations was not statistically different at either time point (all, P >.05). CONCLUSIONS: Webinar AFIX consultations were as effective as in-person consultations in achieving short-term increases in vaccine coverage for younger adolescents. AFIX consultations for adolescents need improvement to have a stronger and more durable impact, especially for HPV vaccine.

Trends in HPV Vaccine Initiation among Adolescent Females in North Carolina, 2008–2010

Background: To better target future immunization efforts, we assessed trends and disparities in human papillomavirus (HPV) vaccine initiation among female adolescents in North Carolina over 3 years. Methods: We analyzed data from a stratified random sample of 1,427 parents who, between 2008 and 2010, completed two linked telephone surveys: the Behavioral Risk Factor Surveillance System and the Child Health Assessment and Monitoring Program surveys. Weighted analyses examined HPV vaccine initiation for girls ages 11 to 17 years. Results: HPV vaccine initiation increased modestly over time (2008, 34%; 2009, 41%; 2010, 44%). This upward trend was present within 11 subpopulations of girls, including those who lived in rural areas, were of minority (non-black/non-white) race, or had not recently received a preventive check-up. Looking at differences between groups, HPV vaccine initiation was less common among girls who attended private versus public school, were younger, or lacked a recent check-up. However, the latter difference narrowed over time. The low level of initiation among girls without recent check-ups increased substantially (from 11% to 41%), whereas initiation among girls with recent visits improved little (from 39% to 44%, Pinteraction = 0.007). Conclusions: Although HPV vaccine initiation improved among several groups typically at higher risk for cervical cancer, the lack of progress among girls with recent check-ups suggests that missed opportunities for administration have hampered broader improvements. Impact: Achieving widespread coverage of HPV vaccine will require redoubled efforts to vaccinate adolescents during routine care. Cancer Epidemiol Biomarkers Prev; 21(11); 1913–22. ©2012 AACR.

Professionalization and the Experience-Based Expert: Strengthening Partnerships Between Health Educators and Community Health Workers

The recent inclusion of community health workers (CHWs) in the U.S. Department of Labor’s 2010 Standard Occupational Classification System provides an opportunity for health educators to reflect on their relationship with CHWs. The authors discuss the ways that health educators and CHWs differ in their orientation toward professionalization and employ the concept of the “experience-based expert” to highlight what they believe to be the unique contributions of CHWs. Finally, considerations important for health educators and CHWs as they work to advance supportive and complementary practices are discussed.

Effective interdisciplinary training: lessons from the University of North Carolina's student health action coalition.

Purpose To identify essential elements of effective interdisciplinary training through an evaluation of the University of North Carolina’s Student Health Action Coalition (SHAC), an interdisciplinary service learning program for health science students. Method In 2004, 516 SHAC volunteers were asked to complete a 52-item, online questionnaire. Responses were tallied by volunteer role, and four of the resulting “divisions” (counseling, medical care, interpretation, and community outreach) were analyzed using qualitative and quantitative rating schemas. The four divisions were compared on volunteers’ perception of two concepts: (1) the level of interdisciplinary training achieved and (2) the potential for working together, or “community capacity.” Results A total of 283 students accessed the online questionnaire, and 281 provided consent and filled out some portion of the questionnaire, an overall response rate of 54%. A total of 159 of the 281 respondents (57%) reported volunteering most often for one of the four divisions of interest. The respondents in each volunteer division reported a level of interdisciplinary training similar to that division’s level of community capacity. The division responsible for counseling services indicated the least interdisciplinary training, earning 4 points on an 8-point rating schema. This group also reported low levels of participation, group skills, information sharing, shared values, sense of community, and social networks. The community outreach division reported the highest level of interdisciplinary training, receiving 8 out of 8 points. They also had high levels of participation, group skills, information sharing, networking, and sense of community. Conclusions Effective interdisciplinary training goes hand in hand with five elements identified from the community capacity literature: participation, training in group skills, information sharing, networking, and critical reflection. Program planners and evaluators should pay particular attention to the social environment so as not to reinforce professional stereotypes that interdisciplinary programs are meant to dispel.