Barriers, Facilitators, and Potential Strategies for Increasing HPV Vaccination: A Statewide Assessment to Inform Action

The purpose of this evaluation was to identify contextually appropriate intervention strategies that may be feasible, acceptable, and effective for improving human papillomavirus (HPV) vaccination in South Carolina (SC), United States (US).

HPV vaccination rates are even lower in SC than they are nationally, with 1st and 3rd dose coverage respectively at 54% and 34% among girls and 29% and 16% among boys. In response to the low national uptake of HPV vaccination, the 2014 President's Cancer Panel Report made 3 recommendations: 1) use of multi-level intervention strategies; 2) thoughtful collaboration and coordination of resources and services among diverse stakeholders; and 3) state-specific strategies that account for factors such as the preferences and needs of state residents and existing health systems, resources and policies. After publication of the 2014 report, the Hollings Cancer Center in SC was one of 18 sites funded by the National Cancer Institute (NCI) to carry out environmental scans to evaluate the barriers, facilitators, and potential strategies needed to improve state-level HPV vaccination rates.

For the scan, 34 key informant interviews were conducted with state leaders who represented diverse organisations that have potential to impact HPV vaccination policies and practices. The Socio-Ecological Model (SEM) informed the development of an interview guide that focused on characterising barriers and facilitators, partnerships and promising intervention strategies across each level of the SEM to address underutilisation of the HPV vaccine. The SEM describes 5 nested levels of influence: individual (knowledge, attitudes, skills), interpersonal (social network), organisational (environment, ethos), community (cultural values, norms), and public policy/environmental context.

As the quotations shared in Table 2 of the report illustrate, some of the themes that emerged from the interviews were:

• Lack of HPV awareness among the general public: Absence of systematic messaging to promote accurate information about HPV vaccination; lack of awareness of importance of HPV vaccination among key stakeholders in the state; lack of awareness among parents/patients; parental lack of awareness compounded by poor provider vaccine endorsement; and lack of awareness that males need the vaccine.
• Lack of provider recommendation for HPV vaccination: Provider lack of awareness of guidelines; provider discomfort discussing the topic; perceptions about time required to present HPV vaccination; and difficulty with addressing preventive care issues because adolescents tend to only visit physicians for acute health issues.
• Concerns about HPV vaccination: Sexually transmitted nature; sexually transmitted nature significant in context of recommended age for vaccination; uncertainty about safety of vaccines and HPV vaccine in particular; and greater concern among African-American parents in regards to new interventions.
• Lack of access: Cost barriers; HPV vaccination not included in SC Vaccine Program for adolescents; and lack of coverage for HPV vaccination among young adults.
• Practice-level barriers: Lack of suitable recall systems for follow-up doses in practices; cost of administering HPV vaccine; and pharmacy reimbursement.

Several facilitating factors specific to SC were identified. For example, the perception is that there is a high degree of momentum in commitment to addressing HPV vaccination uptake. Enthusiasm about momentum at the national level was fueled by the President's Cancer Panel Report in 2014, the Cervical Cancer-Free America movement, and federal funding to address HPV vaccination efforts. At a state level, Cervical Cancer Free SC, a state partner of the national advocacy organisation committed to elimination of cervical cancer through vaccination, screening, and education, had made efforts to promote coordination among state players.

Promising strategies for improving HPV vaccination mentioned by the participants fell into 3 general categories:

1. Addressing lack of awareness about the importance of HPV vaccination among general public and providers
   • Widespread public education about HPV vaccination via local engagement, mass media, and/or social media. One person suggested, "Peer to peer pressure is key....You give kids something and they run with it. Some of these kids are incredibly intelligent. They can take any message and figure out how to make other people listen. Plant some seeds with the kids who plant some seeds and then you have a network of youth..."
   • Targeted education of healthcare providers through in-service sessions at state provider meetings, email listservs, and continuing medical education (CME) credit programmes.
   • Synergistic effect of reaching out to these 2 groups - e.g., doctors and the media need to strongly encourage the vaccine.
2. Advocacy for policy changes around coverage of HPV vaccines, vaccine education, and pharmacy-based vaccination. One person suggested, "Get community buy-in. We need religious leaders who understand the science and have connections to organizations like the SC Policy Council, SC Palmetto Council, SC Catholic Coalition, SC Baptist Convention. That speaks volumes legislatively and in churches back home."
3. Robust coordination of state stakeholder efforts. Suggestions fell into the categories of: (i) public education/engagement (e.g., work with schools and faith communities); (ii) provider education (e.g., hold a webinar offering CME credits); and (iii) health system prompts (e.g., work with pharmaceutical companies to help with both reminder and recall systems and provider education); (iv) coordination and tracking (e.g., invest in Cervical Cancer Free South Carolina as a home for coordinating these efforts).

To enable comparison of these results with those from other NCI-funded HPV environmental scan projects, the researchers identified 5 studies that were conducted in diverse parts of the US. One finding was that, in contrast to this study, the 3 environmental scans conducted in settings that served a high volume of medically underserved or multi-cultural/lingual patients identified additional needs for reading-level, language, and culturally-tailored health education materials. Two of these same studies also identified challenges in verbally communicating about HPV vaccination with clients who spoke another language and the need for more onsite interpreters, given the complexity of HPV vaccination communication.

As reported here, since the time of this environmental scan, the Cervical Cancer Prevention Act, which was stalled at the time of interviews, was passed in SC in April 2016. The policy states that all middle schools are required to educate parents about HPV vaccination and that underinsured adolescents can receive HPV vaccination through the State Vaccination Program. Momentum in commitment to HPV vaccination at the state level was demonstrated by a press release from the Hollings Cancer Center, hich encouraged HPV vaccination and was signed by over 25 state partners. Finally, the approval of a 2-dose schedule for HPV vaccination for adolescents under the age of 14 in October 2016 not only alleviates barriers to completing the 3-dose series, but also encourages physicians to recommend vaccination earlier.

"For further progress on HPV vaccination, sustained and coordinated efforts are required in SC. This environmental scan effectively evaluated the current barriers and facilitators to timely HPV vaccination in SC. This project also generated information that will be helpful in designing contextually appropriate strategies for improving HPV vaccination across the Southeast, where HPV vaccination rates are lower than many other regions of the US."