Advertisement

Human Papillomavirus Immunization in Rural Primary Care

      Introduction

      Despite the safety and efficacy of the human papillomavirus vaccine, thousands are impacted by human papillomavirus and its related cancers. Rural regions have disproportionately low rates of human papillomavirus vaccination. Primary care clinics play an important role in delivering the human papillomavirus vaccine. A positive deviance approach is used to identify workflows, organizational factors, and communication strategies in rural clinics with higher human papillomavirus vaccine up-to-date rates. Positive deviance is a process by which exceptional behaviors and strategies are identified to understand factors that enable success.

      Methods

      Rural primary care clinics were rank ordered by human papillomavirus vaccine up-to-date rates using 2018 Oregon Immunization Program data, then recruited via purposive sampling of clinics in the top and bottom quartiles. Two study team members conducted previsit interviews, intake surveys, and 2-day observation visits with 12 clinics and prepared detailed field notes. Data were collected October–December 2018 and analyzed using a thematic approach January–April 2019.

      Results

      Four themes distinguished rural clinics with higher human papillomavirus vaccine up-to-date rates from those with lower rates. First, they implemented standardized workflows to identify patients due for the vaccine and had vaccine administration protocols. Second, they designated and supported a vaccine champion. Third, clinical staff in higher performing sites were comfortable providing immunizations regardless of visit type. Finally, they used clear, persuasive language to recommend or educate parents and patients about the vaccine's importance.

      Conclusions

      Positive deviance identified characteristics associated with higher human papillomavirus vaccine up-to-date rates in rural primary care clinics. These findings provide guidance for rural clinics to inform human papillomavirus vaccination quality improvement interventions.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Preventive Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      REFERENCES

      1. The HPV vaccine.
        National Cancer Institute, Center for Cancer Research, 2019 (Published)
        • Drolet M
        • Bénard É
        • Pérez N
        • Brisson M
        • HPV Vaccination Impact Study Group
        Population-level impact and herd effects following the introduction of human papillomavirus vaccination programmes: updated systematic review and meta-analysis.
        Lancet. 2019; 394: 497-509
      2. HPV vaccination is safe and effective.
        CDC, 2019
        www.cdc.gov/hpv/parents/vaccinesafety.html
        Date accessed: July 31, 2019
        (Published)
        • Vorsters A
        • Arbyn M
        • Baay M
        • et al.
        Overcoming barriers in HPV vaccination and screening programs.
        Papillomavirus Res. 2017; 4: 45-53
      3. About HPV. CDC. www.cdc.gov/hpv/parents/about-hpv.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fhpv%2Fparents%2Fwhatishpv.html. Published 2019.

        • Walker TY
        • Elam-Evans LD
        • Yankey D
        • et al.
        National, regional, state, and selected local area vaccination coverage among adolescents aged 13-17 years - United States, 2017.
        MMWR Morb Mortal Wkly Rep. 2018; 67: 909-917
        • Swiecki-Sikora AL
        • Henry KA
        • Kepka D
        HPV vaccination coverage among US teens across the rural-urban continuum.
        J Rural Health. 2019; 35: 506-517
      4. The HPV vaccine: access and use in the U.S.
        Kaiser Family Foundation, October 9, 2018
      5. ALERT immunization information system data. Oregon Immunization Program. Oregon Health Authority.www.oregon.gov/oha/ph/preventionwellness/vaccinesimmunization/alert/pages/index.aspx. Published 2020. Accessed April 3, 2020.

      6. Clinical decision support for immunization (CDSi).
        CDC, 2019
        • Mills LA
        • Head KJ
        • Vanderpool RC
        HPV vaccination among young adult women: a perspective from Appalachian Kentucky.
        Prev Chronic Dis. 2013; 10: E17
        • Vanderpool RC
        • Breheny PJ
        • Tiller PA
        • et al.
        Implementation and evaluation of a school-based human papillomavirus vaccination program in rural Kentucky.
        Am J Prev Med. 2015; 49: 317-323
        • Lai D
        • Ding Q
        • Bodson J
        • Warner EL
        • Kepka D
        Factors associated with increased HPV vaccine use in rural-frontier U.S. states.
        Public Health Nurs. 2016; 33: 283-294
        • Kepka D
        • Spigarelli MG
        • Warner EL
        • Yoneoka Y
        • McConnell N
        • Balch A
        Statewide analysis of missed opportunities for human papillomavirus vaccination using vaccine registry data.
        Papillomavirus Res. 2016; 2: 128-132
        • Cunningham-Erves J
        • Koyama T
        • Huang Y
        • et al.
        Providers’ perceptions of parental human papillomavirus vaccine hesitancy: cross-sectional study.
        JMIR Cancer. 2019; 5: e13832
        • Cartmell KB
        • Young-Pierce J
        • McGue S
        • et al.
        Barriers, facilitators, and potential strategies for increasing HPV vaccination: a statewide assessment to inform action.
        Papillomavirus Res. 2018; 5: 21-31
        • Holman DM
        • Benard V
        • Roland KB
        • Watson M
        • Liddon N
        • Stokley S
        Barriers to human papillomavirus vaccination among US adolescents: a systematic review of the literature.
        JAMA Pediatr. 2014; 168: 76-82
        • Sussman AL
        • Helitzer D
        • Bennett A
        • Solares A
        • Lanoue M
        • Getrich CM
        Catching up with the HPV vaccine: challenges and opportunities in primary care.
        Ann Fam Med. 2015; 13: 354-360
        • Boyd ED
        • Phillips JM
        • Schoenberger YM
        • Simpson T
        Barriers and facilitators to HPV vaccination among rural Alabama adolescents and their caregivers.
        Vaccine. 2018; 36: 4126-4133
        • Shipman SA
        • Lan J
        • Chang CH
        • Goodman DC
        Geographic maldistribution of primary care for children.
        Pediatrics. 2011; 127: 19-27
        • Walling EB
        • Benzoni N
        • Dornfeld J
        • et al.
        Interventions to improve HPV vaccine uptake: a systematic review.
        Pediatrics. 2016; 138e20153863
        • Wishik SM
        • Vynckt S.
        The use of nutritional ‘positive deviants’ to identify approaches for modification of dietary practices.
        Am J Public Health. 1976; 66: 38-42
        • Baxter R
        • Taylor N
        • Kellar I
        • Lawton R
        What methods are used to apply positive deviance within healthcare organisations? A systematic review.
        BMJ Qual Saf. 2016; 25: 190-201
        • Howell EA
        • Ahmed ZN
        • Sofaer S
        • Zeitlin J
        Positive deviance to address health equity in quality and safety in obstetrics.
        Clin Obstet Gynecol. 2019; 62: 560-571
      7. Goff SL, Mazor KM, Priya A, Moran M, Pekow PS, Lindenauer PK. Organizational characteristics associated with high performance on quality measures in pediatric primary care: a positive deviance study. Health Care Manag Rev. In press. Online May 20, 2019. https://doi.org/10.1097/HMR.0000000000000247.

        • Bradley EH
        • Curry LA
        • Ramanadhan S
        • Rowe L
        • Nembhard IM
        • Krumholz HM
        Research in action: using positive deviance to improve quality of health care.
        Implement Sci. 2009; 4: 25
        • Marsh DR
        • Schroeder DG
        • Dearden KA
        • Sternin J
        • Sternin M
        The power of positive deviance.
        BMJ. 2004; 329: 1177-1179
        • Perkins RB
        • Fisher-Borne M
        • Brewer NT
        Engaging parents around vaccine confidence: proceedings from the National HPV Vaccination Roundtable meetings.
        Hum Vaccin Immunother. 2019; 15: 1639-1640
        • Niccolai LM
        • Hansen CE
        Practice- and community-based interventions to increase human papillomavirus vaccine coverage: a systematic review.
        JAMA Pediatr. 2015; 169: 686-692
        • Wheldon CW
        • Krakow M
        • Thompson EL
        • Moser RP
        National trends in human papillomavirus awareness and knowledge of human papillomavirus–related cancers.
        Am J Prev Med. 2019; 56: e117-e123
        • Nagykaldi Z
        • Mold JW
        • Robinson A
        • Niebauer L
        • Ford A
        Practice facilitators and practice-based research networks.
        J Am Board Fam Med. 2006; 19: 506-510
        • Creswell JW.
        Steps in conducting a scholarly mixed methods study.
        University of Nebraska, Lincoln2013
        • NIH Office of Behavioral Science
        Best Practices for Mixed Methods Research in the Health Sciences.
        2nd ed. NIH, Bethesda, MD2018
        • Ivankova NV
        • Creswell JW
        • Stick SL
        Using mixed-methods sequential explanatory design: from theory to practice.
        Field Methods. 2006; 18: 3-20
        • Leech NL
        • Onwuegbuzie AJ.
        A typology of mixed methods research designs.
        Qual Quant. 2009; 43: 265-275
        • Carney PA
        • Hatch B
        • Stock I
        • et al.
        A stepped-wedge cluster randomized trial designed to improve completion of HPV vaccine series and reduce missed opportunities to vaccinate in rural primary care practices.
        Implement Sci. 2019; 14: 30
        • Robison SG.
        Addressing immunization registry population inflation in adolescent immunization rates.
        Public Health Rep. 2015; 130: 161-166
      8. Rural-urban commuting area codes.
        U.S. Department of Agriculture, 2019
      9. About rural and frontier data: Oregon zip codes, towns, cities, and service areas and their ORH Urban/Rural/Frontier Designation.
        Oregon Office of Rural Health, 2018
        • Braun V
        • Clarke V.
        Using thematic analysis in psychology.
        Qual Res Psychol. 2006; 3: 77-101
      10. (IQIP) Immunization Quality Improvement for Providers.
        CDC, 2019
        www.cdc.gov/vaccines/programs/iqip/index.html
        Date accessed: September 23, 2019
        • Saunders B
        • Sim J
        • Kingstone T
        • et al.
        Saturation in qualitative research: exploring its conceptualization and operationalization.
        Qual Quant. 2018; 52: 1893-1907
        • Leung L.
        Validity, reliability, and generalizability in qualitative research.
        J Fam Med Prim Care. 2015; 4: 324-327
        • Creswell JW
        • Miller DL.
        Determining validity in qualitative inquiry.
        Theor Pract. 2000; 39: 124-130
        • Morse JM.
        Critical analysis of strategies for determining rigor in qualitative inquiry.
        Qual Health Res. 2015; 25: 1212-1222
        • Spillett MA
        Peer debriefing: who, what, when, why, how.
        Acad Exch Q. 2003;
        • Chuang E
        • Cabrera C
        • Mak S
        • Glenn B
        • Hochman M
        • Bastani R
        Primary care team- and clinic level factors affecting HPV vaccine uptake.
        Vaccine. 2017; 35: 4540-4547
        • Escoffery C
        • Riehman K
        • Watson L
        • et al.
        Facilitators and barriers to the implementation of the HPV VACs (Vaccinate Adolescents Against Cancers) program: a consolidated framework for implementation research analysis.
        Prev Chronic Dis. 2019; 16: E85
        • Cates JR
        • Diehl SJ
        • Fuemmeler BF
        • et al.
        Toward optimal communication about HPV vaccination for preteens and their parents: evaluation of an online training for pediatric and family medicine health care providers.
        J Public Health Manag Pract. 2020; 26: 159-167
        • Askelson NM
        • Ryan G
        • Seegmiller L
        • Pieper F
        • Kintigh B
        • Callaghan D
        Implementation challenges and opportunities related to HPV vaccination quality improvement in primary care clinics in a rural state.
        J Community Health. 2019; 44: 790-795
        • Gilkey MB
        • Dayton AM
        • Moss JL
        • et al.
        Increasing provision of adolescent vaccines in primary care: a randomized controlled trial.
        Pediatrics. 2014; 134: e346-e353
        • Gilkey MB
        • Moss JL
        • Roberts AJ
        • Dayton AM
        • Grimshaw AH
        • Brewer NT
        Comparing in-person and webinar delivery of an immunization quality improvement program: a process evaluation of the adolescent AFIX trial.
        Implement Sci. 2014; 9: 21
        • Daley EM
        • Vamos CA
        • Thompson EL
        • et al.
        The feminization of HPV: how science, politics, economics and gender norms shaped U.S. HPV vaccine implementation.
        Papillomavirus Res. 2017; 3: 142-148
        • Virginia Commonwealth University
        ‘Virtual focus groups’ uncover clues to rural and urban HPV vaccination disparities.
        Sci Daily. March 13. 2019;
        • Carter N
        • Bryant-Lukosius D
        • DiCenso A
        • Blythe J
        • Neville AJ
        The use of triangulation in qualitative research.
        Oncol Nurs Forum. 2014; 41: 545-547
        • Vanderpool RC
        • Stradtman LR
        • Brandt HM
        Policy opportunities to increase HPV vaccination in rural communities.
        Hum Vaccin Immunother. 2019; 15: 1527-1532
      11. Vamos CA, Vázquez-Otero C, Kline N, et al. Multi-level determinants to HPV vaccination among Hispanic farmworker families in Florida. Ethn Health. In press. Online September 27, 2018. https://doi.org/10.1080/13557858.2018.1514454