Clinic-based interventions for human papillomavirus (HPV) vaccination
Clinic-based interventions supporting HPV vaccination combine information about HPV and the benefits of vaccinating against it with efforts to support vaccine series completion. Interventions can include education for patients and their parents (e.g., brochures, phone calls, or physician conversations), patient or parent reminders, physician education, multi-component interventions,and decision support alerts throughout the vaccine series.
HPV vaccines protect against HPV and HPV-associated diseases, including some cancers. Vaccines are recommended for individuals ages 11-26, and up to age 45 in some circumstances; vaccines are most effective in those who receive all doses and have no previous exposure to HPV1.
What could this strategy improve?
Expected Benefits
Our evidence rating is based on the likelihood of achieving these outcomes:
Increased vaccination
Potential Benefits
Our evidence rating is not based on these outcomes, but these benefits may also be possible:
Reduced incidence of HPV
What does the research say about effectiveness?
There is strong evidence that clinic-based interventions can increase HPV vaccination rates among eligible adolescent girls and young women, including multi-component interventions2, 3, 4, patient or parent reminders5, 6, 7, physician education6, and decision support8, 9, 10. Additional evidence is needed to confirm effects in adolescent boys and young men6.
Multicomponent strategies that address multiple barriers to HPV vaccination appear to have a greater impact on vaccination rates than strategies that address individual barriers alone11. Physician recommendation is important for vaccination uptake and appears to be particularly effective at increasing vaccination when recommendations are strong and phrased with the assumption that the patient will be vaccinated12. Experts suggest more physician education is needed to ensure providers are knowledgeable about and willing to recommend the HPV vaccine13. Several studies suggest trainings, including onsite14 and online trainings15 as well as presumptive messaging trainings16, for providers can increase HPV vaccination initiation. Incorporating specific language suggestions for providers in health care provider reminder prompts may also improve HPV vaccination rates9.
Worldwide, lack of knowledge about HPV and the HPV vaccine, along with concerns about its safety and effectiveness, remains a major barrier to uptake17. Behavioral interventions to assist with patient or parent decision making, like patient prompts and alerts, can increase HPV vaccination rates18. Overall, patient or parent education can help mitigate barriers caused by the lack of knowledge about HPV vaccination11, 19. Education by providers that includes safety information and the benefits of HPV vaccination may increase parent’s willingness to vaccinate their children20. Culturally tailored text messaging interventions are associated with increased vaccination21. Patient navigators may help increase vaccination initiation and completion22.
There is no evidence that receipt of the HPV vaccine increases sexual risk behavior among adolescent girls and young women23, 24, 25. HPV vaccination for all children, including males, is recommended by the American Academy of Pediatrics and the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention26.
How could this strategy advance health equity? This strategy is rated inconclusive impact on disparities.
It is unclear what impact clinic-based interventions for human papillomavirus (HPV) vaccination may have on disparities in HPV vaccination outcomes.
HPV prevalence varies by race, ethnicity, and age, and is higher among Black populations29, 30. HPV strains are categorized into two categories: low-risk and high-risk. Low-risk HPVs don’t cause disease while high-risk HPVs can cause several types of cancers; two of these strains cause most HPV-related cancers31. HPV-related cancer disparities exist by race and gender. Hispanic, American Indian, and Alaska Native women have the highest incidence of cervical cancer, which is the most common HPV-related cancer found in those with a cervix32. Black and Hispanic men are more likely to die from HPV-related throat cancer33 (now the most common form of cancer associated with HPV) even though HPV-related throat cancer is more likely to occur in white men than men of other races and ethnicities34.
Although HPV vaccination is recommended for all children from age 9-12 years old35, adolescent boys have been consistently less likely to complete the series than adolescent girls36, 37. Additionally, people of color appear to be less likely to complete the HPV vaccine series despite being more likely to initiate it38, disparities persist between rural and urban areas36, 39, and lower socio-economic status is also associated with decreased vaccination initiation and completion40.
Low vaccination rates among males may be due to perceptions about who is most at risk for HPV and HPV-related cancers6. Barriers in rural communities which also contribute to low vaccination rates include cost, access to health care, transportation, and parental concerns about the vaccine41.
Limited evidence suggests multicomponent clinic-based interventions may improve vaccination rates among male students when implemented on college campuses42. They may also be particularly effective in Hispanic populations43. Several studies suggest parent education may increase intentions to vaccinate children among Hispanic mothers44, 45.
What is the relevant historical background?
Sexually transmitted infections (STIs), like HPV, have carried stigma for centuries, shaped by negative views of poverty, women, and sex46. For women, STIs are associated with promiscuity and deviant behavior, perhaps due to connections with prostitution, while STIs in men are treated merely as a medical condition47. Despite the stigma, HPV-related cancers have been diagnosed in both men and women and include cervical, vulvar, vaginal, penile, anal, mouth and throat cancers34.
When the first HPV vaccine became available in 2006, the Advisory Committee on Immunization Practices (ACIP) recommended it for all adolescent girls. Vaccination recommendations expanded in 2011 to include boys and anyone up to age 4548.
Despite the HPV vaccine being developed to protect against certain cancers, a vaccine against an STI brought pushback from parents who did not believe their children were sexually active because they were too young11, 19, as well as fears that getting the vaccine could lead to sexual promiscuity49. Over the years these fear-fueled myths have been debunked19 and vaccination rates continue to increase. In 2021, approximately 77% of adolescents aged 13-17 had received at least one dose of HPV vaccine, a 1.8 percentage point increase from the previous year36. To counter misinformation and promote positive perception of the HPV vaccine, public health officials have emphasized the benefits of the vaccine, such cancer prevention50, and use evidence-based messaging to improve attitudes and behaviors51.
Equity Considerations
- Who is eligible for the HPV vaccine in your community but hasn’t received it?
- What barriers, like stigma, are preventing people from accessing information about HPV vaccination in your community? What additional strategies can be implemented to overcome those barriers?
- How are clinics in your community currently providing resources on HPV vaccination? Are they easily accessible? How are the interventions tailored to reflect the cultures of people in your community?
Implementation Examples
Clinic-based interventions for HPV vaccination vary widely. Toolkits can help organizations consider what sort of intervention would work at their organization. Project HPV-Free has created a toolkit that focuses on collegiate vaccination campaigns27, and the HPV Campus Vaccination Campaign provides health centers on campuses with tools to increase HPV vaccinations28.
Implementation Resources
‡ Resources with a focus on equity.
CDC-HPV QI - Centers for Disease Control and Prevention (CDC). HPV quality improvement & evidence based interventions.
HPV-CVC - HPV Campus Vaccination Campaign. HPV Campus Vaccination Campaign Toolkit.
Project HPV-Toolkit - Project HPV-Free. Collegiate vaccination toolkit.
Footnotes
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1 CDC MMWR-Meites 2019 - Meites E, Szilagyi PG, Chesson HW, et al. Human papillomavirus vaccination for adults: Updated recommendations of the Advisory Committee on Immunization Practices. Morbidity and Mortality Weekly Report (MMWR). 2019;68:698-702.
2 Cochrane-Abdullahi 2020 - Abdullahi LH, Kagina BM, Ndze VN, Hussey GD, Wiysonge CS. Improving vaccination uptake among adolescents. Cochrane Database of Systematic Reviews. 2020;(1):CD011895.
3 Gilkey 2022 - Gilkey MB, Grabert BK, Heisler-MacKinnon J, et al. Coaching and communication training for HPV vaccination: A cluster randomized trial. Pediatrics. 2022;150(2):e2021052351.
4 Fiks 2013 - Fiks AG, Grundmeier RW, Mayne S, et al. Effectiveness of decision support for families, clinicians, or both on HPV vaccine receipt. Pediatrics. 2013;131(6):1114-1124.
5 Mohamed 2022 - Mohamed R, Kelly KM, Nili M, Kelley GA. A systematic review with meta-analysis of parental interventions for human papillomavirus vaccine uptake. Journal of the American Pharmacists Association. 2022;62(4):1142-1153.
6 Eisenhauer 2021 - Eisenhauer L, Hansen BR, Pandian V. Strategies to improve human papillomavirus vaccination rates among adolescents in family practice settings in the United States: A systematic review. Journal of Clinical Nursing. 2021;30(3-4):341-356.
7 Niccolai 2015 - Niccolai LM, Hansen CE. Practice-and community-based interventions to increase human papillomavirus vaccine coverage: A systematic review. JAMA Pediatrics. 2015;169(7):686-692.
8 Harry 2022 - Harry ML, Asche SE, Freitag LA, et al. Human papillomavirus vaccination clinical decision support for young adults in an upper midwestern healthcare system: A clinic cluster-randomized control trial. Human Vaccines and Immunotherapeutics. 2022;18(1):e2040933.
9 Zimet 2018 - Zimet G, Dixon BE, Xiao S, et al. Simple and elaborated clinician reminder prompts for human papillomavirus vaccination: A randomized clinical trial. Academic Pediatrics. 2018;18(2):S66-S71.
10 Mayne 2014 - Mayne SL, duRivage NE, Feemster KA, et al. Effect of decision support on missed opportunities for human papillomavirus vaccination. American Journal of Preventive Medicine. 2014;47(6):734-744.
11 Vollrath 2018 - Vollrath K, Thul S, Holcombe J. Meaningful methods for increasing human papillomavirus vaccination rates: An integrative literature review. Journal of Pediatric Health Care. 2018;32(2):119-132.
12 Constable 2022 - Constable C, Ferguson K, Nicholson J, Quinn GP. Clinician communication strategies associated with increased uptake of the human papillomavirus (HPV) vaccine: A systematic review. CA: A Cancer Journal for Clinicians. 2022;72(6):561-569.
13 Sackey 2022 - Sackey M, Markey K, Grealish A. Healthcare professional’s promotional strategies in improving human papillomavirus (HPV) vaccination uptake in adolescents: A systematic review. Vaccine. 2022;40(19):2656-2666.
14 Fisher-Borne 2018 - Fisher-Borne M, Preiss AJ, Black M, Roberts K, Saslow D. Early outcomes of a multilevel human papillomavirus vaccination pilot intervention in federally qualified health centers. Academic Pediatrics. 2018;18(2):S79-S84.
15 Szilagyi 2021 - Szilagyi PG, Humiston SG, Stephens-Shields AJ, et al. Effect of training pediatric clinicians in human papillomavirus communication strategies on human papillomavirus vaccination rates: A cluster randomized clinical trial. JAMA Pediatrics. 2021;175(9):901-910.
16 Brewer 2017 - Brewer NT, Hall ME, Malo TL, et al. Announcements versus conversations to improve HPV vaccination coverage: A randomized trial. Pediatrics. 2017;139(1):e20161764.
17 Zheng 2021 - Zheng L, Wu J, Zheng M. Barriers to and facilitators of human papillomavirus vaccination among people aged 9 to 26 years: A systematic review. Sexually Transmitted Diseases. 2021;48(12):e255-e262.
18 Rodriguez 2019 - Rodriguez AM, Do TQN, Goodman M, et al. Human papillomavirus vaccine interventions in the U.S.: A systematic review and meta-analysis. American Journal of Preventive Medicine. 2019;56(4):591-602.
19 Holloway 2019 - Holloway G. Effective HPV vaccination strategies: What does the evidence say? An integrated literature review. Journal of Pediatric Nursing. 2019;44:31-41.
20 Donahue 2018 - Donahue K, Hendrix K, Sturm L, Zimet G. Provider communication and mothers’ willingness to vaccinate against human papillomavirus and influenza: A randomized health messaging trial. Academic Pediatrics. 2018;18(2):145-153.
21 Lee 2016c - Lee HY, Koopmeiners JS, McHugh J, Raveis VH, Ahluwalia JS. MHealth pilot study: Text messaging intervention to promote HPV vaccination. American Journal of Health Behavior. 2016;40(1):67-76.
22 Berenson 2019 - Berenson AB, Rupp R, Dinehart EE, et al. Achieving high HPV vaccine completion rates in a pediatric clinic population. Human Vaccines and Immunotherapeutics. 2019;15(7-8):1562-1569.
23 Kasting 2016 - Kasting ML, Shapiro GK, Rosberger Z, Kahn JA, Zimet GD. Tempest in a teapot: A systematic review of HPV vaccination and risk compensation research. Human Vaccines and Immunotherapeutics. 2016;12(6):1435-1450.
24 Mayhew 2014 - Mayhew A, Mullins TLK, Ding L, et al. Risk perceptions and subsequent sexual behaviors after HPV vaccination in adolescents. Pediatrics. 2014;133(3):404-411.
25 Rysavy 2014 - Rysavy MB, Kresowik JD, Liu D, et al. Human papillomavirus vaccination and sexual behavior in young women. Journal of Pediatric and Adolescent Gynecology. 2014;27(2):67-71.
26 AAP-HPV Vaccine 2012 - American Academy of Pediatrics (AAP), Committee on Infectious Diseases. HPV Vaccine recommendations. Pediatrics. 2012;129(3):602-605.
27 Project HPV-Toolkit - Project HPV-Free. Collegiate vaccination toolkit.
28 HPV-CVC - HPV Campus Vaccination Campaign. HPV Campus Vaccination Campaign Toolkit.
29 Risley 2020 - Risley C, Clarke MA, Geisinger KR, et al. Racial differences in human papillomavirus type 16 prevalence in women with atypical squamous cells of undetermined significance of the uterine cervix. Cancer Cytopathology. 2020;128(8):528-534.
30 CDC-HPV Prevalence - Centers for Disease Control and Prevention (CDC). National Center for Health Statistics. Prevalence of HPV in adults aged 18-69: United States, 2011-2014. 2017.
31 US NIH-NCI HPV and Cancer - National Institute of Health (NIH), National Cancer Institute (NCI). HPV and cancer.
32 CDC-USCS Cervix 2020 - Centers for Disease Control and Prevention (CDC). United States cancer statistics: Data visualization rate of new cancers, cervix. 2020.
33 Villalona 2022 - Villalona S, Stroup AM, Villalona S, Ferrante JM. Racial/ethnic disparities in HPV-related oropharyngeal cancer outcomes among males in the United States: a national cohort study. Annals of Cancer Epidemiology. 2022;6(May):4-4.
34 Coyne-Beasley 2023 - Coyne-Beasley T, Ortiz R. Recommending HPV vaccination at age 9 to reduce health disparities: Communication challenges and opportunities. Human Vaccines and Immunotherapeutics. 2023;19(1).
35 CDC-HPV Vaccine - Centers for Disease Control and Prevention (CDC). HPV Vaccine.
36 CDC MMWR-Pingali 2022 - Pingali C, Yankey D, Elam-Evans LD, et al. National vaccination coverage among adolescents aged 13-17 years – National Immunization Survey-Teen, United States, 2021. Morbidity and Mortality Weekly Report (MMWR). 2022;71(35):1101-1108.
37 McElfish 2021 - McElfish P, Narcisse M, Felix H, et al. Race, nativity, and sex disparities in human papillomavirus vaccination among young adults in the USA. Journal of Racial and Ethnic Health Disparities. 2021;8(5):1260-1266.
38 Spencer 2019 - Spencer JC, Calo WA, Brewer NT. Disparities and reverse disparities in HPV vaccination: A systematic review and meta-analysis. Preventive Medicine. 2019;123:197-203.
39 HPV Roundtable-Rural disparities - National HPV Vaccination Roundtable. Rural disparities in HPV vaccination coverage.
40 Kurani 2022 - Kurani S, MacLaughlin KL, Jacobson RM, et al. Socioeconomic disadvantage and human papillomavirus (HPV) vaccination uptake. Vaccine. 2022;40(3):471-476.
41 Boakye 2023 - Boakye E, Fedorovich Y, White M, et al. Rural-urban disparities in HPV vaccination coverage among adolescents in the central part of the state of Illinois, USA. Journal of Community Health. 2023;48:24-29.
42 Kessler 2021 - Kessler R, Auwaerter P. Strategies to improve human papillomavirus (HPV) vaccination rates among college students. Journal of American College Health. 2021.
43 Cox 2022 - Cox JE, Bogart LM, Elliott MN, et al. Improving HPV vaccination rates in a racially and ethnically diverse pediatric population. Pediatrics. 2022;150(4):e2021054186.
44 Khodadadi 2022 - Khodadadi AB, Hansen B, Kim Y, Scarinci IC. Latinx immigrant mothers’ perceived self-efficacy and intentions regarding human papillomavirus vaccination of their daughters. Women’s Health Issues. 2022;32(3):293-300.
45 Obulaney 2016 - Obulaney PA, Gilliland I, Cassells H. Increasing cervical cancer and human papillomavirus prevention knowledge and HPV vaccine uptake through mother/daughter education. Journal of Community Health Nursing. 2016;33(1):54-67.
46 McGough 2005 - McGough LG. HIV/AIDS stigma: Historical perspectives on sexually transmitted diseases. Virtual Mentor: Ethics Journal of the American Medical Association. 2005;7(10):710-715.
47 East 2012 - East L, Jackson D, O’Brien L, Peters K. Stigma and stereotypes: Women and sexually transmitted infections. Collegian. 2012;19(1):15-21.
48 CHOP-Vaccine history - Children’s Hospital of Philadelphia (CHOP). Vaccine history: Developments by year. 2023.
49 Brouwer 2019 - Brouwer A, Delinger R, Eisenberg M, et al. HPV vaccination has not increased sexual activity or accelerated sexual debut in a college-aged cohort of men and women. BMC Public Health. 2019;19:821.
50 US NIH-NCI Cancer Prevention - National Institute of Health. National Cancer Institute. Cancer prevention message is key for HPV vaccination discussions with parents.
51 Kim 2022a - Kim S, Schiffelbein J, Imset I, Olson A. Countering antivax misinformation via social media: Message-testing randomized experiment for human papillomavirus vaccination uptake. Journal of Medical Internet Research. 2022;24(11).
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