School-based HPV immunization of young adolescents: Effects of two brief health interventions Effect of provider prompts on adolescent immunization rates: a randomized trial. Increasing Provision of Adolescent Vaccines in Primary Care: A Randomized Controlled Trial Effectiveness and Net Cost of Reminder/Recall for Adolescent Immunizations A pilot program to improve vaccination status for hospitalized children. Human Papillomavirus Vaccine Intent and Uptake Among Female College Students Effectiveness of Decision Support for Families, Clinicians, or Both on HPV Vaccine Receipt Effectiveness of a citywide patient immunization navigator program on improving adolescent immunizations and preventive care visit rates. Effectiveness and Cost of Immunization Recall at School-Based Health Centers Effectiveness of centralized text message reminders on human papillomavirus immunization coverage for publicly insured adolescents. A randomized trial of the effect of centralized reminder/recall on immunizations and preventive care visits for adolescents. Staying on track: a cluster randomized controlled trial of automated reminders aimed at increasing human papillomavirus vaccine completion. Effects of a Narrative HPV Vaccination Intervention Aimed at Reaching College Women: A Randomized Controlled Trial A randomized intervention of reminder letter for human papillomavirus vaccine series completion.
Adolescent immunization rates for human papillomavirus ( HPV ) are low and interventions within school-based health centers ( SBHCs ) may increase HPV uptake and series completion . We examined the effect of a parent health message intervention on HPV vaccination intent , first dose uptake and series completion among adolescents who received care at SBHCs . Via computer-assisted telephone interviews ( CATI ) , 445 parents of young adolescents were r and omly assigned to 2 two-level interventions using a 2 × 2 design ( rhetorical question ( RQ ) or no-RQ and one-sided or two-sided message ) . The RQ intervention involved asking the parent a question they were likely to endorse ( e.g. , “ Do you want to protect your daughter from cervical cancer ? ” ) with the expectation that they would then behave in a manner consistent with their endorsement ( i.e. , agree to vaccinate ) . For the one-sided message , parents were given information that emphasized the safety and effectiveness of HPV vaccine , whereas the two-sided message acknowledged that some parents might have concerns about the vaccine , followed by reassurance regarding the safety and effectiveness . At CATI conclusion , parents indicated intentions to have their adolescents vaccinated . Parents who endorsed any intent were sent a consent form to return and all adolescents with signed returned consents were vaccinated at SBHCs . Medical records were review ed for uptake/completion . Parents were 87 % female ; adolescents were 66 % male and racially/ethnically diverse . 42.5 % of parents indicated some intention to immunize , 51.4 % were unsure , and 6.1 % were not interested . 34 % ( n = 151 ) of adolescents received their first dose with series completion rates of 67 % ( n = 101 ) . The RQ component of the intervention increased intention to vaccinate ( RR = 1.45 ; 95%CI 1.16,1.81 ) , but not first dose uptake or series completion . The 1-sided and 2-sided messages had no effect . This brief , RQ health intervention enhanced intent , but did not impact vaccination rates , likely due to the time delay between the intervention and consent form receipt OBJECTIVE  Adolescent immunization rates  are suboptimal . Experts recommend provider prompts at health care visits to improve rates . We assessed the impact of either electronic health record ( EHR ) or nurse- or staff-initiated provider prompts on  adolescent immunization rates .  METHODS We conducted a r and omized controlled trial , allocating practice s in 1 of 2 practice -based research networks ( PBRN ) to provider prompts or st and ard-of-care control . Ten primary care practice s participated , 5 intervention and 5 controls , each matched in pairs on urban , suburban , or rural location and practice type ( pediatric or family medicine ) , from a PBRN in Greater Rochester , New York ( GR-PBRN ) ; and 12 practice s , 6 intervention , 6 controls , similarly matched , from a national pediatric continuity clinic PBRN ( CORNET ) . The study period was 1 year per practice , ranging from June 2011 to January 2013 . Study participants were adolescents 11 to 17 years attending these 22 practice s ; r and om sample of chart review s per practice for baseline and postintervention year to assess immunization rates ( n = 7,040 total chart review s for adolescents with > 1 visit in a period ) . The intervention was an EHR prompt ( 4 GR-PBRN and 5 CORNET practice pairs ) ( alert ) that appeared on providers ' computer screens at all office visits , indicating the specific immunizations that adolescents were recommended to receive . Staff prompts ( 1 GR-PBRN pair and 1 CORNET pair ) in the form of a reminder sheet was placed on the provider 's desk in the exam room indicating the vaccines due . We compared immunization rates , stratified by PBRN , for routine vaccines ( meningococcus , pertussis , human papillomavirus , influenza ) at study beginning and end . RESULTS Intervention and control practice s within each PBRN were similar at baseline for demographics and immunization rates . Immunization rates at the study end for adolescents who were behind on immunizations at study initiation were not significantly different for intervention versus control practice s for any vaccine or combination of vaccines . Results were similar for each PBRN and also when only EHR-based prompts was assessed . For example , at study end , 3-dose human papillomavirus vaccination rates for GR-PBRN intervention versus control practice s were 51 % versus 53 % ( adjusted odds ratio 0.96 ; 95 % confidence interval 0.64 - 1.34 ) ; CORNET intervention versus control rates were 50 % versus 42 % ( adjusted odds ratio 1.06 ; 95 % confidence interval 0.68 - 1.88 ) . CONCLUSIONS AND RELEVANCE In both a local and national setting , provider prompts failed to improve adolescent immunization rates . More rigorous practice -based changes are needed 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 r and omly 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 state 's 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 OBJECTIVE : To assess the effectiveness of reminder/recall ( R/R ) for immunizing adolescents in private pediatric practice s and to describe the associated costs and revenues . METHODS : We conducted a r and omized controlled trial in 4 private pediatric practice s in metropolitan Denver . In each practice , 400 adolescents aged 11 to 18 years who had not received 1 or more targeted vaccinations ( tetanus-diphtheria-acellular pertussis , meningococcal conjugate , or first dose of human papillomavirus vaccine for female patients ) were r and omly selected and r and omized to intervention ( 2 letters and 2 telephone calls ) or  control  ( usual care ) groups . Primary outcomes were receipt of > 1 targeted vaccines and receipt of all targeted vaccines 6 months postintervention . We calculated net additional revenue for each additional adolescent who received at least 1 targeted vaccine and for those who received all targeted vaccines . RESULTS : Eight hundred adolescents were r and omized to the intervention and 800 to the control group . Baseline rates of having already received tetanus-diphtheria-acellular pertussis , meningococcal conjugate , and first dose of human papillomavirus vaccine before R/R ranged from 33 % to 54 % . Postintervention , the intervention group had significantly higher proportions of receipt of at least 1 targeted vaccine ( 47.1 % vs 34.6 % , P < .0001 ) and receipt of all targeted vaccines ( 36.2 % vs 25.2 % , P < .0001 ) compared with the control group . Three practice s had positive net revenues from R/R ; 1 showed net losses . CONCLUSIONS : R/R was successful at increasing immunization rates in adolescents and effect sizes were comparable to those in younger children . Practice s conducting R/R may benefit financially if they can generate additional well-child care visits and keep supply costs low OBJECTIVES Screening of immunization status at each health care encounter is recommended to improve immunization coverage rates but is often limited to primary care practice s. A pilot intervention study was performed to ascertain the immunization status of hospitalized children and determine if development of an immunization plan before discharge would improve the vaccination status for such children . METHODS On the basis of power calculations estimated to detect an increase in immunization status from 60 % to 70 % with 80 % power , 356 r and omly selected children were enrolled between March 6 , 2012 and June 14 , 2012 . Immunization records were obtained , immunization status determined , and parent/guardian informed if catch-up dose(s ) were needed . If parent requested vaccine dose(s ) , they were administered before discharge . RESULTS Vaccination status was current per Advisory Committee on Immunization Practice s guidelines in 73 % of hospitalized children , and 27 % children required catch-up dose(s ) ( 200 doses for 95 children ) . Human papilloma virus vaccine ( dose 1 ) , varicella zoster vaccine ( dose 2 ) , and meningococcal conjugate vaccine were the most commonly identified dose(s ) needed . Of those requiring catch-up dose(s ) , 25 % were caught up , increasing vaccination status to 80 % at 1-month post hospital discharge . CONCLUSIONS This is the first study to determine the immunization status of hospitalized pediatric patients of all ages , including adolescents , providing new data on the immunization status of the inpatient pediatric population . A pilot intervention consisting of obtaining immunization records , determining immunization status , and discussing catch-up dose(s ) before discharge result ed in improvement of immunization status , suggesting that the inpatient setting may be used along with many other national strategies to help address missed vaccination opportunities Abstract Objective : To examine human papillomavirus ( HPV ) vaccine intent and the effect of an educational intervention on vaccine uptake among female college students . Participants : Females aged 18 to 26 attending a university health service gynecology clinic ( n = 256 ) . Methods : Participants were r and omized to receive either HPV-specific education with a mailed reminder or st and ard care . Predictors of HPV vaccine intent and uptake at 6 months following enrollment were identified . Results : At baseline , 41 % intended to undergo HPV vaccination . Participants who were currently sexually active and lacked supplemental health insurance had decreased intent . Perceived parental approval regarding HPV vaccination , perceived vulnerability to HPV infection , and belief in health benefits of HPV vaccine were associated with increased intent . HPV vaccine uptake was low ( 5.5 % ) and did not differ by study group . However , baseline intent was significantly associated with HPV vaccine uptake . Conclusions : Interventions to increase HPV vaccine uptake in college students should address HPV-related beliefs and broader barriers to vaccination OBJECTIVE : To improve human papillomavirus ( HPV ) vaccination rates , we studied the effectiveness of targeting automated decision support to families , clinicians , or both . METHODS : Twenty-two primary care practice s were cluster-r and omized to receive a 3-part clinician-focused intervention ( education , electronic health record-based alerts , and audit and feedback ) or none . Overall , 22 486 girls aged 11 to 17 years due for HPV vaccine dose 1 , 2 , or 3 were r and omly assigned within each practice to receive family-focused decision support with educational telephone calls . R and omization established 4 groups : family-focused , clinician-focused , combined , and no intervention . We measured decision support effectiveness by final vaccination rates and time to vaccine receipt , st and ardized for covariates and limited to those having received the previous dose for HPV # 2 and 3 . The 1-year study began in May 2010 . RESULTS : Final vaccination rates for HPV # 1 , 2 , and 3 were 16 % , 65 % , and 63 % among controls . The combined intervention increased vaccination rates by 9 , 8 , and 13 percentage points , respectively . The control group achieved 15 % vaccination for HPV # 1 and 50 % vaccination for HPV # 2 and 3 after 318 , 178 , and 215 days . The combined intervention significantly accelerated vaccination by 151 , 68 , and 93 days . The clinician-focused intervention was more effective than the family-focused intervention for HPV # 1 , but less effective for HPV # 2 and 3 . CONCLUSIONS : A clinician-focused intervention was most effective for initiating the HPV vaccination series , whereas a family-focused intervention promoted completion . Decision support directed at both clinicians and families most effectively promotes HPV vaccine series receipt OBJECTIVE To assess the impact of a tiered patient immunization navigator intervention ( immunization tracking , reminder/recall , and outreach ) on improving immunization and preventive care visit rates in urban adolescents . DESIGN R and omized clinical trial allocating adolescents ( aged 11 - 15 years ) to intervention vs st and ard of care control . SETTING Eight primary care practice s. PARTICIPANTS Population -based sample of adolescents ( N = 7546 ) .  INTERVENTION Immunization navigators at each practice implemented a tiered protocol : immunization tracking , telephone or mail reminder/recall , and home visits if participants remained unimmunized or behind on preventive care visits . MAIN OUTCOME MEASURES Immunization rates at study end . Secondary outcomes were preventive care visit rates during the previous 12 months and costs . RESULTS The intervention and control groups were similar at baseline for demographics ( mean age , 13.5 years ; 63 % black , 14 % white , and 23 % Hispanic adolescents ; and 74 % receiving Medicaid ) , immunization rates , and preventive care visit rates . Immunization rates at the end of the study were 44.7 % for the intervention group and 32.4 % for the control group ( adjusted risk ratio , 1.4 ; 95 % confidence interval , 1.3 - 1.5 ) ; preventive care visit rates were 68.0 % for the intervention group and 55.2 % for the control group ( 1.2 ; 1.2 - 1.3 ) . Findings were similar across practice s , sexes , ages , and insurance providers . The number needed to treat for immunizations and preventive care visits was 9 . The intervention cost was $ 3.81 per adolescent per month ; the cost per additional adolescent fully vaccinated was $ 465 , and the cost per additional adolescent receiving a preventive care visit was $ 417 . CONCLUSION A tiered tracking , reminder/recall , and outreach intervention improved immunization and preventive care visit rates in urban adolescents . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00581347 BACKGROUND AND OBJECTIVE : Effectiveness of recall for immunizations has not been examined in the setting of school-based health centers ( SBHCs ) . We assessed ( 1 ) immunization rates achieved with recall  among sixth- grade girls ( demonstration study ) ; ( 2 ) effectiveness of recall among sixth- grade boys ( r and omized controlled trial [ RCT ] ) ; and ( 3 ) cost of conducting recall in SBHCs . METHODS : During October 2008 through March 2009 , in 4 Denver public SBHCs , we conducted ( 1 ) a demonstration study among 265 girls needing ≥1 recommended adolescent vaccine and ( 2 ) an RCT among 264 boys needing vaccines , with half r and omized to recall and half receiving usual care . Immunization rates for recommended adolescent vaccines were assessed 6 months after recall . First dose costs were assessed by direct observation and examining invoices . RESULTS : At the end of the demonstration study , 77 % of girls had received ≥1 vaccine and 45 % had received all needed adolescent vaccines . Rates of receipt among those needing each of the vaccines were 68 % ( 160/236 ) for tetanus toxoid , reduced diphtheria toxoid and acellular pertussis vaccine , 57 % ( 142/248 ) for quadrivalent meningococcal conjugate vaccine , and 59 % ( 149/253 ) for the first human papillomavirus vaccine . At the end of the RCT , 66 % of recalled boys had received ≥1 vaccine and 59 % had received all study vaccines , compared with 45 % and 36 % , respectively , of the control group ( P < .001 ) . Cost of conducting recall ranged from $ 1.12 to $ 6.87 per recalled child immunized . CONCLUSIONS : SBHC-based recall was effective in improving immunization rates for all adolescent vaccines , with effects sizes exceeding those achieved with younger children in practice setting PURPOSE We evaluated a managed care organization (MCO)-generated text message reminder-recall system design ed to improve human papillomavirus ( HPV ) vaccination coverage . METHODS We conducted a r and omized controlled trial of text reminder-recall for parents of 3,812 publicly insured adolescents aged 11 - 16 years with no prior HPV vaccinations who were enrolled in a single MCO and were patients at one of 39 primary care practice s. We determined the rate of HPV receipt for intervention versus control with the Kaplan-Meier failure function and determined hazard ratios using a clustered stratified Cox model , clustering on primary care provider and stratified on practice . We examined results for all subjects , and for those with a valid phone number , stratified by age group ( 11 - 13 years and 14 - 16 years ) and gender . A post hoc analysis included all subjects and controlled for age and gender . RESULTS HPV dose 1 vaccination rates were not significantly different when all participants were included , but for the subset of parents ( 54 % ) able to receive messages , HPV dose 1 rates were 13 % for the control group and 16 % for the intervention group ; hazard ratio , 1.3 ( 95 % confidence interval , 1.0 - 1.6 ; p = .04 ) , when controlling for age and gender . There were no significant findings in the analysis stratified by age and gender . CONCLUSIONS MCO-based text reminders are feasible and have a modest effect on HPV dose 1 vaccination rates for those parents able to receive text messages with valid phone numbers in the MCO data base . Future studies should examine a similar intervention for those parents who already accepted the first HPV vaccine dose OBJECTIVE To assess the impact of a managed care-based patient reminder/recall system on immunization rates and preventive care visits among low-income adolescents . METHODS We conducted a r and omized controlled trial between December 2009 and December 2010 that assigned adolescents aged 11 - 17 years to one of three groups : mailed letter , telephone reminders , or control .  Publicly insured youths ( n = 4115 ) were identified in 37 participating primary care practice s. The main outcome measures were immunization rates for routine vaccines ( meningococcus , pertussis , HPV ) and preventive visit rates at study end . RESULTS Intervention and control groups were similar at baseline for demographics , immunization rates , and preventive visits . Among adolescents who were behind at the start , immunization rates at study end increased by 21 % for mailed ( P < .01 vs control ) , 17 % for telephone ( P < .05 ) , and 13 % for control groups . The proportion of adolescents with a preventive visit ( within 12 months ) was : mailed ( 65 % ; P < .01 ) , telephone ( 63 % ; P < .05 ) , and controls ( 59 % ) . The number needed to treat for an additional fully vaccinated adolescent was 14 for mailed and 25 for telephone reminders ; for an additional preventive visit , it was 17 and 29 . The intervention cost $ 18.78 ( mailed ) or $ 16.68 ( phone ) per adolescent per year to deliver . The cost per additional adolescent fully vaccinated was $ 463.99 for mailed and $ 714.98 for telephone ; the cost per additional adolescent receiving a preventive visit was $ 324.75 and $ 487.03 . CONCLUSIONS Managed care-based mail or telephone reminder/recall improved adolescent immunizations and preventive visits , with modest costs and modest impact OBJECTIVES To evaluate whether automated reminders increase on-time completion of the three-dose human papillomavirus ( HPV ) vaccine series . METHODS Ten reproductive health centers enrolled 365 women aged 19 - 26 to receive dose one of the HPV vaccine . Health centers were matched and r and omized so that participants received either routine follow-up ( control ) or automated reminder messages for vaccine doses two and three ( intervention ) . Intervention participants selected their preferred method of reminders - text , e-mail , phone , private Facebook message , or st and ard mail . We compared vaccine completion rates between groups over a period of 32 weeks . RESULTS The reminder system did not increase completion rates , which overall were low at 17.2 % in the intervention group and 18.9 % in the control group ( p=0.881 ) . Exploratory analyses revealed that participants who completed the series on-time were more likely to be older ( OR=1.15 , 95 % CI 1.01 - 1.31 ) , report having completed a four-year college degree or more ( age-adjusted OR=2.51 , 95 % CI 1.29 - 4.90 ) , and report three or more lifetime sexual partners ( age-adjusted OR=3.45 , 95 % CI 1.20 - 9.92 ) . CONCLUSIONS The study intervention did not increase HPV vaccine series completion . Despite great public health interest in HPV vaccine completion and reminder technologies , completion rates remain low This longitudinal study reports on the development and evaluation of a narrative intervention aim ed at increasing  human papillomavirus ( HPV ) vaccination among college women . The prevention of HPV is a public health priority due to its pervasiveness and relationship to cervical cancer , the second leading cause of cancer deaths among women worldwide . Pilot work utilizing culture-centric narrative theory guided development of the intervention content . Exemplification theory led to hypotheses comparing communication sources of the narrative messages ( peer only , medical expert only , or a combination of the two source types ) in a four-arm r and omized controlled trial ( N = 404 ; 18–26 year olds ) . The combined peer-expert narrative intervention nearly doubled vaccination compared to controls ( 22 % vs. 12 % ) . The pragmatic goal of increasing HPV vaccination and the theoretical predictions about message source were supported . As predicted , the inclusion of peer and medical expert sources plays a critical role in promoting HPV vaccination among college women . Furthermore , the intervention increased HPV vaccination by increasing vaccine self-efficacy and intent . Theoretical and practical implication s for design ing effective HPV vaccine messages are discussed PURPOSE Completion rate for the three-dose series of the human papillomavirus ( HPV ) vaccine has generally been low . This study evaluated the effectiveness of a reminder letter intervention on HPV vaccine three-dose series completion . METHODS Female members of Kaiser Permanente Southern California Health Plan who received at least one dose , but not more than two doses , of the HPV vaccine by February 13 , 2013 , and who were between ages 9 and 26 years at the time of first HPV vaccination were included . Eighty percent of these females were r and omized to receive the reminder letter , and 20 % were r and omized to receive st and ard of care ( control ) . The reminder letters were mailed quarterly to those who had not completed the series . The proportion of series completion at the end of the 12-month evaluation period was compared using chi-square test . RESULTS A total of 9,760 females were included in the intervention group and 2,445 in the control group .  HPV vaccine series completion was 56.4 % in the intervention group and 46.6 % in the control groups ( p < .001 ) . The effect of the intervention appeared to be stronger in girls aged 9 - 17 years compared with young women aged 18 - 26 years at the first dose and in blacks compared with whites . CONCLUSIONS Reminder letters scheduled quarterly were effective to enhance HPV vaccine series completion among those who initiated the vaccine . However , a large gap in series completion remained despite the intervention . Future studies should address other barriers to series completion , including those at the providers and the health care system level
We review ed intervention studies design ed to increase  human papillomavirus ( HPV ) vaccination coverage  to further underst and the impact interventions can have on HPV vaccination coverage .