HPV vaccination intervention promotes decision-making among adolescents
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An HPV vaccination intervention that was implemented in schools modestly improved psychosocial vaccine-related outcomes like decision-making in adolescents, according to findings published in JAMA Network Open.
“The intervention also increased adolescents’ knowledge about HPV, vaccination and the vaccination process,” Cristyn Davies, BA, a senior research associate in child and adolescent health at the University of Sydney, and colleagues wrote. “This outcome, in turn, promoted vaccination literacy at a time when adolescent cognitive, physical, and emotional processes and health-related behaviors are developing.”
Davies and colleagues enrolled 6,967 adolescents aged 12 to 13 years from 40 high schools in Western or Southern Australia in 2013 and 2014. For the cluster randomized trial, the researchers assigned 21 schools to participate in the intervention, while the remaining 19 schools served as controls. Intervention schools provided education and distraction strategies to adolescents receiving vaccinations, a shared decision-support tool for parents and adolescents and logistical strategies for the school. The researchers assessed the impact of the intervention on completion of the three-dose HPV vaccine series, as well as how adolescents felt about the vaccine using the HPV Adolescent Vaccination Intervention Questionnaire (HAVIQ).
The mean age of the students was 13.7 years. The intervention group included 3,805 students (1,689 girls), while the control group included 3,162 students (1,471 girls). The overall response rate of the HAVIQ was 55%, according to Davies and colleagues. It was even lower — 35% — in Western Australia, where parental consent was required. In Southern Australia, where parental consent was not required, the response rate was 97%.
The average HAVIQ score for decision-making was slightly yet significantly higher in the intervention group compared with the control group (3.5 vs. 3.4; 95% CI, 0.06-0.16). The intervention group also displayed slightly higher reductions in vaccine-related anxiety and increased vaccine self-efficacy following each of the three doses. Needle-related anxiety was prevalent in both groups at baseline. Davies and colleagues found that students experienced more confidence and less anxiety with each vaccine dose, according to a smaller focus group of 111 adolescents in intervention and control schools.
“School-based vaccination provides unique opportunities that help support the adolescent vaccination experience,” they wrote. “Improved health literacy, combined with logistical strategies, resulted in improved vaccination experiences for adolescents in the school setting.”
Perspective
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Jane R. Montealegre, PhD, MSPH
Australia’s National HPV Vaccination Program represents one of the greatest modern-day public health success stories. First implemented in 2007, the program has achieved national vaccine initiation and completion rates of over 85% and 75%, respectively, among adolescent girls and boys. Furthermore, these high levels of coverage were achieved early in the program’s implementation and have been sustained or incrementally increased over the past decade and a half. The effectiveness of the program has been dramatic. In the age cohorts offered vaccination, there have been significant reductions in vaccine-targeted HPV prevalence, genital warts and high-grade cervical dysplasia. Genital warts among young people have now become a rare occurrence.
The cornerstone of Australia’s effective national HPV vaccine program is publicly funded school-based vaccination. School-based implementation offers the unique opportunity for program implementers to capitalize on normative influences positive to vaccination. What the HPV.edu study group demonstrates in their most recently published study is that an adolescent-targeted, school-based educational intervention, centered on adolescent education and distraction, decision support and logistical support for schools, can promote pro-vaccination psychosocial outcomes, including adolescent decision-making, vaccine-related anxiety and vaccination self-efficacy and skills. While the improvements in these outcomes were quantitatively small, the qualitative process evaluation data elucidate the potentially profound impact of such an intervention. In focus group discussions, adolescents who received the educational and decision-making support intervention reported being more involved in HPV vaccine decision-making with their parents, based on improved knowledge, motivation and competence to make well-informed health decisions. The qualitative results, in particular, suggest that a multi-component intervention such as this could help sway and maintain normative influences in the direction of being health promoting (as opposed to what we see in some countries and regions of the world where normative influences are helping to propagate vaccine hesitancy).
The small gains from the intervention in the Australian context, where pro-vaccine sentiment is high, also suggest that such an intervention could have broader and more dramatic impacts in countries such as the U.S., where pro-vaccine sentiment is losing ground, particularly in the COVID-19 era. Could increased involvement of adolescents in vaccine decision-making with their parents improve HPV and other vaccine uptake? More profoundly, given the historically low adolescent HPV vaccination rates achieved through clinic-based vaccination in the U.S., it may be time to disrupt our vaccination paradigm and more broadly consider the public health potential of school-based vaccination.
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