Elsevier

Vaccine

Volume 32, Issue 33, 16 July 2014, Pages 4171-4178
Vaccine

Intervention effects from a social marketing campaign to promote HPV vaccination in preteen boys

https://doi.org/10.1016/j.vaccine.2014.05.044Get rights and content

Highlights

  • We evaluated a social marketing intervention to stimulate HPV vaccination.

  • We modeled change in vaccination rates in 9–13 year old boys using NC registry data.

  • Probability of vaccination increased significantly in the intervention region.

  • HPV vaccination rates were highest in the 11–12 year old boys.

  • Social marketing can promote timely vaccination of preteen boys against HPV.

Abstract

Objectives

Adoption of human papillomavirus (HPV) vaccination in the US has been slow. In 2011, HPV vaccination of boys was recommended by CDC for routine use at ages 11–12. We conducted and evaluated a social marketing intervention with parents and providers to stimulate HPV vaccination among preteen boys.

Methods

We targeted parents and providers of 9–13 year old boys in a 13 county NC region. The 3-month intervention included distribution of HPV vaccination posters and brochures to all county health departments plus 194 enrolled providers; two radio PSAs; and an online CME training. A Cox proportional hazards model was fit using NC immunization registry data to examine whether vaccination rates in 9–13 year old boys increased during the intervention period in targeted counties compared to control counties (n = 15) with similar demographics. To compare with other adolescent vaccines, similar models were fit for HPV vaccination in girls and meningococcal and Tdap vaccination of boys in the same age range. Moderating effects of age, race, and Vaccines for Children (VFC) eligibility on the intervention were considered.

Results

The Cox model showed an intervention effect (β = 0.29, HR = 1.34, p = .0024), indicating that during the intervention the probability of vaccination increased by 34% in the intervention counties relative to the control counties. Comparisons with HPV vaccination in girls and Tdap and meningococcal vaccination in boys suggest a unique boost for HPV vaccination in boys during the intervention. Model covariates of age, race and VFC eligibility were all significantly associated with vaccination rates (p < .0001 for all). HPV vaccination rates were highest in the 11–12 year old boys. Overall, three of every four clinic visits for Tdap and meningococcal vaccines for preteen boys were missed opportunities to administer HPV vaccination simultaneously.

Conclusions

Social marketing techniques can encourage parents and health care providers to vaccinate preteen boys against HPV.

Introduction

Public health interventions often take years to be broadly adopted and sustained in practice settings, [1] and the human papillomavirus (HPV) vaccine is no exception [2], [3]. Two vaccines have been approved by the Food and Drug Administration (FDA) for use in the United States: HPV2, which protects against two types (16 and 18) of the virus, and HPV4, which protects against four types (6, 11, 16, 18). HPV types 6 and 11 cause genital warts and types 16 and 18 are associated with cervical, vaginal, vulvar, anal, penile, and throat cancers [4], [5]. Initial studies of vaccine effectiveness in reducing HPV infection and disease are promising [4], [6].

Vaccination against HPV is most effective when given before sexual exposure to the virus [7], [8]. The Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices (ACIP) first recommended HPV4 vaccination for routine clinical use in females, ages 11–12, in 2006 [7] and in males, ages 11–12, in 2011 [8]. HPV4 vaccine is the only one licensed for males. However, adoption of the vaccine has been slower than expected [2]. At the end of 2012, completion of the 3-dose HPV4 vaccine series among females and males ages 13–17 in the US was only 33% and 7% respectively [2]. By contrast, coverage estimates among teens aged 13–15 years for ≥1 Tdap vaccine dose and ≥1 meningococcal vaccine dose were 85% and 74%, respectively, indicating that the Healthy People 2020 goal of 80% vaccination coverage for adolescent vaccines is achievable [2], [9]. This lag in HPV vaccination coverage exists in spite of ACIP's recommendation that all age-appropriate vaccines be administered at a single visit [2].

HPV vaccine has been primarily marketed to females to protect against cervical cancer [10]. Yet, HPV vaccination of boys would prevent most of an estimated 7490 cases of HPV-associated cancer cases diagnosed annually in males [6], [11], [12]. A significant barrier to HPV vaccination among preteens is reluctance by both healthcare providers and parents to vaccinate at a young age [2], [11], [13], [14]. Health care providers play an influential role in parents’ decisions to vaccinate their sons against HPV, yet evidence suggests providers are not yet fully promoting the vaccine at the recommended ages of 11–12 [2], [13], [14], [15], [16]. Lack of parental awareness coupled with underutilization of the vaccine lead to missed opportunities to reduce HPV disease and associated cancers [2], [14], [17], [18].

The objective of our study was to conduct and evaluate a social marketing intervention with parents and providers to stimulate HPV vaccination among preteen boys at a critical time when the vaccine was new to both parents and clinical practice.

Section snippets

Methods

We evaluated a set of social marketing strategies intended to promote HPV vaccination in preteen boys, especially among racial and ethnic populations at greater risk of disease. We report here county-level vaccination data from the North Carolina Immunization Registry (NCIR) to assess outcome effects from the intervention. We also compared self-reported pre and post intervention vaccine knowledge, attitudes, beliefs, intentions and behaviors in parents and providers in intervention counties;

Characteristics of sample

In the NCIR data, there were 176,590 boys at risk for HPV vaccination during the study period, including 19,842 in the intervention and 6027 in the control counties. Demographics for the entire state, and by intervention group, are in Table 1.

Compared to the intervention counties, boys not yet vaccinated for HPV at baseline in the control counties were slightly older (59.5% vs. 56.8% age 12–13, p < .0001). The control and intervention counties also had different racial breakdowns (p < .0001), with

Discussion

The “Protect Him” campaign was a social marketing intervention to increase HPV vaccine uptake among 11–12 year old boys in a 13-county region in North Carolina. Our analyses of the state's immunization registry data suggest a modest but significant intervention effect by boosting HPV vaccination of preteen boys in the targeted counties. We found that an unvaccinated boy in NCIR was 34% more likely to get vaccinated during the 12-week campaign period in an intervention county than in a control

Conclusion

The objective of our study was to conduct and measure a social marketing intervention with parents and providers to stimulate HPV vaccination among preteen boys at a critical time when the vaccine was new to both parents and clinical practice. We hypothesized that our outreach would increase HPV vaccine uptake among preteen boys in intervention counties compared to control counties. We recommend comparing adolescent immunization trends on a county and regional level as an important mechanism

Funding source

This study was supported by grants from the National Institutes of Health 1R21A1095590-01A1 (Cates PI), and by the North Carolina Translational and Clinical Sciences Institute, through support from the National Center for Advancing Translational Sciences (NCATS), National Institutes of Health, Grant Award Number 1UL1TR001111. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH.

Acknowledgements

The authors would like to thank Amy Grimshaw, Beth Quinn and Amanda Dayton from NC DHHS, Immunization Branch for facilitating NCIR data access and its interpretation, and the NC South Central Partnership for Public Health for ongoing support and feedback.

Conflict of interest: Dr. Coyne-Beasley receives research funding from Merck & Co. None of these funds were used in the conduction or completion of the research contained in this manuscript. No other authors have conflicts of interest to

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