A postpartum human papillomavirus vaccination program was locally implemented to address low initiation rates among young adults. Within 20 months, the program achieved high vaccine initiation and series completion rates. Based on the program’s success, it was expanded to all 36 counties served by a public hospital.
This study aimed to conduct a quantitative and qualitative evaluation to examine the success and limitations of the program when expanded from 1 county to 36 counties, many of which are home to rural and medically underserved communities.
Patient navigators reviewed the electronic medical records and immunization registry records of women aged ≤26 years, who delivered an infant at the public hospital, to determine whether they needed to initiate or complete the human papillomavirus vaccine series. Eligible women were counseled and offered the human papillomavirus vaccine during their hospital stay. Patient navigators scheduled follow-up injections in addition to the mother’s postpartum or her infant’s well-child visits, made reminder phone calls, and rescheduled missed appointments. Descriptive statistics, including frequencies and proportions, were used for patients approached in the initial and expansion programs. Frequencies from the initial and expansion programs were examined separately. Qualitative interviews were conducted with the clinic staff to evaluate the program. The qualitative analyses were conducted using NVivo (QSR International, Melbourne, Australia, version 10).
Both initial and expanded programs achieved vaccine completion rates above 70%. Of the 2631 eligible postpartum women enrolled in the initial program, 785 (30%) had already been fully vaccinated. Of the remaining 1846 women, 1265 (69%) women received their first dose, and 196 (11%) women received their second or third dose on the postpartum unit. Of the 1461 women who received at least 1 dose through the initial program, 1124 (77%) completed all 3 doses. Of the 4330 eligible postpartum women enrolled in the expanded program, 886 (21%) had already been fully vaccinated. Of the remaining 3444 women, 2284 (66%) received their first dose, and 343 (10%) received their second or third dose on the postpartum unit. Of the 2627 women receiving at least 1 dose through the expanded program, 1932 (74%) completed all 3 doses. Clinic staff interviewed felt the program benefited the postpartum unit and clinics, because it increased patient knowledge of the vaccine, increased patient volume for vaccination, and gave healthcare providers more time to focus on other tasks.
Human papillomavirus vaccination on the postpartum unit is an effective way to increase catchup rates and is well accepted by healthcare providers. High completion rates can be achieved if adequate support is provided, even among patients residing in rural or underserved areas who need extensive support to access primary healthcare services. Although this particular program may be considered costly, it is overall effective because the vaccine prevents 5 different types of cancer in women. The inclusion of human papillomavirus vaccination in routine postpartum care is a relatively easy way to reach many adults not vaccinated at a younger age and could help address low vaccination rates among young women in the United States, including hard-to-reach populations.
Human papillomavirus (HPV) vaccination is expected to greatly reduce HPV-related cancers if adopted at a high rate. Unfortunately, vaccination rates have failed to meet the 80% goal established by Healthy People 2020. In 2017, only 48.6% of 13- to 17-year-olds in the United States were up to date with the recommended 2 doses for 9- to 14-year-olds or 3 doses for ≥15-year-olds. Vaccination rates are even lower among young adults. In 2018, only 21.5% of 18- to 26-year-olds had completed the series. This age group can still benefit from vaccination, because it is unlikely they have been infected by all 9 HPV types covered by the 9-valent HPV vaccine administered in the United States. Thus, innovative strategies are needed to increase HPV vaccine uptake and completion, especially among young adults.
Why was this study conducted?
A program that offered the human papillomavirus (HPV) vaccine was implemented on the postpartum unit to all mothers aged ≤26 years residing in a wide geographic area. Vaccines were provided at no cost to the patients. Follow-up doses were administered at postpartum or well-child visits. Qualitative and quantitative evaluations examined its success and limitations.
The program achieved very high vaccine initiation and series completion rates, but many women needed extensive support from patient navigators to complete the vaccine series as outpatients.
What does this add to what is known?
Offering HPV vaccination to all eligible women during the postpartum hospitalization and subsequent outpatient visits is an effective way to increase catchup vaccination rates. Programs covering a wide geographic area may need to offer patients a high level of support after discharge to be successful.
Postpartum care offers a unique opportunity to provide the HPV vaccine to young women as they obtain medical care at an age when they may not otherwise seek it, particularly if they are healthy, uninsured, or from a minority ethnic group. In addition, 3 studies found that offering the vaccine on the postpartum inpatient unit increased rates among women who required catchup vaccination. However, these studies were limited by sample sizes of only 150 to 312 women. Moreover, observed increases in vaccine uptake were modest, and only 1 study examined the completion rates.
In contrast, our previous report demonstrated that high initiation and completion rates can be achieved. HPV vaccine uptake increased from 25% to 81% over 20 months, and 76% of the patients completed all 3 doses. However, this project was limited to local residents from the county where the hospital was located. In 2016, we obtained additional funding to expand the program to all 36 counties served by the hospital. Evaluation of this all-inclusive program is important to determine whether postpartum HPV vaccination programs can still be effective when implemented at large referral centers serving patients from a wide region, including rural and underserved areas, over an extended period.
With funding from the Cancer Prevention and Research Institute of Texas (CPRIT), The University of Texas Medical Branch (UTMB) instituted an HPV vaccination program at John Sealy Hospital on November 1, 2012, for postpartum women aged ≤26 residing in Galveston County. On September 1, 2016, the program was expanded to include all postpartum women aged ≤26 from 36 counties served by UTMB. Women were offered the vaccine as inpatients with follow-up doses administered at reproductive health and pediatric clinics ( Supplemental Figure ). Patients seen in the initial project received follow-up injections in Galveston County, whereas those in the expanded program utilized 12 UTMB clinics across Southeast Texas. CPRIT funded personnel required for both programs and paid for doses not covered by public or private insurance companies. The expansion program was funded for 3 years, which defined the time this program evaluation occurred. The UTMB Institutional Review Board (IRB) approved this evaluation of program records and qualitative interviews of personnel.
To initially determine whether eligible patients had already completed the vaccine series, patient navigators (PNs) reviewed their electronic medical records (EMRs) and the Texas Immunization Registry records. For patients whose records indicated that ≥1 dose was needed, PNs inquired whether they had previously completed the series, as vaccination records for adults may be incomplete. PNs confirmed self-reported HPV vaccination by checking non-UTMB medical records, when possible. All patients who were previously not fully vaccinated during the 3 years of this evaluation were included to determine the outcomes of the program. PNs then offered patients, who had not completed the series, education on HPV vaccination and the Centers for Disease Control and Prevention (CDC) fact sheets in English or Spanish, as these are the 2 primary languages most frequently spoken in the patient population. Patients who did not speak English or Spanish (2%) were offered printed materials in their own language. PNs also had access to the university’s interpretation services, when needed. Patients who declined or wanted more information were directed to their healthcare providers. Written consent was obtained from patients who agreed to vaccination and parental consent for minors, consistent with the state of Texas regulations. All reasons for declining vaccination were recorded.
After obtaining consent, a dose was administered before discharge. Initially, their physician had to order the vaccine. If the order was not completed in a timely manner, the patient left the hospital unvaccinated and was scheduled for vaccination as an outpatient. In July 2017, standing orders for HPV vaccination were implemented, which alleviated this issue.
Follow-up doses were given along with the mother’s postpartum or her infant’s well-child visits, whenever possible. Approximately 1 month before the next dose was due, PNs reviewed the patient’s EMR for upcoming appointments. When an appointment fit the timing for the next dose, PNs added a vaccination request to the EMR and informed the patient that she would receive the next dose at that visit. If this was not possible, PNs scheduled a vaccine-only visit at a facility near the patient’s residence. Automated telephone calls and text messages reminded patients about upcoming appointments, based on their preference.
PNs telephoned patients who missed appointments within 24 hours to reschedule. Those who could not be reached were sent letters and emails instructing them to reschedule. Alternative contacts, obtained from participants during their hospitalization, were called, if necessary. Patients who missed 5 appointments or could not be reached were considered inactive. Those who informed PNs they were not willing to complete the series were no longer contacted.
Descriptive statistics, including frequencies and proportions, were used to describe patients approached for counseling and those who initiated and completed the series. Reasons given for declining the vaccine were compared between the initial and expansion programs. We examined frequencies from the initial and expansion programs separately to determine whether results differed when the program covered a larger geographic area.
Qualitative interview methods to assess perspectives of the program
To gain insight into how the program affected patient flow and whether it was adaptable in the settings where participants were receiving initial or follow-up doses, we conducted 25 qualitative interviews in December, 2019 during the final year of the expanded project. Qualitative analyses were conducted by examining commonly occurring themes using NVivo (QSR International, Melbourne, Australia, version 10). The UTMB IRB determined that these evaluations were not human subject research. Healthcare providers and staff, who were working in the postpartum unit or in participating clinics and who were responsible for vaccinating patients in clinics or on the postpartum unit or who were normally responsible for scheduling patients in clinics, were interviewed in person or by phone. Questions also examined current barriers to HPV vaccination to better understand what issues remained. Interviewed participants received a $25 gift card as reimbursement for their time.
During the initial program involving only Galveston County, the UTMB EMRs of 2631 women were evaluated. It was initially determined that 2031 of 2631 patients (77%) were not fully vaccinated against HPV ( Figure 1 ). When questioned, 185 of 2031 patients (9%) reported that they had been vaccinated at another facility, which was subsequently confirmed. Therefore, the baseline rate of fully vaccinated postpartum women was 29.8% (785 of 2631 patients). PNs personally educated the remaining 1846 women, of which 892 (48%) were Hispanic, 408 (22%) were Black non-Hispanic, 510 (28%) were White non-Hispanic, and the remaining 36 (2.0%) of other ethnicities, on the need for HPV vaccination. Overall, 1265 of 1846 women (69%) agreed to receive an initial dose, and an additional 196 of 1846 women (11%), who had previously received at least 1 dose, agreed to receive the second or third dose. Of the 1265 women who received an initial dose postpartum, 1096 (87%) received a second dose, and 929 (73%) received a third dose. Among those who either initiated or continued the series, 1124 of 1461 (77%) completed all 3 doses with a total of 3532 vaccine doses administered ( Figure 1 ). During the initial program, PNs made 3694 reminder phone calls. A total of 302 participants missed 1 appointment, 168 missed 2 appointments, 118 missed 3 appointments, 74 missed 4 appointments, and 196 missed ≥5 appointments.
During the expansion program involving 36 counties, the EMRs of 4330 women were evaluated, and 3870 of 4330 women (89.4%) indicated an incomplete HPV vaccination ( Figure 2 ). Of these, 426 of 3870 women (11%) reported and were confirmed to have previously completed the series. Therefore, the baseline rate of fully vaccinated postpartum women in the expansion program was 20.5% (886 of 4330 women). Of the remaining 3444 eligible patients, 2422 (70%) were Hispanic, 362 (11%) were Black non-Hispanic, and 579 (17%) were White non-Hispanic. Among those who required at least 1 dose, 2284 of 3444 women (66%) initiated the HPV vaccine series, whereas 343 of 3444 women (10%) continued the series by receiving the second or third dose. Among 2284 women who received the first dose through the expansion program, 2012 (88%) received the second dose, and 1636 (72%) received the third dose. Among 2627 women who either initiated or continued the series, 1932 (74%) completed all 3 doses with 6378 total doses administered. During the expansion program, PNs made 13,752 reminder phone calls. A total of 488 participants missed 1 appointment, 292 missed 2 appointments, 197 missed 3 appointments, 157 missed 4 appointments, and 337 missed ≥5 appointments.