Joan R. Cates
Jamie L. Crandell
Sandra J. Diehl
Tamera Coyne-Beasley
Publication Date
November 21, 2017

University of North Carolina at Chapel Hill

"The Protect Them study shows promise for practice-based communication strategies - including age-appropriate discussion of HPV as a preventable STI - to be effective in promoting preteen HPV vaccination."

The objective of this study was to conduct and measure a practice-based intervention with communication tools to motivate preteen human papillomavirus (HPV) vaccination in North Carolina, the United States (US) through provider/parent/preteen conversations about HPV as a sexually transmitted infection (STI) preventable by vaccination. Many parents in the US may not consent to HPV vaccination because of concerns about safety and side effects and possibly their worry that it will encourage early sexual activity. Many providers do not stress the effectiveness of early vaccination, despite its being recommended by the Advisory Committee on Immunization Practices (ACIP) for routine use in females in 2006 and in males in 2011. For these and other reasons, uptake of the vaccine has stalled well below the goal of 80% of the US population.

With extensive input from parents, preteens, and providers, as part of the Protect Them study, researchers developed tools to encourage communication and persuade parents and providers to choose HPV vaccination at the routine recommended ages of 11-12. With an emphasis on the principle of involving the preteen in the decision making process, the researchers asked practices (clinics) to 1) commit 50% of their providers to online training about vaccine epidemiology, communication with parents and preteens about HPV and HPV vaccine, and systems-level supports; 2) display posters and brochures in English and Spanish with the headline "1 in 2 people will get HPV, which causes genital warts and cancer" for 9 months in their clinics; and 3) screen parent/preteen dyads for a smaller nested study (data not reported in this paper) to test the acceptability and efficacy of an original video game, Land of Secret Gardens, which uses growing a healthy garden as a metaphor for a healthy body protected against HPV.

The researchers compared vaccine initiation and completion rates over three 9-month periods (baseline, intervention, post-intervention) between practices enrolled in the intervention and a comparable comparison group. All practices reported to the North Carolina Immunization Registry (NCIR) and had at least 100 11- and 12-year-olds who had not completed the HPV vaccine series. Of 175 eligible practices, the 14 intervention practices included 19,398 individuals, and the 161 comparison practices included 127,896 individuals. An extended Cox model was used to test the intervention effect.

The intervention was found to have had a significant effect on both initiation and completion during the intervention and post-intervention periods; the estimated hazard ratio (HR) for initiation was 1.17 (p = .004) during the intervention and 1.11 (p = .005) post-intervention. Likewise, after controlling for baselines differences, individuals in the intervention practices were 17% more likely to initiate and complete HPV vaccination than in the comparison practices during the intervention period; this effect increased in the post-intervention period to 30% higher (p = .03).

The researchers conclude: "What makes our tools particularly strong is the considerable input from parents and preteens and providers who serve them....With the continuing gaps in HPV vaccination among preteens, we recommend using and measuring the impact of these tools in other settings."


Vaccine Volume 36, Issue 1, January 2 2018, Pages 122-127. Image credit: WithinReach