Year of Publication

2017

Degree Name

Doctor of Nursing Practice

Committee Chair

Dr. Elizabeth Tovar

Clinical Mentor

Dr. Jessica Murray

Committee Member

Dr. Lynne Jensen

Abstract

Abstract

Problem: The CDC estimates one person every 20 minutes every day acquires an HPV-related cancer. Kentucky’s HPV associated cancer burden is among the highest in the nation. Adolescent HPV vaccination rates in Kentucky are far below HealthyPeople 2020 goals. Barriers are multifaceted and include provider, patient and system barriers. The AFIX model is an evidenced based quality improvement program that addresses key provider barriers. The USPSTF findings identify a gap in the literature related to AFIX methods to improve rates of adolescent vaccines.

Objectives: The purpose of this study was to evaluate the effects of an intervention using the AFIX model and provider education focusing on the HPV vaccine as cancer prevention. Goal: To evaluate provider knowledge & attitudes of the HPV vaccine and evaluate the effects of provider education on vaccine rates. Specific Aims: 1. Evaluate frequency of use of CDC Talking Points (rubric) 2. Evaluate changes in vaccination with use of rubric.

Methods: Utilizing the Assessment Feedback Incentives eXchange (AFIX) model, this quasi-experimental pilot research project included four phases: a retrospective chart review to establish baseline rates of HPV vaccination and a provider survey to identify barriers and facilitators (Phase 1), an educational intervention focused on presenting the HPV vaccine as cancer prevention (Phase 2), a process/outcome evaluation (Phase 3&4) to assess use and feasibility of the CDC talking points rubric and an outcome evaluation to assess any change in vaccine uptake.

Primary outcome variable: adolescents age 11-17, with no prior history of the HPV vaccine receiving at least one dose.

Results: 63 of 100 medical records reviewed met inclusion criteria. 79% of adolescents received one dose of the HPV vaccine at a well-child visit. Only 34% received dose 2, and only 8% received dose 3. Significant demographic findings: older adolescents and non-Hispanics were less likely to initiate HPV vaccine. Provider survey results revealed the most commonly reported barrier at 80% was the HPV vaccine not being required for school entry. Participation in the Vaccines for children (VFC) program was the most commonly reported facilitator at 82%. The post-intervention process evaluation revealed 50% of the providers changed the way they presented the HPV vaccine to parents. None of the providers used the CDC rubric and the most common barrier was not having a copy to refer to. Two-thirds of the providers felt uptake of the vaccine had increased since the 2-dose series introduced. Only 83% offer vaccine to females & males 100% of the time. None of the providers feel the vaccine is accepted 100% of the time.

Summary/Implications: At 79%, the proportion of adolescents at HealthFirst Bluegrass age 11-17 with one dose of the HPV vaccine was above the statewide average of 58%. The proportion with 2 and 3 doses were on par with national averages, but were still below benchmark. Because the baseline rates were just below the 80% goal and the provider surveys revealed the school requirement barrier, the PI chose to shift the focus to a policy intervention at the school level. Using a CDC drafted school nurse letter to parents of adolescents, the PI proposed a new version of the 5th grade letter to be sent to all Fayette county incoming middle school students. The current letter only lists the 2 state required vaccines (Tdap, MCV) and not the third ACIP recommended HPV vaccine. Given the recent change in the ACIP recommendation to a 2-dose regimen for young teens, this provides a prime opportunity to promote the HPV vaccine to Fayette county middle school students and their parents.