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A b s t r a c t Objective: This study examined patient-, care team- and clinic-level factors associated with human papillomavirus (HPV) vaccine initiation and completion. Methods: HPV vaccine initiation and completion rates among adolescents aged 9–18 years were assessed using administrative data (n = 38,277) from a large federally qualified.

Vaccine xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
Primary care team- and clinic level factors affecting HPV vaccine uptake Emmeline Chuang a,b,⇑, Claudia Cabrera c, Selene Mak a, Beth Glenn a,b, Michael Hochman d, Roshan Bastani a,b a
Department of Health Policy and Management, UCLA Fielding School of Public Health, University of California, Los Angeles, USA Jonsson Comprehensive Cancer Center, UCLA Fielding School of Public Health, University of California, Los Angeles, USA c Loyola University of Chicago Stritch School of Medicine, USA d Gehr Family Center for Implementation Science, Keck School of Medicine, University of Southern California, Los Angeles, USA b
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Article history: Received 29 April 2017 Received in revised form 13 June 2017 Accepted 10 July 2017 Available online xxxx Keywords: Human papillomavirus Vaccine Adolescent Mixed methods research
a b s t r a c t Objective: This study examined patient-, care team- and clinic-level factors associated with human papillomavirus (HPV) vaccine initiation and completion. Methods: HPV vaccine initiation and completion rates among adolescents aged 9–18 years were assessed using administrative data (n = 38,277) from a large federally qualified health center serving predominantly Latino patients. Four clinics with particularly high and low adolescent HPV vaccine uptake were selected for in-depth case study analyses. Semi-structured interviews with clinic leaders, providers, and support staff in these clinics (n = 36) examined multilevel factors perceived as affecting vaccine initiation and completion. Results: On average, less than half (45%) of patients had initiated the HPV vaccine; of these, 52% of patients completed all recommended doses. Vaccine uptake varied significantly across clinics but was higher among patients seen by providers specializing in pediatrics. Qualitative findings confirmed the importance of provider communication strategies but indicated that other health care team structures and processes also play an important role in vaccine uptake. Care team members in higher performing clinics were more likely to describe vaccination as a team effort rather than solely the provider’s responsibility. Support staff in higher performing clinics also spent more time reviewing patient preventive care needs and preparing patients for the provider encounter. Clinic-level factors such as performance management systems and the use of immunization champions were described as important for developing an organizational climate supportive of vaccination. Tracking and reminder systems were described as important but insufficient for ensuring vaccine uptake in the absence of other supports. Conclusions: Efforts to improve HPV initiation and completion could benefit from additional attention to factors at the health care team and clinic levels. Interventions that target factors at multiple levels of influence are most likely to achieve higher vaccination rates. Quality monitoring programs may influence clinic investment in improving vaccination rates. Ó 2017 Published by Elsevier Ltd.
1. Introduction Persistent human papillomavirus (HPV) infection is the primary causal agent in cervical cancer [1] and is responsible for a significant percentage of vulvar, vaginal, anal, penile, and oropharyngeal cancers as well as genital warts [2,3]. Certain racial/ethnic groups are disproportionately affected by HPV-associated cancers. For example, Latinos have higher incidence of cervical and penile cancers than non-Latino whites, while African-Americans have higher incidence of cervical and vaginal cancers [2,4]. ⇑ Corresponding author at: University of California Los Angeles, Fielding School of Public Health, 650 Charles E Young Dr. South, Los Angeles, CA 90095-1772, USA. E-mail address: [email protected] (E. Chuang).
Highly effective prophylactic HPV vaccines have been available since 2006 and are approved for use with adolescents as young as 9 years old [5–11]. Although the Advisory Committee on Immunization Practices (ACIP) recommends routine vaccinations for adolescents [12,13], HPV vaccine uptake remains low [2,14]. Nationally, 60% of adolescent girls and 42% of adolescent boys aged 13–17 years have initiated the HPV vaccine, i.e., received 00011 dose [15]. Vaccine completion rates are significantly lower [15]. Robust prior research has identified a range of patient-level factors contributing to variation in HPV vaccine uptake, including HPV awareness, beliefs regarding vaccination, age, insurance status, gender, and race/ethnicity [16–23]. Research also indicates that health care provider recommendation significantly affects vaccine
http://dx.doi.org/10.1016/j.vaccine.2017.07.028 0264-410X/Ó 2017 Published by Elsevier Ltd.
Please cite this article in press as: Chuang E et al. Primary care team- and clinic level factors affecting HPV vaccine uptake. Vaccine (2017), http://dx.doi. org/10.1016/j.vaccine.2017.07.028
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E. Chuang et al. / Vaccine xxx (2017) xxx–xxx
uptake [24–27], but that providers vary in the consistency and quality of recommendations made [28–32]. Other health care team- and organization-level factors that may influence vaccine initiation and/or completion remain underexamined in the literature. Particularly in primary care practices providing care under the patient-centered medical home model [33,34], team structure and functioning may affect whether patients receive recommended preventive care [35]. Clinic-level policies and practices may also play a role. However, little research has explored the effect of such factors on HPV vaccine uptake. The current study sought to address this gap by identifying patient-, care team-, and clinic-level factors affecting HPV vaccine uptake among adolescents aged 9–18 years. Study activities were conducted in a federally qualified health center (FQHC) providing care to predominantly low-income, Latino patients and were intended to inform subsequent efforts to improve vaccine uptake with this population.
yses of FQHC administrative data examined HPV vaccine uptake among adolescents aged 9–18 years and identified clinics with particularly high and low HPV vaccine initiation and completion rates. Consistent with 2016 guidelines, completion was defined as receipt of 2+ doses at least 5 months apart for patients <15 years and 3+ doses for patients aged 000115 years. Key stakeholder interviews provided insight into multilevel factors affecting HPV vaccine uptake. 2.2. Quantitative approach
2. Methods
We analyzed administrative data on 38,277 patients aged 9– 18 years that received FQHC services between 06/01/2012 and 05/31/2014. A total of 37 clinics saw at least 1 patient aged 9– 18 years; however, almost all adolescent patients (99%; n = 37,996) received services at one of 19 clinics. Descriptive analyses examined variation in vaccine uptake at the patient and clinic levels. Logistic regression identified patient characteristics associated with HPV vaccine uptake, controlling for clustering of patients within clinics. All analyses were conducted using Stata 13.0 [36].
2.1. Study design and setting
2.3. Qualitative approach
This mixed methods study was conducted at a large FQHC providing care at

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