HPV Ambassador Program: A Collaborative Approach to Increasing Vaccination Uptake

State: FL Type: Model Practice Year: 2019

Description of LHD Pinellas County, located on the west coast of Florida, has a population of approximately 970,637 residents in 2017 [1]. According to the U.S. Census Bureau, non-Hispanic, white residents comprised 74.2% of the Pinellas County population in 2017 and 52% of the residents were female. Approximately 153,300 (15.8%) of the residents were between the ages of 11 and 26 [2]. Situated on 608 square miles, only 274 of which are land, Pinellas County is the most densely populated county in Florida, with a density of 3,292 people per square mile. The Florida Department of Health in Pinellas County (DOH-Pinellas) is one of 67 County Health Departments operating under the Florida Department of Health. DOH-Pinellas serves Pinellas County with more than 600 employees in six different health department locations throughout Pinellas. DOH-Pinellas is divided into six Divisions that provide a wide range of public health services including infectious disease control, health promotion, chronic disease prevention, environmental health monitoring, disaster preparedness and response, as well as personal health services, including home visiting and clinic services. Public Health Issue The human papillomaviruses (HPV) are a very common family of viruses that infect the epithelial tissues. According to the Centers for Disease and Control Protection (CDC), HPV infections lead to HPV-related cancers in about 19,000 females and 12,000 males annually in the United States. Not only was the state of Florida ranked the lowest in HPV vaccination rates in 2012 by the CDC, they also showed the second highest rate in HPV-associated cancer in the U.S. from 2011-2015. While HPV vaccines are provided by DOH-Pinellas, it was found through a series of questionnaires to both parents and healthcare professionals that the HPV vaccine was not being strongly recommended in the community. Goals The overarching goal is to reduce the rate of HPV-related cancers by increasing HPV vaccination rates in Pinellas County through the establishment of the HPV Ambassador Program. Objectives The objectives of the HPV Ambassador Program are to 1) educate the community, healthcare professionals, and middle, high school and college students about the benefits and importance of the HPV vaccine for the prevention of cancer and related diseases and 2) increase the HPV immunization rates among eligible youth (i.e., ages 11 to 26 years old) throughout Pinellas County. Implementation In 2015, DOH-Pinellas received funding from the NACCHO HPV Partnership to work on improving vaccination rates. Through this funding the HPV Ambassador Program was established in July 2017 to expand the objectives of the partnership. DOH-Pinellas worked together with Partners Immunizing Towards Community Health (PITCH) to start the first HPV Ambassador trainings in January 2018 and the program was called Ask Me About HPV!”. Following initial success within the community, trainings were expanded to healthcare professionals and students to have a larger impact. Trainings for the community members were in-person, 2.5-hour educational classes using CDC's You Are the Key (YRTK) to HPV Cancer Prevention, Someone You Love documentary and several HPV information packets. Trainings took place in local hospitals, churches, health departments and community training facilities. Upon completion, trainees receive the title HPV Ambassador and are encouraged to educate other community members about HPV. In addition, healthcare professionals are trained using the SAME DAY/SAME WAY method to learn how to effectively recommend adolescent vaccination. Results/Outcomes The two main objectives of this practice were met: DOH-Pinellas trained over 1100 individuals with over 70% being healthcare professionals. Pinellas County HPV vaccination completion rates (i.e., all doses received) among eligible youth increased from 41.1% in January 2018 to 52.4% in June 2018. The highest increase was observed in the age group 19-26 with an increase from 37.8% to 62.8%. An increase in HPV immunizations was also observed in DOH-Pinellas STD and family planning clinics, where vaccination rates among eligible clients increased from 1.42% in January 2018 to 13.35% in June 2018. Public health impact This practice has increased awareness and education about the importance of the HPV vaccine in the community and among health care professionals. Data collected during the first two quarters of the HPV Ambassador Program showed an increase in HPV vaccination rates between January and June 2018 among eligible youth. Website for LHD The official website is
Problem/Public health issue In the U.S., 79 million individuals are infected with HPV at any point and 14 million new HPV infections will be acquired annually [1]. Moreover, around 26,000 cancers result from HPV infections each year. Data from 2012 showed that Florida ranked fifth among states with the lowest HPV immunization rates and had some of the highest rates of HPV-associated cancers [1]. Concurrently, Pinellas County was found to have one of the lowest HPV immunization rates [2]. Target population The HPV Ambassador Program efforts are focused on those at high risk and for whom the HPV vaccine is recommended: adolescents in the age range 11-26 years. Demographic data for 2017 suggests that the population size of residents who are between 11 and 26 years old in Pinellas County is 153,300, representing 15.8% of the entire Pinellas County population [3]. To reach this younger population, those targeted through the HPV Ambassador Program were the lay community, students and healthcare professional. Specifically, the educational institutions targeted by the HPV Ambassador Program were those with students within the age range eligible for the vaccine. Past efforts In 2015, DOH received funding from NACCHO to launch the HPV Partnership with the goal to increase HPV immunization rates. Funding for the HPV Partnership was utilized toward ensuring community collaboration and developing an action plan that resulted in the HPV Ambassador Program. An active training and education component was not part of the initial HPV Partnership and educational outreaches on HPV-related cancers were not being provided. Innovation This approach, highlighted by NACCHO among its grantees, combines existing tools, including educational packets from the American Cancer Society, NACCHO, and CDC, with a new approach to train healthcare professionals and the community to become HPV Ambassadors. One of the training tools that is used is CDC's You Are the Key” tool – an online on-demand video that was released in October 2017 which focuses on the role of the healthcare professional in recommending the HPV vaccine and preventing HPV-related cancers. The SAME DAY/SAME WAY method, a short interactive role-play simulation, is used by physicians recommending adolescent vaccines. Verbal Judo, an existing tool developed for law enforcement, is used as a powerful persuasion technique for education about HPV. Someone You Love and Lady Ganga are two documentaries that follow the lives of several women affected by HPV cancer and are shown at trainings provided to the community. Finally, The Kahoot! mobile learning application was utilized to administer the pre- and post-assessments. Another innovative aspect of the program is the target population that encompasses a broad audience including the lay community, students, and most importantly, healthcare professionals who recommend vaccines. By educating the community and having them become HPV Ambassadors, DOH-Pinellas is promoting the spread of information to a broader audience, especially parents who have children within the high-risk age range. By providing training and education to the healthcare professionals and medical students, the program is ensuring that a strong recommendation for HPV vaccination is made during patient appointments, which helps to increase vaccination rates. Evidence-based The HPV Ambassador Program addresses the low vaccination rates and high HPV-related cancers the CDC data showed for Florida and Pinellas County. Studies have shown that patients seen by a provider who recommends the HPV vaccine are 4-5 times more likely to receive the vaccine than those who do not receive a recommendation [2,3]. The results of this study point to an important aspect of HPV cancer prevention efforts: educating healthcare professionals about HPV is as important, if not more, than educating the community about the long-term implications of HPV and the role of the HPV vaccine in preventing HPV-related cancers. In addition to these findings, the efficacy of the HPV vaccine in preventing HPV-related cancers has been widely studied. Thus, the HPV Ambassador Program providing training to healthcare professionals to strongly recommend vaccination, should help improve vaccination rates and reduce the rate of HPV-related cancers in Pinellas County.
Goals The overarching goal is to reduce the rate of HPV-related cancers by increasing HPV vaccination rates in Pinellas County through the establishment of the HPV Ambassador Program. Objectives Two primary objectives were established for the practice: 1) educate the lay community, healthcare professionals, and students about the benefits and importance of the HPV vaccine for the prevention of cancer and related diseases and 2) increase the HPV immunization rates among eligible youth throughout Pinellas County. Selection criteria The selection criteria of youth eligible for HPV vaccination in Pinellas County were based on age, risk factors, and the CDC, the Northwest Florida Cancer Collaborative, and the American Cancer Society HPV vaccination recommendations. Although the CDC algorithm for HPV vaccination is changing constantly, individuals 11 through 26 years of age who reside in Pinellas County are considered eligible. Educational outreach events were performed at middle and high schools as well as colleges and universities to directly reach the population at-risk and eligible for vaccination. Additionally, healthcare professionals and parents of at-risk youth, were targeted. Timeframe While funding for the program began in September 2017, trainings started in January 2018. Stakeholders Several agencies partnered with DOH-Pinellas to ensure education on HPV and vaccinations was received by the community. The steps taken to foster collaboration consisted of making connections and reaching out to contacts in the community made through the annual Florida Immunization Summit. Other stakeholders involved with trainings and responsible for providing tools, training space, continuing education credits as well as funding include NACCHO, PITCH, the Suwannee River Area Health Education Center (AHEC), Myrtle Pediatrics, local hospital systems, the National Association for the Advancement of Colored People (NAACP) Youth Council, Pinellas County School System and Student Working Against Tobacco (SWAT). Implementation The HPV Ambassador Program focuses on providing HPV education and training HPV Ambassadors on HPV-related cancers and immunization. Healthcare professionals, including medical, pharmaceutical, and dental students, were trained to educate parents and patients about the HPV vaccine and the importance of receiving the vaccine in preventing HPV-related cancers and other diseases. The SAME DAY/SAME WAY method is employed to teach healthcare professionals how to effectively strongly recommend adolescent vaccination. Furthermore, healthcare professionals use CDC's in-person You Are the Key to HPV Cancer Prevention- Train the Trainer technique (YRTK) which is a web-on-demand video that was released in October 2017. In addition to healthcare professional trainings, the lay community members are also educated about the cancers and diseases caused by the HPV virus, the age at which the vaccine should be offered, and where additional information can be obtained. Trainings for the community members were in-person 2.5-hour educational classes using CDC's YRTK to HPV Cancer Prevention, Someone You Love, and several HPV information packets. These trainings took place in local hospitals, churches, health departments, and community training facilities. The trainees receive the title HPV Ambassador and are encouraged to educate other community members about HPV. An educational website through the DOH-Pinellas has been launched and can be accessed via the following link: Funding Startup costs included state funding of the HPV Ambassador Program Consultant position and training materials as well coverage of the outreach events that are part of the practice. Additional costs, such as those for Continuing Education Units for nurses Continuing Medical Education for physicians, are covered by the CDC and AHEC. An estimated $100,000 in resources are dedicated annually to cover the costs of the initiative.
Objectives and results The main objectives of the practice were to 1) educate the target population including healthcare professionals, community members and students of all ages about the importance of the HPV vaccine in preventing cancers and other diseases related to HPV and 2) to increase the HPV immunization rates among eligible youth in Pinellas County. To ensure achievement of the first objective, through partnerships and collaborations, nearly 1,100 HPV Ambassadors have been trained, a total of 1,283 attendees were reached through HPV Ambassador presentations, and 848 individuals were reached through outreach events between October 2017 and June 2018. Over 70 percent of these individuals were healthcare professionals including non-Pinellas County residents, which has enabled the program to expand its reach. Beginning in January 2018, data is collected to assess the HPV vaccination rate and measure the long-term effects of the HPV Ambassador Program. Data from the HPV Partnership showed that the HPV immunization rates increased from 41.1% in January 2018 to 52.4% in June 2018 among eligible adolescents (second objective). The largest increase in HPV vaccination rates was seen among eligible youth in age group 19 to 26 years: the HPV immunization rate in this age group increased from 37.8% to 62.8% between January and June 2018. These data show a continuous, significant increase in vaccination rates in those who are 11 to 26 years old in Pinellas County, accomplishing the second objective of the HPV ambassador program. Additionally, between January and June 2018, the percentage of eligible clients who were vaccinated in DOH-Pinellas STD and family planning clinics increased from 1.42% to 13.35%. Evaluation The first objective to educate healthcare professionals, community members, and students about HPV was evaluated utilizing the Kahoot! mobile application. Pre- and post- assessments were administered utilizing the mobile application to assess the knowledge level about HPV among the target population before and after the training. To evaluate whether immunization rates increased since the launch of the program, two data sources are used with January 2018 being the baseline. Secondary data on immunization rates among eligible youth collected by healthcare facilities throughout the county are obtained quarterly through the FDOH and are extracted from a statewide immunization database. The percentage of HPV immunization rates by gender and age group are calculated for each quarter. In addition to the secondary data obtained from FDOH, primary data are collected at STD and family planning clinics at all DOH-Pinellas centers. These data are extracted monthly and evaluated by health center location and setting (STD vs family planning clinic). The number of eligible clients who are serviced in each type of clinic and location are evaluated. Clients who have completed the full HPV series are excluded from the analysis; only those who have not previously received the HPV series are accounted for and considered susceptible clients. The percentage of susceptible clients who received the vaccine during their visit is calculated against the total number of susceptible clients for each location and setting monthly.
Lessons learned Lessons learned regarding the target population was to ensure education not only to the lay community, but also healthcare professionals with a focus on medical students. Although immunization rates were improving with the launch of the HPV Partnership, with the education piece missing, DOH-Pinellas was not seeing strong recommendations among healthcare professionals for the HPV vaccine. DOH-Pinellas identified this as a further opportunity to increase HPV immunization rates within the county. Furthermore, the expansion of the program to healthcare professionals outside the county is resulting in nationwide impact. The tool kits used in the HPV Ambassador Program ensure continued education, taking us a step closer to be HPV free. In addition, the trainees receive a button that says HPV Ambassador”, that way people can see it and ask more about HPV, promoting education about the virus and cancer-related conditions preventable by vaccination. As a result of the data findings, the practice was modified and expanded to provide all adolescent vaccines at no cost to middle school students as part of TDAP clinics provided to all sixth-grade students. Lessons learned from partner collaboration Partnering with the Suwannee River AHEC and PITCH while utilizing existing tools developed by the CDC and the American Cancer Society was key to current and future success of the HPV Ambassador Program. Through these collaborations, the program reached a broader audience to increase education regarding HPV which assists with improving vaccination coverage. Sustainability plans Future sustainability plans include the launching of the HPV Jr. Ambassador program in January 2019, using the peer-to-peer education model to include middle, high school, and college students. This program will include peer educators participating in education and vaccination days and the HPV Jr. Ambassador program will use Students Working Against Tobacco (SWAT) as a model for after school programs and community-based youth programs. DOH-Pinellas will employ a pilot in May 2019 with the NAACP Youth Council with the target of training, and will host a Youth Health Summit for students between 12 and 18 years old. For college students, DOH-Pinellas is partnering with the University of South Florida (USF), University of Central Florida, Valencia Community College and Saint Petersburg College to develop an HPV Health Awareness Day, which will include screening and HPV vaccines. Through the work with local collaborators and stakeholders, the HPV Ambassador Program has increased Pinellas County's HPV vaccinations rates. Therefore, by educating an audience that ranges from middle school-aged students to healthcare professionals and the lay community, the program continues to highlight the importance of HPV vaccination and cancer prevention. References Human papillomavirus-associated cancers – United States, 2004-2008. MMWR. 2012. 61(15):258-261. Health care provider recommendation, human papillomavirus vaccination, and race/ethnicity in the U.S. National Immunization Survey. American Journal of Public Health. 2013. 103 (1):164-169. U.S. Census Bureau. Quick Facts. Population (2017). Accessed Nov 21, 2018 Factors associated with human papillomavirus vaccine-series initiation and healthcare providers recommendation in U.S. adolescent females: 2007 National Survey of Children's Health. Vaccine. 2012. 30(20):3112-3118.
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