Digital Repository Doctoral Projects Spring 2021 Improving HPV Immunization Rates Through Provider Education Emily Ostarcevic MSN, APRN, FNP-C Weber State University Follow this and additional works at: https://dc.weber.edu/collection/ATDSON Ostarcevic, E. (2021). Improving HPV Immunization Rates Through Provider Education Weber State University Doctoral Projects. https://cdm.weber.edu/digital/collection/ATDSON This Project is brought to you for free and open access by the Weber State University Archives Digital Repository. For more information, please contact archives@weber.edu. Improving HPV Immunization Rates Through Provider Education by Emily Ostarcevic A project submitted in partial fulfillment of the requirements for the degree of DOCTOR OF NURSING PRACTICE Annie Taylor Dee School of Nursing Dumke College of Health Professions WEBER STATE UNIVERSITY Ogden, Utah April 18, 2021 Jessica Bartlett DNP, CNM, RN, IBCLC _____________________________ Faculty Advisor/Committee Chair Melissa NeVille Norton DNP, APRN, CPNP-PC, CNE ________________________________ (Graduate Programs Director) Running head: IMPROVING HPV IMMUNIZATION RATES 1 Improving HPV Immunization Rates Through Provider Education Emily Ostarcevic, MSN, APRN, FNP-C Anne Taylor Dee School of Nursing, Weber State University Running head: IMPROVING HPV IMMUNIZATION RATES 2 Acknowledgements There are many people to thank for assistance in this quality improvement project. First and foremost, this project would not have been possible without the support of my husband, Bruno Ostarcevic. Thank you for pushing me to reach my goals, supporting my crazy ideas, and picking up slack at home. I am indebted to my children Ari and Charlie that have been patient with me throughout this process when I was busy, unable to play, and irritable. I love you both! Thank you to my parents and siblings for the encouragement. Thank you to Dr. April Greener, a dear friend that motivated me to go back to school and served as a mentor throughout this journey. My special thanks to the staff of Wee Care Pediatrics for participating in my project. Thank you to Matt West that served as my project team lead, and Jeff Jones that collected the quantitative data and responded to my tireless emails. Without their support and participation, this project would not have been successful. I am particularly grateful to the faculty of the DNP program at Weber State University. Specifically, Dr. Jessica Bartlett that served as my faculty team lead, and Dr. Mary Anne Reynolds. Without your direction and guidance, I would have been lost! Finally, thank you to my classmates who cheered me on and made this an enjoyable experience. Running head: IMPROVING HPV IMMUNIZATION RATES 3 Abstract The human papillomavirus (HPV) is the most common sexually transmitted infection in the United States, causing multiple forms of cancer and genital warts. Although the HPV vaccine has been determined to be safe, immunization rates are low. The purpose of this project was to evaluate provider perception of patient barriers about the HPV vaccine. Through education and system changes provider and patient barriers were addressed. Increasing HPV immunization awareness included provider education and utilizing electronic health record (EHR) alerts. Patients were educated through posters placed in each room and with follow-up reminder calls. Provider knowledge and perception about the HPV vaccine was assessed through pre- and post-surveys. The survey consisted of 7 multiple choice questions and four open-ended questions. The EHR provided HPV series completion data. Thirteen providers completed both the pre- and post-survey. The post-survey showed improvement in provider knowledge about the HPV vaccine and 62% of the providers reported they were more likely to strongly recommend the HPV vaccine and look for other opportunities to vaccinate outside of the well check visit. Overall, HPV immunization completion rates increased from 13.6% to 18.6%. HPV immunization completion rates continue to be low in Utah, educating providers on how to address barriers about the HPV vaccine could improve immunization uptake and decrease cancers caused by HPV. The interventions used in this quality improvement project can also be applied to improving other immunization rates, decreasing preventable diseases. Keywords: human papillomavirus, hpv vaccine, provider education Running head: IMPROVING HPV IMMUNIZATION RATES 4 Improving HPV Immunization Rates Through Provider Education The human papillomavirus (HPV), is the most common sexually transmitted infection in the United States, causing multiple forms of cancer and genital warts in both males and females. (Centers for Disease Control and Prevention, 2019). The CDC estimates that nearly eighty million Americans are currently infected by HPV and that each year 30,000 Americans develop cancer as a result of HPV infection. The Advisory Committee on Immunization Practices (ACIP) recommends routine HPV vaccination of children aged 11-12 years old. The vaccine can be given as early as 9 years and up to 45 years in men and women. The CDC states that the HPV vaccine has shown to be safe and is almost 100% effective in preventing nine different strands of HPV that can cause cancer (CDC, 2019). Although the HPV vaccine has been determined to be safe, national immunization rates for HPV vaccination has remained below target rates. In 2018, the CDC estimated that nationally 65.5% of adolescents had started the HPV series with only 51.1% completing the series. In Utah, that rate was decreased to 58.8% getting the first injection and only 37.4% completing the series (CDC, 2019). At Wee Care Pediatrics the HPV immunization completion rate is only 13.6%. The purpose of this paper is to discuss HPV and HPV vaccination, identify patient and parent barriers about the HPV vaccine and suggest interventions that would improve provider education to address patient barriers and improve the HPV immunization rate at Wee Care Pediatrics. Literature Review Currently, Utah is one of the five lowest states in completion rates for the HPV vaccination series (CDC, 2019). 73% of Utah residents are affiliated with a Christian based faith (World Population Review, 2020). Having a high percentage of residents affiliated with an organized religion may play a role in the low HPV immunization rates. Although the evidence is Running head: IMPROVING HPV IMMUNIZATION RATES 5 limited, it is thought that religion plays a role in decisions around certain health behaviors, which in turn can influence a parent’s decision to accept the HPV vaccine (Franco, Mazzucca, Padek & Brownson, 2019). A survey study conducted by the University of Utah and Huntsman Cancer Institute showed that young women who practice organized religion have lower HPV knowledge compared with those that don’t practice an organized religion. They found that educating providers who serve religious patients may be effective in improving the knowledge about the HPV immunization and increase HPV immunization rates (Bodson, Wilson, Warner & Kepka, 2017). A parent’s decision to vaccinate for HPV can be influenced by multiple complex factors. Many of them depend on parental attitudes, beliefs, and acceptance of vaccines (Allen et al. 2010). Hansen, Credle, Shapiro and Niccolai (2015) conducted a qualitative survey to better understand why parents decide to accept or refuse HPV vaccination. The survey showed reluctance to vaccinate due to safety concerns about the immunization. Other beliefs included the vaccine was unnecessary since it is given prior to a child becoming sexually active, and/or they were promoting sexual activity by giving the vaccine. Anderson et al. (2018) conducted a survey focusing on a predominantly low-income urban and suburban Hispanic patient population. The survey showed there were deficits in recommending the HPV vaccine for both genders, lack of education on cervical cancer prevention, and education on the risks and benefits of the vaccine. This supports Allen et al. (2010) findings that despite high levels of awareness, actual knowledge about the virus and vaccine are low. Addressing the knowledge gap along with patient and parent barriers about the HPV vaccine is the responsibility of the family practitioner or pediatric clinician. Multiple studies Running head: IMPROVING HPV IMMUNIZATION RATES 6 showed that provider recommendation and education is the most influential intervention. Anderson et al. (2017) found that physician recommendation to vaccinate was far more influential in a parent’s decision to vaccinate when compared to television and other sources. Dempsey et al. (2018) conducted a randomized clinical trial to evaluate if a health care professional communication intervention would improve HPV immunization rates. The study showed that a health care providers communication intervention significantly improves HPV vaccination initiation and completion among adolescent patients. With provider recommendation being a key factor in a parent’s decision to vaccinate, focus needs to be placed on effective communication. Gikey and McRee (2015) conducted a systematic review of 101 qualitative and quantitative studies to review the evidence on provider communication about HPV vaccination. The findings showed significant shortcomings in provider communication. The practice of describing the HPV vaccine as optional and failing to endorse it strongly were some of the main themes. The review showed that providers often face barriers in communicating about the HPV vaccination. Interventions need to be placed to improve provider communication in an effective and efficient manner. In Utah, efforts have been made to increase HPV immunization rates. In 2013 the Utah Immunization Program (UIP) was awarded a CDC Prevention and Public Health Fund (PPHF) grant focused on increased HPV immunization rates. The grant has been used to form a statewide immunization coalition and to develop and implement HPV education for parents and adolescents. Other measures include improving provider knowledge about the HPV vaccine and identifying missed opportunities for vaccination (Utah Department of Health, 2015). Although notable effort has been made in recent years, there is still a lot of work that needs to be done to Running head: IMPROVING HPV IMMUNIZATION RATES 7 improve the HPV vaccination rates in Utah (Intermountain West HPV Vaccination Coalition, 2020). Continuing to have low HPV vaccination rates places both males and females at risk for malignant disease and pre-cancers caused by the HPV virus. Women that develop HPV or the pre-cancerous cells may be limited in their ability to have children. Expensive and invasive medical procedures such as hysterectomy, radiation therapy, and cryotherapy may be a result of not having the HPV vaccine (American Cancer Society, 2020). Setting This project took place at Wee Care Pediatrics (WCP). WCP is a physician-owned outpatient pediatric clinic with four locations in Davis and Weber Counties. These clinics are staffed by eleven physicians and eleven advanced practice clinicians. The main clinic location is open twenty-four hours per day, three hundred and sixty-five days per year. The patients are pediatric and range from newborn to eighteen years old. The clinic accepts both private and government insurances with 18.34% of its payments coming from Medicaid in 2019. WCP sees children for sick visits, injuries and provides preventative care with well check visits. WCP had 93,600 encounters in 2019. Population This project focused on educating the physicians and advanced practice clinicians (APC’s) on effective ways to communicate with patients about the HPV vaccine. Education will be provided to eleven physicians and nine APC’s . There are eighteen full-time providers and three part-time providers. The physicians at WCP are all board-certified in Pediatrics. The APC’s include 7 Physician Assistants and 4 Nurse Practitioners. Running head: IMPROVING HPV IMMUNIZATION RATES 8 Secondary targets included both male and female patients ages 9-18 that have not yet initiated or completed the HPV immunization series. Education was provided for these patients and their parents at all four WCP clinics. Gaps in Knowledge The American Academy of Pediatrics (AAP) states that immunizations are a key preventative cornerstone in pediatric care (AAP, 2017). This puts the responsibility of immunization education and recommendation on the primary care provider. The CDC recommends that HPV immunizations be given at age 11 or 12 years but can be started at age 9. Two doses of the HPV vaccine are recommended if the series was started before their 15th birthday. The second dose of HPV vaccine should be given 6 to 12 months after the first dose. Three doses of the HPV vaccine are recommended for teens and young adults who start the series at ages 15 through 25 years and for immunocompromised persons (ACIP, 2020). At Wee Care Pediatrics there was not a protocol or program focusing on education about the HPV vaccine or the risks and benefits for clinicians or patients. In Utah, the HPV vaccine is not required to attend school (Utah Department of Health, 2020). At WCP, HPV vaccination is usually done during a well care visit at the same time other adolescent immunizations are given. Often the series is initiated but not completed due to inadequate follow-up and missed opportunities when being evaluated for non-well check visits. The gaps seen at Wee Care Pediatrics included lack of training on how to efficiently communicate and educate a largely religious population on the HPV vaccination. The literature has shown that there was a significantly lower HPV vaccine-related awareness, knowledge, and receipt among young women who practice organized religion compared to those that do not. Educating providers who serve religious patients may be effective in improving the knowledge Running head: IMPROVING HPV IMMUNIZATION RATES 9 about the HPV vaccine (Bodson, Wilson, Warner & Kepka, 2017). Other gaps included missed opportunities to vaccinate when a child was seen for a sick visit or a non-preventative visit. A survey was conducted at WCP to evaluate provider perception about the HPV vaccine and identify barriers. Learning how to make explicit recommendations with an evidence-based rationale has shown to be beneficial in increasing HPV immunization rates (Shay et al., 2016). Health Belief Model The Health Belief Model (HBM) has been used to explain change and health-related behaviors since the early 1950s. The HBM provides a framework for health behavior interventions (Skinner, Tirio, & Champion, 2015). The literature has shown that using the HBM provides an understanding of vaccination intention and uptake. The HBM model can help explore parent’s and patient’s perceptions and attitudes about the HPV immunization (Donadiki et al. 2014). There are four key concepts of the HBM. The first concept is perceived susceptibility. This intervention evaluated the clinicians of WCP’s perception and knowledge of the HPV vaccine through the pre/post provider surveys. Education for parents and patients also took into account the perceived susceptibility. The second concept is perceived severity or the belief about how serious a condition is. This intervention focused on the cancer prevention benefits of the HPV vaccine. The third concept is perceived benefits or the belief that the advised action will reduce the risk of harm. This intervention focused on educating the providers of WCP and patients on the benefits of HPV immunization focusing again on the cancer prevention aspects. The fourth concept is perceived barriers. This is the belief about the psychological costs of the advised action. This intervention identified patient and provider barriers and effective ways address those through provider and patient education (Skinner, Tirio, & Champion, 2015) Cues to action and self-efficacy are also considered part of the HBM. Cues to action include Running head: IMPROVING HPV IMMUNIZATION RATES 10 strategies that can trigger actions. Self-Efficacy is confidence in one’s ability to take action (Skinner, Tirio, & Champion, 2015). Part of this project included selecting an educational sign for the exam rooms to promote HPV vaccine uptake. The HBM helped guide this part of the project by identifying predictors of parental acceptance of the HPV vaccine (Cassidy, Braxter, Charron-Prochownik, & Schlenk, 2014). The HBM concepts were also utilized when creating pre/post provider surveys. The HBM helped identify the beliefs and barriers about the HPV vaccine from the clinicians at WCP. The educational module was based on the pre-survey responses with the intent to provide education on how to effectively educate parents on the HPV vaccine and address the barriers. Project Implementation This project aimed to educate providers on how to effectively communicate and educate patients and parents on HPV immunizations, improve the HPV immunization rate at WCP from 13% to 20% and provide patient and parent education about the HPV vaccination. Measures were established through pre-provider surveys and quantitative data about HPV immunization rates at WCP. The quantitative data was gathered by Jeff Jones, CFO of WCP. The first intervention was a pre-intervention survey (Appendix A). This was given to the providers at WCP to establish a baseline of knowledge concerning the HPV vaccine and possible barriers. Short surveys are a cost-effective way to provide immediate feedback (IHI, 2020). The University of Utah conducted a closed survey from 2014-2015 via email to three provider organizations in Utah. Knowledge of HPV vaccination and knowledge of HPV vaccination guidelines was measured using closed-ended survey questions. Providers’ perception of HPV vaccination barriers was analyzed through open-ended questions (Warner et al. 2017). The Running head: IMPROVING HPV IMMUNIZATION RATES 11 survey for WCP providers was developed around the same principals of this University of Utah study. The survey data was collected electronically and went directly into a computer database. The information from the survey was used to direct provider education. The second intervention was educating the providers of WCP on how to effectively communicate and educate parents and patients about the HPV vaccine. Education and training can impact the attitudes, knowledge, skills and potentially behaviors of those that participate (The Health Foundation Inspiring Improvement, 2012). A presentation based on information from the CDC was presented at the quarterly provider meeting. Providers were also given weekly educational handouts. A free continuing medical education (CME) course from the CDC was also recommended for all providers. Mandatory education is not always successful. Using an empowering education model of self-directed learning and practical learning can achieve greater mastery of professional skills among health care providers (Chaghari, Saffari, Ebadi & Ameryoun, 2017). Continuing medical education (CME) has the potential to improve provider recommendations and increase HPV immunization rates in the United States (Kornides, Garrell, & Gilkey, 2017). The third intervention was utilization of the electronic health record (EHR) to prompt providers and staff when a child requires the HPV immunization. The goal of the EHR prompt was to decrease missed opportunities by reviewing vaccination status at all visits including the annual well check. Setting up EHR prompting is a cost-effective tool that can be a useful and effective way to decrease missed opportunities and improve HPV immunization rates (Bernstein & Bocchini, 2017). The fourth intervention was establishing patient/parent reminder calls or text messages. The parents were also contacted through the patient portal for immunization reminders. Utilizing Running head: IMPROVING HPV IMMUNIZATION RATES 12 communication technologies such as telephone or text message reminders to parents have shown to improve HPV immunization rates (Francis et al. 2017). The fifth intervention was to provide patient and parent education about the HPV immunization. An educational handout from the CDC was mounted in all 50 exam rooms (Appendix C) . Due to coronavirus each patient is immediately placed in an exam room to wait. Research has shown that patients take notice of and engage with health information in the waiting room and can be used as a place of education (Williams, Elliott, Gall & Woodward- Kron, 2019). Patients and parents were also given a handout from the CDC on the HPV vaccine. The handout was provided to parents in the clinic and also published to the patient portal. Providing a FAQ brochure, HPV counseling at well check appointments and reminder telephone calls can provide a significant difference in HPV vaccine uptake (Cassidy, Braxter, Charron- Prochownik, & Schlenk, 2014). Evaluation and Data Analysis Pre and Post provider surveys were conducted to evaluate perceived patient barriers about the HPV vaccine, knowledge about the vaccine, and if provider education was effective at improving provider confidence and perceived knowledge about the HPV vaccine. Quantitative data were also collected by Jeff Jones, the CFO of Wee Care Pediatrics on HPV immunization completion rates from 10/1/2020-12/31/2020. The provider surveys were done in electronic form using Google Forms. The pre-survey consisted of 7 multiple choice questions about basic HPV immunization knowledge followed by three open-ended questions about providers’ perceived barriers concerning the HPV vaccine. The pre-survey was completed by fifteen providers at Wee Care Pediatrics. The post-survey consisted of the same 7 multiple choice questions about basic knowledge and three open-ended questions Running head: IMPROVING HPV IMMUNIZATION RATES 13 about perceived outcomes of the provider education. The post-survey was completed by 13 providers at Wee Care Pediatrics. Both surveys were based on a survey conducted at the University of Utah which assessed providers’ perception of HPV vaccination barriers through open-ended questions and knowledge of the HPV guidelines (Warner et al. 2017). Pre and post-test means were run using a paired t-test with no observed difference in questions 1,2,3,4 and 6. Question 5 showed that from a dataset with a sample size of 15, a sample mean for question 5 pre-test of 7.87 and a sample mean for question 5 post-test of 9. This observed difference of 1.13 was tested for whether true population difference was different from 0. From this test, the resulting p-value was 0.0441 and indicates that because the p-value<=0.05 the null hypothesis is rejected and there is statistical evidence to support the hypothesis that the mean-averages from the two variables are different from one another (See Table 1. Table 2. ) (Lambert, 2021). In the pre-survey open-ended questions providers felt barriers for HPV immunization included parental concern about safety, increase in sexual promiscuity and lack of education. Providers felt that Wee Care Pediatric could improve HPV immunization rates through improving patient/parent education, recommending HPV vaccination with other adolescent immunizations, and focusing on cancer prevention. The main perceived barrier for providers at Wee Care Pediatrics was time constraint to provide education and inconsistent message between clinics and support staff (Table 3). In the post-survey open ended questions the majority of providers felt like they were more likely to recommend the HPV vaccine after the provider education. Providers reported no change in their feelings concerning the HPV vaccine since all were supportive of it prior to the education. In regard to changing practice to strongly recommending the HPV vaccine along with Running head: IMPROVING HPV IMMUNIZATION RATES 14 other adolescent immunizations and looking for opportunities outside of well checks to vaccinate were most frequently reported (Table 4). Quantitative data was collected by Jeff Jones the Chief Operating Officer at WCP. The data was pulled from the EHR. Pre intervention data was collected from the 2019-2020 calendar year using the Merck rebate program. Criteria included all non-Medicaid patients ages 11 and up that had completed the HPV immunization series. A percent distribution was used to show the proportion of patients who completed the series. HPV immunization completion rate was 13.6% pre-intervention. Post intervention data was collected using the same criteria from 10/1/2020- 11/30/2020 and showed an HPV immunization completion rate of 18.6% (Table 5.) Discussion This quality improvement project evaluated provider perception of patient and parent barriers about the HPV vaccine and if provider education on how to address these barriers would increase HPV immunization rates at WCP. Four interventions were implemented including provider education, utilization of the EHR for immunization prompts, establishing reminder calls and text messages, and patient and parent educational material given at well checks and displayed in exam rooms. It was predicted that these interventions would improve the HPV immunization rates at WCP. Qualitative data showed that providers at WCP had a good understanding of the HPV vaccine and many providers reported similar perceived patient and parent barriers. Despite the low HPV immunization rates at WCP all providers stated they endorsed the HPV vaccine. Multiple providers reported that time constraint was a barrier in educating patients and parents about the HPV vaccine and may contribute to the low HPV immunization rates. The quantitative data collected during this project showed an improvement in HPV immunization completion Running head: IMPROVING HPV IMMUNIZATION RATES 15 rates from 13.6% to 18.6% at WCP. Providers also reported changes in practice post HPV education to include strongly recommending the HPV vaccine along with other adolescent vaccines and looking for opportunities to vaccinate outside of the well check visit. There was also improvement in provider knowledge about how many strains of HPV coverage the vaccine protects against and that it is recommended for both boys and girls starting at the same age. Educational posters were placed in each exam room in all four WCP clinics so after this project is completed patients will still be exposed to the information about HPV at each visit. Recommendations Limitations and Lessons Learned Limitations of this quality improvement project included decreased patient well checks and sick visits due to the COVID-19 pandemic. Only 71% of providers participated in the pre-survey, 61% participated in the post-survey, and 76% attended the provider education. Those that did not participate may have different perspectives on the HPV vaccine. Another limitation is that Medicaid patients were not calculated in the HPV immunization completion numbers. Education was only given to the providers at WCP. The support staff is often asked questions about the HPV vaccine so providing education to the support staff on how to address patient barriers should be given. Implications Increasing provider knowledge on how to address patient barriers concerning HPV immunization can increase immunization uptake. Improving HPV immunization rates will decrease cancer caused by the HPV virus, lower health care costs, and benefit the health of patients. The four interventions used in this project can also be applied to other immunizations to help improve patient health and wellness and decrease preventable diseases. Running head: IMPROVING HPV IMMUNIZATION RATES 16 Conclusion In conclusion, cervical cancer is the fourth most common cancer diagnosed in women (American Cancer Society (ACS), 2020). Nearly all cases of cervical cancer result from HPV infection (ACS, 2020). Although, the HPV vaccine has been determined to be safe, national and state immunization rates for HPV remain low. Continuing to have low HPV vaccination rates places both males and females at risk for malignant disease and pre-cancers caused by the HPV virus. Women that develop HPV or the pre-cancerous cells may be limited in their ability to have children. Expensive and invasive medical procedures such as hysterectomy, radiation therapy, and cryotherapy may be a result of not having the HPV vaccine (American Cancer Society, 2020). Implementing provider education on how to address patient barriers about the HPV vaccine, utilizing the EHR, providing reminder calls and texts, and educating patients on the HPV vaccine can improve HPV immunization rates. Running head: IMPROVING HPV IMMUNIZATION RATES 17 References Advisory Committee on Immunization Practices (ACIP). (2020). Human papillomavirus (hpv) acip vaccine recommendations. Retrieved from: https://www.cdc.gov/vaccines/hcp/acip-recs/ vacc-specific/hpv.html Allen, J., Othus, M., Shelton, R., Li, Y., Norman, N., Tom, L., & Carmen, M. (2010). Parental decision making about the hpv vaccine. Cancer Epidemiol Biomarkers Prevention, 19(9), 2187-2198. doi:10.1158/1055-9965.EPI-10-0217. American Academy of Pediatrics (AAP). (2017). Practical approaches to optimize adolescent immunization. Pediatrics, 139(3). Doi: 10.1542/peds.2016-4187. American Cancer Society. (2020). HPV and cancer. Retrieved from: https://www.cancer.org/cancer/cancer-causes/infectious-agents/hpv/hpv-and-cancer-info. html Anderson, A., Taylor, Z., Georges, R., Carlson-Cosentino, M., Nguyen, L., Salas, M., Bhaloo, T. (2017). Primary care physicians’ role in parental decision to vaccinate with hpv vaccine: learnings from a south texas hispanic patient population. Journal of Immigrant and Minority Health, 20(5), 1236–1242. doi: 10.1007/s10903-017-0646-9 Bernstein, H., & Bocchini, J. (2017). Practical approaches to optimize adolescent immunization. American Academy of Pediatrics, 139(3). Doi: 10.1542/peds.2016-4187 Bodson, J., Wilson, A., Warner, E., & Kepka, D. (2017). Religion and HPV vaccine-related awareness, knowledge, and receipt among insured women aged 18-26. PLOS One, 12(8). https://doi.org/10.1371/journal.pone.0183725. Cassidy, B., Braxter, B., Charron-Prochownik, D., & Schlenk, E. (2014). A quality improvement initiative to increase hpv vaccine rates using an educational and reminder strategy with parents of Running head: IMPROVING HPV IMMUNIZATION RATES 18 preteen girls. Journal of Pediatric Helath Care, 28(2), 155-164. https://doi.org/10.1016/j.pedhc.2013.01.002. Centers of Disease Control and Prevention. (2019). Human papillomavirus, hpv coverage data Retrieved from https://www.cdc.gov/hpv/hcp/boostin-vacc-rates.html Centers of Disease Control and Prevention. (2020). Human papillomavirus: Continuing education. Retrieved from https://www.cdc.gov/hpv/hcp/continuing-ed.html Chaghari, M., Saffari, M., Ebadi, A., & Ameryoun, A. (2017). Empowering education: A new model for in-service training of nursing staff. J Adv Med Educ Prof, 5(1), 26-32. Dempsey, A. F., Pyrznawoski, J., Lockhart, S., Barnard, J., Campagna, E. J., Garrett, K., … O’Leary, S. T. (2018). Effect of a health care professional communization training intervention on adolescent human papillomavirus vaccination a cluster randomized clinical trial. JAMA Pediatrics, 172(5) doi:10.1001/jamapediatrics.2018.0016 Donadiki, E., Garcia, R., Barrera, V., Soutzi, P., Garrido, P., Andres, A., Trujillo, I., & Velonakis, E. (2014). Health belief model applied to non-compliance with hpv vaccine among university students. Public Health, 128(3), 268-273. https://doi.org/10.1016/j.puhe.2013.12.004. Francis, D., Cates, J., Wagner, K., Zola, T., Fitter, J., & Coyne-Beasley, T. (2017). Communication technologies to improve hpv vaccination initiation and completion: A systematic review. Patient Education and Counseling, 100(2017), 1280-1286. http://dx.doi.org/10.1016/j.pec.2017.02.004. Franco, M., Mazzucca, S., Padek, M., & Brownson, R. (2019). Going beyond the individual: How state-level characteristics relate to hpv vaccine rates in the united states. BMC Public Health, 19(246), 1-9. https://doi.org/10.1186/s12889-0196566-y Running head: IMPROVING HPV IMMUNIZATION RATES 19 Gilkey, M., & McRee, A., (2016). Provider communication about hpv vaccination: A systematic review. Human Vaccines & Immunotherapeutics, 12(6). 1454-1468. https://doi.org/10.1080/21645515.1129090. Hansen, C., Credle, M., Shapiro, E., & Niccoli, L. (2015). “It all depends”: A qualitative study study of parents’ views of human papillomavirus vaccine for their adolescents at ages 11-12 years. Cancer Education, 31, 147-152. doi:10.1007/s13187-014-0788-6. Institute for Healthcare Improvement (IHI). (2020). Short survey. Retrieved from: http://www.ihi.org/resources/Pages/Tools/ShortSurvey.aspx Intermountain West HPV Vaccination Coalition. (2020). Improving human papillomavirus vaccination rates in our region. Retrieved from: https://healthcare.utah.edu/huntsmancancerinstitute/about-us/hpv-coalition.php Jones, T., Baxter, M., & Khanduja, V. (2013). A quick guide to survey research. Ann R Coll Surg Engl, 95(1), 5-7. Kornides, M., Garrell, J., & Gilkey, M. (2017). Content of web-based continuing medical education about hpv vaccination. Vaccine, 35(2017), 4510-4514. http://dx.doi.org/10.1016/j.vaccine.2017.07.038 Shah, A. (2019). Using data for improvement. BMJ, 364(189). Doi: https://doi.org/10.1136/bmj.l189. Shay, L., Street, R., Baldwin, A., Marks, E., Lee, S., Higashi, R.,…, Tiro, J. (2016). Characterizing safety-net providers’ hpv vaccine recommendations to undecided parents: A pilot study. Patient Education and Counseling, 99(2016), 1452-1460. http://dx.doi.org/10.1016/j.pec.2016.06.027. Skinner, C., Tiro, J., & Champion, V. (2015). Helath behavior: Theory, research, and practice. Running head: IMPROVING HPV IMMUNIZATION RATES 20 Retrieved from http://sphweb.bumc.bu.edu/otlt/MPH -Modules/SB/BehavioralChangeTheories/BehavioralChangeTheories2.html The Health Foundation Inspiring Improvement. (2012). Quality improvement training for healthcare professionals. Retrieved from https://www.health.org.uk/sites/default/files/QualityImprovementTrainingForHealthcareP rofessionals.pdf Utah Department of Health. (2015). Utah health status update: Hpv immunization. Retrieved https://ibis.health.utah.gov/ibisphview/pdf/opha/publication/hsu/2015/1501_HPV.pdf. Utah Department of Health. (2020). School and childcare immunization requirements. Retrieved from: https://immunize.utah.gov/information-for-the-public/immunization-recommendations/ school-childcare-immunization-requirements/ Warner, E., Ding, Q., Pappas, L., Bodson, J., Fowler, B., Mooney, R., Kirchoff, A., & Kepka, D. (2017). Helath care providers’ knowledge of hpv vaccination, barriers, and strategies in a state with low hpv vaccine receipt: Mixed methods study. JMIR Cancer, 3(2). Doi: 10.2196/cancer.7345. Williams, C., Elliott, K., Gall, J., & Woodward-Kron, R. (2019). Patient and clinician engagement with health information in the primary care waiting room: A mixed case study. J Public Health Res, 8(1), 1476. doi:10.4081/jphr.2019.1476. World Population Review. (2020). Utah population 2020 (demographics, maps and graphs). Retrieved from http://worldpopulationreview.com/states/utah-population/. Running head: IMPROVING HPV IMMUNIZATION RATES 21 Table 1. Provider Pre-Survey Data Question Percentage Answered Correct Percentage Answered Wrong Mean 1 100% (15/15) N/A 2 100% (15/15) N/A 3 100% (15/15) N/A 4 100% (15/15) N/A 5 80% (12/15) 20% (3/15) 7.87 6 100% (15/15) N/A 7 93.3% (14/15) 6.7% (1/15) 1.07 Table 2 Provider Post-Survey Data Question Percentage Answered Correct Percentage Answered Wrong Mean 1 100% N/A 2 100% N/A 3 100% N/A 4 100% N/A 5 100% 9 6 100% N/A 7 100% 1 Table 3. Open Ended Questions Pre-Survey Most Common Responses Question 1: Perceived patient/parent barriers about the HPV Vaccine? Parental concerns about safety 53% (8/15) Concern about increasing sexual promiscuity. 40% (6/15) Lack of Education 27% (4/15) Question 2: How can Wee Care Pediatrics Improve HPV Immunization Rates? Improve education to parents and patients about the HPV vaccine. 53% (8/15) Recommend with other adolescent vaccines 33% (5/13) Discuss cancer prevention 27% (4/15) Question 3: Perceived barriers among providers at Wee Care Pediatrics? Time constraints for education 33% (5/15) Running head: IMPROVING HPV IMMUNIZATION RATES 22 None 33% (5/15) Inconsistent recommendation between providers, different clinics, and support staff. 20% (3/15) Table 4. Open Ended Questions Post-Survey Most Common Responses Question 1: Do you feel like you are more or less likely to recommend the HPV vaccine? More 85% (11/13) No change, I was always likely to recommend 15% (2/13) Question 2: Have your feelings about the HPV vaccine changed? No. I was already an advocate 100% (13/13) Question 3: Will this education change the way you practice? Yes, I will strongly recommend it along with other adolescent vaccines. 62% (8/13) Yes, I will look for other opportunities outside of well checks to vaccinate. 15% (2/13) No, I already knew the information presented 15% (2/13) Table 5. HPV Immunization Completion Rates Pre/Post Intervention Pre-Intervention HPV Series Completion Rate 1/1/2019-12/31/2019 13.65% Total visits-1,333 Completed Vaccination-182 Post-Intervention 10/1/2020-12/1/2020 18.6% Total Visits-648 Completed Vaccination-121 Running head: IMPROVING HPV IMMUNIZATION RATES 23 Appendix A. HPV Provider Pre- Survey: Wee Care Pediatrics My name is Emily Ostarcevic and I am a DNP student at Weber State University. My DNP project is improving HPV immunization rates through provider education. You will be sent a pre and post provider survey to better understand provider knowledge and perception of the HPV vaccine. This survey was based on a survey done at the University of Utah by Echo Warner, MPH, and Deanna Kepka MPH, Ph.D. Thank you for your participation in my project! Warner, E., Ding, Q., Pappas, L., Bodson, J., Fowler, B., ..,Kepka, D. (2017). Health care providers' knowledge of hpv vaccination, barriers, and strategies in a state with low hpv vaccine receipt: Mixed-methods study. JMIR, 3(2). doi:10.216/cancer.7345 1. Long-lasting immunity is obtained from the HPV vaccine True False 2. The HPV vaccine is considered safe, and the benefits outweigh the risks. True False 3. The HPV protects against genital warts along with cervical cancer. True False 4. Sexual promiscuity does not increase after the HPV vaccine True False 5. The HPV vaccine protects against how many types of cancer-causing HPV? 7 2 9 6 6. When is the HPV vaccination recommended? After the patient becomes sexually active Before the patient becomes sexually active 7. The recommended age for the HPV vaccine for boys and girls are the same True False 8. What barriers do you perceive with your patient's parents and the HPV vaccine? Your answer 9. How can Wee Care Pediatrics Improve HPV immunization rates? Your answer 10. What barriers do you perceive among providers at Wee Care Pediatrics Running head: IMPROVING HPV IMMUNIZATION RATES 24 Appendix B Physician /Provider Post-Survey: Wee Care Pediatrics My name is Emily Ostarcevic and I am a DNP student at Weber State University. My DNP project is improving HPV immunization rates through provider education. You will be sent a pre and post provider survey to better understand provider knowledge and perception of the HPV vaccine. This survey was based on a survey done at the University of Utah by Echo Warner, MPH, and Deanna Kepka MPH, Ph.D. Thank you for your participation in my project! Warner, E., Ding, Q., Pappas, L., Bodson, J., Fowler, B., ..,Kepka, D. (2017). Health care providers' knowledge of hpv vaccination, barriers, and strategies in a state with low hpv vaccine receipt: Mixed-methods study. JMIR, 3(2). doi:10.216/cancer.7345 1. Long-lasting immunity is obtained from the HPV vaccine True False 2. The HPV vaccine is considered safe, and the benefits outweigh the risks. True False 3. The HPV protects against genital warts along with cervical cancer. True False 4. Sexual promiscuity does not increase after the HPV vaccine True False 5. The HPV vaccine protects against how many types of cancer-causing HPV? 7 2 9 6 6. When is the HPV vaccination recommended? After the patient becomes sexually active Before the patient becomes sexually active 7. The recommended age for the HPV vaccine for boys and girls are the same True False 8. Do you feel like you are more or less likely to recommend the HPV vaccine? 9. How or did your feelings about the HPV vaccine change? 10. Will this education change the way you practice? If so how? Running head: IMPROVING HPV IMMUNIZATION RATES 25 Appendix C