ABSTRACT
Background: The human papillomavirus (HPV) vaccine is a cancer prevention tool, yet vaccination coverage among adolescents remains suboptimal in the United States. Research shows significant disparate incidence and mortality rates of HPV-related cancers in Puerto Rico (PR). In 2018, the PR Department of Health (DOH) enacted an HPV vaccine school-entry requirement for adolescents 11 to 12 years old, and on August 2020 extended the requirement to include adolescents up to 16 years old. Amid the COVID-19 pandemic in the US, during March-August 2020, national data showed that HPV vaccine uptake rates decreased about 75%. Public health measures, such as stay-at-home orders, may have caused this decline by limiting access to preventive services. Our study explored, using a qualitative assessment, the impact of the COVID-19 pandemic on the implementation of the HPV vaccine school-entry requirement in PR. Method(s): We conducted 26 interviews with stakeholders from schools, DOH employees, Department of education staff, health providers, and community-based organizations from 08/2021-03/2022. Interviews were recorded and transcribed in Spanish. Data were analyzed using applied thematic techniques by two trained coders using Atlas-ti 8. We discussed eight of these interviews among the team to identify major barriers related to the HPV school-entry implementation during the pandemic. Result(s): Our analysis identified the following preliminary emergent themes including: (1) lockdown limitations and access barriers to the vaccine and (2) shifting immunization priorities. Most participants noted that the March 2020 lockdown limited parents' ability to get their kids vaccinated and for schools to monitor the vaccine requirements;however, as vaccination centers and schools re-opened, gradually, vaccination processes increased. Participants described how during the pandemic, public health agencies prioritized the COVID-19 vaccine missing other vaccines that are required for school-entry, including the HPV vaccine. Discussion(s): Continuation of the implementation of the HPV vaccine school-entry requirement was challenging during early stages of the pandemic due to public health measures enacted to stop the spread of COVID-19. Moreover, once the COVID-19 vaccine was available, public heath vaccination priorities shifted. Nonetheless these barriers, efforts to increase HPV vaccine to pre-pandemic rates should continue, including providing educational support to parents, increase vaccine promotion, and creating community collaborations. As new guidelines recommend COVID-19 boosters, for everyone ages 5 years and older, this opportunity could serve to vaccinate against HPV as part of the bundling implementation of the HPV vaccine school-entry requirement.
ABSTRACT
Prior to the COVID-19 pandemic, Puerto Rico (PR) had one of the highest Human Papillomavirus (HPV) vaccine rates in the United States. Yet, widespread misleading information about the COVID19 vaccine might negatively impact HPV vaccine attitudes. This study aims to assess and compare HPV and COVID-19 vaccines attitudes toward school-entry policies among adults living in PR. A convenience sample of 222 adults (>=21 years old) living in PR were recruited through social media and completed an online survey from November 2021 to January 2022. Participants answered questions about HPV and COVID-19 vaccines knowledge (ranging from 0=none to 3=high knowledge), attitudes toward vaccination policies for school-entry, and perceptions of trusted and untrusted sources of information. Descriptive statistics were computed to identify the demographics characteristics of the participants. We also estimated the prevalence ratio (PRadjusted) using a logistic regression model to assess the magnitude of association between COVID-19 vaccination for the school-entry policy and HPV vaccination for school-entry policy agreement, adjusting for different confounders. The mean age of the study sample was 36.73 +/- 11.18 years. The majority of the sample were female (87%, n=194), with at least some college of education (92%;n=205) and employed (61%;n=165). One-fifth of the participants reported having children between ages 11 and 16 (n=46). Participants' perceived knowledge about the HPV vaccine was moderate (mean=1.72;SD=1.12), while for COVID-19 vaccine was moderately high (mean=2.47;SD=.68). The most trusted form of information for HPV and COVID-19 vaccines were health care providers (42% and 17%, respectively), the Centers for Disease Control and Prevention (35% and 55%, respectively), and the Department of Health (15% and 19%, respectively). The least trusted source of information included social media (40% and 39%, respectively), friends and family (23% n=47, and 17% n=33, respectively), and the Department of Health (15% n=30, and 18% n=36, respectively). More than half of the participants agreed that HPV (76% n=156) and COVID vaccines (69% n=136) should be required for school-entry. Agreement with COVID-19 vaccination for the school-entry policy was significantly associated with HPV vaccination for school-entry policy agreement (PRadjusted:1.96;95% CI:1.48-2.61) after controlling for age, sex, education, and having children between age 11 and 16. Findings suggest that adults living in PR have an overall positive attitude about mandatory HPV and COVID-19 vaccination school-entry policies, and these attitudes are interrelated. Yet, it is concerning that the Department of Health is identified as one of the least trusted sources of information, as it has a prominent role in implementing HPV and COVID-19 vaccine policies in PR. Further research should elucidate why the Department of Health is considered an untrusted source of information among adults living in PR and evaluate the implications of the COVID-19 pandemic on HPV vaccine attitudes and adherence rates.
ABSTRACT
Introduction:?Puerto Rico Libre de Enfermedades Prevenibles (Puerto Rico Free of Preventable Diseases) was an online, community-based initiative consisting of eight educational training programs regarding school entry vaccines, including HPV vaccine as the most recent requirement. The Community Advisory Board of the HPV-PIVac study (CAB-PIVac) developed this activity in response to barriers identified on school personnel by the HPV-PIVac study: lack of knowledge about the HPV vaccine and its school entry requirement and need for training. In February 2020, CAB-PIVac members collected data through a self-administrated survey to identify potential topics. After several meetings, members identified the topics and resources for these webinar series. Our purpose is to present how the integration of community members into an ongoing research study allowed rapid response to developing an educative initiative to impact school staff concerning preventable diseases and the HPV vaccine. Methods: Eight webinars in four weeks were transmitted in-live through the Zoom platform from June 26 to July 17, 2020. They were on-demand until July 24, 2020. Theme per week: World without vaccine: COVID-19;Teenager vaccine in School;Future free of HPV-related cancer;and Legal aspects of vaccination for the school-entry. The participants received via email an evaluation form to assess the impact of these webinars. Using data from the registration form, we collected the following participants' characteristics: sex, age, education sector, and role in the school. We performed a thematic analysis collecting all the messages posted in the Q & A section of each webinar to identify the topics in which the participants had doubts or more interest. Results: A unique participation of 954 participants were registered, and the range of involvement on the education webinars was 588 to 780 participants. Based on the type of education, 28.8% were private, and 70.9% were from public education. Most of the participants were females (89.6%) and with an average age of 42 years (range: 21 -74). Of the participants who reported their role at their schools (n=648), 31.4% were school nurses, followed by the school director (22.7%). Twelve percent of the participants were teachers. The evaluation was satisfactory (99.7%) considering the tools offered and the clear information presented. The thematic analysis results showed that the two topics discussed in the Q &A section were the immunization registry (problems with system access) and the vaccination series (age to initiate the series). Conclusion: This initiative was developed and performed in less than five months. Many national and international organizations, coalitions, and government agencies are working to achieve the same goal: eradicated HPV-related cancers and strengthen the awareness for HPV prevention. Involve these community members in the research is crucial to secure how the results of the investigation studies could impact the community quickly and accurately.
ABSTRACT
Introduction: Individuals and groups against vaccination have used various outlets, such as mass media, social media, and legislative hearings to express doubts about the human papillomavirus (HPV) vaccine. In 2018, the Puerto Rico Department of Health included the HPV vaccine as a school-entry requirement for children ages 11-12. Currently, the requirement extends to students ages 11-16. Since the announcement in 2017 of the new school-entry requirement as a preventive cancer strategy, many groups have expressed opposition. Although studies have documented the barriers and facilitators for implementing this policy on the island, qualitative studies assessing stakeholders' views against the implementation of the new requirement are lacking. We aimed to describe stakeholders' perspectives who opposed the HPV vaccine and the implementation as a school-entry requirement in PR. Methods: In-depth interviews (n=8) were conducted between March 2019-January 2020. Healthcare providers, religious leaders, and coalition spokespersons were interviewed. The Consolidated Framework for Research Implementation (CFIR) was used to develop the semi-structured interview guide. CFIR domains (and constructs) included were characteristics of individuals (knowledge, attitudes, and beliefs about the HPV vaccination, school-entry requirement, and exemptions), intervention characteristics (current practices, advantages and disadvantages of the implementation), and implementation procedures (planning, commitment of implementers and evaluation). Interviews were audio-recorded and transcribed in Spanish. Transcripts were analyzed using qualitative thematic analysis. Additional constructs were derived from CFIR constructs and emergent codes were included. Results: The most common CFIR domain observed was individual characteristics (knowledge and beliefs), of which HPV hesitancy and vaccine distrust were emergent themes. Arguments against the policy also cited the adverse effects of the vaccine under the intervention characteristics domain (evidence strength and quality). Lastly, excessive government interference was discussed by stakeholders in which concerns regarding the HPV vaccine school-entry requirement and how this policy does not align with their values of religious freedom, parental, educational and sexual rights were mentioned. Conclusion: Despite the recent documented positive impact of the school-entry requirement in HPV immunization rates in PR, many continue to oppose the vaccine mandate. Stakeholders' arguments against the HPV vaccine policy, including knowledge and beliefs, and excessive government interference, echo concerns of other mandated vaccines reported in the literature. Understanding arguments against school-entry requirements is necessary to tailor educational campaigns to increase vaccination rates, which were affected by the COVID-19 pandemic, prevent HPV-related cancers, and reduce the hesitancy in of school-entry policies in the future.