Dissertation
A multilevel assessment of factors contributing to missed opportunities for human papillomavirus vaccination
University of Iowa
Doctor of Philosophy (PhD), University of Iowa
Summer 2021
DOI: 10.17077/etd.005820
Abstract
Despite the existence of evidence-based interventions (EBIs) to improve delivery of the human papillomavirus (HPV) vaccine, vaccination rates remain low in Iowa, as well as the rest of the country. There is extensive research on initiation and uptake and factors associated with these outcomes, but less is known about missed opportunities (MOs) for HPV vaccination. Briefly, MOs can be defined as visits to a healthcare provider where an adolescent eligible to receive the HPV vaccine does not receive it. This dissertation addresses gaps in knowledge about MOs and EBIs through (1) descriptive analyses quantifying MOs for HPV vaccination and time to completion of the series, (2) regression analyses exploring factors related to occurrence of MOs, and (3) qualitative interviews to understand barriers and facilitators to the implementation of EBIs designed to reduce MOs. The first study used medical claims data from a large Midwestern insurance provider to assess the extent of MOs among adolescents in Iowa occurring between ages 9 and 13 (n=22,359) as well as the amount of time between doses in the HPV vaccine series. Sub-group differences were explored using t-tests, and included comparisons between urban and rural adolescents, as well as males and females. Across these subgroups, the total number of MOs ranged from 9.73 to 10.64. These MOs occurred most frequently prior to the first dose in the series and among those who never initiated the series. Adolescents in rural areas tended to have fewer MOs than adolescents in urban areas. In looking at time to completion, adolescents in all sub-groups exceeded the amount of time recommended between doses (one month between first and second doses and three months between second and third doses). Most adolescents had a gap of nearly five months between the first and second doses, and over nine months between the second and third doses.
The second study built on these results and used regression modeling with the same medical claims data from Study 1 to understand association of individual/adolescent-, interpersonal/provider-, and community-level factors on the occurrence of MOs. The sample (n=14,730) was split by initiation status, and stratified models showed that only individual-level variables were significantly associated with MOs. For both initiators and non-initiators, number of well-child visits and receipt of vaccines for tetanus, diphtheria, and pertussis or meningococcal disease were significantly and positively associated with MOs. For non-initiators, being male was positively associated with MOs and birth year was negatively associated. No provider-level or community-level variables were significant in regression models.
Finally, Study 3 used semi-structured qualitative interviews to explore barriers and facilitators to the implementation of EBIs to reduce MOs. Participants (n=19) were recruited from middle management positions, roles supervised by top-level managers within large healthcare systems, but that also involve supervising frontline employees. Telephone interviews were completed and transcribed, and data were analyzed using a directed content analysis approach. Participants reported varying levels of EBI implementation to reduce MOs as well as a variety of organizational-level barriers and facilitators to these efforts. No single factor emerged as the most distinguishing barrier or facilitator. Participants reported both negative and positive influences in areas like receptivity to new ideas, structural characteristics of their healthcare system, and available resources. Additionally, given that these interviews were completed between August and November 2020, all participants reported significant barriers presented by the COVID-19 pandemic. Mainly, participants reflected that implementation of EBIs for HPV vaccination, and other similar programming for preventive care, was not as much of a priority due to the pandemic.
Together, results from these three studies offer insights into the extent of MOs for HPV vaccination among adolescents in Iowa and some of the factors driving their occurrence. Results from all studies indicate that not only are MOs occurring at high rates, but that HPV vaccination coverage for adolescents in Iowa is low. These studies suggest factors within the individual, interpersonal/provider, organizational and community levels may be driving these MOs. Future research should build on these findings and focus on understanding how these factors relate to each other, and how best to tailor and adapt existing EBIs to reduce MOs for HPV vaccination.
Details
- Title: Subtitle
- A multilevel assessment of factors contributing to missed opportunities for human papillomavirus vaccination
- Creators
- Grace Ryan
- Contributors
- Natoshia M Askelson (Advisor)Sato Ashida (Committee Member)Mary Charlton (Committee Member)Paul A. Gilbert (Committee Member)Aaron Scherer (Committee Member)
- Resource Type
- Dissertation
- Degree Awarded
- Doctor of Philosophy (PhD), University of Iowa
- Degree in
- Community and Behavioral Health
- Date degree season
- Summer 2021
- DOI
- 10.17077/etd.005820
- Publisher
- University of Iowa
- Number of pages
- xv, 214 pages
- Copyright
- Copyright 2021 Grace Ryan
- Language
- English
- Description illustrations
- color illustrations
- Description bibliographic
- Includes bibliographical references (pages 173-196).
- Public Abstract (ETD)
The vaccine for human papillomavirus (HPV) is safe and effective and when given during adolescence, it can prevent numerous health problems, including many types of cancers. Unfortunately, rates of coverage for this vaccine are very low, especially compared to the other vaccines that adolescents typically get. This dissertation included three studies to explore why adolescents who are eligible to get the vaccine often have doctor’s visits at which they do not receive it. First, the number of times adolescents in Iowa went to the doctor between ages 9 and 13 and did not get the HPV vaccine was calculated; these are called missed opportunities. Then, the relationship between these missed opportunities and adolescent and provider characteristics was explored to understand what might be causing them to occur. Finally, clinic managers were interviewed about their work to establish best practices in their workplaces to make sure adolescents get vaccinated. Overall, it is clear that missed opportunities are occurring at high rates among adolescents in Iowa but there is not a single factor that is causing this. Results suggest that providers are not treating all encounters with adolescents as an opportunity to provide the vaccine and that clinics face challenges in implementing best practices to encourage vaccination. Future efforts need to help clinics and healthcare providers understand the extent of this issue and to help them to use best practices to ultimately reduce how many missed opportunities occur.
- Academic Unit
- Community and Behavioral Health
- Record Identifier
- 9984124360302771
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