A home-school-doctor model to break the barriers for uptake of human papillomavirus vaccine

The findings of this study have added knowledge on how a school-based vaccination program would improve vaccine uptake rate even when the users need to pay. The study has identified independent factors associated with higher or lower HPV vaccine uptake based on multi-variate analysis. The ‘Home-School-Doctor’ model had very strong impact on parents’ decision for their daughter to opt for HPV vaccine with a very high odds ratio (OR 26.6). Families willing to pay HK$1,000 (US$125) or more for a full course of vaccination were also more likely to take up the vaccine. The availability of the model increased parents’ likelihood to consider vaccination if they were uncertain of possible venues for vaccination. Worries over side effects were significant independent factors associated with low uptake as well as those parents allowing their daughters to make decision and not caring too much about their social life.

A systematic review published in 2012 identified factor such as coverage by health insurance, more health care utilization particularly for preventive care, having health care providers as source of information, positive attitude towards the vaccine and higher vaccine related knowledge associated with HPV vaccine uptake among teenage girls [24]. The systematic review also noted considerably higher uptake rate in settings with a school-based program. [6, 14, 17, 27, 36‐38]. Our findings are consistent with study by Skinner and Copper Robins that the most acceptable way to achieve high uptake of HPV vaccine is to offer voluntary school-based vaccination [10]. Skinner and Cooper Robins also addressed voluntary on site-school-based mass vaccination as one of the evidence-based approaches to increase vaccine uptake among adolescents apart from strict mandate for vaccination [10]. Strict mandates have been debated with controversies in USA as genital wart is exclusively sexual transmitted so infected individuals do not pose an immediate risk to others in school setting [39, 40].

The systematic review also highlighted the important role of primary care providers in providing HPV-related information and assisting girls to initiate and/or complete the vaccine series. If both school setting and primary care setting become reliable source of information for parents and teenage girls, this would have significant impact on the beliefs, attitudes and intention regarding HPV vaccination. Hong Kong study in 2009 reported that school providing information on cervical cancer prevention had significantly motivated their consideration for HPV vaccination [22]. Study among Japanese mothers highlighted the importance of physicians actively addressing the safety concerns and the necessity for the vaccine at particular age to achieve high uptake even in publically funded HPV vaccine program [41]. Our Home-School-Doctor model introduced the vaccine to parents via school setting through academic institutions in partnership with physicians in the local catchment area. The support of medical professional organization in mobilizing district network of doctors not only conveyed a strong message of endorsement to the public, but also added confidence to both primary care providers and the recipients (parents and teenage girls). Studies have shown a consistent finding that primary care providers are less comfortable in vaccinating younger versus older adolescents, and thus the endorsement of vaccination by a professional organization is of great importance [42]. The Home-School-Doctor model has an additional endorsement from academic institution which could be important in the context where Government’s official support is still lacking.

Paper by Tissot et al. addressed the needs of educating paediatricians about the high prevalence of HPV among all sexually active adolescents and universal recommendation for the vaccine [42]. That study revealed the need to enhance access to vaccination by providing HPV vaccines in alternative settings, addressing specific educational needs related to HPV and HPV vaccines, and providing pediatricians with guidance as to how to address the specific concerns that parents might have about a vaccine for sexually transmitted disease. School can therefore be an alternative setting. It is often difficult to identify the educational needs for both consumers and health care providers as they are from diverse background, especially the consumers. One would try to have fact sheets with credible information provided by academic institution delivered via school setting matching the educational needs of students and parents. Studies have also shown the effectiveness of school-based health promotion programs in changing health behaviors including sexual behaviors [43], and improvement of health literacy [44]. The online education video incorporated in our model not only allowed parents and students to explore at their time of convenience, it also enhanced their confidence with messages from doctors in tackling the common myths regarding the vaccine and prevention of cervical cancer. Both printed and online materials could act as supplementary information for schools in developing comprehensive school health education on reproductive health and disease prevention. A study by Garland et al. reported the high coverage rate of HPV vaccine in Australia after commencing the school-based government vaccination program since 2007 [45]. The study also highlighted the challenge around the public perceptions of the appropriateness and safety of vaccinating large numbers of children in school setting. The traditional separation of the roles of health and education sectors regarding immunization poses further challenges as students might not be well informed, or the relevant information might not be readily accessible to them. Parents and students might not have the opportunity to ask further questions. This Home-School-Doctor model has tried to resolve some of these challenges by professional inputs and endorsement from doctors and also academic institutions. It would help those parents initially uncertain where to go for vaccination as reflected by higher vaccine uptake of their daughters (Table 3).

Parents expressing their wishes to let daughters to make their own decisions or not caring much about the social life of their daughters were found to be less likely to join the program. Women with no sex experience usually reported not being at risk as the main reason for not wanting the vaccination [46]. The prevalence of early sexual experience among adolescent girls in Hong Kong is not high [47]. If parents left the decision entirely to their daughters, they would perceive themselves not being at risk and not taking up the vaccination during early adolescence for better protection.

This model has also provided educational opportunities for health care providers. Seminars were organized for them with the latest update on HPV vaccine covering safety, duration of immunity, contraindications and description of HPV-related diseases. The seminars also provided practical tips in raising sensitive issues with teenage girls. A recent study from Hong Kong has revealed a low level of knowledge on HPV infection among primary care physicians, and their prescription of HPV vaccine was hindered by the perceived parental concerns, and they relied passively on Government recommendations [48]. The opportunity for doctors to give health talk to schools in this program would help the doctors to gain better understanding on the needs and concerns of parents and young girls, thus further providing reassurance to them. Information is also available in CD format for those doctors who could not attend the seminars. Fulfilling the education needs of primary care providers is important as this will indirectly improve communication to the consumers. Health professionals remain central in influencing parents’ decision and parental intention to have their daughters vaccinated approximates the uptake rate [49].

Cost has been identified as an important factor in many studies [35], therefore the subsidized price would help to boost up the vaccination uptake among parents. US study by Brown et al. revealed mean willingness to pay was US$560 on average for 80 % cervical cancer prevention for duration of 10 years even without added protection against genital warts [178. The GDP per capita in Hong Kong is comparable to USA (US$36,667 and US$49,922, respectively, according to International Monetary Union, 2012) so one would target those families willing to pay US$250 for the full course (Table 4). The current market price of three doses of HPV vaccine in Hong Kong is around US$400. Whilst the Hong Kong Government does not provide a free-of-charge HPV vaccination program, it could consider a subsidized scheme in school setting similar to our model.

Apart from cost, school-based vaccination is a complex initiative with many logistic factors needs to be considered. These include dissemination, collection and recording of consent forms, management of adolescent anxiety on site, as well as education of teachers, parents and students about vaccination [45]. Our model managed to address some of those complex logistic factors smoothly, which was the key to success. While the setting of schools and colleges would offer special opportunities for vaccine delivery, school attendance is variable particularly in less well developed countries [50]. This current model would lead us to consider adopting the concept of healthy setting approach to promote health in the context of their living environment as school is only one example of setting. One would consider non-traditional, non-institutional settings such as social venues for youth relevant to particular culture to ensure that the settings approach would respond to societal changes and addresses inequalities [51].

There is strong evidence that engagement of adolescents would lead to higher compliance with medical advice [45]. Adolescents who had the energy and willpower to take care of themselves, complied with health regimens with a 6.69 fold likelihood compared to adolescents who did not have energy and willpower [45]. Our study showed that those parents wanting to leave decision to their daughter or not wanting to deal with their social life were less likely to opt for HPV vaccination for their daughters. More active engagement and direct involvement with adolescents is another strategy for improvement of HPV vaccination among the young age group. In fact, many of the participating schools continued to arrange HPV vaccination using this model.

There are several limitations to this study. The participation of schools, students and parents was voluntary, so there could be a volunteer bias. The self-selection rather than random selection could affect the representativeness of our study population. Nevertheless, if a lot of randomly selected schools declined and not co-operated with the protocol, this would forfeit the aims of the study. Our study population consisted of schools from different parts of the territory with higher proportion from districts which were not in metropolitan areas, and a substantial proportion came from lower socio-economic class. We also noticed that the education level of parents in this study was higher comparable to whole Hong Kong population.

We only used the completion of second dose at primary care clinic as a measurement of uptake rate. As the families needed to pay for second dose and they chose their own primary care clinics, they were highly unlikely to default the third dose. The research team used SMS message to remind them for the second and third dose, and their primary providers also had reminder mechanism. Although they all received the first dose free and needed to pay for the second dose, and yet over 80 % of the students attended for second dose at their chosen primary care clinics. Once the primary care providers have established rapport with their patients, their compliance to preventive health services in primary care setting is very high [51, 52, 53].