Exploring Changes in HPV Vaccine Communication and Uptake Across Phases of the COVID-19 Pandemic in Pennsylvania

Background: The COVID-19 pandemic was declared a national emergency in the United States (US) from March 2020 to May 2023. Within healthcare, a primary concern was the interruption in healthcare services, causing delays in well-visits where minors would have the opportunity to receive preventive services. These delays led to patients falling out of schedule with their routine childhood vaccines, including the human papillomavirus (HPV) vaccine which had already been lagging other vaccines. Additionally, during the COVID-19 pandemic, a vaccine was approved to counteract the severe symptoms caused by the infection. However, skepticism was present across parents towards the vaccine as it was deemed to be produced ‘too quickly without enough scientific evidence to back it up’. Some of this skepticism joined existing sentiments of vaccine hesitancy across US communities. The purpose of this study was to 1) explore changes in HPV vaccine communication and conversations among primary care team members (PCTMs) in Pennsylvania (PA) and 2) characterize vaccination trends of routine childhood vaccines with a primary focus on HPV vaccination. Methods: This doctoral work was based on a convergent mixed methods design to explore changes in HPV vaccine conversations qualitatively and characterize vaccination trends quantitatively. For Aim 1, which focused on the qualitative data, PCTMs from across PA were recruited to complete a short, 17-item survey and an online interview. The interview inquired about changes in HPV vaccine conversations within the lens of the Theory of Planned Behavior (TPB) and the Increasing Vaccination Model (IVM), frameworks that have been previously used to study HPV vaccination-related topics. PCTMs were also asked to simulate HPV vaccine conversations for different age groups and talk about how they go through distinct steps of the Announcement Approach. PCTMs included physicians, medical assistants, and nurses that provided healthcare services to minors between the ages of 9 through 17 during the COVID-19 pandemic in PA. A total of 25 participants were recruited. For Aim 2, an electronic health record inquiry was conducted across Penn State Health – Hershey Medical Center affiliated clinics related to minors between 9 to 17 years of age at any given point between January 1, 2018 and December 31, 2023. Historical vaccination data for HPV, tetanus-diphtheria-acellular pertussis (Tdap), quadrivalent conjugate meningococcal (MenACWY), Influenza, and COVID-19 vaccines was requested alongside sex, race, ethnicity, and insurance type. A total of 29,928 unique patients were included. The data was analyzed using descriptive statistics, unadjusted Cox proportional hazard models, and survival analysis approaches through Kaplan-Meier methods and adjusted Cox proportional hazard models. Results: Results for Aim 1 included six emergent themes: 1) parents show a range of reactions about HPV vaccination; 2) disruptions in healthcare visits and heightened parental concerns impede vaccination; 3) PCTMs notice clear changes in vaccine acceptance rates; 4) reasons for vaccination refusal have not substantially changed as a result of the pandemic; 5) importance of interpersonal relationships with parents; and 6) PCTM burnout impacts conversations. In Aim 2, the findings were that HPV vaccination uptake has improved across birth cohorts, yet it continue to lag compared to Tdap and MenACWY. Upon age-eligibility, Tdap and MenACWY vaccine administration occurs fairly quicly within the first one or two years. Contrastingly, HPV vaccine initiation takes longer to occur, with events occurring across a longer time span. Adjusted hazard ratios (aHRs) for HPV vaccine initiation by age 12 consistently increased until the 2008 birth cohort (aHR=2.87; 95%CI: 2.61-3.15), followed by stagnation in the 2009 birth cohort, and a decrease in the 2010 birth cohort (aHR=2.70; 95%CI: 2.46-2.97). On the other hand, decreasing changes in Tdap and MenACWY vaccine administration were observed for birth cohorts 2007 through 2009, but were seen to increase for birth cohort 2010. Conclusion: From a quantitative perspective, understanding the particular needs of birth cohorts allows researchers and primary care practitioners to identify best practices tailored to the vaccination gaps for each group. From a qualitative perspective, exploring changes in vaccine conversations informs steps to refine existing communication interventions for primary care sites to strengthen their approaches. Overall, post-pandemic efforts to explore and characterize changes that occurred related to HPV vaccination behaviors and vaccine conversations is imperative to tailor existing interventions that have been successful in the past to educate and protect our communities.