Potential process improvements to increase coverage of human papillomavirus vaccine in schools – A focus on schools with low vaccine uptake

Highlights

• Government schools have lower HPV vaccination coverage compared to other schools.

• Absenteeism, consent, language barriers and low literacy are barriers to uptake.

• Process improvements with a focus on low coverage schools can address barriers.

Abstract

Introduction

Human papillomavirus (HPV) vaccination is offered in Australia through school-based programs. While HPV vaccination coverage is high, coverage of the full course of vaccination is suboptimal in Australia and there is a drop in coverage between the first and third doses. This study aimed to describe the drivers of low HPV vaccination coverage in Western Australian (WA) schools and barriers and enablers to improving vaccine coverage. This paper focusses on process and system-level factors.

Materials and methods

This was a mixed methods study. We analysed WA vaccination coverage data by school, undertook an online survey targeting the individuals responsible for the HPV vaccination program in their schools and school nurses, and compared survey findings and HPV vaccine dose three coverage in schools with 50 or more students in the eligible cohort. We also conducted focus groups with students and interviews with parents in schools with low HPV vaccine coverage.

Results

Schools with low HPV vaccine coverage had low coverage for the first dose of HPV vaccine as well as a higher drop off between first and third doses compared to schools with higher HPV vaccine coverage. Respondents from low and middle HPV vaccine coverage schools reported more issues with return of consent forms, low parental literacy, language barriers, absenteeism and difficulty contacting parents compared to schools with high coverage. Parents and students raised a number of challenges in relation to HPV vaccination including student absenteeism, language barriers, and issues with the return of consent forms.

Conclusions

A multifaceted approach to improving HPV vaccination coverage should be targeted at schools with low coverage. Based on our findings, these actions should include a range of approaches to obtaining parental consent and intensive follow up with students who are absent on vaccination days.

Introduction

School based immunisation programs (SBIP) are the most effective way of vaccinating adolescents [1], [2]. Human papillomavirus (HPV) vaccination in Australia is provided in SBIPs, which are the responsibility of states and territories. HPV vaccination has been offered to girls via SBIPs in Western Australia (WA) since 2007, and to boys since 2014. Until 2019, WA students were offered the vaccine in year 8, when they were aged 12–14 years. In 2019, the vaccine was offered to students in years 7 and 8 with view to offering it only in year 7 subsequently. HPV vaccination is also available in general practice. A central registry (previously the National HPV Vaccination Program Register, now the Australian Immunisation Register) records all publicly funded HPV vaccinations given, regardless of where they were administered. HPV vaccine coverage in Australia has been steadily increasing over time [3]. However, coverage for multiple dose vaccines tends to drop off between doses [3], [4], [5], [6], [7], [8], and is lower in communities with lower socioeconomic status [3], [8], and in remote areas of Australia [3]. This means coverage may not be sufficient to ensure herd immunity, particularly in some communities [9].

While there have been a number of studies about the factors associated with low HPV vaccination coverage in Australia and elsewhere, many of these are in countries without SBIPs [4], [5], [7], [10], [11]. A range of qualitative studies have assessed barriers and enablers to vaccination [12], [13], [14], [15], [16], [17]. These studies have consistently found increasing knowledge and understanding about HPV vaccination to be important. However, a randomised controlled trial of initiatives to increase knowledge and understanding of adolescent vaccination found that while knowledge, acceptance and understanding increased, there were no improvements in vaccination coverage in intervention schools [15]. This study also aimed to improve the processes around HPV vaccination in schools, including the consent process. However, it was not successful in achieving implementation of the process improvements in schools in the intervention arm [15].

The introduction of a two-dose HPV vaccination schedule for adolescents in Australia in 2019 [18] has simplified the HPV vaccination process in schools and reduced the cost of administration. However, challenges may remain in achieving high vaccination coverage, particularly with the six months duration between the two doses required in order to achieve full immunity. Therefore, it is still useful to assess barriers and enablers to achieving high HPV vaccine coverage in order to inform interventions.

This mixed methods study aimed to further understand the drivers of low vaccination coverage in schools and potential barriers and enablers to improving vaccination coverage. This paper focuses on process and system-level factors.