Electronic Messaging to Increase Human Papillomavirus Vaccine Utilization and Adherence Among College Students
Condition: Patient Compliance; Health Knowledge, Attitudes, Practice
Study type: Interventional
Phase: Early Phase 1

Summary: 
      Introduction: Although vaccination against HPV and subsequent HPV-related cancers is a
      significant breakthrough, uptake is low. We sought to understand whether a low-cost
      intervention of electronic (text and/or email) appointment reminders coupled with electronic
      health educational messaging about HPV and the HPV vaccine could increase HPV vaccine uptake
      and knowledge among college students.

      Methods: Study participants included both female and male English speaking students between
      the ages of 18-26 who attended a large university in North Carolina. Students were randomized
      to the intervention or control group. Intervention group participants received the electronic
      messaging while the control group received standard of care at the student health center
      across a 7-month study period. Baseline and follow-up survey data was collected. Main outcome
      measures were completion of HPV-2 and HPV-3 and HPV and HPV vaccine knowledge. Study
      recruitment ran from August 2011 to December 2013.

      Results: Completion rates for the intervention and control group were similar for HPV-2 (53%
      vs. 52%) and HPV-3 (34% vs. 32%), respectively. The mean knowledge score at follow-up for
      intervention group participants (n=44, mean knowledge score = 93%, SD = 0.08) was
      significantly higher (p=0.01) than the mean knowledge score at baseline (n=44, mean knowledge
      score = 87%, SD = 0.11). No significant changes in knowledge from baseline to follow-up were
      found for control group participants. The single most important predictor of HPV vaccine
      uptake overall was female gender where female participants were 2.35 times [confidence
      interval (CI) 1.17-4.69] as likely to complete the series as compared to male participants.

      Conclusion: In this sample of college students, the electronic messaging intervention
      increased knowledge but not uptake. More randomized controlled trials on the efficacy of HPV
      vaccine electronic reminder interventions for catch-up age populations for both females and
      males are needed.
    

Detailed description: 
      Oncogenic types of human papillomavirus (HPV) infection can cause cervical cancer, with HPV
      types 16 and 18 causing roughly 70% of cervical cancers worldwide.1 Persistent HPV infection
      has also been linked to vaginal and vulvar cancer in women, penile cancer in men, as well as
      oral pharyngeal cancer, anal cancer, and genital warts in both sexes.2-4 There are two safe
      and effective vaccines which protect against HPV types 16 and 18 and one of the two vaccines
      (HPV4) also protects against two additional HPV types that account for 90% of the cases of
      genital warts.5 Because HPV vaccination provides maximum protection if administered prior to
      sexual debut, HPV4 guidelines recommend administration to males and females ages 11 and 12,
      with catch-up vaccination up to age 26, for the prevention of cervical and anal cancers as
      well as for the prevention of genital warts.1,5-8 Although vaccination against HPV-related
      cancers is a significant breakthrough, uptake is low. The National Immunization Survey-Teen
      (NIS-teen) estimated that in 2013, HPV vaccination coverage for 13-17 year-old females was
      37.6%, while for males in the same age group coverage was 13.9%. Additionally, coverage for
      13-17 year-old females dropped slightly between 2011 and 2012.9 Although vaccination coverage
      for teens has been increasing over time overall, these rates are far from meeting the Healthy
      People 2020 goal of 80% of 13-15 year old females being fully vaccinated against HPV by 2020.
      In addition to teens, it has been shown that there is a benefit to providing HPV vaccines to
      young adults, even those who have already been sexually active. However, an NIS-adult study
      showed that only 10-12% of 18-26 year-old women are completing the HPV vaccine series.10
      Additionally, studies have found significantly lower completion rates among African
      Americans.9,11-12 This is problematic given that African American women demonstrate a
      mortality rate from cervical cancer that is twice that of Caucasian women.13 It has also been
      suggested that lack of knowledge may be a barrier to vaccine adherence14 and that educational
      interventions may increase adherence among 18-26 year-old women.12 Given the importance of
      immunizing young adults for the prevention of cancer and given the low uptake of HPV vaccines
      in this group, it is important to develop and evaluate strategies to increase use and
      adherence among this population. We sought to understand whether a low-cost intervention of
      electronic (text and/or email) appointment reminders coupled with electronic health
      educational messaging about HPV and the HPV vaccine could increase HPV vaccine utilization,
      adherence, and knowledge among college students (both female and male) attending a large
      university in eastern North Carolina. Although we only found one peer-reviewed study that
      assessed text and email electronic HPV reminders primarily among adolescents, we found a few
      other studies that assessed mail and telephone HPV vaccination reminders among adolescents.
      All of these studies found vaccination reminders to be effective in increasing adherence
      among adolescents and/or young adults.15-17 Hard copy and electronic messaging reminders have
      also proven to be effective when coupled with other prevention strategies such as
      immunizations for influenza and pneumococcal pneumonia as well as screening for colon,
      breast, and cervical cancer in adults.18 We found no literature that tested electronic HPV
      vaccine interventions among a college population.

      Our primary hypothesis was that students who receive the intervention would be more compliant
      in their uptake of the second (HPV-2) and third (HPV-3) doses of the vaccine as compared to
      the control group. Secondarily, we further hypothesized that students that receive the
      intervention will demonstrate higher knowledge about HPV and the HPV vaccine as compared to
      the control group and that African American students and younger students (defined as 18-19
      years of age) would be less compliant as compared to Caucasian and older students (defined as
      students 20 and older), as demonstrated in the literature. Lastly, we sought to describe
      satisfaction of health messages and reminders among those that received it.
    

Intervention name(s): Electronic Message
Intervention type(s): Procedure
Intervention description(s): Students enrolled in the intervention group received 7 electronic contacts over a 7-month period. Specifically, participants received 4 electronic education messages, 2 electronic reminder/education messages, as well as 1 baseline and 1 final assessment contacts. Up to 4 reminder contacts were used if surveys were not completed for both intervention and control group participants. Control group participants will receive 2 contacts throughout the study, 1 at baseline and 1 at their final assessment. Up to 4 reminder contacts were used if surveys were not completed. Intervention & control groups were compared longitudinally for 7 months on the differences in HPV vaccine utilization and adherence, knowledge and attitudes about HPV, and the HPV vaccine (parallel design).
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Double (Participant, Care Provider)
Primary purpose: Prevention
Keywords: HPV vaccine; Vaccine adherence; Vaccine utilization; Electronic Messaging