Electronic Messaging to Increase Human Papillomavirus Vaccine Utilization and Adherence Among College Students

Study Overview
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Brief Summary
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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
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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.

Official Title
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A Randomized Longitudinal Intervention Study to Assess Whether Electronic Messaging Can Increase HPV Vaccine Utilization and Adherence Among College Students in Eastern North Carolina.

Conditions
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Patient Compliance, Health Knowledge, Attitudes, Practice

Intervention / Treatment
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* Procedure: Electronic Message


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Male & Female Students enrolled at East Carolina University (ECU) Exclusion Criteria: Non-English speaking students Students under the age of 18 or over 26 Individuals not enrolled at ECU

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 26 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: Double


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Electronic Messages<br>Intervention group participants received electronic (text and/or email) reminder messages coupled with health educational messages about HPV and HPV vaccine across 7 months | Procedure: Electronic Message<br>* 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).<br>|
| No Intervention: Standard of Care<br>Control group participants received standard of care at the student health center which included a card with their next appointment written on it. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Increase in HPV vaccine uptake among intervention group participants. | To determine if electronic reminders coupled with electronic educational messaging can increase HPV vaccine use and adherence among college students in eastern North Carolina. | One year | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Increase knowledge of HPV and HPV vaccine among intervention group participants | To measure whether electronic health educational messaging increases HPV and HPV vaccine knowledge among college students in eastern North Carolina. | One year | 
| Compliance rates among Race/ethnicity and other socio-demographic characteristics. | We hypothesize that African American students and younger students (defined as 18-19 years of age) will be less compliant as compared to Caucasian and older students (defined as students 20 and older) as demonstrated in the literature. Items measuring race/ethnicity and socio-demographic variables will be included on baseline and follow-up surveys. We will assess whether these variables predict vaccine adherence among study participants. | One year | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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HPV vaccine, Vaccine adherence, Vaccine utilization, Electronic Messaging