Implementation of evidence-based strategies to optimize HPV vaccination in rural primary care settings

摘要 人类乳头瘤病毒(HPVV)疫苗接种率的一些最大差异存在于农村社区， 这意味着错失了癌症预防的机会，因为HPV相关癌症的发病率 与城市地区相比，农村地区的增长不成比例。尽管有有效的 在临床实践中提高青少年HPVV感染率的循证策略，目前的差距包括缺乏 针对社区做法和农村人口的干预措施。有针对性的干预是不顾一切的 需要将覆盖范围扩大到以农村社区为基础的初级保健实践，以提高HPVV感染率并满足 服务不足的农村社区的需求，那里的人乳头状瘤病毒感染率一直很低。为了解决这一差距，我们 为农村初级保健实践制定了以实施科学为重点的干预措施(PC TACH)， 认为社区、文化和卫生系统是增加青少年HPVV感染率的上游因素 使用促进实践的方法让整个医疗团队参与进来。在目前的提案中，我们将测试 我们创新的实践级干预方法(PC TACH)的有效性：(I)增加HPV疫苗 青春期男孩和女孩的接种率和完成率，以及(2)降低#年接种疫苗的平均年龄 以社区为基础的初级保健做法。我们假设HPVV的启动率和完成率为 与之前的比率相比，实践后促进循证PC教学的疫苗接种策略的优势 干杯干杯。我们将使用阶梯-楔形整群随机试验设计，它节省了样本量，同时 通过一个综合执行框架以及进程和结果评价，维持权力，以 解决以下目标：目标1-实施和测试PC教学实践便利化的有效性， 运用实施科学方法，探讨农村社区小学人乳头状瘤病毒的启动和完成 护理实践。目标2--衡量和监测实践层面的特征(例如，规模、范围、社会经济 环境和新冠肺炎大流行期间的疫苗接种经验)，以及患者级别的特征 (例如，性别、年龄、保险类型、HPV知识、儿童疫苗接种史和疫苗迟疑)，以确定 影响HPV疫苗投放率和接种率的因素，并可能影响干预效果。目标3- 评估实践促进活动在多大程度上最容易导致采用和实施 循证PC讲授初级保健实践现场工作人员提供的疫苗接种策略。这个 建议的研究是创新的，因为我们使用社区参与的方法增强了 在服务不足的农村初级保健环境中实施科学干预，以使系统能够改变 提高HPVV感染率。这项研究的结果将是理解如何实施系统化的 农村社区初级保健实践水平的变化以及如何培育实践文化 在农村社区支持HPVV，尽管观察到 美国农村地区HPV相关疾病发病率上升和HPVV感染率较低。

ABSTRACT Some of the largest disparities in human papillomavirus vaccination (HPVV) rates exist in rural communities, which represent missed opportunities for cancer prevention since incidence of HPV associated cancers have been increasing disproportionately in rural compared to urban areas in the U.S. While there are effective evidence-based strategies to improve adolescent HPVV rates in clinical practices, current gaps include a lack of interventions targeting community-based practices and rural populations. Targeted interventions are desperately needed to expand reach to rural community-based primary care practices to increase HPVV rates and meet the needs of underserved rural communities where HPVV rates have remained low. To address this gap, we developed an implementation science focused intervention for rural primary care practices (PC TEACH) that considers community, culture, and health systems as upstream factors to increase adolescent HPVV rates by engaging the entire medical team using a practice facilitation approach. In the current proposal, we will test the effectiveness of our innovative practice-level intervention approach (PC TEACH) to: (i) increase HPV vaccine uptake and completion rates in adolescent boys and girls, and (ii) lower the average age at vaccination in community-based primary care practices. We hypothesize that HPVV initiation and completion rates will be superior after practice facilitation of evidence-based PC TEACH vaccination strategies compared to rates prior to intervention. We will use a stepped-wedge cluster randomized trial design, which conserves sample size while maintaining power, with an integrated implementation framework, and process and outcome evaluation, to address the following aims: Aim 1 - Implement and test the effectiveness of practice facilitation of PC TEACH, using an implementation science approach, on HPVV initiation and completion in rural community-based primary care practices. Aim 2 - Measure and monitor practice-level characteristics (e.g., size, scope, socioeconomic environment, and vaccination experiences during the COVID-19 pandemic), and patient-level characteristics (e.g., gender, age, insurance type, HPV knowledge, child vaccination history, and vaccine hesitancy), to identify factors that influence HPV vaccine delivery and uptake rates, and may moderate intervention effects. Aim 3 - Evaluate the extent to which practice facilitation activities most readily lead to adoption and implementation of the evidence-based PC TEACH vaccination strategies as delivered by the primary care practice site staff. The proposed study is innovative in that our use of community-engaged methods enhance scalability of the implementation science intervention in underserved rural primary care settings to enable system changes to improve HPVV rates. Findings from this study will be essential in understanding how to implement systematic practice-level changes in rural community-based primary care practices, and how to cultivate a practice culture supportive of HPVV in rural communities, a population underrepresented despite the observed incongruence of increasing incidence of HPV-associated disease and low HPVV rates in rural areas in the U.S.