Investigating facilitator-driven, multi-level implementation strategies in Federally Qualified Health Centers to improve provider recommendation and HPV vaccination rates among Latino/a adolescents

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Project Summary/Abstract Approximately 46,143 new cases of human papillomavirus (HPV) associated cancers occur annually in the U.S and there are substantial racial, ethnic, socioeconomic, geographic and gender disparities in the incidence and mortality of these cancers. Despite the availability of highly effective HPV vaccines that can reduce HPV- associated cancer mortality, HPV vaccination rates in Texas rank 48th nationwide. Although evidence shows Latino parents are more accepting of HPV vaccination than non-Hispanic parents, this disparity in vaccination rates underscores the importance of understanding Latino parental HPV vaccine hesitancy. Latinos/as typically receive healthcare at Federally Qualified Health Centers (FQHCs), which often need support implementing and improving access to evidence based preventive services. However, the current literature around implementation comes from large integrated healthcare systems and there is limited research around what works in the FQHC settings with Latino/a patients. Implementation studies, with an equity focus, in these resource-limited settings like FQHCs, are essential to make progress towards state and national HPV vaccination targets. Preliminary data from our previous work suggest practice facilitation is a feasible approach for building the capacity in FQHCs to select and implement provider- and practice-level strategies for increasing vaccination rates. Using a stepped-wedge cluster randomized trial, we will randomize three FQHCs (n=9 practices, 3 per FQHC) to receive facilitator-driven provider- (i.e., education, clinical practice plan) and practice-level (i.e., technical assistance plus assessment and feedback, training, and education of immunization navigators) implementation strategies. Informed by our conceptual framework and i-PARIHS, we will measure effectiveness (i.e., HPV vaccination initiation and completion among adolescent patients) and implementation outcomes (i.e., number of providers giving HPV vaccine recommendations and confidence among parents in vaccinating their children). We will conduct a baseline assessment at each clinical practice, which will provide comprehensive data to assist the practice facilitator in engaging with the providers and leadership using a participatory approach to develop an implementation plan with strategies for each practice. Along with quantitative evaluations, we will employ theory-guided, qualitative methods of inquiry, to assess the complexity associated with context (including parental HPV vaccine hesitancy and provider confidence in addressing it) and the recipients involved in the implementation of strategies in practices, along with sustainability. The study will advance our understanding of what it means to conduct implementation research in resource limited practices that work with populations experiencing substantial disparities. Findings from the current study will inform national implementation efforts and contribute towards future research targeting dissemination and scale-up, key foci for health equity focused implementation research.