HPV ECHO: Increasing the adoption of evidence-based communication strategies for HPV vaccination in rural primary care practices

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Abstract of the Parent Grant (5R37CA253279-03; William Calo, PI) Despite the availability of the human papillomavirus (HPV) vaccine that can prevent over 34,800 HPV-related cancers in the US every year, only 51% of girls and boys were up-to-date by 2018. Rural populations are the most impacted by HPV-related cancers. Best practices like the Announcement Approach training and systems communication have proven effective in increasing HPV vaccination, but rural providers struggle to access and implement such best practices. These data prompt the question: “How can academic centers support HPV vaccination in rural primary care practices?” Although never tested for HPV vaccination, the ECHO (Extension for Community Healthcare Outcomes) Model is a promising implementation strategy (practice facilitation) that allows “experts” at academic centers to connect with primary care providers to discuss best practices in care and complex cases managed within local practices. The objective of this R01 is to test two ECHO-delivered HPV vaccination communication interventions in rural primary care clinics. The first will provide Announcement Approach training (HPV ECHO); the second will provide this approach plus systems strategies to communicate with parents who initially decline vaccination (HPV ECHO+). The rationale for the project is that ECHO is a robust, highly-accessible platform to deliver best practices to rural providers and address the context-specific communication needs of parents. Our long-term goal is to improve HPV vaccination rates in rural clinics and reduce the health inequity rural populations experience in cancer outcomes. Aim 1 is to evaluate the impact of HPV ECHO and HPV ECHO+ on HPV vaccination among adolescents. We will conduct a 3-arm cluster randomized trial with 36 primary care clinics in rural Pennsylvania. Clinics will be randomized to: HPV ECHO, HPV ECHO+, or control. Our primary outcome will be change in HPV vaccine initiation (≥1 doses) among adolescents, ages 11-14, at 12-month follow-up. Aim 2 is to evaluate the impact of HPV ECHO and HPV ECHO+ on implementation outcomes. Guided by implementation science frameworks, we will conduct a mixed-methods evaluation to compare interventions on acceptability, adoption, cost, penetration, and sustainability. Aim 3 is to evaluate the impact of interventions’ vaccine information on secondary acceptance of HPV vaccination at the clinic level. We will also follow a subset of 200 vaccine-declining parents for up to 12 months to assess exposure to and impact of vaccine information from study arms versus naturally-occurring sources (e.g., social media) on secondary acceptance. Our expected outcome is to demonstrate the effectiveness of a highly efficient and scalable implementation strategy, ECHO, to support HPV vaccination in rural clinics. This study is innovative in leveraging existing infrastructure at academic centers to deliver best practices for HPV vaccination where they are needed most and in developing a greater understanding of the influences on decision making among vaccine-declining parents. We expect the project to have a significant impact on HPV vaccine uptake as we address the communication needs of both rural providers and parents.