Advancing the implementation of evidence-based strategies for HPV vaccination in safety-net primary care settings

摘要 迫切需要加快和维持对人类健康的循证策略(EBS 将人乳头瘤病毒(HPV)疫苗接种到安全网医疗保健环境中，因为#年的疫苗接种率不太理想 建议的年龄组(11-12岁)和子宫颈癌和其他HPV相关癌症的持续差异 在低收入、种族/少数民族人口中。尽管建议使用EBS来提高HPV疫苗接种 ，但很少有研究充分研究提供者、诊所和卫生系统之间的相互关系 使人乳头瘤病毒疫苗成功整合到常规临床护理中的EBS水平。这个 拟议的四年顺序混合方法研究寻求(1)确定多个水平的因素，这些因素 与实施EBS相关，以及(2)改善服务不足的次优HPV疫苗接种率 处于安全网环境中的青少年。在实践变革模式的指导下，我们将吸引利益相关者参与 系统全面考察可操作EBS在HPV疫苗接种中的实施和应用 联邦政府在一个城市、多个地点中有目的地选择三个诊所地点的示范研究结果 合格健康中心(FQHC)。然后，我们使用覆盖范围、有效性、采用率、实施和 维护(RE-AIM)框架，以表征和理解针对HPV实施的EBS 在示范诊所现场接种疫苗。这项研究将：确定不同的利益相关者如何看待、确定优先顺序和 通过深度访谈，调整可操作的提供者、诊所和系统级别的EBS，以增加HPV疫苗接种 和概念图(目标1)；开展一个示范项目，以实施可操作的EBS，确定自 目标1，通过在多地点FQHC内的三个临床地点的有目的的样本中通过实践促进的方法 系统(目标2)；并审查与实施HPV疫苗EBS相关的基于实践的因素 使用实践观察、深度访谈和对医生、诊所工作人员和FQHC领导的调查(AIM 3)。成功实施以医疗保健为基础的EBS以增加HPV疫苗接种将需要 系统地了解影响实践的医疗保健环境内部和之间的动态关系 变化。研究结果将确定将EBS转化为HPV疫苗的关键动机和障碍 安全网设置，并告知为实践更改确定优先顺序、调整和实施EBS所需的流程 在安全网的背景下。这项研究还为后续检查提供了机会 在各实习地点维护和扩大电子数据交换系统，将在较长的后续期间进行评估，以及 为在不同的医疗保健环境中与更多的诊所进行更大规模的试验奠定了基础。

ABSTRACT There is a critical need to accelerate and sustain the adoption of evidence-based strategies (EBS) for Human Papillomavirus (HPV) vaccination into safety-net healthcare settings given the suboptimal vaccination rates in recommended age groups (11-12 years) and persistent disparities in cervical and other HPV-associated cancers among low-income, racial/ethnic minority populations. Although recommended EBS to improve HPV vaccination are available, few studies have fully examined the interrelationships among provider, clinic, and health system levels that enable or inhibit successful integration of EBS for HPV vaccination into routine clinical care. The proposed four-year sequential mixed-methods study seeks to (1) identify factors at multiple levels that are associated with implementation of EBS and (2) improve suboptimal HPV vaccination uptake for underserved adolescents within safety-net settings. Guided by the Practice Change Model, we will engage stakeholders to systematically and comprehensively examine implementation of actionable EBS for HPV vaccination and apply findings in a demonstration study of three purposively selected clinic sites within an urban, multi-site federally qualified health center (FQHC). We then use the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to characterize and understand the implementation of EBS for HPV vaccination in demonstration clinic sites. The study will: identify how diverse stakeholders view, prioritize, and adapt actionable provider, clinic and system-level EBS for increasing HPV vaccination through depth interviews and concept mapping (Aim 1); conduct a demonstration project to implement actionable EBS, identified from Aim 1, through practice-facilitated approaches in a purposive sample of three clinic sites within a multi-site FQHC system (Aim 2); and examine practice-based factors associated with implementation of EBS for HPV vaccination using practice observation, depth interviews, and surveys with physicians, clinic staff, and FQHC leaders (Aim 3). Successful implementation of healthcare setting-based EBS to increase HPV vaccination will require a systematic understanding of dynamic relationships within and between healthcare settings that influence practice change. Study findings will identify critical motivators and barriers to translating EBSs for HPV vaccination in safety-net settings and inform the processes needed to prioritize, adapt, and implement EBS for practice change within the safety-net context. The study also establishes an opportunity for subsequent examination of maintenance and scale-up of EBS across practice sites, to be assessed in a longer follow-up period, as well as a foundation for a larger trial to be conducted with more clinics across varying healthcare settings.