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

ABSTRACT Some of the largest disparities in human papillomavirus vaccination (HPVV) occur in rural communities, which may represent missed opportunities for cancer prevention since incidence of HPV associated cancers have been increasing in rural areas in the U.S. While there are evidence-based strategies to improve adolescent HPVV for cancer prevention in clinical practices, current gaps include a lack of tools available for community-based practices and rural communities. Targeted approaches are needed by rural community-based primary care practices to increase HPVV for cancer prevention and meet the needs of low-resourced rural communities. To address this gap, we developed an implementation science focused strategies for rural primary care practices (PC TEACH) that considers community, culture, and health systems as upstream factors in adolescent HPVV for cancer prevention 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 approach (PC TEACH) to address: (i) HPVV for cancer prevention in adolescent boys and girls, and (ii) the average vaccination age in primary care practices. We hypothesize that HPVV for cancer prevention will depend on practice facilitation of evidence-based PC TEACH strategies. 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 for cancer prevention in rural community-based primary care practices. Aim 2 - Measure and monitor practice-level characteristics (e.g., size, scope, socioeconomic, and vaccination experiences during the COVID-19 pandemic), and patient-level characteristics (e.g., sex, age, insurance type, HPV knowledge, and child vaccination history), to identify factors that influence HPVV for cancer prevention. Aim 3 - Evaluate the extent to which practice facilitation activities most readily lead to adoption and implementation of the evidence-based PC TEACH 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 low-resource rural primary care settings to enable system changes related to HPVV for cancer prevention. Findings from this study will be essential in understanding how to implement systematic practice-level changes in primary care practices in rural communities where there is increasing incidence of HPV-associated cancers.