Literature Review
An article by Stewart (2008) sets a good background for the topic by discussing the school-entry HPV vaccine in the context of public policy and legislation. The author uses the methodology of policy synthesis and legal analysis to describe the implications of establishing the HPV vaccine as a school-entry requirement for policy and practice. The article argues that the HPV vaccine is effective and using school-entry requirements is a proven method of increasing coverage rates, as well as a direct implementation of national health recommendations. Since HPV is not communicable in school settings and parental concerns were present, jurisdictions requiring the vaccine permitted opt-out rights, and it is up to policymakers to determine whether schools should be used for the health services delivery.
The study by Hansen, Okoloko, Ogunbajo, North, and Niccolai (2017) focuses on the acceptability and attitudes towards school-based health centers (SHBCs) for administering HPV vaccinations. The authors used the methodology of qualitative interviews and structured surveys with both parents and students. The results found that participants favorably viewed using SHBCs for vaccines, with 59.5% for middle schools and 80.5% for high schools. Nevertheless, the parents voiced concerns that may serve as barriers to using the school resources including worry about health services outside a health facility and fragmentation of medical records as well as a generally negative perception of SHBC’s. The authors believe this can be addressed through education and the improvement of coordinated care.
A study by Goggin et al. (2018) is an international example of utilizing school-based vaccinations in Quebec, Canada. The study is meant to determine the prevalence of HPV infections five years after introducing a public-school HPV vaccination. The researchers recruited a sample of more than 2000 women aged 17-29 from post-secondary institutions. Their risk factors and vaccination status were assessed by a computer program and a biological sample was taken to test for the presence of STIs include HPV infections. The authors found that vaccination rates were at 83.5% in ages 17-19 and only 19.1% in older women.
The general prevalence of HPV was 34.9% in sexually active women of all ages. The study concludes that HPV prevalence is rare in women who have had the vaccine, while practically nonexistent if the first vaccine was administered before sexual debut.
The article by Pierre-Victor et al. (2017) focuses on the specific mandated school-entry HPV vaccine policy in Virginia for 13-17-year-old females. The researchers used data from the National Immunization Survey-Teen including a sample of 3,203 females, with statistical analysis conducted to compare VA with other neighboring states without mandated school-entry vaccines. It was found that the Virginia policy had no significant effect on HPV vaccination coverage among adolescent females. Neither did it impact the commonality of physician recommendations which was the most effective factor in association with increased vaccination not just in Virginia but in neighboring states.
A study by Thompson, Livingston, Daley, & Zimet (2018) focuses on examining a similar mandated school-entry requirement initiative in Rhode Island, which included both sexes. Data was also used from the National Immunization Survey-Teen database which estimated gender-specific effects and using a difference-in-difference design to examine state policy. The results found an 11% increase in vaccination rates among boys, but no significant differences among girls in Rhode Island compared to other states. The researchers conclude that although school-mandated vaccines remain controversial and with mixed results, they can potentially narrow the gap to vaccine delivery and improve the strategy of increasing vaccine uptake for both genders.
Finally, Niccolai and Hansen (2015) conducted a synthesis of literature regarding various practice and community-based interventions, including school programs on HPV vaccine coverage. The methodology consisted of searching medical databases with keywords and identifying studies with adolescents and HPV vaccinations. The studies included reminder and recall, physician-focused interventions, school interventions, and social marketing. Conducted with various populations and geographical areas, the majority found significant increases in vaccination uptake, with only one showing minor improvement and one with mixed results. This is an indication that varied approaches to HPV vaccinations can be effective for diverse populations.
Strengths and Limitations of Literatures
As a whole, the body of literature demonstrates some of the initial efforts in health policy research for HPV vaccine mandates or programs. The studies are able to examine varying perspectives on the issue as well as outline the epidemiological aspects of the disease. The discussion around policy implementation, such as the primary reasoning behind it, comparisons to other programs, and public health justifications for it are competently presented.
The limitations of the literature can be attributed mostly to methodology. since all of the studies indicated reliance on self-reporting of vaccination of status which may be biased. Analysis of the issue is also rather limited or short-term, that may be insufficient to see results of interventions in the long-term as public health policy, especially as controversial as school-initiated vaccinations, take time to come into effect and become accepted by the public. Few of the studies present potential recommendations or policy alternatives.
It is currently not clear, particularly what can increase the HPV vaccine intake considering that school-mandated vaccinations only had minor impacts, particularly in jurisdictions where the policy was implemented. It is unclear the extent to which the schools and government agencies are able to correctly present this vaccination with triggering parental concerns due to the sensitive sexual-related nature of HPV.
Further research can also focus on identifying reasons for such strong public dissent against this particular vaccine, leading to suboptimal rates in the United States when generally the population adheres to standards on all other vaccinations. There are also potential ethical and legal challenges regarding mandated HPV vaccination, particularly to children at such as young age. Further research is necessary into the ethics of the issue as the vaccine may have an impact on the sexual behavior of teens as well as the common mandate to only vaccinate girls rather than both genders.
Policy and Practice Implications
The overall body of literature’s impact on policy suggests that while school-mandated HPV vaccinations can slightly increase rates, the negative perceptions of school-based health centers and initiatives, as well as parental concerns regarding the vaccination call to pursue other policy and practical avenues. Research suggests that community-based initiatives and physician-recommended vaccinations have a positive influence on the uptake of HPV vaccinations, including “catch-up” individuals seeking the immunization at a later age.
Therefore, in terms of policy, the school-mandated vaccinations have received tremendous backlash in both Virginia and Rhode Island, with the former demonstrating little impact on its low vaccination rates, while the latter has relatively high coverage. More time is potentially necessary to study states such as Rhode Island and countries internationally (Australia) that have had success with mandated HPV vaccinations.
However, the government should utilize a mixed method of approaching the issue along with school mandates. Police should focus on universal vaccine coverage to increase uptake through physician recommendations that at least two of the studies noted as effective. This would help to remove barriers to access to healthcare for vulnerable and low-income populations that are unable to receive the vaccine easily. Health equity is a critical concept in terms of mass vaccinations, and it is vital that all populations have access regardless of their socio-economic status.
It may viable to allow health professionals such as school nurses or pharmacists to administer the vaccine to anyone at a recommended age and with parental permission. Finally, the policy should focus on improved awareness and education, which is largely responsible for the success of programs in Rhode Island, as well as other countries which were discussed in the literature, even if community initiatives were used to administer the vaccine.
Literature indicates that there are a rather broad unfamiliarity and lack of understanding of HPV, particularly in the context of young children. This leads to underutilization of the vaccine, even by populations to whom it is readily available. Therefore, policy focus should be directed towards social marketing and education in combination with programs to implement HPV vaccination initiatives in healthcare settings where there is greater trust from the public and parents unlike attitudes towards educational institutions.
It is important to consider diversity as part of the policy approach. A study by Lai et al. (2018) shows that racial and ethnic minorities, especially those who are immigrants in the United States have significantly lower awareness and knowledge of the HPV vaccine, and those that do, heard it through personal networks rather than reliable health resources. In the context of health equity, it may be viable for community-focused policies to improve access and culturally competent delivery of HPV information through official healthcare system sources, and potentially increase voluntary participation in providing the vaccine to their children.
This creates numerous policy and health opportunities to develop community-based programs towards HPV education and vaccination availability. As noted by several studies, the sociopolitical climate is a consideration as well when designing policy, and in most states, including Virginia, it is not currently present for widespread support of the school-mandated policy. Nevertheless, the importance of HPV vaccinations should be advocated and directed towards funding programs at local levels that would cooperate with healthcare providers and community health organizations as the most direct method of bringing awareness and providing the vaccine. In turn, this will have an extensive impact on public health as the burden of the disease and its potential risk factors will be reduced.
Conclusions
A wide variety of literature exists on school-based interventions for HPV vaccinations, with interventions ranging from school health centers to a mandatory requirement for entry into the public education system. The practice of using schools as a mechanism for HPV vaccine coverage or awareness is common, both in the United States and internationally. However, there have been mixed results regarding the uptake of HPV vaccinations as well as various policy and social challenges to both implementing school-based programs or achieving successful results.
References
Centers for Disease Control and Prevention. (2017). HPV fact sheet. Web.
Goggin, P., Sauvageau, C., Gilca, V., Defay, F., Lambert, G., Mathieu-C., S., … Coutlée, F. (2017). Low prevalence of vaccine-type HPV infections in young women following the implementation of a school-based and catch-up vaccination in Quebec, Canada. Human Vaccines & Immunotherapeutics, 14(1), 118–123. Web.
Hansen, C. E., Okoloko, E., Ogunbajo, A., North, A., & Niccolai, L. M. (2017). Acceptability of school-based health centers for Human Papillomavirus Vaccination visits: A mixed-methods study. Journal of School Health, 87(9), 705-714. Web.
Lai, D., Bodson, J., Davis, F. A., Lee, D., Tavake-Pasi, F., Napia, E., … Kepka, D. (2016). Diverse families’ experiences with HPV vaccine information sources: A community-based participatory approach. Journal of Community Health, 42(2), 400-412. Web.
Niccolai, L. M., & Hansen, C. E. (2015). Practice- and community-based interventions to increase Human Papillomavirus vaccine coverage. JAMA Pediatrics, 169(7), 686-692. Web.
Pierre-Victor, D., Page, T. F., Trepka, M. J., Stephens, D. P., Li, T., & Madhivanan, P. (2017). Impact of Virginia’s school-entry vaccine mandate on Human Papillomavirus vaccination among 13–17-Year-old females. Journal of Women’s Health, 26(3), 266-275. Web.
Stewart, A. (2008). Childhood vaccine and school entry laws: The case of HPV vaccine. Public Health Reports, 123(6), 801-803. Web.
Thompson, E. L., Livingston, M. D., Daley, E. M., & Zimet, G. D. (2018). Human Papillomavirus vaccine initiation for adolescents following Rhode Island’s school-entry requirement, 2010–2016. American Journal of Public Health, 108(10), e1–e3. Web.