Interventions to Increase Uptake of the Human Papillomavirus Vaccine in Unvaccinated College Students: A Systematic Literature Review

"Determining what kind of health education program will be effective at increasing vaccination rates is essential."

Considering the suboptimal rates of human papillomavirus (HPV) vaccination uptake in the United States (US), there is an identified need to identify effective strategies to encourage catch-up vaccination for those who reach young adulthood unvaccinated. The purpose of this systematic review is to provide evidence on interventions that could be implemented in the college environment to increase HPV vaccination uptake.

Pubmed, CINAHL, PsycINFO, Cochrane, and EBSCO were searched in December 2017 to identify all literature meeting the following criteria: human subjects, English language, HPV, HPV vaccination, and college. The focus was only on manuscripts that reported vaccine uptake, excluding studies that only reported vaccine intentions. Nine articles, all but one being randomised controlled trials (RCTs), were deemed eligible for final qualitative review. Seven of the 9 only included female participants, and 8 of the 9 were conducted in the US, with 1 conducted in Australia.

Table 1 in the article summarises the 9 articles. Interventions ranged from tailored messages on websites to gain- and loss-framed video messages, to stigmatising and fear-oriented messages, to enhanced reminder systems. Most (7 of 9) used some sort of educational intervention. In short, HPV vaccine uptake rates ranged from 5% to 53%. Examples of strategies, with impact, include:

• Hopfer demonstrated a 21.8% vaccination uptake rate of at least one dose in the group that watched a peer and medical expert-led video about the vaccination, vs. 11.8% in the control group (Hopfer and Clippard, 2011).
• Juraskova et al. achieved a 44% uptake rate of one dose with an information leaflet that describe the vaccines protection from cervical cancer and genital warts (Juraskova et al., 2011).
• Richman et al. achieved completion of 2 doses in 53% and 3 doses in 34% of the intervention group that received monthly health education and reminder prompts (Richman et al., 2016).

Notably, all but one of the studies had a non-significant treatment effect. One hypothesis presented here is that lack of significant differences between the intervention and control conditions may indicate that simply participating in a study related to HPV vaccination impacts uptake; thus, the control conditions may have had higher uptake than would naturally have occurred.

The researchers observe that the only intervention in the review that significantly increased HPV vaccine uptake did so by using a joint peer and medical provider message, which was found to be more effective than a message from a peer or provider alone (Hopfer, 2012). The interventions that achieved the highest vaccination rates appear to be relatively easy to implement, such as videos, leaflets, and monthly reminders (Hopfer, 2012; Juraskova et al., 2011; Richman et al., 2016). According to the researchers, replication of these interventions to examine effectiveness in other samples is needed.

While the primary outcome of interest was HPV vaccine uptake, most of the studies (8 of 9) included in this review also included assessment of knowledge and perceptions related to HPV and the HPV vaccine. Assessment of perceptions related to HPV and the HPV vaccine (e.g., perceived susceptibility, perceived risks and benefits, subjective norms, and self-efficacy) were guided by theories, including the Health Belief Model, the Theory of Planned Behavior, Culture-Centric Narrative Theory, and Exemplification Theory. Variables from these theories were found to be associated with vaccine uptake.

The researchers point to "a clear gender gap in the literature, as few studies have examined the impact of intervention vaccine uptake by male students."

In conclusion: "Few interventions resulted in substantial HPV vaccine uptake. A combination of peer and provider encouragement may be the most effective method to increase vaccine uptake in this population."