br Phase br Phase education which started immediately
Phase 2 education, which started immediately following phase 1, was provided to adolescents and their parents by the pro-
viders and staff at each study site. The education included dis-tributing the cancer prevention awareness booklets to all adolescents and their parents who came to an office visit over a 12-month period. It was left to the discretion of each prac-tice to determine the logistics for when to provide the book-lets to the patients during the visit (check-in, when patient is assigned a room, or when provider enters the room), and when to use the booklet to actively point out a specific educational detail.
Practice-specific HPV vaccination rates were determined im-mediately prior to phase 1 education and again 6 and 12 months after beginning phase 2. Phase 2 WZB117 was defined by the date the practice began to distribute the booklets to their pa-tients. In an effort to control for external factors, which may affect adolescent HPV vaccination rates, including media-specific public service announcements and statewide mail-ings of HPV vaccine information, the practice-specific HPV vaccination rates were compared with statewide and countywide HPV vaccination rates at the same time points. Statewide and countywide immunization rates were retrieved from the New York State Immunization Information System, the state’s im-munization registry that is mandated for all vaccines admin-istered prior to 19 years of age.
Vaccination rates and change in rates from baseline (prior to phase 1) were calculated for each practice and county of prac-tice at 6 and 12 months following the initiation of the inter-vention. Descriptive statistics and 95% CI estimates were calculated for mean rates for individual intervention sites and for counties. Vaccination rates and change in rates for the prac-tices were compared with county rates at 6 and 12 months using paired Wilcoxon signed-rank tests. Analysis was stratified by sex and age group within sex. All statistical analyses were con-ducted using SPSS v 24 (SPSS Inc, Chicago, Illinois).
Six large general pediatric practices, A through F, each serving between 1900 and 6000 adolescents, participated in the program (Table III; available at www.jpeds.com). All 6 practices accept patients who are covered by public or private health insur-ance. Four of the practices describe themselves as serving a sub-urban population. Two practices describe themselves as serving rural, suburban, and urban communities.
All 46 providers and nurses working in the 6 practices com-pleted the anonymous survey just before phase 1 education was started, but not all participants answered every question included on the survey. At least 96% of the providers and nurses who responded strongly agreed with the following state-ments: HPV infection is associated with cancer, HPV vaccine is effective in preventing cancer (n = 45), and HPV vaccine is an important cancer prevention method for their adolescent patients (n = 44). Eight-five percent (n = 39) of participants strongly agreed that cancer prevention guidance was within
146 Suryadevara et al
February 2019 ORIGINAL ARTICLES
Practice rates 70 County rates
60 NYS rates
Figure 3. Overlapping graph depicting HPV vaccination rates by practice (colored columns), county of practice (horizontal bars), and New York state (NYS, diamonds) before, 6 months, and 12 months after implementation of phases 1 and 2 of the cancer prevention education program. Represented rates include A, vaccine initiation and B, completion among 11- to 12-year-olds, and C, vaccine initiation and D, completion among 13- to 18-year-olds. (Continues)
the scope of their practice and that their adolescent patients are at risk for acquiring HPV infection and the subsequent de-velopment of cancer (Figure 1; available at www.jpeds.com).
The self-reported delivery of cancer prevention guidance prior to the start of phase 1 varied by risk factor, with just over one-half of participants providing verbal counseling to all ado-lescent patients regarding smoking and HPV vaccine, and less than one-half regarding sun exposure, tanning bed expo-sure, physical activity, and hepatitis B vaccine (Figure 2, A; avail-able at www.jpeds.com). Written counseling to all adolescent patients regarding the following cancer preventing lifestyle
choices varied by factor, but none were 50% or higher (Figure 2, B; available at www.jpeds.com).