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HPV ECHO for Providers:

Strengthening Opportunities to Increase HPV Vaccination Coverage in Rural Primary Care

By William A. Calo and Josheili Y. Llavona-Ortiz

HPV vaccination rates are particularly low in rural areas of the United States, including Pennsylvania. Well-known barriers for low HPV vaccination rates include lack of provider recommendations and few available evidence-based interventions focused on the vaccine communication needs of both rural providers and families. To address these issues in rural Pennsylvania, we are conducting a study using the Extension for Community Healthcare Outcomes (ECHO) Model to disseminate evidence-based HPV vaccine communication training to rural primary care clinics or clinics predominantly serving rural families.

"We must continue to offer evidence-based training to providers to increase HPV vaccination in rural communities. Simultaneously, we should consistently follow up with those parents who initially refused the vaccine or who didn’t vaccinate their children due to healthcare disruptions caused by the pandemic so that they get the HPV vaccine in a future clinic visit."

- William A. Calo, PhD, JD, MPH

William A. Calo

Our National Cancer Institute-funded study is a cluster randomized controlled trial (RCT) evaluating the impact of HPV ECHO using the Announcement Approach to train primary care providers and HPV ECHO+ using the Announcement Approach and also recall notices to vaccine-declining parents) compared to no intervention on HPV vaccine initiation among adolescents, ages 11–14, between baseline and 12-month follow-up. We are also surveying primary care providers from participating clinics and vaccine-declining parents to understand HPV vaccine communication practices. In this study, we have recruited 30 clinics, serving over 41,000 adolescent patients in rural Pennsylvania. Primary outcome data collection will continue until August 2024.

Our initial results show that:

  1. Clinics struggle to send notices to follow up with parents after they decline the HPV vaccine.
  2. Almost half of primary care providers do not offer or plan to talk about HPV vaccination with vaccine-declining parents at the child’s next visit.
  3. A majority of vaccine-declining parents are willing to talk again about the HPV vaccine despite only one-third of them reporting that their child’s provider revisited their decision at the next visit.
Josheili Y. Llavona-Ortiz, MS

There’s no doubt that the COVID-19 pandemic brought an array of challenges that, as researchers, we need to acknowledge and address. However, we must continue to do so from a perspective of kindness, understanding, and respect alongside our community members. 

By being aware of the vaccination rates and adaptations in communication practices that took place during to the pandemic, we can identify opportunities that will help us increase HPV vaccination uptake.
- Josheili Y. Llavona-Ortiz, MS

These data reveal opportunities to increase secondary acceptance of HPV vaccination by improving systems communication and provider messaging to vaccine-declining parents.

As part of another grant, we are also conducting a project to understand the impact of the COVID-19 pandemic on HPV vaccination rates and HPV vaccine recommendations in Pennsylvania. This diversity supplement supports Ms. Josheili Llavona-Ortiz, the first female Hispanic student of the Doctor of Public Health program at Penn State. This student-led project will be conducted in two phases. In Phase 1, the recommended vaccine rates (including HPV, Tdap, and meningococcal) for children 9-17 years old from 2019-22 are being assessed across Penn State Health clinics. For Phase 2, primary care providers are being interviewed to understand how the COVID-19 pandemic and the approval of the COVID-19 vaccine for children have changed their vaccine communication practices.

To learn more about these studies, visit NIH Reporter R37CA253279 and ClinicalTrials.gov NCT04587167.

William A. Calo, PhD, JD, MPH is an Associate Professor in the Department of Public Health Sciences at Penn State College of Medicine, Director of the Implementation Science Core of the Penn State Clinical and Translational Science Institute, co-leader of the Cancer Control Program, and Assistant Director, Community Outreach and Engagement, Penn State Cancer Institute.   

Dr. Calo is a Hispanic implementation scientist with expertise in HPV vaccine communication and systems interventions. He is the PI of the HPV ECHO Study, a cluster RCT evaluating HPV vaccine communication training to rural primary care providers and exploring secondary acceptance among parents. Dr. Calo is the Co-leader of the Intervention Core for the NCI-funded Program Project “Improving Provider Announcement Communication Training (IMPACT).” He is very active serving the community, including as co-leader for the Pennsylvania HPV/HBV Related Cancers Workgroup. 

Josheili Y. Llavona-Ortiz, MS is a Doctor of Public Health student in the Department of Public Health Sciences at Penn State College of Medicine.

Josheili is a first-generation Puerto Rican doctoral student. Her work has primarily focused on cancer prevention and control. She previously worked on a colorectal cancer screening behavioral trial across Federally Qualified Health Clinics across Puerto Rico. Additionally, she worked as an epidemiologist during the COVID-19 pandemic response. She moved to Pennsylvania in 2021 after being recruited by Dr. William Calo. Under Dr. Calo’s mentorship, she has been training in HPV and COVID-19 vaccine communication across diverse communities. She has also served as an interpreter at flu and COVID-19 vaccination events in the state.