Partnering with healthcare systems to improve HPV vaccination:The perspective of immunization program managers

ABSTRACT

The US’s 64 CDC-funded immunization programs are at the forefront of efforts to improve the quality of adolescent vaccination services. We sought to understand immunization program managers’ perspectives on partnering with healthcare systems to improve HPV vaccine uptake. Managers of 44 state and local immunization programs completed our online survey in 2019. Immunization managers strongly endorsed the importance of partnering with systems to improve HPV vaccine uptake (mean = 3.8/4.0), and most wanted to do so in the next year (mean = 3.5). Immunization managers reported that common barriers included difficulty contacting systems’ leadership (57%), differing organizational cultures (52%), and time (52%). Many perceived systems as not prioritizing HPV vaccination (77%). Immunization managers expressed strong interest in participating in a training on partnering with systems (mean = 3.5). Overall, immunization managers are highly interested in partnering with systems to improve HPV vaccine uptake. Training and other support are needed to expand programs’ capacity for such partnerships.

PLAIN LANGUAGE SUMMARY

Immunization managers are interested in partnering with healthcare systems to improve HPV vaccination. However, support may be needed to facilitate partnerships between immunization programs and healthcare systems.

KEYWORDS:

• immunization manager
• quality improvement
• human papillomavirus vaccine

Introduction

Widespread human papillomavirus (HPV) vaccination could prevent most of the more than 34,000 HPV-associated cancers diagnosed in the United States (US) annually.¹ However, despite national guidelines for routine HPV vaccination before age 13, only 45% of 13 year-olds were up to date on the multi-dose series in 2019.² Centers for Disease Control and Prevention (CDC)-funded immunization programs, which are based in health departments in all 50 US states and 14 additional local and territorial areas, are important sources of support for HPV vaccination.³ Working directly with primary care providers, immunization programs distribute vaccine doses through the federally-funded Vaccines for Children (VFC) program, which provides recommended vaccines at no cost to eligible children nationwide.⁴ Immunization programs additionally promote vaccination in their jurisdictions by educating primary care providers about vaccine administration and communication, and by conducting assessment and feedback on providers’ HPV vaccination rates, often using data from state and regional immunization information systems (IIS).^5–9 In these ways, immunization programs provide an existing network of implementation support for the delivery of vaccines, including HPV vaccine, in primary care settings.

Immunization programs have traditionally worked with individual clinics or practices (hereafter “clinics”) to improve vaccination services, but primary care in the US is rapidly consolidating.^10–12 Primary care clinics increasingly operate within large healthcare systems, and immunization programs are beginning to partner with these systems on vaccination quality improvement efforts.^10,11,13 Shifting from an individual clinic-by-clinic approach to a healthcare system approach may require different strategies. For example, immunization program staff may need to work with a healthcare system leader rather than individual clinics or they may need to select vaccination strategies that can be implemented consistently across multiple clinics within a system. Systems’ organizational cultures may focus on serving the needs of existing patients facing more acute or chronic health conditions, and in this way differ from health departments’ focus on preventive care at the broader population level. In addition, systems may be increasingly reliant on their own data to track vaccination rates, rather than depending on immunization programs to provide data from the IIS.^13,14 Given the shifting role immunization programs play in supporting vaccine delivery, research is needed to understand programs’ experience working with healthcare systems, interest in building partnerships with systems, and perceived barriers to forming productive relationships.

To address this gap, we conducted a study of immunization program managers in partnership with the Association of Immunization Managers (AIM). Founded in 1999 with funding from organizations including the CDC, AIM fosters collaboration among immunization program managers (hereafter “managers”) across 64 US jurisdictions.³ Managers, often partnering with other stakeholders, work to track and improve vaccination rates in their states or jurisdictions, through context-specific programming, education of providers, policymakers, and the public, and coalition building.³ We partnered with AIM to conduct an online survey of their members to better understand managers’ perceptions about and experience partnering with healthcare systems to improve HPV vaccine uptake. We also sought to identify perceived barriers to building relationships between immunization programs and healthcare systems to improve HPV vaccine uptake. By providing novel data on an understudied aspect of vaccine delivery, this study can help inform future programming designed to support managers in their efforts to partner with healthcare systems to best serve patients in their jurisdictions.

Materials and methods

Participants and procedures

In partnership with AIM, we surveyed managers of CDC-funded immunization programs in 2019. These 64 programs serve six cities (Chicago, IL; District of Columbia; Houston, TX; New York, NY; Philadelphia, PA; San Antonio, TX;), 50 US states (including four “rest of state” jurisdictions in IL, NY, TX, and PA), and eight territories or affiliated jurisdictions (e.g., Puerto Rico). We administered the survey online through AIM’s established communication network from December 2019 through February 2020. We sent non-respondents one e-mail reminder six weeks after the initial survey invitation. A total of 44 of 64 managers (69%) completed the survey. Of these, respondents managed immunization programs serving states (n = 38, 86%), cities (n = 3, 7%), or territories (n = 2, 5%); one jurisdiction response was missing (2%). All participants provided informed consent, and the research was determined to be exempt from review by the University of North Carolina Office of Human Research Ethics. This paper summarizes our findings.

Measures and analysis

The survey instrument began with an introductory statement that defined healthcare systems as those “with 4 or more clinics or practices owned by the same parent company. Healthcare systems can include health maintenance organizations (HMOs), managed care plans (e.g. Kaiser Permanente), physician networks, and other integrated delivery systems. This definition does not include Federally Qualified Health Centers (FQHCs).” The survey assessed managers’ perceptions of working with healthcare systems to improve HPV vaccine uptake with four closed-ended items that assessed: the importance of partnering with systems, their desire to work closely with systems’ leadership, and their experience working with systems’ leadership using a 4-point response scale (1 = “strongly disagree”; 2 = “disagree”; 3 = “agree”; 4 = “strongly agree”). The survey also assessed managers’ interest in a training session on how to work with systems using a 4-point response scale (1 = “not interested”; 2 = “slightly interested”; 3 = “moderately interested”; 4 = “very interested”) (Table 1). Two items assessed perceived barriers to partnering from the perspective of immunization programs and healthcare systems, respectively. For each item, respondents could endorse a pre-specified list of barriers or elect to specify an “other” response as an open-ended response.

Table 1. Immunization managers’ perceptions of working with healthcare systems to improve HPV vaccine uptake (n = 44)

	Mean	(SD)
It is important for my immunization program to partner with healthcare systems to administer HPV vaccine to adolescents.^a	3.8	(0.54)
Our immunization program would like to work closely with healthcare systems’ leadership to improve HPV vaccine uptake in the next year.^a	3.5	(0.76)
Our immunization program has experience working with healthcare systems’ leadership to improve HPV vaccine uptake.^a	3.0	(0.82)
How interested would you be in attending a brief training about working with healthcare systems to improve HPV vaccine uptake?^b	3.5	(0.72)

SD: standard deviation.

^aResponse options ranged from “strongly disagree” (1) to “strongly agree” (4).

^bResponse options ranged from “not interested” (1) to “very interested” (4).

Results

Immunization managers strongly endorsed the importance of partnering with healthcare systems to improve HPV vaccine uptake (mean = 3.8 of 4.0, Table 1), and many wanted to work closely with systems in the next year to do so (mean = 3.5). However, managers rated their actual experience working with systems’ leadership to improve HPV vaccine uptake more modestly (mean = 3.0). Most managers were interested in attending a brief training about working with healthcare systems to improve HPV vaccine uptake (mean = 3.5).

Managers most often perceived difficulty making contact with system leaders as a barrier they faced to working with systems (57%, Figure 1). Other common barriers included immunization programs lacking time (52%) and differing organizational cultures (52%). Eleven managers (26%) cited other barriers to working with healthcare systems that included competing priorities, getting buy-in from systems, difficulty adapting a single strategy to work with diverse communities, and lack of financial support for HPV vaccine programs.

Figure 1. Perceived barriers immunization programs face to partnering with healthcare systems to improve HPV vaccine uptake (n = 44).

In terms of barriers managers perceived for systems, respondents most often reported that systems do not always prioritize HPV vaccine uptake (75%, Figure 2). Other common barriers were that healthcare systems preferred to rely on their own data (55%) or HPV vaccine quality improvement programs (41%), or that they didn’t see the value to partnering (37%). Five managers (11%) cited other perceived barriers, including lack of time and resources in systems to dedicate to HPV vaccine quality improvement, a perception in systems that immunization program interventions are intrusive or disruptive, and staff turnover.

Figure 2. Perceived barriers healthcare systems face to partnering with immunization programs to improve HPV vaccine uptake (n = 44).

Discussion

Our study found that immunization program managers are highly interested in working with healthcare systems to improve HPV vaccine uptake and believe that it is important to do so. However, fewer managers reported having experience working with healthcare systems. Perceived barriers included that system leaders are difficult to contact, do not prioritize HPV vaccination, and prefer to use their own vaccine data rather than IIS data. Given that most managers indicated they would be interested in training about how to work with systems, each of these barriers warrants further consideration.

First, managers’ reported difficulty contacting healthcare system leadership likely because they are used to working with separate clinic-level contacts on vaccine QI. However, many healthcare systems now have in-house QI leaders to manage vaccine QI projects system wide.¹⁴ As managers shift from working with individual clinics to larger systems, they will likely need to work with these QI leaders.¹² Managers’ difficulty reaching system QI leaders may be partly due to the challenge of identifying the correct person to contact in a large healthcare system; system QI leaders often have a wide variety of titles and training, and typically hold more senior roles in healthcare systems than clinic-level contacts.¹⁴ The managers themselves may need to engage in outreach activities, rather than relying on the more junior immunization program consultants who typically deliver clinic-based education. Other organizations with established ties to systems, such as the American Academy of Pediatrics and other professional organizations, could be instrumental in facilitating these relationships.

A second key barrier was managers’ perception that healthcare systems do not prioritize HPV vaccination, which may indicate another opportunity for training and support. Managers can play a key role in motivating systems to focus on HPV vaccination, and making sure that adolescent vaccine QI metrics are not overlooked in the midst of many other competing priorities or differing organizational cultures. Managers can work to communicate CDC’s national goals around vaccination that clinics and healthcare system leaders may not be aware of. As described above, managers may be instrumental in establishing relationships with QI leaders in healthcare systems to ensure success of future vaccination education sessions. Managers may be interested to know that, contrary to their perceptions, recent research has found that healthcare system leaders are very interested in HPV vaccine QI projects, and express willingness to consider outside partnerships for HPV vaccine QI.¹⁴ A partnership with interested healthcare system leaders could enable managers to provide motivation, data, and implementation expertise at a level that has a larger impact on HPV vaccine improvement efforts than the traditional single clinic approach.¹² For this reason, CDC’s Immunization Quality Improvement for Providers (IQIP) program, has increasingly encouraged immunization programs to engage systems.¹⁵

Managers reported that a third key barrier to working with healthcare systems on HPV vaccine QI is that leadership often prefers to use vaccination data from their own systems’ EHRs. In the past, individual providers often relied on vaccination data provided by IIS and managers, but now many healthcare systems have developed their own electronic health records to track vaccination. However, systems may not have high-quality data and may track vaccine metrics other than guideline-consistent quality metrics.^14,16 Inconsistent measurement may give providers the mistaken impression that HPV vaccination guidelines are flexible,¹⁷ and fragmented vaccination tracking can lead to both under-immunization and over-immunization.¹⁸ The shift in the role of vaccination data may be an opportunity for managers to advocate for systems to use guideline-consistent metrics, such as the Healthcare Effectiveness Data and Information Set (HEDIS) measure, which evaluates completion of the HPV vaccine series before age 13.¹⁹ Furthermore, interoperability between healthcare systems’ EHR data and IIS is essential to ensure that immunization programs can accurately track vaccinations jurisdiction-wide and may enhance insights and provide opportunity to tailor strategies to systems’ needs to improve HPV vaccine delivery.¹⁸ Working toward interoperability between IIS and systems’ EHRs can help build relationships and improve systems’ data and metrics, thus resulting in increased quality of IIS data. Systems may also have more granular information about vaccine refusals or other barriers and have data from an entire healthcare system EHR available;¹² managers may need to be more flexible about vaccine data sources, and consider the EHR data that systems may bring to the table. Additionally, managers may also be able to use systems’ EHR dashboards to communicate feedback to providers, or leverage systems’ learning management systems to offer educational content directly to providers.¹²

Our study’s strengths include a geographically diverse sample, representing over two thirds of US immunization program managers. Immunization programs play an understudied but vital role in supporting adolescent vaccine delivery; understanding how to best support managers in navigating the changing US healthcare system is crucial to ensuring the success of federally-funded immunization programs. Our study also has several limitations. We acknowledge that, while managers provide an important perspective in HPV vaccine QI efforts, the inclusion of other perspectives, including systems leaders, is also important. We also recognize that healthcare systems are not monolithic; systems have a wide variety of sizes, types, cultures, and populations served. Future research can extend the present study by identifying key characteristics of successful partnerships between immunization programs and healthcare systems and exploring opportunities to enhance relationships to improve HPV vaccine QI.

Conclusion

The changing landscape of US healthcare presents new challenges and opportunities for immunization program managers to improve HPV vaccination. As systems increasingly have their own data systems and their own HPV vaccine QI programs, immunization managers may need to adjust their roles from data providers working with individual clinics to collaborators and motivators working with system leadership to prioritize HPV vaccination. While this adjustment may require some training on how best to engage healthcare systems, managers agree that working with systems is important and express interest in learning how to create good partnerships to best serve their populations.

Abbreviations

Table

AIM	Association of Immunization Managers
CDC	Centers for Disease Control and Prevention
FQHCs	Federally Qualified Health Centers
HEDIS	Healthcare Effectiveness Data and Information Set
HMOs	health maintenance organizations
HPV	human papillomavirus
IQIP	Immunization Quality Improvement for Providers
VFC	Vaccines for Children

Disclaimer

The findings and conclusions in this report are those of the author(s) and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Disclosure Statement

N.T. Brewer has served as a paid advisor for Merck, CDC and WHO. A. Bjork is currently employed by the US Centers for Disease Control and Prevention, which provided funding for this research to the UNC Department of Health Behavior, Gillings School of Global Public Health by the US Centers for Disease Control and Prevention through Cooperative Agreement U01IP001073-02. The remaining authors disclosed no conflicts of interest.

Additional information

Funding

This study was funded by a cooperative agreement with the Centers for Disease Control and Prevention [U01IP001073-02]. Brigid Grabert’s and Rachel Kurtzman’s time was supported by a training grant from the National Cancer Institute [T32CA057726-30].