The human papillomavirus (HPV) vaccine is effective in preventing infections that cause anogenital and oropharyngeal cancers in 37,300 US adults annually. Despite the safety and efficacy of the HPV vaccine to protect against six cancer types and other diseases, vaccine series completion rates among Texas youth (51.5%) continue to lag behind national completion rates (61.7%). A major barrier to vaccination is vaccine hesitancy, which can be addressed by increasing parental confidence and convenience and reducing complacency. Availability and implementation of adolescent immunizations in alternative settings, such as schools and community settings, can increase vaccination rates, particu...

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The human papillomavirus (HPV) vaccine is effective in preventing infections that cause anogenital and oropharyngeal cancers in 37,300 US adults annually. Despite the safety and efficacy of the HPV vaccine to protect against six cancer types and other diseases, vaccine series completion rates among Texas youth (51.5%) continue to lag behind national completion rates (61.7%). A major barrier to vaccination is vaccine hesitancy, which can be addressed by increasing parental confidence and convenience and reducing complacency. Availability and implementation of adolescent immunizations in alternative settings, such as schools and community settings, can increase vaccination rates, particularly among underserved populations. Overall Project Strategy: All for Them (AFT) is a multilevel multicomponent program comprising three evidence-based strategies (social marketing, comprehensive adolescent vaccination clinics, and school nurse training) aimed at reducing barriers to HPV vaccine uptake. This project implements AFT among youth living in medically underserved areas in four diverse Texas public school districts and communities in Harris, Chambers, and Tarrant counties. The social marketing campaign reframes HPV vaccination as cancer prevention and helps parents and high school youth recognize the vaccine as part of routine adolescent healthcare. The campaign uses empathy and empowerment in educational messages to increase HPV vaccine knowledge, positive attitudes, and ultimately vaccination. AFT provides print and digital creative media with a simple, positive message that all parents can endorse: Get your children all the vaccines they need to be healthy. Bilingual and culturally appropriate messages appeal to parents at different stages of readiness to adopt the HPV vaccine for their adolescent. The campaign includes collateral and messages for high school youth of age to consent for the HPV vaccine themselves and is designed to raise awareness about the opportunity to participate in comprehensive adolescent vaccination clinics. At pre-consented school-based vaccination clinics in public middle and high schools, youth are offered all ACIP-recommended childhood and adolescent vaccines at low or no cost. This successful strategy has been implemented since 2017 and has resulted in a 96% parental acceptance for HPV vaccination for students participating in AFT clinics. An expansion to the school-based vaccination clinics includes district- and community-wide clinics throughout the year. School nurse training is implemented to increase school nurses' HPV vaccine knowledge, positive attitudes, effective communication with parents, and documentation of HPV vaccination in students' school health records. Online (asynchronous) and live (synchronous) continuing nursing education courses are free for all Texas school nurses, providing 1.5 continuing education units. Skills training to enhance vaccine data recordkeeping will be implemented with nurses in participating districts, and audit and feedback will be conducted with nurses in participating schools to improve HPV vaccine record entry and management in school data systems. Specific Goals: In four Texas public school districts and communities, we will use the AFT social marketing campaign and clinics to increase HPV vaccine initiation and completion rates. We will deliver the campaign to communities including the parents of 51,000 public middle and high school youth in participating schools annually, as well as adult-age high school youth themselves. Clinics will be offered in 65 schools, with a specific goal of increasing HPV vaccination initiation by 12 percentage points over baseline and series completion by 10 percentage points over baseline for middle schools and 5 percentage points each for high schools. We will deliver 3,900 HPV vaccines to youth through clinics in participating schools and 3,180 HPV vaccines to youth in district- and community-wide clinics (n=7,080 total). We will conduct nurse training at multiple levels: educational course offered statewide, vaccination data entry skills training for participating districts, and audit and feedback for participating schools. Significance and Impact: The synergistic approaches used in this project can increase positive perceptions and acceptance of the HPV vaccine among parents, reduce logistical and access barriers to vaccination, increase nurses' recognition of the importance of the HPV vaccine and their role in the vaccination conversation with parents, and normalize HPV vaccination as part of routine adolescent healthcare for parents, youth, and school nurses. The parent and nurse education coupled with increased access to immunization services for youth in public middle and high schools can increase HPV vaccination uptake, ultimately reducing the prevalence of HPV infection and related cancers in diverse Texas communities.

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