Understanding system-level influence on practice change for HPV vaccination improvement within safety-net clinics

Context: Practice change for human papillomavirus (HPV) vaccination improvement within a large, multisite federally qualified health center (FQHC).

Objective: To understand system-level influence on practice change for increasing HPV vaccination rates among adolescents (ages 9-17) at a FQHC.

Study Design and Analysis: Qualitative design and analysis guided by Practice Change Model (PCM) and RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance).

Setting or Dataset: Practice observation and 35 in-depth interviews completed at three safety-net clinic sites from Oct 2022-Jan 2023.

Population Studied: Clinic leaders (e.g., site medical directors), providers (e.g., physicians), and staff (e.g., medical assistants) at three clinics and system leaders (e.g., quality director, vaccine director).

Intervention/Instrument: Semi-structured interview guides and observation form developed using PCM and RE-AIM.

Outcome Measures: System and practice-based factors associated with implementation of evidence-based strategies (EBS).

Results: Findings revealed conflicting views and motivations between system and clinic leaders resulting in inconsistent implementation of HPV vaccination EBS. System leaders rolled out EBS including standing orders for HPV vaccine doses (e.g., second and third doses) and changing electronic health record (EHR) prompts to begin at age 9 instead of age 11 for first dose. Inconsistent awareness about system-level EBS (e.g., standing orders, EHR prompts) emerged among clinic leaders, providers, and staff. Although some knew of change to EHR prompts, few reported standing orders existed or stated for different doses (e.g., first dose). Clinic leaders, providers, and staff also shared HPV vaccination was not consistently introduced at age 9, with many providers across sites preferring to introduce at age 11 to bundle with other vaccines. System leaders communicated changes by email to clinic leaders/providers and in meetings that many providers reported not attending. Overall, system leaders were unaware of inconsistent implementation that hindered adoption of EBS at clinic sites.

Conclusions: Findings illuminate challenges with implementation and maintenance of system-level EBS for improving HPV vaccination that may threaten sustainability. System-level factors that enable consistent change across clinics include clearly established communication channels, provider/staff trainings on changes, and routine follow-up with clinic leaders.