1. Feasibility of Adolescent Vaccination in Non-Traditional Settings: A Qualitative Study in Denver, Colorado,
Matthew F. Daley, MD

2. Disclosures No relevant financial relationships
with any commercial interests are present
No reference will be made to the use of medications in manners not licensed by the Food and Drug Administration

3. Background
3 vaccines targeted at adolescents (MCV4, Tdap, HPV) recently licensed
Renewed focus on addressing challenges to adolescent immunization delivery
One challenge: adolescent health care utilization
Most adolescents identify a source of primary care
No visits within year: 18% to 32%
Adolescents who are poor, uninsured, from racial/ethnic minority groups less likely to routinely access care
Ref: Klein et al, Arch Pediatr Adolesc Med, 1998; Yu et al, J Adolesc Health, 2001; Newacheck et al, Health Serv Res, 2003

4. Non-Traditional Settings
Because adolescents underutilize primary care, increased attention to immunization in non-traditional settings
Non-traditional settings:
Working definition: settings that do not typically serve as comprehensive medical and vaccination homes for their patients
Broad: may include settings, such as school-based health centers, that do provide comprehensive care
Adolescent immunization delivery in non-traditional settings not extensively studied
Ref: Schaffer et al, Pediatrics, 2008

5. Study Objectives
In several different types of non-traditional settings, use standard qualitative techniques to explore:
Adolescent immunization delivery processes
Perceived advantages/disadvantages of adolescent immunization in these settings
Perceived advantages/disadvantages of HPV immunization

6. Study Setting Conducted May 2007-February 2008
Key informant interviews of administrators and clinicians in 4 settings, metro Denver, CO:
School-based health centers (SBHC)
Public health departments (PH)
Independent family planning clinics (FP)
Emergency departments/urgent care clinics (ED)
Within public health, interviews in immunization, FP, sexually transmitted diseases (STD) clinics
FP/STD clinics typically combined in PH

7. Participant Recruitment
Potential study sites identified by a variety of means:
Local clinic listings (internet, telephone books)
Sites’ recommendation of other sites
Investigators’ knowledge and contacts in community
A key initial contact identified at each site
Initial contact referred study team to other key informants within institution

8. Analytic Methods
Interviews digitally recorded, transcribed, imported into ATLAS.ti qualitative software
Analyzed using standard qualitative techniques, including both template and editing approaches
Ref: Crabtree and Miller, Sage Publications, 1999

9. Results: Settings for Interviews
31 key informant interviews conducted:
9 interviews in 4 school-based health centers
14 interviews in 4 public health departments
5 interviews in a large network of family planning clinics
3 interviews in 2 emergency department/ urgent care clinics

10. Characteristics of Sites and Informants
Majority of patients served by study sites were publicly insured or uninsured
Key informants:
27 of 31 female
Most either nurse practitioners or physician assistants
Most with >10 years clinical experience

11. Adolescent Immunization Delivery
All sites offered one or more immunizations to adolescents
SBHCs and PH immunization clinics offered all routinely recommended vaccines
Family planning and STD clinics within public health offered limited vaccines (e.g. Hep B)
Emergency/urgent care primarily provided tetanus-containing vaccines

12. Process of Immunization Delivery
Assessing vaccination status:
Written records
Immunization information systems (registries)
Parental consent: required in all settings except some family planning and STD settings

13. (Combined FP/STD clinic within public health)
Parental Consent
“We get the parents to sign for all vaccines at the time of registration for the school year” (SBHC)
“[Adolescents] are able to consent for testing and treatment of STDs and hepatitis B is an STD. They are able to consent on their own”
(Combined FP/STD clinic within public health)

14. Financing of Vaccines Given
Majority of sites participated in Vaccines for Children (VFC) program
Not participating in VFC:
Emergency department
Independent family planning clinic network
Some FP/STD clinics within public health
Many sites did not have processes for billing private insurance for vaccines given

15. (Independent FP clinic network)
Vaccine Financing
“[Whether to participate in VFC] basically boiled down to again taking federal or state dollars and then being accountable for everything else that comes with that”
(Independent FP clinic network)
“We are not set up, we are not capable, we do not have the feasibility to bill for anything we do for anybody” (FP/STD clinic within public health)

16. Advantages of Adolescent Vaccination in These Settings
Most sites described benefits such as convenience, saving parents’ time, easy access to adolescents in schools
Some sites described potential to reach adolescents who might not otherwise be seen for vaccination

17. Perceived Advantages
“I could see us being a benefit to the patients in terms of getting them immunized because this may be the only time they come in and a lot of patients do use us only”
(ED)
“It’s easier. Parents don’t have to take time off from work. We chase [the students] around!” (SBHC)
“Providing them with the whole gamut of preventive health services is very important because for many of them we are their only provider” (SBHC)

18. Disadvantages of Adolescent Vaccination in These Settings
Challenges across multiple types of settings:
Competing clinical priorities
Staff knowledge and demands on staff time
Infrastructure issues such as vaccine storage
Vaccine tracking and potential for overimmunization
In ED settings only: perception that offering vaccines other than tetanus did not fit with overall clinical mission

19. Perceived Challenges with Vaccine Knowledge and Tracking
“If you don’t keep updated on your vaccines…it is going to take you twice as long to draw them up and figure out what you are actually giving than it would be for anybody else. And I think your chance of error would be greater”
(ED)
“The STD clinic doesn’t have access to [the state registry] and it takes time to [check the registry]. You know, you are giving somebody a tetanus and maybe they got it before and so you can be overimmunizing people”
(FP/STD clinic within public health)

20. Perceived Lack of Fit with Mission
“We are an Emergency Department. Our mission is to deal with emergent issues and visits. Concern about that type of preventive care is really outside our scope.” (ED)
“We tell them you have to go to your doctor [for routine vaccines] and that’s probably the way it is going to be.” (ED)

21. HPV Vaccination: Advantages in These Settings
Some sites described potential benefits such as synergy with mission, convenience, providing an opportunity for additional education
FP/STD clinics, in particular, described benefits related to expertise in sexually transmitted infections and anonymity

22. Perceived Advantages (HPV)
“If they have a reaction, they just have to walk down to the clinic and say, ‘my arm is red and swollen.’ It is not a matter of calling the doctor and waiting [to be seen.]” (SBHC)
“Maybe there is a certain amount of anonymity about coming to a clinic that is not your normal primary care clinic.”
(FP/STD clinic in public health)
“It is easy to talk to them about cervical cancer because cervical cancer is really our forté. We understand it. It would be easy to counsel an adolescent about that.”

23. HPV Vaccination: Perceived Barriers in These Settings
Vaccine financing
Parental consent issues
Vaccine tracking and the need for 3 doses
Need for additional staff training and infrastructure

24. Perceived Barriers to Offering HPV
“It makes perfect sense to us [to offer HPV.] To our attorney, he just didn’t feel like that was covered under the role of a Title X clinic.”
(FP/STD clinic in public health)
“We don’t offer [HPV vaccine] because we don’t have funds to pay for it. So we refer kids to the immunization clinic or community health centers”

25. Perceived Barriers to Offering HPV
“We have to kind of wrestle with…do we require parental consent [for HPV vaccine.] A lot of parents wouldn’t want their children coming to family planning to begin with and then also receiving a vaccine they didn’t consent to…so it’s really a philosophical and policy decision that we have yet to make.”
(FP/STD clinic in public health)
“It is not practical to provide 3 doses of anything. We are not the medical home.” (ED)

26. Limitations
Standard qualitative approach is to conduct interviews until saturation of ideas reached
While saturation reached for SBHCs, PH clinics, may not have been reached for:
Independent FP clinics: only one large network in Colorado from which to sample
EDs: few agreed to participate (more interviews planned)
Other types of non-traditional settings (pharmacies, teen clinics, retail-based clinics) not examined

27. Summary of Findings
Many non-traditional settings already providing at least some immunizations to adolescents
SBHCs reported providing comprehensive vaccination services
Challenges around vaccine financing common:
Most sites participated in VFC
Non-VFC sites reported barriers to funding vaccines for VFC-eligible patients
Many sites did not bill private insurance, limiting ability to vaccinate privately insured

28. Summary of Findings
For some sites, perceived lack of fit of routine adolescent vaccination with mission
However, many sites recognized opportunities to immunize high-risk adolescents, such as those without medical homes, those who only seek care in non-traditional settings

29. Implications
Non-traditional settings are diverse; some may have greater barriers to comprehensive adolescent vaccination
Additional quantitative work needed to better define immunization delivery capacity in non-traditional settings with high potential (e.g. SBHCs)
Non-traditional settings may serve as an immunization “safety-net” for high-risk adolescents, particularly if issues of vaccine financing resolved

30. Research Collaborators
University of Colorado Denver
Allison Kempe, MD, MPH
Deborah Main, PhD
Lori A. Crane, PhD, MPH
Carolyn Nowels, MSPH
Jennifer Barrow, MSPH
Jennifer L. Pyrzanowski, BA
Centers for Disease Control and Prevention
C. Robinette Curtis, MD, MPH

31. Acknowledgments
This investigation was funded by the Centers for Disease Control and Prevention