1. INCREASING UPTAKE OF ADOLESCENT VACCINES IN NC SCHOOL HEALTH CENTERS Ashley Leighton, MPH Cervical Cancer-Free NC Cathy DeMason, RN, BSN Director, Rockingham County Student Health Centers Rockingham County Student Health Centers

2. CCFNC is funded by an unrestricted educational grant from GlaxoSmithKline. Conflict of Interest Statement

3. Background and Framework School Health Center Survey Intervention Planning & Partnerships Intervention

4. Background and Framework School Health Center Survey Intervention Planning & Partnerships Intervention

5. Becoming Cervical Cancer-Free  Cervical cancer is fully preventable through screening and vaccination  Each year 300 women in North Carolina die from this preventable disease  CCFNC’s priorities are vaccination and screening

6. The Carolina Framework identifies 4 main causes of cervical cancer deaths: HPV infection Lack of screening Screening errors Not receiving follow-up care Carolina Framework

7. Becoming Cervical Cancer-Free  US uptake of HPV vaccine lags behind Source: NIS-Teen 2010. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6033a1.htm?s_cid=mm6033a1_w

8. Let’s make HPV vaccine part of routine adolescent care.

9. Why schools?  Meet adolescents where they are  Adolescents least likely to see doctors  School health centers often already equipped to administer vaccines  Other countries with high rates of HPV uptake have utilized school settings

10. A step back  How can we help school health centers increase uptake of adolescent vaccines? Let’s ask them!

11. School Health Advisory Board  Created Advisory Board with representatives from NCSCHA, DPH, DPI, Immunization Branch, school health center staff, and others with SHC expertise

12. Background and Framework School Health Center Survey Intervention Planning & Partnerships Intervention

13. SHC survey  Fall 2010  Topics  Barriers to HPV vaccine  Potential interventions  Partnership with NCSCHA  33 SHCs offering HPV vaccine

14. SHC survey results  School health centers are already doing a lot! 37%Asking parents for consent while they are at school 42%Printing and mailing letter endorsing adolescent vaccines 82%Parent reminders that children are due for adolescent vaccines

15. SHC survey results  Several barriers still exist Barrier (%) Greatest Concern (%) Out-of-pocket costs for children to receive privately purchased HPV vaccine 7951 Upfront costs of ordering and stocking the privately purchased HPV vaccine 6730 Inadequate reimbursement by insurance companies for providing privately purchased HPV vaccine 4218 Out-of-pocket costs for children to receive VFC supplied HPV vaccine 3321 Students not returning the consent form 7621 Obtaining records of prior immunizations 616 School administrators’ concern that providing HPV vaccine will take students away from classes 210 Cost

16. SHC survey results  82% of school health centers interested in interventions  but many had limited staff  Most do-able interventions:  student incentives for getting adolescent vaccines  printing and mailing letters endorsing adolescent vaccines  Interventions rated most likely to work:  student incentives for getting adolescent vaccines  parent reminders for adolescent vaccines  asking parents for consent while they are at school

17. Background and Framework School Health Center Survey Intervention Planning & Partnerships Intervention

18. Creating an action plan Demonstration project… Cost barrier… Consent barrier…

19. Bringing on partners  School health centers with  Interest in partnership  Proximity to CCFNC office  Strong leadership Rockingham County Student Health Centers

20. Designing an intervention  Create materials that make the consent process easier for parents  Make sure the materials  Are easy to use (especially consent form)  Promote adolescent vaccines  Highlight convenience of SHCs  Use voices and images of parents and students

21. Testing materials 9 parents 4 Rockingham 3 Durham 2 other counties 12 SHC staff 7 directors or managers of SHCs 5 nurses and other clinical staff Cognitive interviewsOnline survey

22. Background and Framework School Health Center Survey Intervention Planning & Partnerships Intervention

29. Other elements  STAMPED and addressed return envelope  Movie ticket drawing  Other incentives

30. Implementation  CCFNC printed and prepared packets

31. Implementation  Rockingham SHCs took the lead from there  Distribution and mailing of packets  Reminder auto-calls

32. Implementation  Surprising amount of phone calls regarding cost of vaccines  Additional letter sent to parents with private insurance  Materials needed to make costs clearer

33. Evaluation: Process  CCFNC tracking hours, costs, time  Rockingham staff tracking  Packet and letter distribution  Data from received consent forms  Costs  Hours  Bi-weekly partner meetings

34. Evaluation: Process  Phone interviews with parents are underway

35. Evaluation: Outcome  Tracking Doses  Comparison sites  Results forthcoming

36. Challenges  Phone calls from parents  Cost  Vaccine history  Time  Ordering vaccines  Incidental change in Health Choice insurance from BC/BS to Medicaid caused confusion

37. Successes  A good amount of forms have come back to SHCs  Children are getting vaccinated  Strong partnership  Parents are asking questions and getting educated

38. Next Steps  Results and materials will be available next year  Implementation Guide  Research-to-Practice Report

39. Next Steps  We hope materials will be useful for…  School health centers  Mass vaccination clinics  Future partnerships  Contact us if you are interested!  Info@ccfnc.org

40. Acknowledgements Rockingham County Student Health Centers staff Rockingham County parents and students SHC staff who took time out of their busy schedules to participate in interviews School Health Center Adolescent Immunization Advisory Committee  Amanda Dayton (NC Division of Public Health)  Cathy DeMason (School health center representative)  Anne Derouin (School health center representative)  Dan Garsen-Angert (NC Division of Public Health)  Chris Minard (NC Department of Public Instruction)  Connie Parker (North Carolina Community School Health Alliance)  Carol Tyson (NC Division of Public Health) CCFNC staff and students