Introduction

Despite the safety and efficacy of the human papillomavirus (HPV) vaccine, vaccination rates in the U.S. and Texas remain low among 13–17-year-olds (61.7% and 51.5% up to date (UTD), respectively). Access to care is a common barrier to vaccination. Leveraging school-based health clinics (SBHCs) in medically underserved areas is one strategy to enhance vaccine delivery. We assessed barriers and opportunities to improve vaccination in SBHC settings. 

Methods

We conducted  structured interviews with providers and staff in 27 SBHCs that care for adolescent patients and are affiliated with Legacy Community Health (Legacy), a Federally Qualified Health Center in Houston, Texas. SBHCs are located within school buildings and operate during school hours. They are staffed by a nurse practitioner and medical assistant and operate independently of the school nurse to provide care for Legacy patients. 

The structured interview consisted of a 45-item questionnaire. Perceived barriers to HPV vaccination were assessed using a 5-point Likert scale. Implementation of HPV vaccine-promoting clinical practices was determined by listing strategies and asking participants if they have been implemented. Open-ended questions were used to elicit perspectives on unique challenges and opportunities at SBHCs. Descriptive statistics were used to summarize responses. Open-ended responses were coded and organized into themes. 

Results

Between March-May 2023, the research team visited each of the Legacy SBHCs serving adolescent patients. Most agreed that adolescents missed opportunities to vaccinate due to the pandemic (81.5%).  Other barriers noted from the survey were lack of vaccine records (77.8%), hesitancy regarding HPV vaccine (48.1%), misinformation about HPV vaccine on the internet/social media (44.4%), and language/cultural barriers (40.7%). All clinics reported carrying both Vaccines for Children and private stock vaccines, recommending the HPV vaccine as strongly as other vaccines, routinely entering records into the electronic medical record, starting the vaccine at 9 years old, using ImmTrac2 to check for records, and having the parent sign a refusal form if they refuse the vaccine. Only 9 clinics reported checking immunization records at both sick visits and well child checks and no clinics regularly followed their HPV vaccination rates. None of the SBHCs reported having a standardized method for recalling patients for booster doses.

 In open-ended responses, interviewees noted challenges unique to the SBHC environment, many because parents frequently are not present at the time of the visit. At 77.8% of clinics, getting signed parental consent forms was an obstacle. Parents are also frequently hard to access by phone at the time of the visit, which decreases time for educating parents about the benefits of vaccination, makes it harder to build trusting relationships, and means that a parent is not able to soothe patients who are afraid of shots. Finally, SBHCs are closed when school is out, which can complicate follow-up appointments and affects supply delivery. Advantages unique to the SBHC setting were also noted. High school affiliated clinics conducted “senior check out” visits, where they bring in Seniors to ensure they are UTD on vaccinations. It was noted that many get their HPV vaccination at this visit, as they are 18 years old and can consent for themselves. Interviewees also noted that SBHCs allow for increased time spent with each patient, allowing providers to build trusting relationships with their adolescent patients.

Conclusion

SBHCs reported unique barriers to delivering the HPV vaccine. While many currently implement HPV vaccine-promoting practices, there is a need and desire for additional HPV vaccination strategies. SBHCs may benefit from additional resources to provide catch-up vaccines for patients who fell behind during COVID, obtain current vaccination records for patients, and follow up on parental consent forms.