Implementation of the human papillomavirus school-entry requirement in Puerto Rico: barriers and facilitators using the consolidated framework for implementation research

Abstract

Background: In 2018, Puerto Rico (PR) enacted a Human papillomavirus (HPV) vaccine school-entry requirement for students ages 11 to 12. Using the Consolidated Framework for Implementation Research (CFIR), we aimed to identify potential barriers and facilitators of this implementation.Methods: We conducted a total of 36 qualitative interviews with key informants who were stakeholders from different organizations (Department of Health, Schools, Healthcare Providers, and Community organizations in favor of the requirement) from July 2018 to January 2020. Three researchers performed the interview guide, data coding, and analysis according to the CFIR framework. We evaluated construct rating variability between the organizations to determine barriers and facilitators.Results: The strongest facilitators determined under the CFIR construct include the stakeholder's awareness of the parent's and student's needs to meet the HPV school-entry requirement. Other facilitators include initiatives for school-entry policies and the relative advantage of this requirement over different strategies. The strongest barriers included the cost for private providers to administer the HPV vaccine, the negative in uence of social media about the vaccine, which affected parents' acceptance, and the lack of school nurses as available staff resources for the school entry requirement.Conclusions: Findings from this study can be used to improve implementation (adaptations/modi cations) and inform other US states and countries in earlier stages of consideration of the adoption of similar immunization policies. Most barriers can be modi able with the implementation of educational programs/training across schools, considering that they are the rst line of response to parents of this school entry requirement. Contributions To The LiteratureThis study is one of the few that explored the barriers and facilitators of the HPV school-entry vaccine requirement using the CFIR framework. This valuable tool leads us to evaluate the implementation process from multiple settings and stages.Results have shown the importance of capacity training to school staff and health stakeholders to boost parents' capacity and engage parents who are unaware or hesitant to vaccinate. These ndings provide new information about challenges that emerged in the implementation. These factors that support or impede the process will help guide other implementers that want to replicate HPVschool entry policies in other jurisdictions or countries.

Epidemiology of Cervical Cancer in the Caribbean

“…Bahamas [32][33][34], Curacao [37,38], French Guiana [40][41][42][43],Dominican Republic [39,78], Haiti [17,[79][80][81][82], Martinique [55], Netherlands Antilles [57,83], Puerto Rico [65,[84][85][86][87][88][89][90][91][92][93], St. Kitts and Nevis [66], St. Vincent and the Grenadines [66], Trinidad and Tobago [5,13,14,25,26], Barbados [35,94], Cuba [30,95], Dominican Republic [96,97], Puerto Rico [98], Jamaica [48,[51][52][53]99]…”

Implementing interventions to start HPV vaccination at age 9: Using the evidence we have

“…However, there were articles describing various approaches to adapt interventions – or components of interventions – for different populations and different channels. 68–72 This included reference to commonly used implementations of science theories, models, and frameworks, as well as needed cultural adaptation. Gilkey and colleagues, 73 examined the challenge with bringing evidence-based HPV vaccination interventions to scale in real-world settings.…”