Evaluation of a Minigrant Program for Multilevel Interventions to Promote Human Papillomavirus Vaccination in Rural Communities in Georgia

Cam Escoffery, PhD, MPH¹; Courtney Petagna, MPH¹; Rithika Chari, MPH¹; Erica Hsu, MPH¹; Rohini Vijay Kadoo, MPH¹; Regine Haardörfer, PhD¹; Yue Guan, PhD¹; Alexandra B. Morshed, PhD, MS¹; Jessica Wells, PhD, RN, FAAN²; Sarah Blake, PhD, MA³; Remy Hutchins, RN, MPH⁴ (View author affiliations)

Suggested citation for this article: Escoffery C, Petagna C, Chari R, Hsu E, Kadoo RV, Haardörfer R, et al. Evaluation of a Minigrant Program for Multilevel Interventions to Promote Human Papillomavirus Vaccination in Rural Communities in Georgia. Prev Chronic Dis 2026;23:250328. DOI: http://dx.doi.org/10.5888/pcd23.250328.

PEER REVIEWED

Abstract

Introduction

Rates of human papillomavirus (HPV) vaccine are lower in rural counties than in urban areas. The objective of the minigrants evaluation was to assess HPV vaccination uptake, factors related to implementation success, and barriers to implementation.

Methods

We conducted a concurrent, mixed-methods evaluation guided by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) and CFIR (Consolidated Framework for Implementation Science) frameworks. Four health departments received funding, a toolkit with implementation strategies, and monthly technical assistance calls or a learning collaborative for 1 year. The data sources were program documents, staff interviews and surveys, immunization databases, and caregiver or young adult surveys. Key evaluation metrics were 1) reach of patients and adoption of intervention levels (patient, provider, or practice); 2) HPV vaccination effectiveness; 3) implementation perspectives from staff, caregivers, and young adults; 4) implementation barriers and facilitators; and 5) program sustainability capacity.

Results

Most sites adopted 2 of 3 levels (patient, provider, or practice). Common multilevel strategies for series completion were patient education, incentives, provider training, and patient reminders. The total HPV vaccination rate increased 26.7% from 2023 to first quarter 2024, and initiation rate increase was 51.8% across the county departments. Overall, on a scale from 1 to 5, with 1 being “strongly disagree” to 5 being “strongly agree,” sites reported positive experiences with program implementation and perceived the program was feasible (mean, 4.4 points), acceptable (mean, 4.4 points), and appropriate (mean, 4.2 points). Staff members also reported high ease of implementation (mean, 4.0 points) and commitment to program delivery (mean, 4.8 points). The parents or caregivers (n = 20) reported in surveys that they saw educational materials (100%), received educational materials (90%), and received a vaccine reminder (75%). CFIR-related facilitators were priority of the health issues, leadership involvement, technology infrastructure, communications about the vaccine and program, available resources, and staff training at the inner setting and external support at the outer setting. Barriers included limited resources, communication and structural characteristics (eg, technology, issues related to electronic health records), and local attitudes and conditions. The mean program sustainability capacity score was 4.2, with highest scores for evaluation, effectiveness, and workflow integration.

Conclusion

Multilevel intervention strategies can successfully increase HPV vaccination rates in rural settings with implementation supports to address cancer prevalence in rural areas.

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Introduction

Human papillomavirus (HPV) is the most common sexually transmitted infection in the US (1), and nearly 42 million people are currently infected (2). HPV is transmitted through genital contact during vaginal and anal sex, but it can also be passed on during oral sex (2). Low-risk HPV types cause genital warts whereas high-risk HPV types are associated with the following cancers: cervical, vaginal, vulval, penis, anal, and oropharyngeal (3,4). It is estimated that 42,700 cases of HPV-associated cancers will occur in the US each year, including about 24,400 among women and 18,300 among men (3). There are sex differences in the distribution of HPV-related cancers; for example, the prevalence of oropharyngeal cancer is higher among men than women and accounts for 78% of all HPV cancers in men (5). Prevention methods for HPV are primarily focused on adolescents and young adults, as they are most often affected by the virus.

In 2009, the US Food and Drug Administration approved the quadrivalent HPV vaccine for girls and women aged 9 through 26 years to prevent genital warts and anal cancer (6). In late 2016, the Advisory Committee on Immunization Practices recommended a 2-dose schedule for adolescents, including male adolescents, initiating between 9 to 14 years (7). In 2023, data from the National Immunization Survey–Teen found that only 61.4% of adolescents aged 13 to 17 years were up to date with both doses of the HPV vaccine, with female adolescents reporting higher completion rates than male adolescents (64% vs 59%) (8). However, people who were not vaccinated or did not complete the HPV series were male, non-Hispanic or Latino, and living in the US South (9). HPV vaccination rates are lower in Georgia than the national HPV vaccination rates; in 2023, only 40.5% of adolescents aged 13 to 17 years overall were up to date with their vaccinations, and the state was ranked 49th nationally (10). Rural communities also have vaccination rates that are 10% to 15% lower than those in metropolitan areas (11,12). Therefore, HPV vaccination rates are suboptimal both nationally and in Georgia, compared with the Healthy People 2030 goal of 80% (13).

Literature reviews of interventions regarding promotion of the HPV vaccine have been conducted in an effort to increase vaccination rates (14–17). Most studies of the promotion of the HPV vaccine among adolescents and teenagers have examined only individual-level strategies, such as creating informational flyers and media campaigns. However, organizational strategies (eg, school-based vaccination, systems change) to increase HPV vaccination rates have been overlooked and should be considered for broader reach and impact. National initiatives and researchers have been recommending interventions at multiple levels to address different individual-, provider-, community-, and systems-level barriers to prevention (18,19). A recent systematic review found that most interventions to increase HPV vaccination were at a single level, mostly at the parent, adolescent, or young-adult level (20). Research has found that common predictors to vaccine uptake are educating the public through awareness campaigns, provider recommendations, patient reminders, training of providers and teachers (vaccine delivery personnel), and multicomponent interventions (21–23). The Community Guide from the Community Preventive Services Task Force recommends using a combination of health care system–based interventions and individual-level approaches to increase vaccination rates in relevant populations (23). Walling et al found that interventions focused on both the parent and provider levels were more successful in increasing HPV vaccine initiation and completion rates (15). Therefore, multilevel interventions should be developed and evaluated to promote HPV vaccine uptake.

Minigrants have been used for health promotion and cancer and chronic disease prevention by giving local organizations funds to support delivery of evidence-based prevention strategies or interventions (24) and are effective in changing cancer-prevention behaviors (25,26). The purpose of this evaluation was to assess the multilevel pilot minigrants program on HPV vaccination rates in rural southwest Georgia and to assess the facilitators and barriers to program delivery.

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Methods

Study design

This minigrants evaluation was a concurrent mixed-methods study focused on primary and secondary outcomes (27). The primary measures were HPV vaccine initiation and completion rates collected from electronic health records and Georgia’s immunization registry. The secondary measures were program delivery, observations of implementation strategies, and Weiner’s implementation outcomes of acceptability, feasibility, and appropriateness (28). This evaluation was reviewed and deemed exempt by Emory University’s institutional review board.

Study setting

The purpose of the HPV Vaccine Mini-grants Program was for grantees to implement a multilevel intervention to increase capacity and HPV vaccination rates in rural communities. For the multilevel intervention, grantees were required to focus on at least 2 of the 3 levels (patient, provider, or practice level) (Figure). Multilevel was defined as the use of a combination of more than 1 level of influence on implementation of the intervention including individual, interpersonal, organizational, or community. To be eligible for the minigrants program, grantees had to be a health department, clinic, health system, or student health center located in southwest Georgia with the ability to offer HPV vaccination. Emory Cancer Prevention and Control Research Network (CPCRN) hosted a 1-hour informational webinar over Zoom where interested organizations attended to find out more about the minigrants program. Organizations that were interested after attending the webinar completed a minigrants application, and a review committee selected 4 final grantees by using a standardized scoring rubric. All 4 grantees were county health departments in southwest Georgia. The program took place from January to December 2023. During this time, Emory CPCRN provided up to $10,000, a toolkit with evidence-based strategies for each of the 3 levels, and technical assistance calls each month. During the monthly calls, the grantees shared their progress and received technical assistance either individually or with all 4 grantees as a group. They also submitted completed activities in workplans.

Figure. Components of a multilevel minigrant intervention to promote HPV vaccination among young adults in rural Georgia, 2023–2024. [A text version of this figure is available.]

Multi-level minigrant intervention for HPV vaccination promotion. Intervention is composed of 2 or more levels. At the patient level, intervention strategies can include small media, client reminders or client incentives. At the provider level, strategies can consist of provider training, provider recommendation, or audit and feedback. At the practice level, strategies can include provider reminders, reducing client cost, standing orders and immunization record systems.

Study data and measures

The overall theoretical frameworks guiding the evaluation were RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) (29) and the Consolidated Framework for Implementation Science (CFIR) (30). RE-AIM framed the overall implementation evaluation in terms of indicators of adoption and reach, description of implementation of the multilevel strategies, HPV outcomes, and comments about maintenance of the minigrants program. CFIR domains were selected to describe factors that assisted with implementation. This mixed evaluation study included caregiver, patient, and staff surveys, and staff interviews during and after implementation in spring 2024. All participants received a $25 gift card when completing a survey or interview. A staff member could receive up to 2 gift cards if they completed both the survey and interview.

HPV vaccine outcomes. The primary outcome measure of HPV vaccines came from the health department electronic medical records. We collected information on total doses and initiation rates from the district health office.

Intervention surveys. Data were collected via 3 separate surveys: 1) caregiver, 2) young adult, and 3) staff. The caregiver survey was for parents whose child received the HPV vaccine, and the young adult survey was for young adults who received the HPV vaccine at 1 of the funded minigrant sites. These 2 surveys were offered in English and Spanish, and in electronic and paper formats. The staff survey was for any medical professional or staff member at a participating health department site enrolled in the minigrants program and was only offered electronically.

Caregiver and young adult surveys. From November 2023 to February 2024, survey data were collected from caregivers and patients aged 18 years or older who received at least 1 dose of the HPV vaccine series at 1 of the 4 minigrant sites. Four flyers, 2 in English and 2 in Spanish, with a QR code to the survey were disseminated. One flyer was for parents whose child received a dose of the HPV vaccine series, and the other flyer was for young adults who received a dose of the HPV vaccine series. The survey took approximately 15 to 20 minutes. The survey inquired about caregivers’ or young adults’ interactions with their health care providers, observation or access to educational materials at the health department, parents’ experiences and reasons for visiting the health department, as well as items related to vaccine reminders and uptake.

Staff surveys. We collected survey data from staff members who helped implement the levels and strategies chosen by their minigrant site between January and February 2024. The Emory CPCRN team sent an invitation email to the minigrant site leads, who then forwarded the email with the survey link to the rest of their team and staff. The survey asked about intervention characteristics, the implementation process, organizational traits, and early sustainability of the intervention. Sustainability capacity was measured using the Clinical Sustainability Assessment Tool (CSAT) (31). CSAT measures determinants of sustainability and comprises items in 7 domains: engaged staff and leadership, engaged stakeholders, monitoring and evaluation, organizational context and capacity, workflow integration, planning and implementation, and outcomes and effectiveness (31). Staff rated the statements about each domain using a 5-point scale with 1 being “to little or no extent” to 5 being “to a very great extent.” Higher scores indicated greater sustainability capacity. We also measured implementation outcomes related to the multilevel intervention using a modified version of Weiner’s implementation outcomes (28). This scale measures the acceptability, appropriateness, and feasibility of the intervention through 2 items. Staff rated these items on a 5-point scale of 1 being “completely disagree” to 5 being “completely agree.” Higher scores reflected greater agreement about those outcomes.

Staff interviews. Semi-structured interviews were conducted with staff members who assisted with implementing the multilevel intervention at their minigrant site. From February to March 2024, the Emory team conducted 5 interviews. The interview domains consisted of factors leading to the adoption of the program, intervention implementation, thoughts about intervention characteristics, factors inside and outside of their organization that helped with implementation, the implementation process, program maintenance, and technical assistance. We broadly applied the 5 CFIR domains in the items related to intervention delivery (individual and innovation characteristics) and inner and outer setting factors (30). The interviews lasted an hour and were conducted and recorded over Zoom (Zoom Communications, Inc). Interviews were transcribed verbatim for data analyses.

Data analyses

We conducted all analyses in Excel for the surveys and used MAXQDA 24 for the qualitative analyses (32). Descriptive statistics were run, and scales (ie, implementation outcomes, CSAT) were calculated. For the qualitative analyses, we developed the codebook from the verbatim transcripts, and subsequent transcripts employed the codebook with minor changes (33). Data were analyzed by using deductive coding (eg, interview questions related to benefits, delivery, and CFIR domains) and thematic analysis with constant comparison (33), which included 1) reviewing and coding the transcripts, 2) comparing different responses to identify themes, 3) coding additional interviews, and 4) refining or adding new themes. Two coders used a finalized codebook to code all transcripts, and quotes were selected to represent major themes. We described where data converged and where interviews expanded our understanding of the survey implementation ratings of the multilevel intervention (27).

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Results

Reach and adoption of intervention levels

All 4 minigrant sites implemented the individual level and most focused on the practice level (Table 1). One site chose to implement all 3 levels. Common individual activities that were used included educational materials, patient reminders, and patient incentives for receiving the HPV vaccine. Other outreach activities included community outreach events at school fairs or education to other partners. Provider education or lunch and learns were given at the provider level, and at the practice level, health departments posted HPV information on signage or electronic boards, implemented standing orders (ie, protocols that allow nonphysician personnel, such as nurses or medical assistants, to vaccinate without direct involvement of a physician at the time of vaccination administration), reduced structural barriers (eg, change of clinic times or workflow, navigation, methods for transportation, or language barriers), and conducted education through other clinical services (eg, influenza clinic).

HPV vaccination

Total HPV vaccinations increased from 547 to 693 (26.7%) from the year before the program to the implementation year (1 year and the first quarter of 2024) (Table 1). The number of vaccinations increased from 191 to 290, a 51.8% increase. Differences were found in the number of vaccinations (both initiation and completion) between sites, with 1 site having a slight decrease in overall vaccination.

Implementation perspectives

Caregiver and young adult surveys. Twenty caregivers and 13 young adults responded to the follow-up survey. Caregivers and parents were mostly female (70%), aged 18 to 50 years (80%), Black (60%), non-Hispanic (94%), and single (56%). Most had less than a college degree (89%) and an income of $50,000 or less (61%). Young adults were mostly female (77%), younger than 26 years (92%), Black (46%) or White (46%), and non-Hispanic (92%). Caregivers and young adults corroborated the activities selected by the health departments (n = 20), with 80% and 77%, respectively, reporting that providers discussed the vaccine; 90% of caregivers and 83% of young adults saw or received materials in the follow-up survey. More caregivers reported that they received reminders for future vaccinations than did young adults (75% vs 46%) (Table 2A). Both groups that had their child or themselves receive the vaccine had high trust in the recommendations of the providers that they met with (parents, mean [SD] = 4.6 [0.6]; young adults, mean [SD] = 4.9 [0.3]) (Table 2B).

Staff implementation survey. Five staff members in total completed the survey; all sites were represented, and 2 were from the same site. They all identified as white (80%) and female (100%). Most worked as county nurse managers (40%) or registered nurses (40%) and reported that they had been with the department for less than 5 years (60%). Overall, health department staff reported positive experiences with program implementation and perceived the program was feasible (mean = 4.4), acceptable (mean = 4.4), and appropriate (mean = 4.2). They also reported high ease of implementation (mean = 4.0) and commitment to program delivery (mean = 4.8) (Table 3).

Interviews with staff. Five staff members (all survey participants) completed interviews; 2 participating staff members were from the same site. Most staff members were either the county nurse manager or the immunization coordinator (80%), had been at the organization less than 5 years (60%), were female (100%), and were White (80%). Across all interviews, health department staff expressed that this was the department’s first time focusing on HPV vaccine promotion efforts. They all similarly shared that the intervention strategies were straightforward to implement and found that gift card incentives were among the most effective strategies in getting people vaccinated, which validated the overall survey rating that the intervention was easy to implement. Although some strategies were more effective than others, staff recognized the importance of a multilevel approach. After the minigrants program concluded, all departments shared that they will continue promoting the HPV vaccine to their patients. For themes regarding what would help them continue to deliver the program, staff mentioned funding, particularly for the gift card as client incentives and use of the GRITS (Georgia Registry of Immunization Transactions and Services) immunization system. Workflow is a critical sustainability element and is one of the highest-rated indicators on the CSAT, and the finding that staff used patient databases aligns with this element.

Implementation barriers and facilitators

Related to CFIR themes, we identified facilitators and barriers to intervention delivery across the domains (Table 4). For facilitators, the staff expressed that leadership was supportive in pushing HPV vaccine promotion efforts forward and encouraged collective work across the department throughout program implementation. CFIR-related facilitators were a relative priority of the topic, leadership involvement, presence of technology infrastructure, communications about the vaccine and program, available resources (eg, minigrant funds, toolkit materials), planning for vaccination education, reminders and access to knowledge (staff training) at the inner setting and external support at the outer setting. For joint analyses, there were high ratings of the alignment of the program with their mission, leadership support in pushing HPV vaccine promotion efforts forward and encouragement of collective work for the HPV intervention delivery on the survey.

Barriers centered around CFIR inner setting domains and were mostly around communication and structural characteristics (eg, technology/electronic health record [HER]) (Table 4). Challenges related to outer setting domains included willingness of people to use the vaccine or hesitancy to use it, transportation issues for accessing health care (ie, local attitudes and conditions), and reaching other providers (ie, partnerships) about vaccine promotion.

Program sustainability capacity

The mean overall program sustainability capacity score was 4.2 (SD, 0.6) with highest scores for domains of monitoring and evaluation (mean [SD] = 4.5 [0.5]), outcomes and effectiveness (mean [SD] = 4.4 [0.5]), workflow integration (mean [SD] = 4.2 [0.5]), and implementation and training (mean [SD] = 4.2 [0.8]) (Table 5). Most staff agreed to a great extent that they would continue to offer the program (mean [SD] = 3.8 [0.8]). Related to training and technical assistance during the minigrants period, staff agreed that the training and technical assistance offered was helpful (mean [SD] = 4.6 [0.6]) and that they plan to continue to use the various web-based resources and toolkit (mean [SD] = 4.6 [0.6]) (data not shown).

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Implications for Public Health

Overall, we found that this pilot minigrants program of multilevel interventions to promote HPV vaccination had a positive impact. There was a 27% increase in HPV vaccinations overall from the year before the year of the implementation of the multilevel intervention, with a 52% increase in HPV vaccine initiation across sites. Most of the health departments experienced increases in both vaccine initiation and overall total vaccinations. Two of the sites with the largest increases were focused on evidence-based strategies at the individual and practice levels, which may mean that future interventions to promote HPV vaccine uptake do not have to focus on all 3 levels. This study contributes to the literature of the impact of minigrants for cancer prevention and control in local communities (24,34). Other multilevel interventions to promote HPV vaccination have found improvements in vaccination (35–37).

Overall staff had fairly positive experiences with the multilevel intervention. Most agreed that it was more effective than their prior practices and that it was easy to implement. They also reported that the program was highly acceptable, slightly feasible, and appropriate for implementation outcomes. From the interviews with health department staff, many CFIR-related facilitators existed for the implementation of the multilevel interventions including leadership support, resources, staff training about the HPV vaccine, advance implementation planning, and partnerships. Other research showed similar results with use of EHR systems for reminders and monitoring, training and education, concrete tools and resources, strong leadership support, provider recommendation, and provider champions as facilitators to implementing HPV vaccination interventions (38,39). Barriers to the multilevel interventions included limited resources and staff, communication and structural characteristics (eg, technology/EHR data at the individual site) at the inner setting, and local attitudes about vaccination, outreach to other providers to increase vaccination and transportation at the outer setting. These results validate other research that cite infrastructure (eg, EHRs), competing priorities, available resources (ie, funding), staff buy-in, training needs, provider characteristics such as knowledge about vaccines, and confidence in relaying information. For the outer setting, elements include patient misinformation about vaccines and vaccine stigma (local attitudes), cultural and language barriers, and lack of public media about vaccination (38–40). Critical incidents such as the COVID-19 pandemic and HPV vaccine supply chain problems are other recent challenges to HPV vaccination programming (40). Given the lower HPV vaccination rates, it is critical to understand implementation challenges in rural areas as public health and researchers promote HPV vaccination in rural communities. Factors external to the organization — including tailored health education and campaigns, addressing health care access, and vaccine hesitancy, in addition to enhancing education among partners in communities — need to be explored to increase rural vaccination rates.

Maintenance of these interventions was perceived by staff to be contingent on evaluation results, monitoring of process, and integration of the intervention into each department’s workflow and training of staff. This program offers proof of concept for implementation strategies of funding (minigrants), a learning collaborative and technical assistance; additional investments may be needed to support the delivery of these evidence-based multilevel grants. Others have called for additional research on the long-term implementation and sustainability of HPV vaccine programs (41). Additionally, 1 funded site did not have increases in total vaccination. This could be that we were working with small, rural health departments in southwest Georgia. These departments may have additional barriers to the conduct of multilevel interventions such as limited personnel, vaccine hesitancy, or other resources despite receipt of minigrant funds and technical assistance. Future capacity-building projects related to promotion of HPV vaccine uptake can assess if there are additional supports needed for diverse types of sites.

Strengths of this implementation evaluation were the multilevel interventions, mixed-methods data collection, and application of implementation science theories. However, our study has several limitations. It was based on the minigrants work of only 4 public health departments, so the findings may not be generalizable. We examined data on HPV vaccinations only for the full year and first quarter (5 quarters) of implementation of the intervention through general data-sharing agreements. Extending the timeframe of the evaluation could offer insights into the longer-term effects of the program. Future evaluations or quality improvement initiatives should assess long-term effects of these implementation strategies. In addition, completion of the parent and caregiver and young adult surveys varied by site (range, 4 to 20). Even so, all sites had survey responses, which validated the multilevel intervention components. Social desirability (response bias) and recall biases may be evident on the parent and caregiver, young adult, and health department surveys. However, we found that the intervention components reported by health departments were corroborated by parents’ and young adults’ survey data and by the staff workplans. Finally for vaccine outcomes, we were able to report on total HPV vaccine shots and initiation and not on completion, relying on the health department vaccine records. In addition, we cannot verify the data quality of the medical records in terms of missingness or accuracy since they were provided as part of the evaluation. Vaccine completion is more difficult to assess due to the study period limits and not having identifiable patient-specific data on the evaluation; data on ongoing vaccine completion for sites is required for further data analyses. Future implementation of the program could extend the data collection timeframe and assess vaccine completion outcomes.

Multilevel intervention strategies can successfully increase HPV vaccination rates in rural settings with implementation supports to address cancer prevalence in rural areas.

Our minigrants program to support implementation of multilevel HPV interventions was successful in increasing HPV vaccination across health department sites. The evaluation showed that the interventions were easy to implement at the health departments and had high acceptability and feasibility. Future research can expand on minigrants and these implementation strategies and examine ways to sustain these programs to increase HPV vaccination in rural communities to reduce cancer health disparities.

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Acknowledgments

The authors declare no potential conflicts of interest with respect to the research, authorship, or publication of this article. No copyrighted material, surveys, instruments, or tools were used in this research. This work was supported in part by a grant from the Centers for Disease Control and Prevention (CDC), SIP 19–005 CPCRN, U48 DP006377. The content is solely the responsibility of the authors and does not necessarily represent the official views of the CDC.

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Author Information

Corresponding Author: Cam Escoffery, PhD, MPH, CHES, Rollins School of Public Health, Emory University, 1518 Clifton Rd NE, Atlanta, GA 30322 (cescoff@emory.edu).

Author Affiliations: ¹Department of Behavioral Sciences and Health Education, Emory University Rollins School of Public Health, Atlanta, Georgia. ²Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia. ³Department of Health Policy and Management, Emory University Rollins School of Public Health, Atlanta, Georgia. ⁴Southwest Health District, 8-2, Division of Public Health, Georgia Department of Public Health, Albany, Georgia.

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References

1. Satterwhite CL, Torrone E, Meites E, Dunne EF, Mahajan R, Ocfemia MC, et al. . Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008. Sex Transm Dis. 2013;40(3):187–193. PubMed doi:10.1097/OLQ.0b013e318286bb53
2. Centers for Disease Control and Prevention. About HPV. Accessed June 15, 2025. https://www.cdc.gov/hpv/about/index.html
3. Chaturvedi AK, Engels EA, Pfeiffer RM, Hernandez BY, Xiao W, Kim E, et al. . Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol. 2023;41(17):3081–3088. PubMed doi:10.1200/JCO.22.02625
4. World Health Organization, International Agency for Research on Cancer. IARC monographs on the evaluation of carcinogenic risks to humans. Volume 90: human papillomaviruses. 2007. Accessed May 8, 2026. https://publications.iarc.who.int/Book-And-Report-Series/Iarc-Monographs-On-The-Identification-Of-Carcinogenic-Hazards-To-Humans/Human-Papillomaviruses-2007
5. Jemal A, Simard EP, Dorell C, Noone AM, Markowitz LE, Kohler B, et al. . Annual Report to the Nation on the Status of Cancer, 1975–2009, featuring the burden and trends in human papillomavirus (HPV)–associated cancers and HPV vaccination coverage levels. J Natl Cancer Inst. 2013;105(3):175–201. PubMed doi:10.1093/jnci/djs491
6. Markowitz LE, Dunne EF, Saraiya M, Lawson HW, Chesson H, Unger ER; Centers for Disease Control and Prevention (CDC); Advisory Committee on Immunization Practices (ACIP). Quadrivalent human papillomavirus vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007;56(RR-2):1–24. PubMed
7. Meites E, Kempe A, Markowitz LE. Use of a 2-dose schedule for human papillomavirus vaccination — updated recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2016;65(49):1405–1408. PubMed doi:10.15585/mmwr.mm6549a5
8. Pingali C, Yankey D, Chen M, Elam-Evans LD, Markowitz LE, DeSisto CL, et al. . National vaccination coverage among adolescents aged 13–17 years — National Immunization Survey–Teen, United States, 2023. MMWR Morb Mortal Wkly Rep. 2024;73(33):708–714. PubMed doi:10.15585/mmwr.mm7333a1
9. Ibrahim-Ojoawo A, Powe N, Rogers R, Learman K, Hefner H. A cross-sectional analysis of 2017–2022 National Immunization Survey: sociodemographic disparities associated with human papillomavirus vaccine initiation and completion series among US adolescents. Cancer Control. 2024;31:10732748241293674. PubMed doi:10.1177/10732748241293674
10. America’s Health Rankings UHF. HPV vaccination in United States. 2024. Accessed May 8, 2025. https://www.americashealthrankings.org/explore/measures/Immunize_HPV
11. Elam-Evans LD, Yankey D, Singleton JA, Sterrett N, Markowitz LE, Williams CL, et al. . National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years — United States, 2019. MMWR Morb Mortal Wkly Rep. 2020;69(33):1109–1116. PubMed doi:10.15585/mmwr.mm6933a1
12. Swiecki-Sikora AL, Henry KA, Kepka D. HPV vaccination coverage among US teens across the rural–urban continuum. J Rural Health. 2019;35(4):506–517. PubMed doi:10.1111/jrh.12353
13. United States Department of Health and Human Services. Healthy People 2030. Increase the proportion of adolescents who get recommended doses of the HPV vaccine — IID-08. Accessed June 21, 2025. https://odphp.health.gov/healthypeople/objectives-and-data/browse-objectives/vaccination/increase-proportion-adolescents-who-get-recommended-doses-hpv-vaccine-iid-08
14. Reiter PL, Stubbs B, Panozzo CA, Whitesell D, Brewer NT. HPV and HPV vaccine education intervention: effects on parents, healthcare staff, and school staff. Cancer Epidemiol Biomarkers Prev. 2011;20(11):2354–2361. PubMed doi:10.1158/1055-9965.EPI-11-0562
15. Walling EB, Benzoni N, Dornfeld J, Bhandari R, Sisk BA, Garbutt J, et al. . Interventions to improve HPV vaccine uptake: a systematic review. Pediatrics. 2016;138(1):e20153863. PubMed doi:10.1542/peds.2015-3863
16. Fu LY, Bonhomme LA, Cooper SC, Joseph JG, Zimet GD. Educational interventions to increase HPV vaccination acceptance: a systematic review. Vaccine. 2014;32(17):1901–1920. PubMed doi:10.1016/j.vaccine.2014.01.091
17. Newman PA, Logie CH, Doukas N, Asakura K. HPV vaccine acceptability among men: a systematic review and meta-analysis. Sex Transm Infect. 2013;89(7):568–574. PubMed doi:10.1136/sextrans-2012-050980
18. President’s Cancer Panel. HPV vaccination for cancer prevention: progress, opportunities, and a renewed call to action. A report to the President of the United States from the chair of the President’s Cancer Panel. 2018. Accessed May 8, 2026. https://prescancerpanel.cancer.gov/reports-meetings/hpv-vaccination-cancer-prevention-report-2018/full-report.pdf
19. Paskett E, Thompson B, Ammerman AS, Ortega AN, Marsteller J, Richardson D. Multilevel interventions to address health disparities show promise in improving population health. Health Aff (Millwood). 2016;35(8):1429–1434. PubMed doi:10.1377/hlthaff.2015.1360
20. Escoffery C, Petagna C, Agnone C, Perez S, Saber LB, Ryan G, et al. . A systematic review of interventions to promote HPV vaccination globally. BMC Public Health. 2023;23(1):1262. PubMed doi:10.1186/s12889-023-15876-5
21. Felsher M, Shumet M, Velicu C, Chen YT, Nowicka K, Marzec M, et al. A systematic literature review of human papillomavirus vaccination strategies in delivery systems within national and regional immunization programs. Hum Vacc Immunother. 2024; 20(1). PubMed doi:10.1186/s12889-023-15876-5
22. Holloway GL. Effective HPV vaccination strategies: what does the evidence say? An Integrated Literature Review. J Pediatr Nurs. 2019;44:31–41. PubMed doi:10.1016/j.pedn.2018.10.006
23. Lu PJ, Yankey D, Fredua B, Hung MC, Sterrett N, Markowitz LE, et al. . Human papillomavirus vaccination trends among adolescents: 2015 to 2020. Pediatrics. 2022;150(1):e2022056597. PubMed doi:10.1542/peds.2022-056597
24. Kegler MC, Carvalho ML, Ory M, Kellstedt D, Friedman DB, McCracken JL, et al. . Use of mini-grant to disseminate evidence-based interventions for cancer prevention and control. J Public Health Manag Pract. 2015;21(5):487–495. PubMed doi:10.1097/PHH.0000000000000228
25. McCracken JL, Friedman DB, Brandt HM, Adams SA, Xirasagar S, Ureda JR, et al. . Findings from the Community Health Intervention Program in South Carolina: implications for reducing cancer-related health disparities. J Cancer Educ. 2013;28(3):412–419. PubMed doi:10.1007/s13187-013-0479-8
26. Arriola KRJ, Hermstad A, Flemming SSC, Honeycutt S, Carvalho ML, Cherry ST, et al. . Promoting policy and environmental change in faith-based organizations: description and findings from a mini-grants program. Am J Health Promot. 2017;31(3):192–199. PubMed doi:10.4278/ajhp.150212-QUAN-724
27. Creswell JWCV. Designing and conducting mixed-methods research. 3rd Ed. ed. Sage Publications; 2018.
28. Weiner BJ, Lewis CC, Stanick C, Powell BJ, Dorsey CN, Clary AS, et al. . Psychometric assessment of three newly developed implementation outcome measures. Implement Sci. 2017;12(1):108. PubMed doi:10.1186/s13012-017-0635-3
29. Glasgow RE, Vogt TM, Boles SM. Evaluating the public health impact of health promotion interventions: the RE-AIM framework. Am J Public Health. 1999;89(9): 1322–7. PubMed doi:10.1016/j.vaccine.2025.127359
30. Damschroder L, Reardon C, Widerquist M, Lowery J. Introduction and application of the consoloidated framework for implementation research (CFIR): version 2 (CFIR V2). Implement Sci. 2022;17(Suppl 1). PubMed doi:10.1186/s13012-017-0635-3
31. Malone S, Prewitt K, Hackett R, Lin JC, McKay V, Walsh-Bailey C, et al. . The Clinical Sustainability Assessment Tool: measuring organizational capacity to promote sustainability in healthcare. Implement Sci Commun. 2021;2(1):77. PubMed doi:10.1186/s43058-021-00181-2
32. Software V. MAXQDA Version 24. VERBI Software; 2024.
33. Miles MB, Huberman M, Saldana J. Qualitative Data Analysis: A Methods Sourcebook. 4th edition. Sage Publications; 2018.
34. Hermstad A, Honeycutt S, Flemming SS, Carvalho ML, Hodge T, Escoffery C, et al. . Social environmental correlates of health behaviors in a faith-based policy and environmental change intervention. Health Educ Behav. 2018;45(5):672–681. PubMed doi:10.1177/1090198118757826
35. Kong WY, Bustamante G, Pallotto IK, Margolis MA, Carlson R, McRee AL, et al. . Disparities in healthcare providers’ recommendation of HPV vaccination for U.S. adolescents: a systematic review. Cancer Epidemiol Biomarkers Prev. 2021;30(11):1981–1992. PubMed doi:10.1158/1055-9965.EPI-21-0733
36. McLean HQ, VanWormer JJ, Chow BDW, Birchmeier B, Vickers E, DeVries E, et al. . Improving human papillomavirus vaccine use in an integrated health system: impact of a provider and staff intervention. J Adolesc Health. 2017;61(2):252–258. PubMed doi:10.1016/j.jadohealth.2017.02.019
37. Paskett ED, Krok-Schoen JL, Pennell ML, Tatum CM, Reiter PL, Peng J, et al. . Results of a multilevel intervention trial to increase human papillomavirus (HPV) vaccine uptake among adolescent girls. Cancer Epidemiol Biomarkers Prev. 2016;25(4):593–602. PubMed doi:10.1158/1055-9965.EPI-15-1243
38. Selove R, Foster M, Mack R, Sanderson M, Hull PC. Using an implementation research framework to identify potential facilitators and barriers of an intervention to increase HPV vaccine uptake. J Public Health Manag Pract. 2017;23(3):e1–e9. PubMed doi:10.1097/PHH.0000000000000367
39. Escoffery C, Riehman K, Watson L, Priess AS, Borne MF, Halpin SN, et al. . Facilitators and barriers to the implementation of the HPV VACs (Vaccinate Adolescents Against Cancers) Program: a consolidated framework for implementation research analysis. Prev Chronic Dis. 2019;16:E85. PubMed doi:10.5888/pcd16.180406
40. Adamus M, Ballová Mikušková E, Kohut M. Conspire to one’s own detriment: strengthening HPV program support through debunking epistemically suspect beliefs. Appl Psychol Health Well-Being. 2024;16(4):1886–1904. PubMed doi:10.1111/aphw.12570
41. Roux K, Roux F, Burns S, Guy R. Effective strategies in human papillomavirus (HPV) vaccination interventions to increase uptake in rural, low socioeconomic, indigenous and migrant populations: a scoping review. Vaccine. 2025;61:127359. PubMed doi:10.1016/j.vaccine.2025.127359

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Tables

Abbreviations: HPV, human papillomavirus; NA, not applicable.
^a Award amount varied based on funds requested in the application.
^b HPV vaccine uptake data from immunization records from 2022 (before intervention) versus 2023 to 2024 1st quarter (5 quarters). Percentage change is the difference from 2022 to 2023; positive numbers indicate more vaccinations while negative numbers indicate fewer vaccinations.

Abbreviations: HPV, human papillomavirus; NA, not applicable.

Abbreviation: HPV, human papillomavirus.
^a Respondents rated these items on a 5-point scale, with 1 being “strongly disagree” to 5 being “strongly agree.” Values for n varied because not all participants responded to every question.

Abbreviations: HPV, human papillomavirus; —, not applicable.
^a Staff rated these items on a 5-point scale, with 1 being “strongly disagree” to 5 being “strongly agree.” Higher scores reflected greater agreement about these outcomes.
^b Staff rated these items from 1 being “completely disagree” to 5 being “completely agree,” with neutral responses being coded as “neither agree nor disagree.”

Abbreviations: CFIR, Consolidated Framework for Implementation Science; EHR, electronic health record; GRITS, Georgia Registry of Immunization Transactions and Services; HPV, human papillomavirus.

Abbreviations: CSAT, Clinical Sustainability Assessment Tool; EMR, electronic medical record.
^a Staff rated the statements about each domain using a 5-point scale with 1 being “to little or no extent” to 5 being “to a very great extent.” Higher scores indicate greater sustainability capacity.

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