Immunization Campaigns and Strategies against Human Papillomavirus in Italy: The Results of a Survey to Regional and Local Health Units Representatives

Despite several promotional activities, human papillomavirus (HPV) vaccination coverage (VC) in Italy is largely unsatisfactory, ranging from 30% to 75% among Italian administrative regions for full HPV vaccination in primary cohorts (birth cohort: 2005) of women and from 0% to 65% among primary cohorts of men. According to this group of researchers, the most studied strategies aimed at increasing HPV VC focus on evaluation of knowledge, attitudes, and determinants of acceptance and refusal, and they mainly focus on preadolescent girls and their parents. However, they suggest, immunisation strategies and organisational aspects of vaccine centres also have a relevant role in determining vaccine compliance. Thus, the present study assesses the different HPV immunisation campaigns carried out in 4 Italian administrative regions, evaluating the impact of organisational aspects, the characteristics of the immunisation programme, and the communication strategies adopted by the regions.

From November 2017 to March 2018, representatives of regional and local health units (LHUs) were invited to complete an online survey including 54 questions evaluating vaccination invite systems, access systems to vaccination centres, reminder and recall systems, and adverse events surveillance. An overall descriptive analysis was conducted. Twenty-six LHUs belonging to 4 northern and southern Italian regions participated in the study.

Selected findings related to communication:

• Almost all LHUs invite preadolescents through letters addressed to parents, which in 76.9% of cases included also informative material. Schools are involved only in 26.9% of cases.
• Informative material available at the immunisation centres is prepared locally in the majority of cases and translated in other languages than Italian only in 19.2% of cases.
• A call centre to discuss about vaccines is active in 53.8% of cases, formative moments such as focus group addressed to preadolescents' parents were conducted in 42.3% of cases, and local media were involved in informative campaigns in about 35% of LHUs.
• The education of healthcare workers on universal strategy was multidisciplinary, and it was conducted in almost all the LHUs.
• The analysis of suboptimal obtained VC and of vaccine hesitancy determinants was conducted only in 57.7% and 34.6% of cases, respectively.

Univariable logistic regression in the female 2003-birth cohort revealed that organisational aspects significantly related to VC higher than the national mean were recall systems for both the first and the second dose, inclusion of the appointment in the invitation letter, availability of a regional immunisation registry, and education of healthcare workers on universal HPV immunisation strategies.

After multivariable analysis, one variable was statistically significant: The probability to obtain VC higher than the national mean is equal to 87.6% if a recall of subjects missing the second dose (e.g., phone call, invitation letter, or SMS, or text message) is active.

In discussing the findings, with regard to communication strategies, the researchers explain that, although almost all participating LHUs reported education activities for healthcare workers on the universal HPV immunisation strategy, interventions are conducted periodically in only half of LHUs, highlighting the need for additional educational activities. This is of particular relevance in the field of HPV primary and secondary prevention, since a variety of professionals operating in different healthcare settings are involved along a decision path. The researchers argue that sharing a coherent message among different stakeholders using available communication tools is crucial to obtain the best results in terms of adherence to HPV vaccine.

In addition, increasing availability of informative material in different languages at immunisation centres could contribute to the circulation of scientifically correct information and mitigate against the spread of misleading messages by "anti-vaxxers". More LHUs could create call centres coordinated by immunisation centres so that young people and their parents could obtain information and address doubt about vaccines. The involvement of media and the conducting of focus groups - in particular, in the school setting - could boost vaccine demand when combined with other activities; nevertheless, such strategies are reported in less than half of participating LHUs. This could be due to the suboptimal economic and human resources currently available for prevention in the majority of Italian regions.

In conclusion, despite communication-centred and other organisational efforts, HPV VC observed in participating LHUs is largely lower than the national objectives in all HPV vaccine targets, and organisational strategies to reach subjects at risk are suboptimal. "Since multicomponent interventions have a synergistic effect, both organizational and educational strategies have to be implemented to improve HPV VC."