Development of an Educational Package for the Universal Human Papillomavirus (HPV) Vaccination Programme: A Co-production Study with Young People and Key Informants

"Incorporating the views of the...young people and professionals involved in delivery of the HPV vaccination programme...throughout the development, design, and testing processes increases the likelihood that the educational package will be acceptable, engaging, persuasive, and easy to use."

Persistent lower uptake rates among minority ethnic groups and young people living in more deprived areas of the United Kingdom (UK) have been identified in the English schools-based human papillomavirus (HPV) vaccination programme. Research shows that complex socio-cultural factors, including information needs, influence beliefs and priorities for young people to be vaccinated. There are also challenges in communicating evidence-based messages in schools-based vaccination programmes. This paper describes the co-production process of EDUCATE, an educational package tailored at increasing vaccine uptake in areas and populations with lower HPV vaccination coverage.

Two geographically distinct areas in England with historically lower uptake of the HPV vaccination programme were selected as research sites: Bristol local authority and the London Borough of Southwark. Recruited by local youth organisations, the 61 participants involved youth in the age group 12-15 years, as they were perceived to have diverse experiences in relation to having been offered the HPV vaccine through the programme.

The planning and development phases involved the following interrelated stages, each of which is described in detail in the paper:

1. Collating and analysing evidence - To inform the initial stages of the planned research, the researchers summarised existing HPV vaccine communication materials for young people. The findings from this content analysis were used to inform topic guides to seek further feedback and clarification from young people (n = 11) and key informants (n = 6) regarding appropriate content to include within the materials for the educational package.
2. Developing guiding principles - In the person-based approach, the guiding principles comprise a design objective and intervention features that address the user/context-specific behavioural need, issue, or challenge identified in the earlier planning stages. In brief, the EDUCATE package aims to: (i) improve young people's knowledge and understanding about the HPV vaccine; (ii) increase young people's confidence to have a vaccine in the school setting; (iii) engage young people in the decision-making and the consent process, and; (iv) be delivered flexibly to meet the needs of the intended population.
3. Undertaking a behavioural analysis - Identified behaviours related to HPV vaccine were mapped onto constructs from the Behaviour Change Wheel to describe the intervention processes and components. The proposed EDUCATE package employs four intervention functions (enablement, education, persuasion, and environmental restructuring), which are enacted by six behavioural change techniques (instruction on how to perform a behaviour, information about health consequences, anticipated regrets, generalisation of target behaviour, pros and cons, and restructuring the social environment).
4. Developing a preliminary logic model - This brought together the findings from the intervention planning activities and how these are anticipated to improve uptake of the HPV vaccination programme. See Figure 1 in the paper.
5. Co-producing the intervention - Co-production approaches involve sharing decision-making and including the expertise of the intended users of an intervention. By incorporating their perspectives, the acceptability, feasibility, and practicality of the intervention is addressed and maximised at the intervention development stage. This philosophy undergirded the development of the educational package, which comprised a PowerPoint presentation integrated with short films and question-and-answer breaks. For example, the content for the films was created by young people (n = 16), an HPV-cancer survivor, an immunisation nurse, and the creative team at Eight Creative Agency, at Knowle West Media Centre in Bristol. Young people were asked to provide in-person feedback on an initial story board developed by an animator and select the music to accompany each film. Feedback from young people resulted in changes related to communicating messages around: the sexual transmissibility of HPV; ensuring imagery of young people were ethnically diverse; and avoiding assumptions around HPV infection risk only affecting heterosexual partnerships. Key informants reviewed and commented in writing on the scripts for the videos and content of the PowerPoint presentation.
6. Refining the intervention - The EDUCATE package was provided to young people through a pre-recorded session delivered during tutor time in a secondary school (Bristol) and a session delivered in a youth organisation (Southwark, London). Young people (n = 17) participated in small group interviews to provide their feedback. Ultimately, the resources for the EDUCATE package created are PowerPoint slides, interspersed with five short films. A guidance document with additional information for the delivery of the session was also produced. Expected to be available in the public domain shortly, the final package is intended to be used alongside, and complement, materials developed for the national HPV vaccination programme.

Reflecting on the experience, the researchers say they enjoyed working closely with young people from disadvantaged backgrounds who are often under-represented in research. They plan a future implementation study to further test the mechanisms of delivery (e.g., engage young people in the decision-making and the consent process) and to gather evidence in relation to changes to uptake of the HPV vaccination programme.

They conclude: "This study has begun to address the need for a rigorously developed, theory-based intervention to meet young people's information needs about the HPV vaccination programme. By working closely with young people and key informants, the content of the communication materials was developed to meet the needs of target users."