ReMARk: A Multi-level Intervention Addressing Disparities in Rural HPV-related Cancer Prevention: Part 3- Evaluation

There are three main objectives of the protocol. First, we will evaluate the added clinical- and cost-effectiveness of parent-targeted motivational aids (reminder/recall and phone-based MI) alone and when combined with community-targeted healthcare access assistance beyond the effects of clinician-targeted training. Second, we will estimate the differential effectiveness of the implementation strategies by patient-level factors (age, race/ethnicity, sex, distance from home to clinic, social vulnerability). Third, we will measure moderation of implementation strategy effectiveness by clinic-level factors (HPV vaccination priority, resources, clinic visit types, scheduling practices, and implementation success).

We propose a multilevel approach, incorporating evidence-based strategies that address clinicians' recommendations, parents' hesitations, and access to healthcare is needed to reduce the HPV-related cancer disparities in rural areas. Within 11 rural North Central Florida counties, we will adapt, implement, and evaluate the layering of evidence-based implementation strategies by progressively addressing clinician, parent, and healthcare access barriers faced by rural communities on HPV vaccination rates among 9- to 12-year-olds. To increase reproducibility, we propose a conceptual framework, specified implementation strategies, randomization, adaptive and sequential implementation strategies, process and outcome measures, appropriate statistical analysis, and conservative power calculations.

To best address our main question of whether layering complementary strategies continues to increase effects on HPV vaccination, we will test our hypotheses with a three-arm cluster randomized study design of nested strategies. The proposed nested study design optimizes evaluation, causal inference, and scientific rigor by putting the maximum number of clinics towards addressing the layering of strategies. Randomization will occur at the clinic level. All clinics will receive implementation strategy A: clinician-targeted recommendation training. A random 20 of 30 of clinics will also receive facilitation of parent-targeted motivational aids (B) for an implementation strategy package of A+B. Finally, a random half of the clinics who receive A+B will also receive community-targeted healthcare access (C) for a total implementation strategy package of A+B+C. This equates to a three-arm cluster randomized trial in which 10 clinics receive clinician-targeted recommendation training alone (A), 10 clinics receive clinician-targeted recommendation training and parent-targeted motivational aids (A+B), and 10 clinics receive clinician-targeted recommendation training, parent-targeted motivational aids, and community-targeted healthcare access (A+B+C).

Random Assignment:

Clinics will be randomized into three equal arms. Ten clinics will receive clinician-targeted recommendation training alone (A). Ten clinics will receive clinician-targeted recommendation training and parent-targeted motivational aids (A+B). Ten clinics will receive clinician-targeted recommendation training, parent-targeted motivational aids, and community-targeted healthcare access (A+B+C).