Reminder-recall letters (RR) are an effective means of increasing vaccination in the United States. However, opposition to HPV vaccination, which is viewed by many as a sexual health intervention, can lead to efforts to thwart RR systems through changes in public health policy. When opposition emerges, however, there is a ‘window of opportunity’, when coalitions can form to provide important evidence-based communication to change the course of policy development.
Using a case study approach, we examine one example of a coalition’s emergence and its efforts to provide rapid evidence-based advocacy in the U.S. state of Indiana. Data inform a point-in-time analysis of state RR communications for HPV vaccination, HPV vaccination completion, opposition emergence, evidence-based advocacy and policy activity. The study time period is from Jan 2012-May 2017.
The Indiana State Department of Health (DOH) initiated RR letters to increase HPV vaccination uptake for girls in 2012, with subsequent RR cycles for both girls and boys annually. Vaccination completion rates steadily increased, reflecting the RR intervention. Opposition emerged in 2015, following a failed state legislative bill to establish an 80% HPV vaccination completion goal, with the focus of stopping the RR program. Executive policy from the state government ensued in an effort to undermine the RR effort. Within 24 hours of the attempt to shut down the RR program, a coalition emerged with a rapid, coordinated advocacy response using social media and news outlets. This coalition, including groups from the academic and public health communities, continues today and works with the new government (new governor and legislative committee chair). The RR intervention also continues, and a new legislative policy is under consideration to allow the DOH to establish a strategic plan to reduce HPV related cancer.
Broad-based, coordinated and rapid communications by community partners with public health evidence to policy makers can have a positive policy impact. The ability to identify partners and leaders, and to coordinate communications is crucial to an effort’s success. Sustained partnerships are helpful, but even in the case of Indiana, a nascent group can also be effective if coordinated, on message and timely. These efforts must be based in the community and not in government or industry to be effective.