Conceptualizing vaccine champions from an implementation science perspective: Findings from a national survey of primary care health professionals

Abstract

Objective:

Clinical champions are healthcare professionals who help their colleagues improve the delivery of evidence-based care. Because little is known about champions working in the context of adolescent vaccination, we sought to identify vaccine champion roles among primary care health professionals (PCHPs).

Methods:

In 2022, we surveyed 2,527 US PCHPs who serve adolescents. The survey assessed the extent to which respondents identified as vaccine champions and the activities they performed. Guided by the Consolidated Framework for Implementation Research, we used these data to categorize PCHPs as: champions who led projects to increase vaccination rates (“implementation leaders”); facilitating champions who more generally shared vaccination data, information, and encouragement (“facilitators”); or non-champions. We used multinomial logistic regression to identify correlates of being a leader or facilitator as opposed to a non-champion.

Results:

About one-fifth (21%) of PCHPs were implementation leaders, one-quarter (25%) were facilitators, and the remainder (54%) were non-champions. Leaders were more common among PCHPs with medium or high versus low practice experience (31% and 36% versus 20%, both p<.01) and adolescent patient volume (29% and 39% versus 17%, both p<.01). Being a facilitator was also associated with higher practice experience and patient volume. Leaders and facilitators reported a similar number of barriers to their work (mean=1.8 and 1.9, respectively), with time and competing quality metrics being most common.

Conclusions:

Our findings suggest that both implementation leaders and facilitators are common vaccine champions in adolescent primary care. These champions are more often found among PCHPs with higher experience and patient volume.

INTRODUCTION

Clinical champions are healthcare professionals who work to improve the delivery of evidence-based care.¹ As “the face” of quality improvement (QI) efforts, champions support their colleagues and address challenges to care delivery by, for example, advocating for adequate time, data, and other resources.^1,2 The 2022 updated Consolidated Framework For Implementation Research (CFIR) distinguishes between two different champion roles.³ “Implementation leads” are individuals who spearhead discrete projects to improve the quality of evidence-based care delivery, while “implementation facilitators” are those with “subject matter expertise who assist, coach or support implementation.”³ Engaging both champion types is a promising approach to improving delivery of evidence-based care.

Human papillomavirus (HPV) vaccination can provide a context for learning more about implementation leaders and facilitators. HPV vaccine uptake remains suboptimal in the United States (US) despite recommendations for adolescents to receive the two-dose series at ages 9–12.⁴ In 2022, only 50% of 13-year-olds were up to date.⁵ Reasons for low HPV vaccination rates include ineffective and infrequent provider recommendations.^6–9 Implementation leaders and facilitators are well-positioned to encourage their colleagues to improve their HPV vaccine recommendations. Such champions can also support provider communication training and clinic assessment and feedback to increase HPV vaccination rates.^10–12 Our prior research suggests that many primary care health professionals (PCHPs) with a role in adolescent vaccination work with one or more champions and these champions are often perceived as highly effective.^13,14 While vaccine champions have the potential to positively impact HPV vaccine uptake, no prior studies have investigated who identifies with the CFIR roles of implementation leader and facilitator in adolescent primary care.^2,15–19

To address this gap, we sought to characterize which PCHPs with a role in adolescent HPV vaccination serve as implementation leaders or facilitators. We focused on vaccine champions generally instead of HPV vaccine champions specifically, given their potential to apply vaccine-related skills and interests to addressing the problem of low HPV vaccine uptake. We also explored perceived barriers PCHPs face in serving as vaccine champions, as well as their training needs. By doing so, our study seeks to characterize vaccine champions from an implementation science perspective to advance opportunities to identify, support, and coordinate different types of champions.

METHODS

Participants and procedures

In May-July 2022, we surveyed US PCHPs to evaluate the extent to which they identified as vaccine champions and their experiences in that role. Eligible PCHPs were physicians, advanced practice providers (i.e., physician assistants and nurse practitioners), and nursing staff (i.e., registered nurses, licensed practical/vocational nurses, medical assistants, and certified nursing assistants). Additional eligibility criteria were: 1) having a specialty in pediatrics or family/general medicine (for physicians) or working in a clinic with one of these specialties (for advanced practice providers and nursing staff); 2) having a role in HPV vaccination for children ages 9–12; and 3) practicing in the US.

We contracted with WebMD Market Research to recruit participants through their Medscape Network. The network provides information, continuing education, and research opportunities to healthcare professionals. Medscape’s membership includes an estimated 60% of physicians in the US. Physicians and advanced practice providers verify their medical licenses during registration.

We conducted survey recruitment in two phases. In the pre-recruitment phase, Medscape invited members with the relevant medical training to indicate their interest in completing our survey, thus filtering out inactive members. We received 6,278 responses. In the recruitment phase, Medscape invited these panel members to complete our web-based survey, which was followed by up to four reminders for non-respondents. We used quotas to establish diversity across PCHP training types, working to recruit similar proportions of physicians in pediatrics, physicians in family medicine, advanced practice providers, and nursing staff. Given the rural-urban disparities in HPV vaccination, we aimed to oversample PCHPs practicing in clinics located in rural counties, according to the USDA Rural-Urban Continuum Codes (RUCC) 4–9.^20,21

PCHPs who initiated the online survey first responded to a screener to confirm eligibility. In total, 2,527 PCHPs met eligibility criteria, provided informed consent, and completed the online survey (response rate of 57%; American Association for Public Opinion Research Response Rate 3).²² The other panel members were not included because they: did not respond to the invitation or complete the screener (n=2,242); completed the screener but were ineligible (n=1,179); or were eligible but did not complete the survey (n=330). Participants received up to a $45 incentive. The University of North Carolina Institutional Review Board approved the study protocol.

Measures

Vaccine champion types.

Guided by CFIR,³ our survey began by defining vaccine champions as “health care professionals [who] are known for helping their colleagues improve vaccination rates. They are passionate about sharing vaccine-related information, data, tools, and encouragement with others in their clinic.” PCHPs then responded to the item, “How much do you consider yourself to be a vaccine champion?” using a 5-point response scale that ranged from “not at all” (1) to “extremely” (5). An additional item used a prespecified list to assess which of five strategies PCHPs identifying as vaccine champions used to improve vaccination rates in their clinic (“share information with colleagues,” “encourage colleagues to improve,” “share data on vaccination rates,” “lead quality improvement projects,” or “communicate effectively with patients and their families”).

We used the responses to the above items to categorize PCHPs into three groups, adapted from CFIR³: champions who led QI projects (or implementation “leaders”); facilitating champions who more generally shared vaccination data, information, and encouragement (or “facilitators”); and non-champions. Leaders were PCHPs who strongly identified as champions by responding “very” (4) or “extremely” (5) to that item, while also reporting that they led QI projects as one of their strategies to improve vaccination rates. Facilitators were PCHPs who strongly identified as champions, while also reporting that they shared information, encouraged colleagues, and/or shared data, but did not lead QI projects. Non-champions were the remaining PCHPs who did not meet these criteria, including those who only reported communicating effectively with parents and families as their champion strategy.

Perceived barriers and training.

One item assessed barriers to being a vaccine champion with a prespecified list of six responses (“lack of time,” “lack of funding,” “lack of data on vaccination rates,” “need to focus on other quality metrics,” “lack of support from clinic leadership,” and “lack of support from others in their clinic”). A second item assessed topics for additional training PCHPs would want to support their role as a vaccine champion with a prespecified list of four responses (“vaccine safety and administration,” “communication,” “data analysis,” and “quality improvement”).

Provider and clinic characteristics.

PCHPs answered nine items to describe their professional roles and the clinics in which they worked. Five items assessed participant characteristics including training (e.g., physician, advanced practice provider, nursing staff), professional/clinic specialty, gender, race/ethnicity, years in practice, and adolescent patient volume in terms of number of patients ages 9–12 seen in a typical week. The remaining four items assessed the clinic characteristics of practice type, healthcare system membership status, and the county and state in which the PCHP’s clinic was located. We recategorized counties by RUCC as rural (RUCC 4–9) or nonrural (RUCC 1–3).

To refine questions, we conducted cognitive interviews with 17 PCHPs prior to fielding our survey. For example, we evaluated whether participants’ interpretation of the concept of “vaccine champion” aligned with the research team’s intention. Using feedback from these cognitive interviews, we iteratively updated survey instructions and items. See Supplemental File 1 for the survey instrument.

Statistical analysis

We used multinomial logistic regression to identify correlates of PCHPs who identified as leaders and facilitators. The model simultaneously compared each champion group (leaders and facilitators) with non-champions. We present conditional odds ratios (ORs), also referred to as relative-risk ratios (RRRs) by some disciplines and statistical packages.^23,24 We first ran unadjusted models to identify statistically significant correlates at the bivariate level. We then entered those correlates into a multivariable model which we refined based on model fit testing. Based on these results, we included training, primary/clinic specialty, practice experience, adolescent patient volume, and healthcare system membership in the adjusted model. We excluded gender, race/ethnicity, rurality, and region due to non-significance in bivariate models (Supplemental File 2) and further excluded practice type based on model fit testing. To further characterize associations between champion types and covariates, we used our multinomial logistic model to calculate average predicted probabilities. We used chi-square tests to assess differences in perceived barriers and additional training needs among leaders versus facilitators. We conducted analyses using Stata Version 18.0 (College Station, TX). Statistical tests were two-tailed with a critical alpha of 0.05.

RESULTS

Sample characteristics

Nearly half of PCHPs in our sample were physicians (48%), about one-quarter were advanced practice providers (24%), and the remainder were nursing staff (28%, Table 1). Equal proportions of PCHPs noted their specialty as pediatrics (50%) versus family medicine (50%). Over two-thirds of participants were women (72%), and most identified as White (66%), Asian (14%), Black (5%), or Hispanic (4%). Our sample included PCHPs whose practice experience was low (≤9 years, 38%), medium (10–19 years, 29%), and high (≥20 years, 33%). Volume of 9- to 12-year-old patients seen in a typical week ranged from low (≤9 patients, 29%) to medium (10–24 patients, 40%) to high (≥25 patients, 32%). Over half of participants worked in clinics that were solo or group practices (61%) and part of a healthcare system (62%). Most PCHPs worked in clinics located in non-rural areas (91%). About one-third were located in the South (33%) with the remainder located in the Northeast (20%), Midwest (23%), and West (24%).

Table 1.

Distribution of PCHP participant characteristics, United States, 2022 (n=2,527)

	n	(%)
Participant characteristics
Training
Physician	1,223	(48)
Advanced practice providera	603	(24)
Nursing staffb	701	(28)
Primary/clinic specialtyc
Family medicined	1,274	(50)
Pediatrics	1,253	(50)
Gender
Woman	1,810	(72)
Man	637	(25)
Another gender/prefer not to saye	80	(3)
Race and ethnicity
Asian	356	(14)
Black	123	(5)
Hispanic	100	(4)
White	1664	(66)
Multiracial	94	(4)
Another race/prefer not to sayf	190	(8)
Practice experience
Low (≤9 years)	950	(38)
Medium (10–19 years)	740	(29)
High (≥20 years)	837	(33)
Patient volume in a typical week for ages 9–12
Low (≤9 patients)	730	(29)
Medium (10–24 patients)	1,000	(40)
High (≥25 patients)	797	(32)
Clinic or practice characteristics
Practice type
Solo or group	1,534	(61)
Otherg	993	(39)
Healthcare system membership
No	963	(38)
Yes	1564	(62)
Rural
No	2,295	(91)
Yes	232	(9)
Region
Northeast	505	(20)
Midwest	576	(23)
South	841	(33)
West	605	(24)

^aIncludes physician assistants (n=198) and advanced practice nurses (n=405), including nurse practitioners and clinical nurse specialist

^bIncludes registered nurses (n=542), licensed practical or vocational nurses (n=64), certified nursing assistants(n=11), and medical assistants (n=84)

^cPhysicians indicated their primary specialty; advanced practice providers and nursing staff indicated their clinic’s specialty

^dIncludes both family medicine and general practice

^eIncludes nonbinary or another gender (n=10) and prefer not to say (n=70)

^fIncludes American Indian or Alaska Natives (n=10), Middle Eastern or North Africans (n=19),

Native Hawaiian or Pacific Islanders (n=4), other race or ethnicity (n=13), and prefer not to say

(n=144)

^gIncludes hospital- and university-affiliated clinic (n=512), Federally Qualified Health Center (n=272), state or local public health department (n=37), local, community, or non-profit clinic (n=116), and other (n=56)

Champion prevalence and correlates

Overall, almost half (46%) of our sample met our definition of vaccine champion, with about one-fifth (21%, n=532) categorized as leaders and one-quarter (25%, n=642) categorized as facilitators.

Leaders.

In the subsample of PCHPs categorized as leaders and non-champions, those with medium or high practice experience were more likely to be leaders than those with low practice experience (conditional odds ratio [OR]=1.68, 95% confidence interval [CI], 1.29–2.17, for medium versus low experience; OR=2.19, 95% CI, 1.69–2.84 for high versus low experience, Table 2), holding other variables constant. PCHPs seeing a medium or high volume of patients ages 9–12 in a typical week were more likely to be leaders than those seeing a low patient volume (OR=2.03, 95% CI, 1.53–2.68 for medium versus low patient volume; OR=3.03, 95% CI 2.24–4.10 for high versus low patient volume). The likelihood of being a leader versus a non-champion was similar by training type, primary/clinic specialty, and healthcare system membership.

Table 2.

Correlates of being an implementation leader or facilitating champion versus a non-champion among PCHPs, United States, 2022 (n=2,527)

	PCHPs identified as leaders/Total PCHPs in categorya (%)		Multivariable		PCHPs identified as facilitators/Total PCHPs in categoryb (%)		Multivariable
			OR	(95% CI)			OR	(95% CI)
Training
Physician	253/937	(27)	1		286/970	(29)	1
Advanced practice provider	122/433	(28)	1.25	(0.95–1.63)	170/481	(35)	1.63	(1.27–2.09)**
Nursing staff	157/515	(30)	0.99	(0.78–1.27)	186/544	(34)	1.10	(0.87–1.38)
Primary/clinic specialty
Family medicine	253/988	(26)	1		286/1,021	(28)	1
Pediatrics	279/897	(31)	0.93	(0.74–1.16)	356/974	(37)	1.28	(1.03–1.58)*
Practice experience
Low (≤9 years)	149/756	(20)	1		194/801	(24)	1
Medium (10–19 years)	172/550	(31)	1.68	(1.29–2.17)**	190/568	(33)	1.47	(1.15–1.88)**
High (≥20 years)	211/579	(36)	2.19	(1.69–2.84)**	258/626	(41)	2.17	(1.71–2.75)**
Patient volume in a typical week for ages 9–12
Low (≤9 patients)	95/567	(17)	1		163/635	(26)	1
Medium (10–24 patients)	220/756	(29)	2.03	(1.53–2.68)**	244/780	(31)	1.22	(0.96–1.56)
High (≥25 patients)	217/562	(39)	3.03	(2.24–4.10)**	235/580	(41)	1.67	(1.28–2.19)**
Healthcare system membership
No	220/692	(32)	1		271/743	(36)	1
Yes	312/1,193	(26)	0.85	(0.69–1.05)	371/1,252	(30)	0.84	(0.69–1.03)

Note. Table shows raw frequencies and adjusted conditional odds ratios. Analyses used multinomial logistic regression, with PCHPs identified as non-champions used as the comparison group for PCHPs identified as leaders and facilitators. PCHP: primary care health professional.

OR: conditional odds ratio. CI: confidence interval.

^aDenominator consists of leaders and non-champions (n=1,885).

^bDenominator consists of facilitators and non-champions (n=1,995).

^*p < 0.05

^**p < 0.01

Facilitators.

In the subsample of PCHPs categorized as being facilitators or non-champions, advance practice providers were more likely than physicians to be facilitators (OR=1.63, 95% CI, 1.27–2.09, Table 2), as were PCHPs whose specialty was pediatrics versus family medicine (OR=1.28, 95% CI, 1.03–1.58). PCHPs with medium or high practice experience were more likely to be facilitators than those with low practice experience (OR=1.47, 95% CI, 1.15–1.88 for medium versus low experience; OR=2.17, 95% CI, 1.71–2.75 for high versus low experience). PCHPs seeing a high volume of patients ages 9–12 were more likely to be facilitators than those seeing a low patient volume (OR=1.67, 95% CI 1.28–2.19 for high versus low patient volume in a typical week). The likelihood of being a facilitator versus a non-champion was similar by healthcare system membership.

Average predicted probabilities

Overall, PCHPs were more likely to be a leader with increasing practice experience and patient volume. The average predicted probability that a PCHP was a leader increased as practice experience increased from 0.164 [95% CI, 0.140, 0.189] with low experience to 0.247 [95% CI, 0.218, 0.277] with high experience (both p<.001, Figure 1A). The average predicted probability that a PCHP was a leader also increased as patient volume increased from 0.130 [95% CI, 0.105, 0.155] with low volume to 0.274 [95% CI, 0.241, 0.306] with high volume (both p<.001, Figure 1B).

Figure 1.

Average predicted probability of champion role among PCHPs based on A) practice experience and B) patient volume, United States, 2022

The same pattern existed for facilitators. The average predicted probability that a PCHP was a facilitator increased as practice experience increased from 0.208 [95% CI, 0.181, 0.234] with low experience to 0.310 [95% CI, 0.278, 0.342] with high experience (both p<.001, Figure 1A). The average predicted probability that a PCHP was a facilitator also increased as patient volume increased from 0.240 [95% CI, 0.207, 0.273] with low volume to 0.278 [95% CI, 0.246, 0.310] with high volume (both p<.001, Figure 1B). Conversely, the probability of being a non-champion decreased with increasing practice experience and patient volume.

Perceived barriers

Over half of leaders and facilitators reported lack of time as a barrier to being a vaccine champion in their clinic, though leaders less often reported it as a barrier than facilitators (61% versus 69%, p<.01, Figure 2A). Leaders reported other barriers to being a vaccine champion more often than facilitators, including lack of funding (27% versus 20%), lack of data on vaccination rates (20% versus 15%), and lack of support from others in their clinic (14% versus 10%, all p<.05). Similar proportions of leaders and facilitators indicated lack of support from clinic leadership (15% versus 14%) and need to focus on other quality metrics (38% versus 35%) as barriers. Leaders and facilitators reported a similar number of barriers on average (mean=1.94, standard deviation [SD]=1.11 versus mean=1.80, SD=0.96).

Figure 2.

Percentages of champions’ A) perceived barriers and B) reported training needs, United States, 2022

*p<.05 **p<.01 ***p<.001

Additional training

Leaders more often reported additional training needs than facilitators in quality improvement (67% versus 49%), data analysis (62% versus 49%), and vaccine safety and administration (59% versus 53%, all p<.05, Figure 2B). Similar proportions of leaders and facilitators reported seeking additional training in communication as a vaccine champion (54% versus 49%).

DISCUSSION

Findings from our national study of PCHPs suggest that vaccine champions are common in adolescent primary care. About one-fifth of our sample identified as implementation leaders who conduct QI projects to improve vaccination rates and one-quarter identified as facilitators who provide information, data, and encouragement to colleagues. PCHPs who had been practicing longer and had higher adolescent patient volume more often served in these roles, suggesting that champions can more often be found among PCHPs with greater experience. Leaders more often reported lacking funding, vaccination rate data, and support from others in their clinic as barriers to serving as champions, while facilitators more often cited lack of time. Both groups indicated interest in additional training in QI, data analysis, and vaccine safety and administration, with these needs being more often reported by leaders than facilitators. Taken together, our findings suggest that leaders and facilitators are a promising resource for improving vaccination rates in adolescent primary care. However, both champion types may need more support to overcome barriers and maximize their potential as partners in vaccine-related QI efforts.

Clinics and healthcare systems may benefit from developing infrastructure to identify these champion types, particularly among PCHPs with more practice experience and higher patient volume. This approach aligns with literature indicating that champions are influential figures who are highly visible in their organizations and have prior experience engaging with key stakeholders in implementation efforts.^2,16 Bonawitz et al²⁵ also suggest that understanding the workflow and culture of a clinic are important champion attributes, supporting our results that leaders and facilitators are more often found among PCHPs with more experience. It is important to note that champion types may evolve over time, as facilitators can become leaders (or vice versa) and non-champions can take on champion roles.

While previous research has grouped champions together broadly, each champion type may be better suited for using certain strategies to improve vaccination rates and have varying ability to contribute time and resources.^2,16 For example, facilitators indicated lack of time as a barrier to champion activities more often than leaders. Clinics and healthcare systems can rely on facilitators to promote immunization efforts more generally through information and data sharing and encouragement, which may take less time than leading QI projects. In contrast, leaders can be expected to take on more time-intensive QI projects but may require more funding, access to vaccination data, and support within the clinic. Opportunities to serve as leaders and facilitators may also differ by training type and future research should consider how barriers and training needs vary across diverse types of PHCPs. Thus, our findings may provide clinics and healthcare systems guidance on where to allocate protected time, resources, and support to ensure that leaders and facilitators are able to use strategies for increasing vaccination best suited to their respective roles.

Our findings extend studies which have found that champions are involved in multiple aspects of implementation across healthcare settings to promote evidence-based care delivery.^2,16,26 Given that these two champion types exist in adolescent primary care, our findings suggest that clinics and healthcare systems can create opportunities to train and support leaders and facilitators based on their unique needs. We found that leaders more often wanted additional training in QI, data analysis, and vaccine safety and administration whereas facilitators expressed interest in all training categories. Thus, healthcare systems can provide more general professional development for facilitators to cover a broader spectrum of champion topics, whereas QI and data focused workshops could help leaders gain tailored skills for leading larger-scale implementation efforts. To better support leaders specifically, healthcare systems may benefit from facilitating relationships between leaders and established system-level QI staff. This could allow leaders to further connect with ongoing QI initiatives and help them share vaccination rates at the system level. Our prior qualitative work with system-level QI staff found that passionate vaccine champions were aids to implementing HPV vaccine QI programs.²⁷ Additionally, QI staff cited limited time, lack of robust data systems, and acceptable QI metrics as common barriers. Thus, encouraging healthcare systems to identify and support leaders as a new type of champion could help address these challenges and increase the QI-focused healthcare workforce.

Stakeholders can leverage existing resources to create trainings so that both leader and facilitator roles are further defined and formalized. One model for this might be the National Cancer Institute’s Patient Navigation Research Program that was developed to create standardized programs for patient navigators.^28–30 This training includes a curriculum on professionalism, communication skills, cultural competency, and developing a network of resources.³⁰ Champion trainings could adapt this approach to focus on adolescent vaccination, thus creating a framework to promote professional standards among champions.^29,30 To tailor more specifically to leaders and facilitators, trainings could also build on existing resources for improving vaccination rates. For example, the American Academy of Pediatrics’ Education in Quality Improvement for Pediatric Practices immunization course which provides PCHPs strategies for successful immunization efforts may be a foundation for QI-related trainings and the American Cancer Society National HPV Vaccination Roundtable’s series of action guides for increasing HPV vaccination rates could be adapted to provide more general vaccine champion training.^31–33

Lastly, clinics and healthcare systems may benefit from bringing leaders and facilitators together to maximize resources to improve adolescent vaccination rates. Our study suggests that many PCHPs identify as either leaders or facilitators. A next step is to understand the relationship between these two roles, including how they might work together. A prior systematic review suggests that collaboration among multiple champions in a team may be more effective than solo champions.¹⁶ Future research should consider whether it would also be more effective for leaders and facilitators to work together on a team.

Understanding the full range of roles and responsibilities performed by champions remains a gap in the field of implementation science.³⁴ Our findings begin to identify who is serving in champion roles as leaders and facilitators. Our work can also be integrated with existing frameworks to help clinics and healthcare systems identify champion types, including Shea’s Conceptual Model of Champion Impact² which suggests that champions’ commitment, experience, and self-efficacy influence their engagement with peers and, in turn, their impact. Thus, future studies should explore where in this conceptual model we can leverage the champion types described in our findings.

Study strengths and limitations

Our study has several strengths, such as a large national sample with diverse PCHPs, including physicians, advanced practice providers, and nursing staff. Yet, the cross-sectional design limits our ability to determine causal relationships, and having PCHPs self-identify as champions presents a potential for social desirability bias. Our study’s focus on champions in primary care with a role in adolescent vaccination may make our findings less generalizable to other health services, populations, and settings beyond the US. Future research can extend our work by exploring the role of leaders and facilitators working to improve health service delivery outside of adolescent vaccination.

CONCLUSION

We found that two types of vaccine champions—implementation leaders and facilitators—are common in adolescent primary care, and that these champions are found more often among PCHPs with more practice experience and higher patient volume. Our study presents a novel approach to understanding types of champions through strategies used to improve vaccination rates, grounded in the CFIR framework. Conceptualizing champions beyond their presence or absence and instead as leaders versus facilitators begins to provide terminology for defining their roles, barriers faced, and training needs. Our findings may also help clinics better identify PCHPs to serve as champions and begin to address the suboptimal delivery of evidence-based care, including HPV vaccination.

Highlights.

• We surveyed a national sample of 2,527 US primary care health professionals (PCHPs)

• About a fifth (21%) were vaccine champions who led quality improvement projects

• One quarter (25%) were champions who facilitated vaccine delivery in other ways

• Leaders and facilitators reported a similar number of barriers to their work

• Champions had more experience and higher patient volume than non-champions

Abbreviations:

CFIR

Consolidated Framework For Implementation Research

HPV

human papillomavirus

PCHP

primary care health professional

QI

quality improvement

RUCC

Rural-Urban Continuum Codes

US

United States