Pediatrician-Parent Conversations About Human Papillomavirus Vaccination: An Analysis of Audio Recordings

Examining strategies for improving healthcare providers' communication about adolescent HPV vaccination: evaluation of secondary outcomes in a randomized controlled trial

There is a critical need for campaigns and interventions to increase rates of human papillomavirus (HPV) vaccination among U.S. adolescents. Healthcare providers are key stakeholders in parents' HPV vaccine decision-making. The current study presents the evaluation of secondary outcomes in a multi-component communication-based intervention to improve healthcare providers' communication about HPV vaccination. Evaluation was conducted via surveys of providers participating in a 12-month randomized controlled trial. Findings suggest use of communication components (combined use of the presumptive approach [PA] with all patients, and motivational interviewing and a fact sheet with vaccine hesitant parents) contributed to providers in the intervention group reporting higher perceived levels of parental HPV vaccine acceptance than control providers, as well as increased vaccination rates in the intervention arm in the main RCT.

Addressing Vaccine Hesitancy in Clinical Practice

Vaccines have had a profound impact on public health; however, parents are increasingly refusing or delaying vaccines for their children. Population-based studies have demonstrated the safety and efficacy of vaccines. Pediatricians should be well informed about vaccine development, safety, and efficacy to inspire parental confidence in vaccines. Systemic challenges in discussing and providing immunizations exist. Discussions about immunizations may be lengthy and time spent discussing immunizations is not routinely reimbursed. Adolescents may be inadequately immunized because they do not routinely present for preventive health visits. Routine immunizations should be offered and discussed at sick visits, particularly for adolescents. Improving immunization rates requires a multifaceted approach. [Pediatr Ann. 2018;47(9):e366-e370.].

An environmental scan to examine stakeholder perspectives on human papillomavirus vaccination: A mixed methods study

PURPOSE

Human papillomavirus (HPV) vaccine series completion rates among females and males remain low in Florida (46.4% and 34.5%, respectively). Multiple stakeholders influence vaccination uptake, including health care providers (HCPs), public health professionals (PHPs), and members of professional organizations. We examined stakeholder efforts related to increasing vaccine uptake and education among parents/adolescents and HCPs.

METHODS

We conducted an environmental scan of stakeholder efforts and identified stakeholders using our professional networks and a snowball sampling approach. Stakeholders (n = 46) completed a survey about involvement in and barriers to vaccination promotion efforts. A subset (n = 12) of stakeholders participated in follow-up interviews further exploring vaccination efforts and barriers. Survey data were analyzed using descriptive statistics. Interview data were analyzed using deductive analysis and coded using constructs from the PRECEDE-PROCEED model.

RESULTS

The majority of our survey sample was PHPs (50.0%) and HCPs (32.6%). Stakeholder efforts were focused on adolescent/parent/HCP education including providing: educational materials for HCPs (55.8%) and adolescents/parents (59.6%), one-on-one consultations for adolescents/parents (55.3%), and HCP education (54.7%). Lack of knowledge/understanding and education/information were barriers reported across almost all groups/areas. Office staff/HCP education and distribution of patient education materials were efforts described as important during qualitative interviews. Stakeholders also noted HCP discomfort when recommending HPV vaccine, parental perceptions that the vaccine is unnecessary, and a lack of education/understanding among parents and HCPs.

CONCLUSIONS

Results suggest the need for parent/adolescent education, specifically targeting key areas we identified: importance and benefits of HPV vaccine, and education and skill building in vaccine communication for HCPs.

A retrospective and prospective look at strategies to increase adolescent HPV vaccine uptake in the United States

The HPV vaccine debuted more than ten years ago in the United States and many strategies have been evaluated to increase HPV vaccination rates, which include not only improving current vaccination behaviors but also sustaining these behaviors. Researchers and practitioners from a variety of backgrounds have engaged in this work, which has included efforts directed at public health and government policies, health education and health promotion programs, and clinical and patient-provider approaches, as well as work aimed to respond to and combat anti-HPV vaccination movements in society. Using a previously developed conceptual model to organize and summarize each of these areas, this paper also highlights the need for future HPV vaccine promotion work to adopt a multi-level and, when possible, integrated approach in order to maximize impact on vaccination rates.

Parents' Views on the Best and Worst Reasons for Guideline-Consistent HPV Vaccination

Background: Human papillomavirus (HPV) vaccination could prevent most HPV-associated cancers, but few U.S. adolescents are vaccinated according to guidelines. To inform efforts to counsel parents more effectively, we sought to quantify their views on the best and worst reasons for guideline-consistent HPV vaccination. We hypothesized that parents' views would differ according to their vaccination confidence.Methods: We developed a best-worst scaling experiment to evaluate 11 reasons healthcare providers commonly give for HPV vaccination. The instrument was administered in 2016 via a national online survey to 1,177 parents of adolescents. Parents completed 11 choice tasks of 5 reasons each, indicating the best and worst reason in each task. We used conditional logistic regression to rank reasons for the sample overall and by vaccination confidence (low/high).Results: Parents viewed cancer prevention as the best reason for HPV vaccination (P < 0.001). Other commonly endorsed reasons were preventing a common infection, having lasting benefits, or being a safe vaccine (all P < 0.001). Reasons viewed as worst were: It is a scientific breakthrough; I got it for my own child; and your child is due (all P < 0.001). Stratified analyses indicated small differences in how often parents with low versus high vaccination confidence endorsed messages (P < 0.001), but the two groups ranked reasons similarly overall.Conclusions: Parents prioritized cancer prevention as the best reason for guideline-consistent HPV vaccination. Several other common reasons, including having vaccinated one's own child, may warrant additional testing.Impact: Providers should emphasize cancer prevention when discussing HPV vaccination, as recommended by the Centers for Disease Control and Prevention, the President's Cancer Panel, and others. Cancer Epidemiol Biomarkers Prev; 27(7); 762-7. ©2018 AACR.

Indicated or elective? The association of providers' words with HPV vaccine receipt

BACKGROUND

Appropriate provider recommendation is crucial to raising HPV vaccination uptake, yet scant research has explored actual conversations between providers and parents, the effect of parental pre-visit vaccine intention on vaccination, or the effect of conversation style on parental satisfaction with that conversation.

METHODS

We analyzed 146 audio-recorded clinical encounters between providers, parents/guardians, and HPV vaccine-eligible adolescents, from May 2015 to March 2017, at eight practices in Northeastern U.S. Parents completed pre-visit measures of intent to vaccinate and post-visit assessments of satisfaction with vaccine conversations. We qualitatively analyzed transcribed audio recordings and evaluated associations between providers' vaccine introductions and vaccine receipt.

RESULTS

Provider recommendations were empirically defined as "indicated" (clear recommendation that the child receive HPV vaccination at that visit), "elective" (vaccination presented as optional), or "contraindicated" (delay recommended). The vaccination rates were 87%, 68%, and 0% following "indicated," "elective," and "contraindicated" presentations respectively. Providers' statements attesting to the vaccine's value to the child did not affect receipt. Parental pre-visit intent to vaccinate was associated with vaccine receipt: 100% for likely/very likely compared to 28% for very unlikely. The association between vaccine recommendation style and vaccine receipt was most pronounced with undecided parents, with 92% accepting vaccination after an "indicated" recommendation vs. 68% after an "elective" recommendation. Satisfaction with vaccine conversations was high regardless of recommendation style.

CONCLUSIONS

The results suggest that the words used to introduce HPV vaccination have the potential to inform parents' HPV vaccination decisions. Providers should be encouraged to simply state, "Your child is due for the HPV vaccine today."

Impact of Childhood Vaccine Discussion Format Over Time on Immunization Status

OBJECTIVE

Presumptive formats to initiate childhood vaccine discussions (eg, "Well, we have to do some shots") have been associated with increased vaccine acceptance after one visit compared to participatory formats (eg, "How do you feel about vaccines?"). We characterize discussion format patterns over time and the impact of their repeated use on vaccine acceptance.

METHODS

We conducted a longitudinal prospective cohort study of children of vaccine-hesitant parents enrolled in a Seattle-based integrated health system. After the child's 2-, 4-, and 6-month visits, parents reported the format their child's provider used to begin the vaccine discussion (presumptive, participatory, or other). Our outcome was the percentage of days underimmunized of the child at 8 months old for 6 recommended vaccines. We used linear regression and generalized estimating equations to test the association of discussion format and immunization status.

RESULTS

We enrolled 73 parent-child dyads and obtained data from 82%, 73%, and 53% after the 2-, 4-, and 6-month visits, respectively. Overall, 65% of parents received presumptive formats at ≥1 visit and 42% received participatory formats at ≥1 visit. Parental receipt of presumptive formats at 1 and ≥2 visits (vs no receipt) was associated with significantly less underimmunization of the child, while receipt of participatory formats at ≥2 visits was associated with significantly more underimmunization. Visit-specific use of participatory (vs presumptive) formats was associated with a child being 10.1% (95% confidence interval, 0.3, 19.8; P = .04) more days underimmunized (amounting to, on average, 98 more days underimmunized for all 6 vaccines combined).

CONCLUSIONS

Presumptive (vs participatory) discussion formats are associated with increased immunization.

Increasing Vaccination: Putting Psychological Science Into Action

Vaccination is one of the great achievements of the 20th century, yet persistent public-health problems include inadequate, delayed, and unstable vaccination uptake. Psychology offers three general propositions for understanding and intervening to increase uptake where vaccines are available and affordable. The first proposition is that thoughts and feelings can motivate getting vaccinated. Hundreds of studies have shown that risk beliefs and anticipated regret about infectious disease correlate reliably with getting vaccinated; low confidence in vaccine effectiveness and concern about safety correlate reliably with not getting vaccinated. We were surprised to find that few randomized trials have successfully changed what people think and feel about vaccines, and those few that succeeded were minimally effective in increasing uptake. The second proposition is that social processes can motivate getting vaccinated. Substantial research has shown that social norms are associated with vaccination, but few interventions examined whether normative messages increase vaccination uptake. Many experimental studies have relied on hypothetical scenarios to demonstrate that altruism and free riding (i.e., taking advantage of the protection provided by others) can affect intended behavior, but few randomized trials have tested strategies to change social processes to increase vaccination uptake. The third proposition is that interventions can facilitate vaccination directly by leveraging, but not trying to change, what people think and feel. These interventions are by far the most plentiful and effective in the literature. To increase vaccine uptake, these interventions build on existing favorable intentions by facilitating action (through reminders, prompts, and primes) and reducing barriers (through logistics and healthy defaults); these interventions also shape behavior (through incentives, sanctions, and requirements). Although identification of principles for changing thoughts and feelings to motivate vaccination is a work in progress, psychological principles can now inform the design of systems and policies to directly facilitate action.

Influencers and preference predictors of HPV vaccine uptake among US male and female young adult college students

Objective

The purpose of the study was to assess the knowledge, attitudes and beliefs of male and female college students in Kentucky about HPV associated diseases and vaccines, and to determine which parameters predicted self-reported uptake of HPV vaccination.

Materials and methods

A self-selected cross-sectional sample of college students completed an evidence-based online survey.

Results

Of approximately 1200 potential respondents, 585 completed the survey. The average age was 20.6 (SD 3.15) and 78% were female; 84% of the population had had one or more sexual partners. Concern for HPV vaccine safety and potential need for boosters did not significantly deter vaccine uptake. Likewise, knowledge about HPV associated cancers was not predictive of vaccine uptake. On the other hand, parental influence for vaccination was a strong predictor for vaccine uptake (aOR = 5.32, 2.71–13.03), and free vaccine nearly doubled the likelihood of being vaccinated (aOR 1.90, 1.05–3.41). In addition, the strong preference for the respondent's partner to be HPV vaccinated predicted vaccine uptake (aOR = 4.04, 95% CI: 2.31–7.05), but the lack of preference for partner vaccination predicted an unvaccinated self (aOR = 0.50, 0.27–0.93).

Conclusions

HPV vaccination has been successful in young adult college students in Kentucky. Young adults prefer their partners to be HPV vaccinated regardless of whether they themselves are vaccinated. Parental influence and free vaccine were positive predictors for vaccine uptake in this population.

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Young adults have a very strong preference for their partner to be HPV vaccinated.

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Doctors do not influence young college adults’ decisions to be HPV vaccinated.

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Parents are a significant influencer for young adult HPV vaccine uptake.

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Young adults realize need for cervical cancer screening regardless of vaccine.

Global human papilloma virus vaccine implementation: An update

Human papillomavirus (HPV) infections continue to be one of the most common sexually transmitted infections worldwide. The oncogenic potential of this virus was well established in anogenital malignancies and oropharyngeal cancers. Even though a fall in cervical cancer rates has been reported worldwide, the subsequent rise in HPV-associated head and neck cancers among men and women have been reported from developed countries, necessitating the vaccination of adolescent boys as well. The objective of this narrative review is to provide an update on the current status of HPV vaccination worldwide. This will be helpful for clinicians in counseling parents and guardians as this vaccine mainly targets sexually naïve preadolescents. An electronic search of the databases was carried out to retrieve information concerning HPV vaccine implementation between July 2006 and 2017, with special emphasis on the current viewpoints, controversies and ethical issues. Globally, 74 countries have implemented the HPV vaccine in the national immunization schedule, and this vaccine is listed as an essential medicine by WHO. About 60% of the low- and lower-middle-income countries have implemented the vaccine with financial assistance from Gavi and WHO. The HPV vaccine is a safe vaccine with no serious adverse effects as per the data available from developed nations as well as low/lower middle/upper middle-income countries. However, long-term follow-up is essential to substantiate the impact of the vaccination programs in cancer prevention.

Simple and Elaborated Clinician Reminder Prompts for Human Papillomavirus Vaccination: A Randomized Clinical Trial

OBJECTIVE

To evaluate the effects of simple and elaborated health care provider (HCP) reminder prompts on human papillomavirus (HPV) vaccine initiation rates.

METHODS

Twenty-nine pediatric HCPs serving 5 pediatric clinics were randomized to 1 of 3 arms: 1) usual practice control, 2) simple reminder prompt, and 3) elaborated reminder prompt, which included suggested language for recommending the early adolescent platform vaccines. Prompts were delivered via a computer-based clinical decision support system deployed in the 5 clinics. Eligible patients were ages 11 to 13 years, had not received HPV vaccine, and were due for meningococcal ACWY (MenACWY) vaccine and/or the tetanus, diphtheria, and pertussis booster (Tdap). Receipt of HPV vaccine was determined via automated queries sent to the Indiana immunization registry. Data were analyzed via logistic regression models, with generalized estimating equations used to account for the clustering of patients within HCPs.

RESULTS

Ten HCPs in the control group saw 301 patients, 8 HCPs in the simple prompt group saw 124, and 11 HCPs in the elaborated prompt group saw 223. The elaborated prompt arm had a higher rate of HPV vaccination (62%) than the control arm (45%): adjusted odds ratio, 2.76; 95% confidence interval, 1.07 to 7.14. The simple prompt arm did not differ significantly from the control arm with respect to HPV vaccine initiation, which might have been because of the small sample size for this arm. MenACWY and Tdap rates did not vary across the 3 arms.

CONCLUSIONS

Results suggest that an elaborated HCP-targeted reminder prompt, with suggested recommendation language, might improve rates of HPV vaccine initiation.

Human Papillomavirus Vaccination: Narrative Review of Studies on How Providers' Vaccine Communication Affects Attitudes and Uptake

The burden of human papillomavirus (HPV) infections is substantial, causing thousands of cancers and deaths in the United States yearly. Safe and effective vaccines exist, yet remains underutilized, particularly among younger adolescents for whom the vaccine is targeted. Provider communication techniques are known to affect parents' and adolescents' acceptance of this vaccine. In this review, we examine the influence that provider communication techniques have on parental attitudes regarding HPV vaccine, as well as how those techniques affect vaccination uptake. We explore the limited literature that has directly measured the influence of provider communication techniques on parental attitudes, which suggests that the strength of a provider recommendation strongly influences parents' perceptions regarding the safety of HPV vaccine, and that brief recommendations might be best for parents without significant concerns. We also review the literature regarding the use of so-called 'presumptive' recommendations, and how these types of recommendations are associated with increased HPV vaccine uptake. Finally, we present new information regarding the use of motivational interviewing as a provider communication technique to improve vaccination uptake, particularly among vaccine-hesitant parents. We close with suggestions for 'best practices' that include using brief, strong, unambiguous language to introduce the HPV vaccine, followed by more nuanced communication techniques, such as motivational interviewing, when encountering resistance.

Content of web-based continuing medical education about HPV vaccination

BACKGROUND

Addressing low HPV vaccination coverage will require U.S. health care providers to improve their recommendation practices and vaccine delivery systems. Because readily available continuing medical education (CME) could be an important tool for supporting providers in this process, we sought to assess the content of web-based CME activities related to HPV vaccination.

METHODS

We conducted a content analysis of web-based CME activities about HPV vaccination available to U.S. primary care providers in May-September 2016. Using search engines, educational clearinghouses, and our professional networks, we identified 15 activities eligible for study inclusion. Through a process of open coding, we identified 45 commonly occurring messages in the CME activities, which we organized into five topic areas: delivering recommendations for HPV vaccination, addressing common parent concerns, implementing office-based strategies to increase HPV vaccination coverage, HPV epidemiology, and guidelines for HPV vaccine administration and safety. Using a standardized abstraction form, two coders then independently assessed which of the 45 messages each CME activity included.

RESULTS

CME activities varied in the amount of content they delivered, with inclusion of the 45 messages ranging from 17% to 86%. Across activities, the most commonly included messages were related to guidelines for HPV vaccine administration and safety. For example, all activities (100%) specified that routine administration is recommended for ages 11 and 12. Most activities (73%) also noted that provider recommendations are highly influential. Fewer activities modeled examples of effective recommendations (47%), gave specific approaches to addressing common parent concerns (47%), or included guidance on office-based strategies to increase coverage (40%).

CONCLUSIONS

Given that many existing CME activities lack substantive content on how to change provider practice, future activities should focus on the practical application of interpersonal and organizational approaches for improving HPV vaccine delivery in the clinical setting.