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

Impact of the COVID-19 pandemic on social media utilization, influences related to parental vaccine decision making, and opinions on trustworthy social media vaccination campaigns: A qualitative analysis

There is a continued need for research to better understand the influence social media has on parental vaccination attitudes and behaviors, especially research capturing the effects of the COVID-19 pandemic. The goal of this study was to explore parents' perspectives related to the impact the pandemic had on 1) social media engagement, 2) vaccine messaging on social media, and 3) factors to guide future intervention development. Between February and March 2022, 6 online, synchronous, text-based focus groups were conducted with parents of adolescents aged 11 to 17 years. Participants who all utilized social media were recruited from across the United States. Qualitative data were analyzed using content analysis. A total of 64 parents participated. Average age was 47 years, and participants were predominantly White (71.9%), female (84.3%), and engaged with social media multiple times per day (51.6%). Participants (95.3%) viewed obtaining all recommended vaccines as important or very important; however, overall vaccination rates for their adolescents were varied (50% ≥1 dose HPV; 59.4% MenACWY; 78.1% Tdap; 65.6% Flu; 81.3% COVID-19). Three themes emerged highlighting the pandemic's impact on parent's (1) general patterns of social media use, (2) engagement about vaccines on social media and off-line behaviors related to vaccination, and (3) perspectives for developing a credible and trustworthy social media intervention about vaccination. Participants reported fatigue from contentious vaccine-related content on social media and desired future messaging to be from recognizable health institutions/associations with links to reputable resources. Plus, providers should continue to provide strong vaccine recommendations in clinic.

Benefits, challenges, and strategies related to using presumptive recommendations for HPV vaccination: A qualitative study with rural and non-rural-serving primary care professionals

HPV vaccination coverage remains far below the national target of 80% among US adolescents, particularly in rural areas, which have vaccine uptake rates that are 10% points lower than non-rural areas on average. Primary care professionals (PCPs) can increase coverage by using presumptive recommendations to introduce HPV vaccination in a way that assumes parents want to vaccinate. Through semi-structured interviews, we explored PCPs' experiences and perceptions of using presumptive recommendations in rural- and non-rural-serving primary care clinics in North Carolina. Thematic analysis revealed that most PCPs in rural and non-rural contexts used presumptive recommendations and felt the strategy was an effective and concise way to introduce the topic of HPV vaccination to parents. At the same time, some PCPs raised concerns about presumptive recommendations potentially straining relationships with certain parents, including those who had previously declined HPV vaccine or who distrust medical authority due to their past experiences with the healthcare system. PCPs dealt with these challenges by using a more open-ended approach when introducing HPV vaccination to parents. In conclusion, our findings suggest that PCPs in both rural and non-rural settings see value in using presumptive recommendations to introduce HPV vaccination, but to adequately address concerns and ensure increased HPV vaccine uptake, PCPs can use simple and culturally sensitive language to ensure fully informed consent and to maintain parental trust. And to further strengthen HPV vaccine discussions, PCPs can utilize other effective HPV communication techniques, like the Announcement Approach, in discussing HPV vaccinations with hesitant parents.

Physicians' Human Papillomavirus Vaccine Communication With Parents of Different Skin Color: Feasibility of Measuring Indicators of Implicit Bias With Virtual Reality

PURPOSE

Virtual reality (VR) may be a viable method to observe and describe signals of implicit bias. Using the context of the human papillomavirus vaccine counseling, we sought to describe physicians' communication practices exploring differences when counseling parents with different skin colors.

METHODS

Physicians (N = 90) at an academic primary care center were recruited for a VR study in which they counseled dark or light-skinned parent avatars who expressed hesitation about human papillomavirus vaccination for their adolescent child. Investigators coded previously recorded simulations. Associations between communication and parent skin color were examined using t-tests and Chi-square tests.

RESULTS

Both direct (e.g., addressing the concern immediately) and circuitous (e.g., providing alternative information) communication patterns were observed. Physicians used passive voice less commonly when counseling dark-skinned versus light-skinned avatars (p < .05).

DISCUSSION

VR demonstrated feasibility in capturing clinicians' communication behaviors including measuring eight distinct indicators of implicit bias.

Identifying Healthcare Professionals With Lower Human Papillomavirus (HPV) Vaccine Recommendation Quality: A Systematic Review

PURPOSE

Strengthening healthcare professionals' (HCPs) communication is an evidence-based approach to increasing human papillomavirus (HPV) vaccine uptake among adolescents. To better target future interventions, we sought to synthesize evidence on HCP subgroups who most need to improve their HPV vaccine recommendation quality.

METHODS

We searched five databases for quantitative studies published from 2012 to 2022 on HPV vaccine recommendation quality, including recommendation consistency and strength, for United States adolescents. Two coders independently abstracted data from each eligible study, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We summarized variation in recommendation quality by clinical and HCP characteristics.

RESULTS

The 28 eligible studies indicated that relatively low proportions of HCPs used higher-quality recommendation practices (median: 61% across 30 measures) and that recommendation quality varied across HCP subgroups. The most consistent findings were that more pediatric HCPs used higher-quality recommendations than family medicine HCPs (8 of 11 studies, 2-60 percentage point difference) and that HPV-related knowledge was associated with higher recommendation quality (four of seven studies). Most studies observed no differences in recommendation quality by clinical role (e.g., provider vs. nurse) or HCP demographics (e.g., gender, age, race/ethnicity).

DISCUSSION

Studies suggest a substantial need to improve HCPs' recommendation quality, with opportunities for targeting future interventions.

Strategies for Improving Vaccine Communication and Uptake

Vaccines have led to a significant decrease in rates of vaccine-preventable diseases and have made a significant impact on the health of children. However, some parents express concerns about vaccine safety and the necessity of vaccines. The concerns of parents range from hesitancy about some immunizations to refusal of all vaccines. This clinical report provides information about the scope and impact of the problem, the facts surrounding common vaccination concerns, and the latest evidence regarding effective communication techniques for the vaccine conversation. After reading this clinical report, readers can expect to: Understand concepts and underlying determinants of vaccine uptake and vaccine hesitancy.Understand the relationship between vaccine hesitancy and costs of preventable medical care.Recognize and address specific concerns (eg, vaccine safety) with caregivers when hesitancy is present.

Impact of visit characteristics on intention to recommend HPV vaccine: An experiment with US health care professionals

OBJECTIVE

Presumptive recommendations that assume parents want to vaccinate can increase human papillomavirus (HPV) vaccine uptake. We sought to examine how visit characteristics affect health care professionals' (HCPs) intention to use this evidence-based recommendation style.

METHODS

In 2022, we conducted an online experiment with 2527 HCPs who had a role in adolescent vaccination in the United States. Participants read 1 of 8 randomly assigned vignettes about a well-child visit. Using a 2 × 2 × 2 between-subjects factorial design, the vignettes varied the following visit characteristics: patient age (9 vs. 12-year-old), prior parental vaccine refusal (yes vs. no), and time pressure on the HCP (low vs. high). HCPs reported on their intention to use a presumptive HPV vaccine recommendation, as well as on related attitudes, subjective norms, and self-efficacy. Analyses used 3-way analysis of variance and parallel mediation.

RESULTS

Participants were pediatricians (26%), family/general medicine physicians (22%), advanced practitioners (24%), and nursing staff (28%). Overall, about two-thirds of HCPs (64%) intended to use a presumptive recommendation. Intentions were higher for older children (b = 0.23) and parents without prior vaccine refusal (b = 0.39, both p < 0.001). Time pressure had no main effect or interactions. HCPs' attitudes and self-efficacy partially mediated effects of patient age and prior vaccine refusal (range of b = 0.04-0.28, all p < 0.05).

CONCLUSION

To better support visits with younger children and parents who have refused vaccines, HCPs may need more training for making presumptive recommendations for HPV vaccine. Reinforcing positive attitudes and self-efficacy can help HCPs adopt this evidence-based recommendation style.

Trust Matters: The Effects of Social Media Use on the Public's Health Policy Support Through (mis)beliefs in the Context of HPV Vaccination

This study examines whether social media exposure is associated with the public's beliefs and misbeliefs about human papillomavirus (HPV) vaccination and how those (mis)beliefs are associated with the public's support for HPV vaccination-related policies. This study also explores whether trust in HPV vaccination-related regulatory organizations moderates the associations between social media exposure and public policy support through (mis)beliefs. We found that social media exposure was positively associated with misbeliefs about HPV vaccination. The findings also indicated that while beliefs about benefits were positively associated with policy support for HPV vaccination, misbeliefs were negatively associated with this support. More interestingly, our analysis revealed that the negative association of HPV-related misbeliefs with vaccination policy support was larger for those who had low levels of trust, compared to their high-trust counterparts.

How to make effective HPV vaccine recommendations starting at age 9

This article provides best and promising practices for recommending HPV vaccination at age 9 as a way to ensure high uptake. An effective method for recommending HPV vaccination is the Announcement Approach, which consists of 3 evidence-based steps. The first step, Announce, involves noting that the child is 9 years old, saying they are due for a vaccine that prevents 6 HPV cancers, and saying you'll vaccinate today. This adapted version of the Announce step simplifies the bundled approach used at ages 11-12 that emphasizes the prevention of meningitis and whooping cough in addition to HPV cancers. For hesitant parents, the second step, Connect and Counsel, involves finding common ground with the parent and communicating the value of starting HPV vaccination at the first opportunity. Finally, for parents who decline, the third step is to Try Again at a later visit. Using the Announcement Approach at age 9 stands to increase HPV vaccine uptake, save time, and lead to high family and provider satisfaction.

Clinician Communication to Address Vaccine Hesitancy

There are several factors that influence childhood vaccine uptake. Pediatric clinicians play a particularly influential role in parent vaccine decision-making. It is critical therefore that pediatric clinicians have a "communication toolbox"--a set of effective, evidence-based communication strategies to facilitate uptake of childhood vaccines--that they can use in conversations with parents about vaccines. In this article, recent advances in our understanding of what constitutes effective clinician vaccine communication with parents are discussed.

Overcoming COVID-19 Misinformation: Lessons Learned at the Epicentre of the Outbreak in the USA

THE COVID-19 pandemic has highlighted the dire need to foster increased public confidence in mitigation and prevention strategies through more and better health literacy. More than 2 years into the worst public health crisis of the 21st century, we continue to be consumed by the most basic health questions: should I get tested for COVID-19, should I get vaccinated and boosted against COVID-19, and should I wear a mask? In many countries, the tension between personal freedoms and public good helps to fuel a global threat, with continued transmission of severe acute respiratory syndrome coronavirus 2 and its evolving, more infectious variants. This short essay discusses the negative effects of misinformation and disinformation, and shares recommendations based on lessons learned.

Qualitative Analysis of Patient-Physician Discussions Regarding Anticoagulation for Atrial Fibrillation

Importance

For patients with atrial fibrillation (AF), the decision to initiate anticoagulation involves the choice between warfarin or a direct oral anticoagulant (DOAC). How physicians engage patients in this decision is unknown.

Objective

To describe the content of discussions between patients with AF and physicians regarding choice of anticoagulation.

Design, Setting, and Participants

This qualitative content analysis included clinical encounters between physicians and anticoagulation-naive patients discussing anticoagulation initiation between 2014 and 2020.

Main Outcomes and Measures

Themes identified through content analysis.

Results

Of 37 encounters, almost all (34 [92%]) resulted in a prescription for a DOAC. Most (25 [68%]) patients were White; 15 (41%) were female and 22 (59%) were male; and 24 (65%) were aged 65 to 84 years. Twenty-one physicians conducted the included encounters, the majority of whom were cardiologists (14 [67%]) and male (19 [90%]). The analysis revealed 4 major categories and associated subcategories of themes associated with physician discussion of anticoagulation with anticoagulation-naive patients: (1) benefit vs risk of taking anticoagulation-in many cases, this involved an imbalance in completeness of discussion of stroke vs bleeding risk, and physicians often used emotional language; (2) tradeoffs between warfarin and DOACs-physicians typically discussed pros and cons, used persuasive language, and provided mixed signals, telling patients that warfarin and DOACs were basically equivalent, while simultaneously saying warfarin is rat poison; (3) medication costs-physicians often attempted to address patients' questions about out-of-pocket costs but were unable to provide concrete answers, and they often provided free samples or coupons; and (4) DOACs in television commercials-physicians used direct-to-consumer pharmaceutical advertising about DOACs to orient patients to the issue of anticoagulation as well as the advantages of DOACs over warfarin. Patients and physicians also discussed class action lawsuits for DOACs that patients had seen on television.

Conclusions and Relevance

This qualitative analysis of anticoagulation discussions between physicians and patients during clinical encounters found that physicians engaged in persuasive communication to convince patients to accept anticoagulation with a DOAC, yet they were unable to address questions regarding medication costs. For patients who are ultimately unable to afford DOACs, this may lead to unnecessary financial burden or abandoning prescriptions at the pharmacy, placing them at continued risk of stroke.

Pediatric hematology/oncology physician and nurse practitioner attitudes towards the COVID-19 vaccines: A qualitative study

As of 05/28/2021, SARS-CoV-2 (COVID-19) had caused 3.9 million infections in the United States (US) pediatric population since its discovery in December of 2019. The development and expansion of vaccination has markedly changed the shape of the epidemic. In this qualitative study, we report on pediatric hematology/oncology provider views on the COVID-19 vaccine prior to approval in the adolescent population <16 years of age. Results from interviews with 20 providers across the state of Indiana showed that most were supportive of the COVID-19 vaccine for healthy adults. However, the majority also expressed a need to see more data on the safety and effectiveness of COVID-19 vaccinations in pediatric hematology/oncology populations. While they recognized the public health importance of vaccination, their duty to protect their patients led to a need for more specific safety and efficacy data.

Healthcare providers' practice protocols, strategies, and needed tools to address parental HPV vaccine hesitancy: An exploratory study

Parental hesitancy related to human papillomavirus (HPV) vaccines has increased during the pandemic, and there is a call to action by the National HPV Vaccination Roundtable to improve vaccination rates. While there are evidence-based strategies available to address parental hesitancy, there are few clear guidelines on how to engage parents to build confidence in the HPV vaccine within the clinical settings. The purpose of this investigation is to explore practice protocols, individual provider strategies, and perceived tools needed to address HPV vaccine hesitant parents from the perspective of providers during the COVID-19 pandemic in the United States. Fifteen healthcare providers participated in qualitative, semi-structured interviews between May 2021 and March 2022. An inductive, qualitative content analysis approach was used to analyze the data. Five themes were described: 1) Provider experiences engaging with HPV vaccine hesitant parents; 2) Existing protocols in the clinics to address HPV vaccine hesitant parents; 3) Strategies used by providers to address parental HPV vaccine hesitancy; 4) Sample message content used by providers to address parental HPV vaccine concerns; and 5) Perceived strategies and tools needed to address parental vaccine hesitancy. Recommendations to address parental hesitancy include recommending HPV vaccinationat 9  years, using a strong recommendation and continued discussion, applying evidence-based approaches and/or promising strategies, linking parents to credible outside sources, and ongoing follow-up if delayed or declined. These findings can be used by researchers and clinicians to improve strategies and messages to inform the development of a protocol to standardize encounters and communication for patient-parent-provider encounters that can influence parental decision-making around HPV vaccine uptake.

Clinician communication strategies associated with increased uptake of the human papillomavirus (HPV) vaccine: A systematic review

Human papillomavirus (HPV) is currently linked to almost 35,000 new cases of cancer in women and men each year in the United States. Gardasil-9 (Merck &amp; Company), the only HPV vaccine now available in the United States, is nearly 100% effective at preventing precancers caused by oncogenic HPV types. In the United States, however, only about one half of adolescents are up to date with HPV vaccination. It is well known that health care clinicians' recommendations play a significant role in parents' decisions regarding HPV vaccination. A growing body of literature examines specific communication strategies for promoting uptake of the HPV vaccine. A comprehensive review of the evidence for each of these strategies is needed. The authors searched the PubMed, EMBASE, Cochrane Central Register of Controlled Trials, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and Web of Science Complete databases for original articles with a defined clinician communication strategy and an outcome of HPV vaccine uptake or intention to vaccinate (PROSPERO registry no. CRD42020107602). In total, 46 studies were included. The authors identified two main strategies with strong evidence supporting their positive impact on vaccine uptake: strong recommendation and presumptive recommendation. Determinations about a causal relationship were limited by the small numbers of randomized controlled trials. There is also opportunity for more research to determine the effects of motivational interviewing and cancer-prevention messaging.

A Clinical Educational Intervention to Increase HPV Vaccination Rates Among Pediatric Patients Through Enhanced Recommendations

INTRODUCTION

The human papillomavirus (HPV) causes largely preventable cancers by completing a vaccination series. However, pediatric HPV vaccination rates remain low. Current evidence indicates that integrating five factors creates a high-quality recommendation associated with higher HPV vaccination rates. This quality improvement project aimed to evaluate the impact of an educational intervention to improve the quality of providers' recommendations and subsequent vaccination rates.

METHOD

Using the Squire 2.0 Guidelines, clinical staff were observed during well-child visits (aged 11-12 years) before and after the intervention across three Plan-Do-Study-Act cycles.

RESULTS

Thirty-nine encounters with mostly (n = 31; 80%) families of color. The quality of vaccine recommendations was improved after the intervention; however, vaccination rates did not increase for the 39 patients. Providers' delivery approach (presumptive vs. conversational) did increase vaccination rates.

DISCUSSION

Providers' delivery style appears to be important when making HPV vaccine recommendations.

Impact of a Virtual Reality Curriculum on Human Papillomavirus Vaccination: A Pilot Trial

Although the strongest predictor of human papillomavirus (HPV) vaccination is a high-quality recommendation, physicians often provide weak recommendations. Thus, the authors developed Virtual Immersive Communication Training on Recommending Immunizations (VICTORI), a virtual reality (VR)‒based intervention that provided physicians the opportunity to deliberately practice recommendation behaviors. VICTORI included VR simulations during which participants counseled caregiver avatars hesitant to vaccinate. Before participation in VICTORI, participants reviewed a smartphone application on recommendation behaviors. A nonrandomized control trial of VICTORI was conducted with licensed and resident physicians. The intervention group completed the application and VICTORI simulations, whereas a comparison group completed only the application. The hypothesis was that HPV vaccination rates would increase for patients in the intervention group. The preintervention period was defined as the 6 months before allocated training (February 1, 2020-July 31, 2020), and the postintervention period was the 6 months after (October 1, 2020-March 31, 2021). The primary outcome was a change in the rates of human papillomavirus vaccine initiation among eligible patients presenting to clinic before and after. Of 142 eligible physicians, 134 (94%) chose to participate, with 93 of /97 (96%) intervention and 30 of 37 (81%) comparison participants completing study protocols. There was a statistically significant increase in patients' HPV vaccine initiation rates after training within the intervention group (54.3%‒72.4%; 18.1% difference [95% CI=11.0, 25.8]; p<0.001) but not within the comparison group (59.5%‒63.4%; 3.9% difference [95% CI= -11.0, 19.0]; p=0.609). In conclusion, HPV vaccine initiation increased after VR training, and further study is warranted.

Obstetrician/gynecologists' HPV vaccination recommendations among women and girls 26 and younger

Background

Obstetrician/gynecologists (OB/GYNs) are well poised to vaccinate girls and young women against HPV, however little is known about if and how they recommend the HPV vaccine. This study aims to understand factors associated with strong and frequent HPV vaccine recommendations among OB/GYNs for patients 26 years and younger.

Methods

224 practicing U.S. OB/GYNs were surveyed for how strongly and frequently they recommend the HPV vaccine to patients 26 and younger. Provider beliefs, knowledge, and preferences surrounding the vaccine, as well as clinic and patient-level variables were examined as covariates. We then examined the relationships using multivariable logistic regression analyses.

Results

Of the 224 respondents, 205 were included in the analysis, with 57% (n = 116) reporting strongly and frequently recommending the HPV vaccination to eligible patients 26 and younger. The regression showed two provider beliefs and two clinic-level attributes to be strongly associated with strong and frequent recommendations. Being a strong and frequent recommender was positively associated with believing other gynecologists frequently recommend the vaccine (aOR 24.33 95%CI[2.56-231.14]) and believing that 50% or more of their patients are interested in receiving the vaccine (aOR 2.77 95%CI[1.25-6.13]). The clinic-level attributes were having the vaccine stocked (aOR 2.66 95%CI[1.02-6.93]) and suburban (aOR 3.31 95%CI[1.07-10.19]) or urban (aOR 3.54 95%CI[1.07-11.76]) location versus rural.

Conclusions

These findings suggest that OB/GYN peer support and educating OB/GYN about patients' interest in HPV vaccination may improve HPV vaccination. This work can inform clinic-level interventions including stocking the vaccine and focusing improvement efforts on rural clinics.

How Were Healthcare Workers after Anti-SARS-CoV-2 Vaccination? A Study of the Emotional Side Effects of Vaccination

Anti-SARS-CoV-2 vaccines appear to be the only escape from the COVID-19 pandemic. As healthcare workers were among the first in society to be vaccinated, understanding their emotional status post-vaccination is fundamental to the promotion of COVID-19 vaccines among the rest of society. The aims of this study were to investigate the predictors of positive and negative emotions experienced by healthcare workers after being vaccinated and to understand whether those emotions were related to the modalities of vaccine promotion within the community. A cohort of 5790 Italian healthcare workers completed an original online survey regarding their experience with anti-SARS-CoV-2 vaccines and reported on a series of personal and environmental factors. The data obtained show that increased risk perception of COVID-19, vaccine confidence and receipt of greater quantities of information regarding vaccines are predictors of a more positive emotional state post-vaccination. Predictors of a more negative emotional state are older age, lower education, lower confidence and receipt of smaller quantities of information, in addition to neurotic personality traits and high risk perception of COVID-19. Importantly, vaccination promotion may be favoured by a happy emotional status after vaccination. This study can serve as a source of guidelines for the promotion of COVID-19 vaccination among healthcare workers and laypeople.

Promoting Strategies to Increase HPV Vaccination in the Pediatric Primary Care Setting

INTRODUCTION

Evaluation of a quality improvement project designed to improve HPV vaccine uptake in a pediatric primary care setting for young adolescents.

METHOD

Three strategies were implemented in one private pediatric practice to promote HPV vaccine uptake for 11- and 12-year-old adolescents. 1) a standardized vaccine policy change was made to include HPV vaccine with other adolescent vaccines, 2) a pre-visit email was sent to parents of teens to provide factual vaccine information in preparation for the visit, and 3) a provider communication initiative was implemented to ensure all providers communicated consistent messages and delivered an effective cancer prevention recommendation for HPV vaccination. A pre/post design was used to compare vaccine rates. Data was obtained via the electronic health records.

RESULTS

The post-intervention group demonstrated HPV vaccine rates increased substantially from 17.8% to 63.6%.

DISCUSSION

Strategically implementing standardized clinical vaccine policies and presumprive provider communication practices has implications for significantly increasing HPV vaccine uptake among teens and may be key to preventing cancer among future generations.

Evaluation of HPV Vaccine: Same Way, Same DayTM: A Pilot Study

Missed clinical opportunities and the lack of strong and consistent vaccine recommendations are key reasons for low HPV vaccination rates. The purpose of this study was to conduct a pilot evaluation of a web-based training's impact on knowledge, attitudes, and self-efficacy related to providing evidence-based HPV vaccine recommendations. Participants completed three online interactive learning modules and the HPV Vaccine: Same Way, Same Day™ smartphone application (app). Participants completed a pre-training survey, immediate post-training survey, and two-month post-survey. Participants demonstrated a statistically significant increase in knowledge scores from T1 to T2 and T1 to T3. Mean attitudes for recommending HPV vaccination for female patients increased from T1 to T2 and T1 to T3. Mean attitudes for recommending HPV vaccination for male patients increased from T1 to T2 and T1 to T3. Mean self-efficacy scores increased from T1 to T2 and T1 to T3. The HPV Vaccine: Same Way, Same Day™ app is a promising strategy for improving HPV vaccine recommendations among physicians. Future research should explore long-term effects and enroll attending and community physicians to examine its efficacy in other physician populations.

Attitudinal Correlates of HPV Vaccination in College Women

This study examined associations between general attitudes toward seeking medical care, attitudes about vaccines/fear of shots, and human papillomavirus (HPV) vaccine uptake and intentions in college women. Hypothesized associations were framed by the Theory of Planned Behavior (TPB). Participants (N = 330, mean age = 18.9 years, 75% White) completed a one-time survey. The majority (61%; n = 201) had received ≥1 HPV vaccine dose. Hierarchical logistic regression examined relationships between attitudes and vaccine uptake. Pearson correlation coefficients and Kruskal-Wallis tests examined associations between attitudes and vaccine intentions. Results were partially consistent with the TPB. In the final model, perceived benefits, but not fear of shots, were associated with vaccine uptake. Among the unvaccinated, perceived benefits, but not fear of shots, were associated with vaccine intentions. Provider recommendation was the strongest predictor of vaccine uptake. Findings suggest interventions incorporating discussion of perceived benefits and provider recommendation may improve HPV vaccine receipt among college women.

Associations Between Health Care Professional Communication Practices and Influenza Vaccination of Hospitalized Children

BACKGROUND

Health care professionals (HCPs) (eg, nurses, doctors) play a key role in vaccine uptake. Few studies describe HCP influenza vaccine communication with parents of hospitalized children.

METHODS

This study included English- and Spanish-speaking parents of influenza vaccine-eligible children hospitalized at a tertiary care pediatric hospital between October 2018 and May 2019. A survey was completed online or via telephone 2 to 15 weeks (median 4 weeks) after discharge. It examined parental intent to vaccinate their child during hospitalization and parent-reported inpatient HCP communication practices (eg, vaccine recommendation strength, format for initiating the recommendation). Multivariable logistic regression examined the associations between HCP communication practices and influenza vaccination during hospitalization, adjusting for demographic, clinical, and visit characteristics.

RESULTS

Parents (n = 194; 63.0% response rate) were mostly white (66.8%) and English-speaking (97.4%). Their children were primarily 5 through 17 years (67.0%) with chronic disease (68.6%); 24.7% were vaccinated before discharge. Most parents initially had no plan (55.6%) or planned to decline (31.1%) influenza vaccine for their child during hospitalization. Of these parents, 22.2% decided to accept the vaccine, 66.7% citing a HCP conversation as the main reason for changing their mind. Overall, 75.3% recalled a HCP conversation about influenza vaccination. Of these parents, 61.0% reported a HCP recommendation (53.8% described it as "very strong"; 11.1% noted a presumptive initiation format). A parent-reported HCP conversation (adjusted odds ratio [AOR] 5.23, 95% confidence interval [CI] 1.64-16.68) and recommendation (AOR 5.59, 95% CI 2.01-15.51) were associated with influenza vaccination during hospitalization.

CONCLUSION

This study highlights the importance of discussing and recommending influenza vaccination with parents of hospitalized children.

An Evidence-based Protocol to Improve HPV Vaccine Initiation Rates at a County Immunization Clinic

Human Papillomavirus (HPV) is responsible for 26,900 cancer cases yearly, including genital and oropharyngeal cancers. Despite providing nearly 100% protection against cancer-causing strains of HPV, only 68.9% of teenagers receive even one dose of the HPV9 vaccine. To increase HPV9 vaccine series initiation rates among 11-14 year-olds. Vaccine rates were examined before and after multi-modal protocol implementation at a nurse-run, walk-in immunization clinic. Initiation increased from 17.9% in 2017 to 35.5% in 2018. Use of same way/same day recommendation practices and inclusion of non-clinician staff could improve quality of care and decrease HPV-related disease.

Disparities in Healthcare Providers' Recommendation of HPV Vaccination for U.S. Adolescents: A Systematic Review

Infrequent provider recommendations continue to be a key barrier to human papillomavirus (HPV) vaccination, including among adolescents at higher risk for future HPV cancers. To inform future interventions, we sought to characterize disparities in health care providers' HPV vaccine recommendation for U.S. adolescents. We systematically reviewed studies published in 2012-2019 that assessed provider HPV vaccine recommendations for adolescents aged 9-17. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, we identified 52 eligible studies and used a standardized abstraction form to assess recommendation prevalence by adolescent demographic characteristics. Studies consistently found that fewer parents of boys than girls reported receiving HPV vaccine recommendations (14 studies, range of difference: -11 to -35 percentage points). Studies also found fewer recommendations for adolescents who were younger (2 studies, -3% to -12% points), non-White (3 studies, -5% to -7% points, females only), lower income (3 studies, -1% to -8% points), or uninsured (1 study, -21% points, males only). Studies identified geographic disparities in southern and rural areas. In conclusion, findings from this systematic review identify disparities in HPV vaccine recommendation that may contribute to suboptimal vaccine uptake. Efforts to improve providers' HPV vaccine communication should focus on increasing recommendation consistency, especially for lower-income, non-White, and rural adolescents.

Identifying HPV vaccine narrative communication needs among parents on social media

Sharing personal experiences is an important communication strategy in public health, including vaccination. This study sought to understand if parents would be receptive to learning about the HPV vaccine from other parent experiences, and what format this information should take on social media. In May 2020, we conducted a qualitative study of six online focus groups across the U.S. with parents (n = 48) of children ages 9–14. Using a text-based discussion format, we discussed their experiences getting information about the HPV vaccine and using Twitter to learn about health topics. Four coders structured qualitative findings by themes including content, delivery, and source of information. An accompanying survey was used to describe participant Twitter use and HPV vaccine knowledge and attitudes. The average participant age was 44.6 years old, 63% were mothers, and the majority had high HPV vaccine knowledge. Parents indicated that they want to hear from other parents about their experiences with the HPV vaccine. However, it was hard to know where to find this information. When experiences are shared on social media, the negative ones are more memorable and more personal. Parents thought Twitter could be an important space to communicate about the HPV vaccine if it was done in a credible, verifiable, and authentic way. Parents want to learn about the HPV vaccine through other parent experiences, especially when this aligns with science supporting the vaccine. Public health and medical communities must embrace this mix of evidence and lived experiences to deliver and discuss health information.

Easing Human Papillomavirus Vaccine Hesitancy: A Communication Experiment With U.S. Parents

INTRODUCTION

The Announcement Approach using presumptive announcements increases human papillomavirus vaccine uptake. This study seeks to understand the impact of the final Announcement Approach steps-easing parents' vaccine concerns and then encouraging them to get human papillomavirus vaccine for their children-on parents' human papillomavirus vaccine hesitancy and confidence in the vaccine's benefits.

METHODS

In 2017-2018, investigators recruited an online national sample of 1,196 U.S. parents of children aged 9-17 years who had not yet completed the human papillomavirus vaccine series. Following the steps of the Announcement Approach, participants viewed brief videos of a pediatrician announcing that a child was due for human papillomavirus vaccine (shown to all the parents). In the 2 × 2 experiment, parents saw (1) a video of the pediatrician attempting to ease a concern that the parent had raised earlier in the survey (Ease video), (2) a video of the pediatrician encouraging the parent to get their child vaccinated (Encourage video), (3) both videos, or (4) neither of the videos. Data analysis was conducted in spring 2020.

RESULTS

Seeing the Ease video message led to lower human papillomavirus vaccine hesitancy than not seeing it (mean=2.71, SD=1.29 vs mean=2.97, SD=1.33; p<0.001). The beneficial impact of easing concerns on lower vaccine hesitancy was explained by higher confidence (p<0.05). By contrast, the Encourage video had no impact on human papillomavirus vaccine hesitancy or confidence.

CONCLUSIONS

Addressing parents' concerns can decrease human papillomavirus vaccine hesitancy and increase confidence. On the basis of these findings, the Announcement Approach retained its emphasis on announcing that children are due for vaccination and easing parent concerns.

Provider communication and HPV vaccine uptake: A meta-analysis and systematic review

Provider communication can be critically important to families as they consider HPV vaccination. We sought to characterize the association of provider communication and HPV vaccine uptake, and when communication better motivates vaccination. We searched four databases for studies published between 2006 and 2019. Eligible studies examined health care provider communication (defined as recommendation or discussion) and HPV vaccine uptake (defined as initiation, completion, or follow-through) in the US. Two coders independently identified eligible studies and coded effect sizes and study characteristics. We pooled effect sizes using random-effects meta-analysis. We identified 59 eligible studies of 265,083 patients. Receiving a provider recommendation was associated with higher HPV vaccine initiation (pooled OR = 10.1, 95% CI: 7.6-13.4). HPV vaccine initiation was 24% for patients without and 60% for patients with a provider recommendation. The pooled effect size for provider recommendation and initiation was smaller for probability samples, clinical records, and NIS-Teen (all p < 0.002). Recommendations were equally effective for males and females, for different patient ages, and over time. Provider recommendation was also associated with higher HPV vaccine series completion and follow-through. Provider discussion was similarly associated with higher HPV vaccine initiation (OR = 12.4, 95% CI: 6.3-24.3). In summary, provider communication was robustly associated with HPV vaccination initiation, completion, and follow-through. These findings suggest that US public health efforts to increase HPV vaccine coverage should continue to emphasize provider communication.

Treatment recommendations to parents during pediatric tonsillectomy consultations: A mixed methods analysis of surgeon language

OBJECTIVE

A deeper understanding of the dialogue clinicians use to relay treatment recommendations is needed to fully understand their influence on patient decisions about surgery. We characterize how otolaryngologists provide treatment recommendations and suggest a classification framework.

METHODS

We qualitatively analyzed surgeon recommendations from 55 encounters between otolaryngologists and parents of children evaluated for tonsillectomy, and classified recommendation types by phrasing. Multilevel logistic regression identified predictors of recommendation phrasing.

RESULTS

Clinicians provided 183 recommendations (mean/visit = 3.3). We identified four domains of recommendation-phrasing (direct, passive, acceptable, parent-oriented). Direct recommendations (n = 68, 37%) included presumptive statements phrasing intentions as inevitable. Passive recommendations (n = 65, 36%) included practice-based recommendations utilizing general statements. Acceptable recommendations (n = 29, 16%) included speaking positively about treatment options. Parent-oriented recommendations (n = 21, 11%) included parent choice statements. Clinicians more commonly made direct recommendations to parents who were racial minorities (OR = 2.7, p = .02, 95% CI [1.7, 5.9]) or had an annual income <$50,000 (OR = 2.2, p = .03, 95% CI [1.1, 4.4]).

CONCLUSION

Clinicians provide treatment recommendations in a variety of ways that may introduce more or less certainty and choice to parental treatment decisions.

PRACTICE IMPLICATIONS

Findings may be implemented into training which increases clinician awareness of dialogue use when recommending treatment alternatives to patients.

HPV vaccine communication training in healthcare systems: Evaluating a train-the-trainer model

BACKGROUND

Large healthcare systems provide an opportunity to disseminate evidence-based interventions to primary care. We evaluated the impact of a train-the-trainer model in two large systems to disseminate the Announcement Approach Training, which teaches providers to communicate about HPV vaccination more effectively.

METHODS

In collaboration with the American Cancer Society, we partnered with two midwestern healthcare systems that served over 77,000 patients ages 11 through 17. Both systems hosted a 2-hour train-the-trainer workshop. Providers from one system then conducted in-person 1-hour CME-eligible trainings, using our standard slide set and script (available at hpvIQ.org). The other system did not implement trainings, providing a natural experiment.

RESULTS

The train-the-trainer workshop included physicians, nurses and other clinical staff (n = 11/13 for intervention/comparison systems). The intervention system delivered 18 trainings to 234 physicians, nurses, and other clinic staff. From baseline to 6-month follow-up, the intervention system had an increase in HPV vaccine uptake that was larger than that of the comparison system for adolescents ages 11 through 12 (1.9%, p = .002) and ages 13 through 17 (1.5%, p = .015). Attending the training was associated with increased intentions to routinely recommend HPV vaccine when patients turn 11 or 12 (mean 4.19 (SD = 0.95) vs. 4.43 (SD = 0.83) as well as increased positive vaccine attitudes, self-efficacy, and norms (all p < .001). Participant satisfaction with the trainings was high (90%-94%).

CONCLUSION

The train-the-trainer model was effective in increasing provider motivation to recommend HPV vaccination and led to a small increase in vaccine uptake. Dissemination through large healthcare systems is promising but faces some challenges.

The COVID-19 vaccine social media infodemic: healthcare providers' missed dose in addressing misinformation and vaccine hesitancy

During the COVID-19 pandemic, antivaccination social media accounts are proliferating online, threatening to further escalate vaccine hesitancy related to the COVID-19 vaccine. This commentary seeks to alert and encourage the health care provider community, including health care professionals and academic organizations, to engage in social media to counter the mounting vaccine-related infodemic. To validate our recommendation for engagement, the authors describe preliminary findings using a mixed methods approach of quantitative Twitter-based ranking algorithms of networks and users with qualitative content analysis of 1 million tweets related to COVID-19 vaccine conversations. Results show highly polarized and active antivaccine conversations that were primarily influenced by political and nonmedical Twitter users. In contrast, less than 10% of the tweets stemmed from the medical community, demonstrating a lack of active health care professional connectivity in addressing COVID-19 misinformation. The authors introduce the concept of Health Care Provider Social Media Hesitancy to refer to the public health threat of health care providers' nonaction in providing pro-vaccine and scientific information about the vaccine on social media. The authors conclude by describing multilevel strategies for encouraging health care providers and the medical community to effectively "Tweet up" to combat the mounting threat of vaccine misinformation and hesitancy.

A National Survey of Obstetrician/Gynecologists' Knowledge, Attitudes, and Beliefs Regarding Adult Human Papillomavirus Vaccination

Background: Many women see an obstetrician/gynecologist (OB/GYN) annually and receive their primary care from an OB/GYN. Understanding OB/GYNs' human papillomavirus (HPV) vaccination practices, including knowledge of and barriers to vaccination, is essential to design effective interventions to increase vaccination. This study evaluated OB/GYN knowledge, attitudes, and beliefs regarding vaccinating both younger (18-26 years) and mid-adult (27-45 years) women. Materials and Methods: Data were collected from OB/GYN providers in October 2019 through a nationwide web-based survey. Items included the following: HPV-related vaccination practices, recommendation strength, knowledge (seven items), benefits (four items), and barriers (eight items). Results: The sample (n = 224) was majority were White (69%), men (56%), and practice in suburban clinics (55%). Most (84%) reported they usually or always recommend HPV vaccine to eligible patients, but estimated only about half (51%) of other OB/GYNs did the same. Recommendation strength varied by patient age with 84% strongly recommending it to patients ≤18 years, compared with 79% and 25% strongly recommending to younger and mid-adult patients, respectively (p < 0.01). Participants reported lower benefits (p = 0.007) and higher barriers (p < 0.001) for 27- to 45-year-old patients compared with younger patients. Cost was the most frequently reported barrier, regardless of patient age. Overall knowledge was high (m = 5.2/7) but 33% of participants did not know the vaccine was safe while breastfeeding. Conclusions: Although providers reported strongly and consistently recommending the HPV vaccination to their adult patients, there were gaps in knowledge and attitudinal barriers that need to be addressed. Provider performance feedback may be important in improving HPV vaccination awareness among providers.

Effect of provider recommendation style on the length of adolescent vaccine discussions

OBJECTIVE

To determine whether providers' vaccine recommendation style affects length of the adolescent vaccine discussions.

METHODS

We analyzed vaccine discussions using audio-recordings of clinical encounters where adolescents were eligible for HPV vaccines ± meningococcal vaccines. We measured length of vaccine discussions, the provider's use of an "indicated" (vaccination due at visit) or "elective" (vaccination is optional) recommendation style, and vaccine receipt. Parent and child demographics, parental vaccination intentions, and parental satisfaction with vaccine discussion were collected from pre- and post-visit surveys. We used linear and logit regressions with random effects to estimate recommendation style's association with discussion length and with vaccine receipt, respectively.

RESULTS

We analyzed 106 vaccine discussions (82 HPV; 24 meningococcal) across 82 clinical encounters and 43 providers. Vaccine discussions were longer when providers presented vaccination as elective versus indicated (140 vs. 74 s; p-value < 0.001). Controlling for vaccine type, parental vaccination intent, and patient characteristics, an elective style was associated with 41 seconds longer vaccine discussion (p-value < 0.05). Providers used the indicated style more frequently with the meningococcal vaccine than with the HPV vaccine (96% vs. 72%; p-value < 0.05). Parents' odds of vaccinating were 9.3 times higher following an indicated versus an elective presentation (p-value < 0.05). Vaccine discussion length and presentation style were not associated with parental satisfaction.

CONCLUSIONS

Our results suggest that using an indicated recommendation improves vaccine discussions' efficiency and effectiveness, but this style is used more often with meningococcal than HPV vaccines. Increasing providers' use of indicated styles for HPV vaccines has the potential to increase vaccination rates and save time during medical visits.

Vaccine Hesitancy in Rural Pediatric Primary Care

Vaccine hesitancy (VH) is a pervasive issue resulting in the delay or refusal of vaccines, which are known to protect against life-threatening diseases. The purpose of this quality improvement project was to determine if early identification of VH using the Parent Attitudes about Childhood Vaccines survey and targeted interventions would decrease VH scores. Of the 70 total participants, 11 participants were VH in the preintervention survey group; of those, nine (81.8%) were not VH in the postintervention survey group, and two (18.2%) remained VH (p = .004) after the intervention. Routine screening for VH using the Parent Attitudes about Childhood Vaccines survey and implementing interventions successfully decreased VH scores and improved vaccine compliance.

Strengthening Vaccine Confidence and Acceptance in the Pediatric Provider Office

Although vaccine acceptance and uptake are overall high among children in the United States, vaccine delays or refusals are a growing concern. Vaccine hesitancy is a challenge for the pediatric provider, given the diverse factors associated with hesitancy and the limited evidence on effective strategies for addressing vaccine hesitancy in the provider office. In this article, we review available evidence and approaches for vaccine communication, including the importance of using a whole-team approach, building trust, starting the conversation early, using a presumptive approach for vaccine recommendations, motivational interviewing with parents who have concerns for vaccines, and additional techniques for responding to parent questions. We also review organizational strategies to help create a culture of immunization in the practice, including evidence-based approaches for increasing vaccine uptake and efficiency. Although these communication approaches and organizational strategies are intended to reassure parents who are vaccine hesitant that all routine, universally recommended vaccines are safe and effective, they likely will take on increased significance as the development, implementation, and evaluation of coronavirus disease 2019 vaccines continue to unfold. [Pediatr Ann. 2020;49(12):e523-e531.].

The role of the media on maternal confidence in provider HPV recommendation

Background

Despite a growing understanding of the importance of provider HPV recommendation on parental acceptance, U.S. HPV vaccination rates remain suboptimal. Given the prevalence and use of the media for health decisions, this study examined the relationship between the media and provider HPV recommendation on maternal HPV vaccine hesitancy.

Methods

Thirty individual interviews with HPV vaccine-accepting mothers in the Midwest U.S. were conducted to examine their feelings of hesitancy around the decision to accept HPV vaccination at the time of provider recommendation and their suggestions for improving the recommendation experience by addressing media concerns.

Results

Media exposure was an antecedent to hesitancy for three main vaccination concerns: safety, protection/efficacy and sexual stigma. Although mothers accepted vaccination, they continued to feel confused and hesitant about HPV vaccination. They had several recommendations for how providers could combat hesitancy to improve confidence in HPV vaccine acceptance.

Conclusions

Providers’ approach to HPV vaccination recommendation must consider concerns reported in the media with delivery techniques modified to adjust to maternal fears absorbed from adverse media information.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-020-09877-x.

Understanding How Adolescents Think about the HPV Vaccine

Despite educational efforts, Tennessee human papillomavirus (HPV) vaccination rates are 43%, among the lowest in the United States. This study examined how adolescents think about the HPV vaccine to identify patterns and misconceptions to enhance educational efforts. Adolescents (ages 11–12) (N = 168) responded to open-ended questions regarding their thinking about the HPV vaccine. Data were analyzed and interpreted using qualitative thematic analysis. Three domains of themes emerged from responses: (1) characteristics of HPV vaccination, (2) knowledge-related themes, and (3) beliefs-related themes. Prevention of HPV and cancer was the most referenced characteristic of HPV vaccination followed by HPV vaccine rates and HPV vaccine efficacy. Student inquiries were mostly centered on HPV vaccine composition, administration, duration and how the vaccine interacts with the body. Some responses indicated a desire for more information about HPV not specific to the HPV vaccine. Overall, adolescent attitudes were positive towards the HPV vaccine. This study highlights specific questions adolescents have about the vaccine that can be used to tailor future HPV educational efforts, empowering adolescents with the knowledge to be more active students in the decision-making process. In addition, the potential for adolescents to serve as community advocates for the vaccine should be considered for future interventions.

Effect of a multi-component intervention on providers' HPV vaccine communication

Objective: To evaluate the effect of a multi-component intervention including communication training on provider beliefs and recommendation practices around the human papillomavirus (HPV) vaccine using both self-reports and audio-recordings of clinical interactions. Methods: We conducted a mixed method study at five family medicine and pediatric practices. Providers self-reported beliefs and practices about HPV vaccination via surveys and qualitative interviews conducted pre- and post-intervention. We also assessed provider recommendation style using audio-recordings of clinical interactions pre- and post-intervention. Content analysis was used to identify themes in qualitative interviews. Matched pre- and post-intervention surveys were analyzed for changes in provider beliefs and attitudes. Pre- and post-intervention audio recordings of clinical interactions were analyzed for observed differences in recommendation styles. Bivariate analyses of quantitative data used Chi-square and Fisher's exact tests; t-tests were used for continuous variables. Results: Providers reported in interviews that the intervention led to communication changes by increasing their knowledge, reframing the HPV vaccine as a routine vaccination, and providing tools for engaging with parents. Surveys indicated that the proportion of providers reporting that the HPV vaccine is one of the most important adolescent vaccines increased from 71% pre-intervention to 100% post-intervention (p = .03). Audio-recording analysis demonstrated that use of an indicated (presumptive) recommendation style increased from 62.5% pre-intervention to 79.6% post-intervention (p = .047). Conclusions: Educating providers about HPV vaccination and giving them tools to facilitate communication with parents can reframe HPV as a routine adolescent vaccination and motivate providers to routinely use effective recommendation styles in practice.

County-level correlates of missed opportunities for HPV vaccination in Indiana: An environmental scan

BACKGROUND

The goal of this study was to examine variability across the 92 Indiana counties in missed opportunities for HPV vaccination and to assess county-level correlates of missed opportunities.

METHODS

The Indiana immunization registry provided county level data on 2017 missed opportunity rates for adolescents ages 11-18. A missed opportunity was an encounter when a patient eligible for HPV vaccination received one or more other recommended vaccines, but not HPV. Potential county-level correlates of missed opportunities included race, income, population density, education, primary care providers per capita, smoking rates, mammography screening, diabetes monitoring, and Pap testing.

RESULTS

The missed opportunity rate ranged from 31% to 85% across Indiana counties. Higher population density, mammography screening, income inequality, and diabetes monitoring were associated with fewer missed opportunities.

CONCLUSIONS

We found wide variability in missed opportunities across counties, which were associated with population density and county-level participation in other health-related behaviors.

SOURCES OF SUPPORT

This study was supported by the National Cancer Institute under Award Number P30 CA082709-18S4.

Human papillomavirus vaccination 2020 guideline update: American Cancer Society guideline adaptation

The American Cancer Society (ACS) presents an adaptation of the current Advisory Committee on Immunization Practices recommendations for human papillomavirus (HPV) vaccination. The ACS recommends routine HPV vaccination between ages 9 and 12 years to achieve higher on-time vaccination rates, which will lead to increased numbers of cancers prevented. Health care providers are encouraged to start offering the HPV vaccine series at age 9 or 10 years. Catch-up HPV vaccination is recommended for all persons through age 26 years who are not adequately vaccinated. Providers should inform individuals aged 22 to 26 years who have not been previously vaccinated or who have not completed the series that vaccination at older ages is less effective in lowering cancer risk. Catch-up HPV vaccination is not recommended for adults aged older than 26 years. The ACS does not endorse the 2019 Advisory Committee on Immunization Practices recommendation for shared clinical decision making for some adults aged 27 through 45 years who are not adequately vaccinated because of the low effectiveness and low cancer prevention potential of vaccination in this age group, the burden of decision making on patients and clinicians, and the lack of sufficient guidance on the selection of individuals who might benefit.

How health care providers should address vaccine hesitancy in the clinical setting: Evidence for presumptive language in making a strong recommendation

Vaccine hesitancy occurs throughout the world and can result in poor vaccine uptake and vaccine-preventable disease-outbreaks. Vaccine hesitancy dates back to the days of Edward Jenner and the smallpox vaccine. It persists despite the preponderance of evidence supporting vaccine safety and effectiveness. Studies show even among parents of well-vaccinated children that 15–35% of those parents are vaccine-hesitant. Studies have failed to show the efficacy of educational interventions, and, indeed, a number of studies of educational interventions show a contrarian effect leaving the vaccine-hesitant more entrenched in their views. Still dozens of studies support health care provider recommendation as a major factor in achieving high rates of vaccine uptake. Furthermore, studies find those recommendations perceived as stronger are more effective than those perceived as weaker. What makes for a stronger recommendation? Several observational studies indicate that presumptive, announcement language as contrasted with participatory, conversational language makes for a stronger more effective recommendation. Several trials now demonstrate that health care providers and practices can implement this language and obtain higher vaccination uptake. The authors recommend the practice be adopted as a routine practice in the clinical setting for all vaccinations

Comparison of the implementation of human papillomavirus and hepatitis B vaccination programs in the United States: Implications for future vaccines

Vaccines for two viruses which cause cancer, human papillomavirus (HPV) and hepatitis B virus (HBV), are recommended for all children in the United States. Numerous parallels exist between the two vaccines in addition to their roles in cancer prevention, including transmission through sexual contact, multiple doses needed for series completion, and vaccine administration in adolescence for HPV and in the initial phase of the HBV vaccination program. All of these factors were viewed as potential barriers to achieving high rates of coverage, yet the ultimate success of the HBV vaccination program led to predictions that similarly high rates of coverage could be achieved for the HPV vaccine. However, currently, only the recommendation for HBV vaccination is supported by mandates for school entry in most states. Uptake of the HPV vaccine has lagged far behind U.S. goals for public health promotion. The aim of this paper is to examine factors which may account for the divergent pathways of the two vaccines. Four main factors are identified: logistical challenges of vaccine administration, attitudes of parents and healthcare providers, safety concerns, and cost. For each factor examined, recommendations are offered to confront similar barriers likely to arise for future vaccines. The authors conclude that gender-neutral state mandates coupled with school-located vaccination programs, stronger gender-neutral messaging from pharmaceutical companies and healthcare providers, and younger age of vaccine administration, if approved, present the most promising approaches to improving uptake of the HPV vaccine, and similar vaccines down the road.

HPV Vaccine Delivery Practices by Primary Care Physicians

BACKGROUND AND OBJECTIVES

To examine, among pediatricians and family physicians (FPs) (1) human papillomavirus (HPV) vaccine delivery practices, (2) delivery experiences, and (3) attitudes regarding new 2-dose HPV vaccination schedules.

METHODS

We surveyed nationally representative networks of pediatricians and FPs by Internet or mail from July 2018 to September 2018. Multivariable regression was used to assess factors associated with refusal or deferral rates of ≥50% among 11- to 12-year-old patients.

RESULTS

The response rate was 65% (302 pediatricians and 228 FPs included). Pediatricians who strongly recommended the HPV vaccine ranged from 99% for patients ≥15 years old (female) to 83% for those 11 to 12 years old (male); FPs ranged from 90% for patients ≥15 years old (female) to 66% for those 11 to 12 years old (male) (P < .0001 between specialties). Sixty-five percent of pediatricians and 42% of FPs always or almost always used presumptive style when discussing the HPV vaccine (P < .0001). Overall, 40% used standing orders and 42% had electronic alerts. Among pediatricians, the proportion reporting a refusal or deferral rate ≥50% was 19% for female patients and 23% for male patients 11 to 12 years old; FPs reported 27% and 36%, respectively. In the multivariable regression (both sexes), refusal or deferral was associated with physicians not strongly recommending the HPV vaccine to 11- to 12-year-old patients, not using a presumptive style, perceiving less resistance when introducing the HPV vaccine to a 13-year-old patient versus an 11- or 12-year-old patient, and anticipating an uncomfortable conversation when recommending the HPV vaccine to an 11- or 12-year-old patient. Eighty-nine percent of pediatricians and 79% of FPs reported that more adolescents <15 years old are completing the HPV series now that only 2 doses are recommended.

CONCLUSIONS

Although most physicians strongly recommend the HPV vaccine to 11- to 12-year-old patients, our data reveal areas for improvement in recommendation and delivery methods. Most physicians perceive that the 2-dose schedule is resulting in higher HPV completion rates.

The effects of message framing and healthcare provider recommendation on adult hepatitis B vaccination: A randomized controlled trial

Many adults in the U.S. do not receive recommended vaccines, and the research literature remains inconclusive on the best communication strategies for increasing this behavior. This study examined the association of message framing (gained-framed vs. loss-framed vs. control), and healthcare provider (HCP) recommendation (offered vs. recommended) on uptake of adult hepatitis B virus (HBV) vaccination in a high risk population using a 3 × 2 block design randomized controlled trial. Fear of shots, fear of vaccines, and perceived message framing were examined in secondary analyses. Of the 1747 participants, 47.7% (n = 833) received 0 doses of HBV vaccine, 27.8% (n = 485) received 1 dose, 10.4% received 2 doses, and 14.1% received all 3 recommended doses. There was not a significant interaction between message framing and HCP recommendation (p = .59). Mean number of doses received by the gain-framed group (m = 0.96) was not significantly different from the loss-framed group (m = 0.97, RR = 0.99, 95% CI = 0.88-1.12). However, those receiving any framing message received significantly more doses (m = 0.96) than those in the control condition (m = 0.81, RR = 1.17, 95%CI = 1.06-1.31). Participants who received a HCP recommendation received significantly more vaccine doses (m = 0.95) than those in the vaccine-offered condition (mean = 0.82, RR = 1.16, 95%CI = 1.05-1.28). These results suggest there is no difference in vaccine uptake between gain-frame and loss-frame messages, but both are better than a control message. These results also support advising HCP to provide a strong recommendation for vaccinations beyond merely offering it to patients. This study has implications for vaccine uptake beyond HBV, and can inform future research on effective vaccine communication research. Clinicaltrials.gov Identifier: NCT00739752. Registration date: August 20, 2008.

The role of healthcare providers in HPV vaccination programs - A meeting report

The Human Papillomavirus (HPV) Prevention and Control Board convened a meeting in Bucharest, Romania (May 2018), to discuss the role of healthcare providers (HCPs) in prevention programs, with a focus on HPV vaccination and cervical cancer screening. International and local experts discussed the role that HCPs can play to increase the uptake of HPV vaccine and screening. Experts recommended: 1) increasing HCP norms of getting vaccinated; 2) training providers to make effective recommendations; 3) making culturally appropriate materials available, in local languages; and 4) centralizing and coordinating education and information material, to direct both HCPs and the general public to the best material available.

Disparities and reverse disparities in HPV vaccination: A systematic review and meta-analysis

Studies disagree about whether racial and ethnic groups have lower or higher human papillomavirus (HPV) vaccination uptake, an important issue given large disparities in some HPV cancers. We sought to characterize and explain racial and ethnic differences in HPV vaccination. We systematically searched PubMed, CINAHL, Embase, and Web of Science to identify US studies through mid-2017 reporting associations of race and ethnicity with HPV vaccination. We identified 118 studies (n = 3,095,486) published in English that reported HPV vaccine initiation or follow-through in the US from which we could calculate effect sizes. We used random effects meta-analysis to synthesize effect sizes for comparisons of Whites or non-Hispanics to Blacks, Hispanics, Asians, or all minority groups combined. Studies showed no racial or ethnic differences in HPV vaccine initiation overall. However, when restricting to studies using provider-verified vaccination data, minorities were 6.1% [3.3%-8.8%] more likely than Whites to initiate HPV vaccination. Advantages were larger for Hispanics, males, and younger samples (age < 18). In contrast, minorities were 8.6% [5.6%, 11.7%], less likely than Whites to follow-through with the full HPV vaccine series, a disparity present across all participant and study characteristics. More recent studies found larger advantages for racial and ethnic minorities in HPV vaccine initiation and smaller disparities in follow-through. In summary, high-quality studies found racial and ethnic minorities are more likely to initiate but less likely to follow-through with HPV vaccination, a clear finding that self-report studies obscure. Higher HPV vaccine initiation among minorities suggests potential reductions in HPV cancer disparities.

A content analysis of HPV vaccine online continuing medical education purpose statements and learning objectives

Numerous online HPV vaccine education interventions for clinicians have been created to improve HPV vaccinations rates. The aims for this study were to (1) assess the content of the purpose statements and learning objectives of online HPV vaccine continuing medical education (CME) activities developed for clinicians and (2) identify themes and gaps in the purpose statements and learning objectives. A content analysis was conducted of the purpose statements and learning objectives for each HPV vaccine online CME activity. Open coding identified the following purpose statements topics: 1) delivering recommendations, 2) HPV epidemiology, 3) HPV vaccine, 4) guidelines, and 5) medical news. The following topics for learning objectives were identified: 1) delivering recommendations, 2) strategies, 3) HPV epidemiology, 4) HPV vaccine, 5) guidelines, 6) prevention services, 7) HPV vaccination advocacy, and 8) disparities. Phrases about guidelines for vaccine administration and vaccine recommendation guidelines were the most common for purpose statements and learning objectives, respectively. One learning objective focused on behavior/skill change, which is concerning considering clinicians do not feel well prepared to provide strong vaccine recommendations. Clear and intentional purpose statements and learning objectives must be used to guide the development of effective CME activities.

Vaccination perspectives among adolescents and their desired role in the decision-making process

Background: To assess the knowledge and attitudes of middle school students toward vaccination, we measured their understanding of vaccine safety and effectiveness, expectations for communication with heath care providers, and their desired role in the vaccination decision-making process. Methods: A cross-sectional, self-administered survey was conducted among seventh and eighth grade students in a middle school in Upstate New York. Bivariate analyses were conducted to identify differences in perspective by gender, grade, and attitudes toward vaccination. Results: Of 346 students attending class, 336 (97.1%) participated. The majority of respondents were White (71.3%) and 11 to 13 years of age (78.2%). Boys were significantly more likely than girls to perceive vaccines to be very safe (48.4% vs 30.2%, p < 0.01) and very effective (49.7% vs 29.0%, p < 0.01). Approximately one-third of adolescents reported having a say in the decision to be vaccinated and a quarter of students expressed a desire for specific information about vaccines. Conclusions: This study found that young adolescents in a nonurban area of Upstate New York were generally marginalized in the vaccine decision-making process yet third of them indicated an interest in how vaccines work and a desire to participate in healthcare decisions. Interventions to improve vaccine uptake among adolescents should capitalize on this desire to understand vaccine safety, effectiveness and mechanism of action.

Questions and Concerns About HPV Vaccine: A Communication Experiment

: media-1vid110.1542/5972295740001PEDS-VA_2018-1872Video Abstract OBJECTIVES: We sought to identify effective responses to parents' questions and concerns about human papillomavirus (HPV) vaccine.

METHODS

In 2017-2018, we surveyed a national sample of 1196 US parents of children aged 9 to 17 years. We recorded brief videos of a pediatrician providing messages that addressed 7 HPV vaccination topics that commonly elicit questions or concerns (eg, recommended age). We randomly assigned parents to 1 of the message topics; parents then viewed 4 videos on that topic in random order and evaluated the messages.

RESULTS

Parents were more confident in HPV vaccine when they were exposed to messages that addressed lack of knowledge about HPV vaccine (b = 0.13; P = .01), messages that included information about cancer prevention (b = 0.11; P < .001), messages that required a higher reading level (b = 0.02; P = .01), and messages that were longer (b = 0.03; P < .001). Parents were less confident in HPV vaccine when exposed to messages in which urgency was expressed (b = -0.06; P = .005). Analyses conducted by using HPV vaccine motivation as an outcome revealed the same pattern of findings.

CONCLUSIONS

We provide research-tested messages that providers can use to address parents' HPV vaccination questions and concerns about 7 common topics. Important principles for increasing message effectiveness are to include information on the benefits of vaccination (including cancer prevention) and avoid expressing urgency to vaccinate when addressing parents' questions or concerns. Additionally, providers may need to be prepared to have longer conversations with parents who express concerns about HPV vaccine, especially regarding safety and side effects.

HPV vaccine recommendation profiles among a national network of pediatric practitioners: understanding contributors to parental vaccine hesitancy and acceptance

Background: Practitioner communication is one of the most important influences and predictors of HPV vaccination uptake. The objective of this study was to conduct a latent class analysis characterizing pediatric practitioner HPV recommendation patterns. Methods: Pediatric practitioners of the American Academy of Pediatrics' (AAP) Pediatric Research in Office Settings (PROS) national network completed an online survey where they were presented with 5 hypothetical vignettes of well child visits and responded to questions. Questions asked about their use of communication strategies, assessments about the adolescent patient becoming sexually active in the next 2 years for decision-making about HPV vaccine recommendation, and peer norms. Latent class analysis characterized practitioner subgroups based on their response patterns to 10 survey questions. Multinomial logistic regression examined practitioner characteristics associated with each profile. Results: Among 470 respondents, we identified three distinct practitioner HPV vaccine recommendation profiles: (1) Engagers (52%) followed national age-based guidelines, strongly recommended HPV vaccination, and perceived peers as strongly recommending; (2) Protocol Followers (20%) also strongly recommended HPV vaccination, but were less likely to engage families in a discussion about benefits; and (3) Ambivalent HPV Vaccine Recommenders (28%) delayed or did not recommend HPV vaccination and were more likely to use judgment about whether adolescents will become sexually active in the next two years. Practicing in a suburban setting was associated with twice the odds of being an Ambivalent Recommender relative to being an Engager (OR = 2.2; 95% CI:1.1-4.1). Conclusions: Findings underscore the importance of continued efforts to bolster practitioner adoption of evidence-based approaches to HPV vaccine recommendation especially among Ambivalent Recommenders.