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

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.

Facilitators and barriers of HPV vaccination: a qualitative study in rural Georgia

INTRODUCTION

Human papillomavirus (HPV) vaccination protects against HPV-associated cancers and genital warts. Healthy People 2030 goal for HPV vaccine uptake is 80%, but as of 2021, only 58.5% of adolescents are up to date in Georgia. The purpose of the study is to assess the attitudes, vaccine practices, facilitators, and barriers to receiving the HPV vaccine in southwest Georgia.

METHODS

We conducted 40 semi-structured interviews in the United States from May 2020-Feburary 2022 with three different audiences (young adults, parents, and providers and public health professionals) guided by the P3 (patient-, provider-, practice-levels) Model. The audiences were recruited by multiple methods including fliers, a community advisory board, Facebook ads, phone calls or emails to schools and health systems, and snowball sampling. Young adults and parents were interviewed to assess their perceived benefits, barriers, and susceptibility of the HPV vaccine. Providers and public health professionals were interviewed about facilitators and barriers of patients receiving the HPV vaccine in their communities. We used deductive coding approach using a structured codebook, two coders, analyses in MAXQDA, and matrices.

RESULTS

Out of the 40 interviews: 10 young adults, 20 parents, and 10 providers and public health professionals were interviewed. Emerging facilitator themes to increase the uptake of the HPV vaccine included existing knowledge (patient level) and community outreach, providers' approach to the HPV vaccine recommendations and use of educational materials in addition to counseling parents or young adults (provider level) and immunization reminders (practice level). Barrier themes were lack of knowledge around HPV and the HPV vaccine (patient level), need for strong provider recommendation and discussing the vaccine with patients (provider level), and limited patient reminders and health education information around HPV vaccination (practice level). Related to socio-ecology, the lack of transportation and culture of limited discussion about vaccination in rural communities and the lack of policies facilitating the uptake of the HPV vaccine (e.g., school mandates) were described as challenges.

CONCLUSION

These interviews revealed key themes around education, knowledge, importance of immunization reminders, and approaches to increasing the HPV vaccination in rural Georgia. This data can inform future interventions across all levels (patient, provider, practice, policy, etc.) to increase HPV vaccination rates in rural communities.

Effect of an HPV Vaccination Multi-Level, Multi-Component Program on HPV Vaccination Initiation and Completion in a Pediatric Clinic Network

Despite clear evidence of the public health benefits of the human papillomavirus (HPV) vaccine in preventing HPV-related cancers and genital warts, underutilization of HPV vaccination in the United States persists. Interventions targeting multi-level determinants of vaccination behavior are crucial for improving HPV vaccination rates. The study's purpose was to implement and evaluate the adapted Adolescent Vaccination Program (AVP), a clinic-based, multi-level, multi-component intervention aimed at increasing HPV vaccine initiation and completion rates in a five-clinic pediatric network in Bexar County, Texas. The adaptation process was guided by established frameworks and involved formative work with clinic stakeholders. The study utilized a quasi-experimental single group pre- and post- study design, with an external comparison data using the National Immunization Survey-Teen (NIS-Teen) datasets for the same time period to examine the AVP's effect on HPV vaccination initiation and completion. A series of interrupted time series analyses (ITSA) compared the clinic system patient outcomes (HPV vaccination initiation and completion rates) in the post-intervention to the general adolescent population (NIS-Teen). Of the 6438 patients (11-17 years) with clinic visits during the 3-year study period, HPV vaccination initiation rates increased from 64.7% to 80.2% (p < 0.05) and completion rates increased from 43.2% to 60.2% (p < 0.05). The AVP was effective across various demographic and economic subgroups, demonstrating its generalizability. ITSA findings indicated the AVP improved HPV vaccination initiation and completion rates in clinic settings and that AVP strategies facilitated resilience during the pandemic. The minimal adaptation required for implementation in a new clinic system underscores its feasibility and potential for widespread adoption.

Facilitators and barriers of HPV vaccination: a qualitative study in rural Georgia

Introduction

Human papillomavirus (HPV) vaccination protects against HPV-associated cancers and genital warts. Healthy People 2030 goal for HPV vaccine uptake is 80%, but as of 2021, only 58.5% of adolescents are up to date in Georgia. The purpose of the study is to assess the attitudes, vaccine practices, facilitators, and barriers to receiving the HPV vaccine in southwest Georgia.

Methods

We conducted 40 semi-structured interviews with three different audiences (young adults, parents, and providers and public health professionals) guided by the P3 (patient-, provider-, practice-levels) model and used deductive coding approach. Young adults and parents were interviewed to assess their perceived benefits, barriers, and susceptibility of the HPV vaccine. Providers and public health professionals were interviewed about facilitators and barriers of patients receiving the HPV vaccine in their communities.

Results

Out of the 40 interviews: 10 young adults, 20 parents, and 10 providers and public health professionals were interviewed. Emerging facilitator themes to increase the uptake of the HPV vaccine included existing knowledge (patient level), providers' approach to the HPV vaccine recommendations (provider level) and immunization reminders (practice level). Barrier themes were lack of knowledge around HPV and the HPV vaccine (patient level), need for strong provider recommendation and discussing the vaccine with patients (provider level), and limited patient reminders and information (practice level).

Conclusions

These interviews revealed key themes around education, knowledge, importance of immunization reminders, and approaches to increasing the HPV vaccination in rural Georgia. This data can inform future interventions across all levels (patient, provider, practice, policy, etc.) to increase HPV vaccination rates in rural communities.

Optimizing timing of adolescent vaccines: Impact of initiating HPV vaccination before Tdap or meningococcal vaccination on timely completion of the HPV vaccine series

To explore the impact on timely series completion of initiating the HPV vaccine series prior to other vaccines in the adolescent platform (Tdap or meningococcal vacccines), we created a cohort of children aged 9 in 2015 who were continuously enrolled through the age of 13 (2019) from a national administrative database of employee-sponsored insurance in the United States (MarketScan). Logistic regressions were used to predict the odds of HPV vaccine series completion among those who started the series prior to, concurrent with, or after receiving Tdap or meningococcal vaccination. The cohort included 100,857 eligible children. Compared with adolescents who received their HPV and Tdap or HPV and meningococcal vaccinations concurrently, those who received HPV prior to other vaccines had higher completion (aOR = 1.38 for Tdap, aOR 1.62 for meningococcal), while those who received their HPV vaccination after other vaccines had lower odds of HPV vaccine series completion (aOR = 0.68 for Tdap, aOR = 0.62 for meningococcal). Other factors associated with series completion included female sex, residing in an urban (vs. rural) area, residing in the Northeast, and receiving primary care from a pediatrician (vs. family medicine physician). These data indicate that beginning the HPV vaccine series prior to the adolescent platform may improve on-time series completion.

HPV vaccine recommendations by age: A survey of providers in federally qualified health centers

Clinician recommendation remains a critical factor in improving HPV vaccine uptake. Clinicians practicing in federally qualified health centers were surveyed between October 2021 and July 2022. Clinicians were asked how they recommended HPV vaccination for patients aged 9-10, 11-12, 13-18, 19-26, and 27-45 y (strongly recommend, offer but do not recommend strongly, discuss only if the patient initiates the conversation, or recommend against). Descriptive statistics were assessed, and exact binomial logistic regression analyses were utilized to examine factors associated with HPV vaccination recommendation in 9-10-y-old patients. Respondents (n = 148) were primarily female (85%), between the ages of 30-39 (38%), white, non-Hispanic (62%), advanced practice providers (55%), family medicine specialty (70%), and practicing in the Northeast (63%). Strong recommendations for HPV vaccination varied by age: 65% strongly recommended for ages 9-10, 94% for ages 11-12, 96% for ages 13-18, 82% for age 19-26, and 26% for ages 27-45 y. Compared to Women's Health/OBGYN specialty, family medicine clinicians were less likely to recommend HPV vaccination at ages 9-10 (p = .03). Approximately two-thirds of clinicians practicing in federally qualified health centers or safety net settings strongly recommend HPV vaccine series initiation at ages 9-10. Additional research is needed to improve recommendations in younger age groups.

Determinants of the Implementation of Human Papillomavirus Vaccination in Zambia: Application of the Consolidated Framework for Implementation Research

Cervical cancer can be prevented, primarily by the administration of the human papillomavirus (HPV) vaccine. Healthcare workers (HCWs) and teachers play important roles when schools are used for vaccine delivery; however, challenges exist. This study aimed to understand the barriers and facilitators to HPV vaccination that are perceived by HCWs and teachers. Guided by the consolidated framework for implementation research (CFIR), key informant interviews were conducted in Lusaka district between June 2021 and November 2021 using a semi-structured questionnaire. Recorded interviews were transcribed verbatim and imported into NVIVO 12 for data management and analysis. We coded transcripts inductively and deductively based on the adapted CFIR codebook. We reached saturation with 23 participants. We identified barriers and facilitators across the five CFIR domains. Facilitators included offering the HPV vaccine free of charge, HPV vaccine effectiveness, stakeholder engagement, and timely planning of the HPV vaccination. Barriers included vaccine mistrust due to its perceived novelty, low levels of parental knowledge, myths and misinformation about the vaccine, lack of parental consent to vaccinate daughters, lack of transport for vaccination outreach, lack of staff incentives, and inadequate sensitisation. Using the CFIR as a guiding framework, we have identified implementation barriers and facilitators to HPV vaccination among HCWs and teachers. Most of the identified barriers are modifiable, hence it is prudent that these are addressed for a high HPV vaccine uptake.

Uptake of HPV vaccination among boys after the introduction of gender-neutral HPV vaccination in Germany before and during the COVID-19 pandemic

BACKGROUND

HPV vaccination has been recommended and reimbursed for girls in Germany since 2007. In June 2018 the German Standing Committee on Vaccination (STIKO) recommended the gender-neutral vaccination of adolescents aged 9 to 14 years with catch-up through age 17. Objectives of this study were to describe the uptake of vaccination in boys before and during the COVID-19 pandemic.

METHODS

The study used data from a proprietary electronic medical record database and a database with information on nationally dispensed vaccine doses. The monthly number of first doses of HPV vaccinations in boys and girls aged 9-17 years in the period from 01/2018 to 12/2021 was determined. In addition, for boys the cumulative vaccination rates were calculated for initiated and completed vaccination series.

RESULTS

Four months after the introduction of mandatory reimbursement for boys, the monthly numbers of first doses were comparable to that of girls. Compared to the same month in 2019, the number of first doses declined by up to 49% (girls) in 2020 and 71% (boys) in 2021. At the end of 2021, the vaccination rate for 15-year-old boys (2006 birth cohort) reached 44.4% for initiated and 26.4% for completed series.

CONCLUSION

After an initial dynamic increase in HPV vaccinations in boys, the impact of COVID-19 was particularly strong in the second year of the pandemic. At the end of 2021 vaccination rates were still low. Efforts are needed to catch-up on adolescents that missed doses during the pandemic and to increase uptake.

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.

Patient-Provider Health Communication Strategies: Enhancing HPV Vaccine Uptake among Adolescents of Color

Cervical cancer remains a public health issue in the United States, particularly among stigmatized racial and ethnic populations. The human papillomavirus (HPV) vaccine has been clinically proven to prevent cervical cancers, and other HPV-associated cancers, among men and women. However, HPV vaccine uptake is suboptimal; only 55% of adolescents complete the two-dose series by age 15. Past research has shown that provider HPV vaccine communication for people of marginalized races/ethnicities is subpar. This article focuses on provider communication strategies to promote HPV vaccine uptake effectively and equitably. The authors reviewed the literature on evidence-based patient-provider HPV vaccine communication techniques to create a set of communication language providers could use and avoid using to enhance HPV vaccine acceptance and uptake among adolescents of marginalized racial and ethnic groups. Evidence has shown that information and the manner of dissemination are critical for influencing HPV vaccine uptake. These communication strategies must be suited to the context of the targeted population, and the message content can be broadly categorized into source, content, and modality. Strategies to improve patient-provider communication among adolescents of color using source, modality, and content include the following: (1) Source: increase provider self-efficacy to provide the recommendation, building rapport between providers and parents; (2) Content: persistent, forceful language with minimal acquiescence should be employed, reframing the conversation focus from sex to cancer; and (3) Modality: use multiple vaccine reminder modalities, and work with the community to culturally adapt the vaccination language. Utilizing effective behavior-change communication adapted for adolescents of color can reduce missed opportunities for HPV prevention, potentially decreasing racial and ethnic disparities in HPV-related morbidity and mortality.

Trends in Reasons for Human Papillomavirus Vaccine Hesitancy: 2010-2020

OBJECTIVES

We sought to identify trends in the main reasons United States parents of unvaccinated children gave for not intending to vaccinate their adolescent children against HPV from 2010 to 2020. As interventions designed to increase vaccine uptake have been implemented across the United States, we predicted that reasons for hesitancy have changed over this period.

METHODS

We analyzed data from the 2010 to 2020 National Immunization Survey-Teen, which included 119 695 adolescents aged 13 to 17 years. Joinpoint regression estimated yearly changes in the top five cited reasons for not intending to vaccinate using annual percentage changes.

RESULTS

The five most frequently cited reasons for not intending to vaccinate included "not necessary," "safety concerns," "lack of recommendation," "lack of knowledge," and "not sexually active." Overall, parental HPV vaccine hesitancy decreased by 5.5% annually between 2010 and 2012 and then remained stable for the 9-year period of 2012 through 2020. The proportion of parents citing "safety or side effects" as a reason for vaccine hesitancy increased significantly by 15.6% annually from 2010 to 2018. The proportion of parents citing "not recommended," "lack of knowledge," or "child not sexually active" as reasons for vaccine hesitancy decreased significantly by 6.8%, 9.9%, and 5.9% respectively per year between 2013 and 2020. No significant changes were observed for parents citing "not necessary."

CONCLUSIONS

Parents who cited vaccine safety as a reason for not intending to vaccinate their adolescent children against HPV increased over time. Findings support efforts to address parental safety concerns surrounding HPV vaccination.