Provider communication and HPV vaccination: The impact of recommendation quality
Introduction
Only a small minority of adolescents in the United States receives human papillomavirus (HPV) vaccine according to national guidelines. Although the Advisory Committee on Immunization Practices recommends completion of the three-dose HPV vaccine series by age 12, just 26% of females and 16% of males were up-to-date at age 13 in 2014 [1], [2]. Coverage estimates for series completion in older adolescents were somewhat higher, reaching 51% for females and 23% for males by age 17, but remain far below the Healthy People 2020 goal of 80% [2], [3]. These low levels of coverage represent a missed opportunity to prevent 53,000 future cervical cancer cases over the lifetimes of today's population of girls ages 12 and younger, as well as many additional cases of other cancers, precancers, and genital warts in both sexes [4].
The urgent need to improve HPV vaccination coverage has generated support for immunization quality improvement efforts across a broad array of leaders in adolescent health and cancer prevention, including the Centers for Disease Control and Prevention (CDC), the President's Cancer Panel, and the American Academy of Pediatrics [4], [5], [6]. A consistent theme in this work is the need to increase the frequency with which healthcare providers recommend HPV vaccine [4], [5], [6]. A provider's recommendation is so highly influential that over 70% of adolescents who receive a recommendation initiate HPV vaccination [7]. In relative terms, receiving a provider recommendation is a stronger predictor of HPV vaccination than other commonly studied factors, including race/ethnicity, insurance status, HPV-related knowledge, or perceptions of HPV vaccine effectiveness and safety [8], [9], [10], [11]. Despite strong evidence of providers’ influence, more than one-third of age-eligible girls and half of age-eligible boys do not receive recommendations for HPV vaccination [12]. Taken together, these data make increasing the frequency of provider recommendations a logical goal for HPV vaccination quality improvement efforts.
In contrast to recommendation frequency, the role that recommendation quality plays in HPV vaccination is less clear. A growing body of research suggests that, in addition to being infrequent, providers’ recommendations for HPV vaccination are often weak insofar as they frame HPV vaccine as less important than other vaccines or suggest deferring HPV vaccination to a future visit [13], [14], [15], [16]. Furthermore, parents who perceive providers’ recommendations as weak may be less likely to get HPV vaccine for their children [17], [18]. In response to these concerns, the CDC encourages providers to deliver “strong” recommendations for HPV vaccination. More specifically, educational materials for healthcare providers suggest strategies such as saying the vaccine is important, emphasizing cancer prevention, and encouraging same-day vaccination [19]. Although these suggestions hold intuitive appeal and were informed by formative research, little is known empirically about how to define a strong recommendation or its relative influence on HPV vaccination behavior.
To address this gap, we used data from a national survey to evaluate the quality of recommendations that parents of adolescents received for HPV vaccination on three factors: strength of endorsement, prevention message, and urgency. We assessed associations between provider recommendation quality and four HPV vaccination behaviors: initiation (≥1 dose), follow through (3 doses, among initiators), refusal, and delay. Finally, we sought to identify disparities in recommendation quality across key demographic characteristics. By providing novel data on the role of recommendation quality, our study seeks to inform the many state and national campaigns aimed at improving provider communication so as to increase HPV vaccination coverage in the U.S.
Section snippets
Participants and procedures
We conducted an online survey of parents of adolescents in November 2014 to January 2015. Respondents were members of a standing panel of U.S. adults maintained by a survey research company [20]. To construct a nationally-representative panel, the company used a probability-based sampling approach consisting of list-assisted, random-digit dialing supplemented by address-based sampling to provide coverage of households without telephones [20]. Eligible respondents were parents of an
Sample characteristics
The sample was balanced with regard to the sex of index children, with 51% of parents reporting on a son and 49% reporting on a daughter (Table 1). The mean age for children was 14 years, and most were non-Hispanic white (65%), Hispanic (17%), or non-Hispanic black (10%). Overall, almost half (46%) had initiated HPV vaccination, with sex-specific coverage being 52% for girls and 40% for boys. Among the 689 adolescents who had initiated HPV vaccination, 234 (or 34%) had followed through to
Discussion
In a national survey of parents of adolescents, we found that provider recommendation quality was consistently associated with HPV vaccination behavior. In keeping with prior research [12], [28], almost half of the parents in our sample had not received an HPV vaccine recommendation for their age-eligible child, and less than one-quarter of the children in this group had initiated HPV vaccination. By contrast, over half of parents who received low-quality recommendations had initiated HPV
Conclusion
The possibility of improving HPV vaccine delivery and, in turn, preventing HPV-attributable cancers simply by changing what healthcare providers say has been a cause for considerable optimism in recent years, motivating large-scale immunization quality improvement efforts. A strong body of evidence speaks to the importance of increasing the frequency of provider recommendations for HPV vaccination. The findings of our study provide empirical support for the hypothesis that recommendation
References (31)
- et al.
Factors associated with human papillomavirus vaccine-series initiation and healthcare provider recommendation in US adolescent females: 2007 National Survey of Children's Health
Vaccine
(2012) - et al.
HPV vaccine hesitancy: findings from a statewide survey of health care providers
J Pediatr Health Care
(2014) - et al.
Predictors of HPV vaccine uptake among women aged 19–26: importance of a physician's recommendation
Vaccine
(2011) - et al.
Parents’ health beliefs and HPV vaccination of their adolescent daughters
Soc Sci Med
(2009) - et al.
Do correlates of HPV vaccine initiation differ between adolescent boys and girls
Vaccine
(2012) - et al.
The accuracy of human papillomavirus vaccination status based on adult proxy recall or household immunization records for adolescent females in the United States
Ann Epidemiol
(2013) - et al.
Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP)
MMWR Recomm Rep
(2014) National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years – United States, 2014
MMWR Morb Mortal Wkly Rep
(2015)Healthy People 2020 Immunization and Infectious Diseases
(2016)Accelerating HPV Vaccine Uptake: Urgency for Action to Prevent Cancer. A Report to the President of the United States from the President's Cancer Panel
(2014)
HPV. You are the Key to Cancer Prevention
Give a Strong Recommendation for HPV Vaccine to Increase Uptake
Human papillomavirus vaccination series initiation and completion, 2008–2009
Pediatrics
Longitudinal predictors of human papillomavirus vaccination among a national sample of adolescent males
Am J Public Health
Longitudinal predictors of human papillomavirus vaccine initiation among adolescent girls in a high-risk geographic area
Sex Transm Dis
Cited by (314)
Identifying Healthcare Professionals With Lower Human Papillomavirus (HPV) Vaccine Recommendation Quality: A Systematic Review
2024, Journal of Adolescent HealthDifferences in Provider Hepatitis C Virus Screening Recommendations by Patient Risk Status
2024, Preventive Medicine Reports