Provider communication and HPV vaccination: The impact of recommendation quality

Highlights

• We conducted a national survey of 1495 U.S. parents of adolescents, ages 11–17.

• Parents reported on healthcare provider recommendations for HPV vaccination.

• High-quality recommendations were positively associated with HPV vaccine uptake.

• High-quality recommendations were negatively associated with refusal and delay.

• Only about one-third of parents received high-quality recommendations.

Abstract

Background

Receiving a healthcare provider's recommendation is a strong predictor of HPV vaccination, but little is known empirically about which types of recommendation are most influential. Thus, we sought to investigate the relationship between recommendation quality and HPV vaccination among U.S. adolescents.

Methods

In 2014, we conducted a national, online survey of 1495 parents of 11–17-year-old adolescents. Parents reported whether providers endorsed HPV vaccination strongly, encouraged same-day vaccination, and discussed cancer prevention. Using an index of these quality indicators, we categorized parents as having received no, low-quality, or high-quality recommendations for HPV vaccination. Separate multivariable logistic regression models assessed associations between recommendation quality and HPV vaccine initiation (≥1 dose), follow through (3 doses, among initiators), refusal, and delay.

Results

Almost half (48%) of parents reported no provider recommendation for HPV vaccination, while 16% received low-quality recommendations and 36% received high-quality recommendations. Compared to no recommendation, high-quality recommendations were associated with over nine times the odds of HPV vaccine initiation (23% vs. 74%, OR = 9.31, 95% CI, 7.10–12.22) and over three times the odds of follow through (17% vs. 44%, OR = 3.82, 95% CI, 2.39–6.11). Low-quality recommendations were more modestly associated with initiation (OR = 4.13, 95% CI, 2.99–5.70), but not follow through. Parents who received high- versus low-quality recommendations less often reported HPV vaccine refusal or delay.

Conclusions

High-quality recommendations were strongly associated with HPV vaccination behavior, but only about one-third of parents received them. Interventions are needed to improve not only whether, but how providers recommend HPV vaccination for adolescents.

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.