Making Effective HPV Vaccine Recommendations

In the United States, approximately 79 million people live with human papillomavirus (HPV) infections. Most people get a form of HPV in their lifetime without getting sick. However, chronic HPV infection can lead to health complications, including six cancers (e.g., cervical, anal, and oropharyngeal cancers). The viruses cause nearly all cases of cervical cancer. The HPV vaccination series can prevent cancers associated with HPV. The Centers for Disease Control and Prevention (CDC) recommends that all youth aged 11 or 12 receive two doses of HPV vaccine 6 to 12 months apart. As of 2016, however, only 60% of adolescents aged 13 through 17 years, the age at which they would be "late" for HPV vaccination, had received at least one dose of the vaccine. The CDC encourages health care providers to routinely recommend HPV vaccine to parents of their adolescent patients and administer the vaccine to these patients. Providers are trusted by parents and can play a vital role in increasing HPV vaccination rates among 11- and 12-year-olds. Interventions that train providers to successfully recommend HPV vaccines are needed to increase HPV vaccination among adolescents.

Making Effective HPV Vaccine Recommendations is a training intervention targeted to HPV vaccine providers whose patients are adolescents. The training is designed to help providers more effectively recommend vaccination to the patients' parents, who must provide consent, resulting in greater vaccination rates. The training teaches the 'announcement' strategy, wherein the provider assumes parents want their children to receive CDC-recommended vaccinations during that day's office visit. This strategy is in contrast with the conversational approach, which uses an open-ended discussion between the provider and parents. The announcement intervention is based on research demonstrating that providers influence vaccination uptake.

A physician educator delivers the training to HPV vaccine providers (e.g., physicians, physician assistants, nurse practitioners) as well as other clinic staff in positions to influence parents' agreement to vaccinate. The 1-hour training, which uses a standardized script and slides, has four parts:

-- Review Evidence: The educator summarizes the latest research on HPV vaccination practices, HPV vaccine effectiveness and safety, and the rationale for targeting younger adolescents for vaccination.

-- Build Skills: The educator describes how to vaccine providers can make effective HPV vaccine recommendations using the announcement strategy. First, the provider announces that the child is due for three vaccines to be given today. (For example, "I see here that Michael just turned 11. Because he's 11, Michael is due for meningitis, HPV, and Tdap vaccines. We'll give those at the end of today's visit.") This announcement mentions the child's age, explains that the child is due for three vaccines recommended for children this age, places the HPV vaccine in the middle of the list of three vaccinations, and states that the vaccination will occur today. Second, only if parents ask questions, the provider asks what the main concern is and eases this concern using a structured approach. Third, for parents who asked questions, the provider clearly and strongly recommends HPV vaccination by giving a motivational statement and ending with "I recommend....," which encourages parents to proceed with vaccination that day. If parents do not agree to vaccinate during the clinic visit, the provider asks them to return in 2 months to discuss it further.

-- Practice: The educator demonstrates the communication approach for the participants, gives them a note card that outlines the steps, and asks them to identify three situations in which they already use announcements with patients. Providers then draft an announcement and complete a short role-play exercise with partners to practice the announcement strategy.

-- Application to Your Practice: The educator engages participants in a discussion on applying the training in their clinic.

The physician educator encourages providers to use announcements with at least five vaccine-eligible patients within 2 weeks of the training. After completing the training, physicians are eligible to receive up to 1 continuing medical education (CME) credit.

 

-- Approximately 3 hours for the physician educator to prepare to deliver the training to providers (e.g., reading the manual, practicing with the slides)

-- Approximately 60 minutes to deliver the training to providers
 

The intervention is intended for pediatric and family medicine providers who treat adolescents.

The intervention is suitable for implementation with HPV vaccine providers in pediatric and family medicine clinics.

Required resources to implement the program include the following:
-- Making Effective HPV Vaccine Recommendations website

For costs associated with this program, please contact the developer, Noel Brewer. (See products page on the EBCCP website for developer contact information.)

This randomized clinical trial involved 30 pediatric and family medicine clinics in central North Carolina (76% were pediatric clinics). Using a stratified random sampling technique based on the size of their patient population, clinics were assigned using a 1:1:1 ratio to an announcement training, conversation training, or control group that received the announcement training by video after the study ended. The conversation training group was trained to deliver HPV vaccine recommendation messages using a conversational approach following the principles of shared decision-making (e.g., introduce the vaccine, discuss the health benefits, and invite parents' questions, making the recommendation later).

To be eligible for the study, clinics were required to have 100 or more patients aged 11 or 12 in the North Carolina Immunization Registry (NCIR), be located within a 2-hour drive of Chapel Hill, North Carolina, and have at least one pediatric or family medicine physician who provided HPV vaccination to adolescents aged 11 or 12. Clinics that had participated in other HPV vaccination interventions within the past 6 months or planned to do so in the next 6 months were ineligible to participate.

All clinic patients who were aged 11 or 12 years (target population) and 13 through 17 years were included in the analysis. Data were obtained from the NCIR and included 17,173 adolescents aged 11 or 12 and 37,796 adolescents aged 13 through 17. The 9 clinics in the announcement training group had an average of 476 11- and 12-year-olds and a mean age breakdown of 49% male, 46% female, and 5% not specified. Clinics in the conversation training group (n=10) had an average of 690 11- and 12-year-olds and a mean gender breakdown of 47% male, 48% female, and 5% not specified. The ten control group clinics had an average of 600 11- and 12-year-olds and a mean gender breakdown of 50% male, 47% female, and 3% not specified. Although clinics did not significantly differ in these characteristics at baseline, significant differences were observed in baseline vaccination coverage: Patients in control clinics had a significantly higher vaccination rate among 11- and 12-year-olds in the first or subsequent HPV dose, all three HPV doses, and Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis). Patients aged 13 through 17 also had higher vaccination rates in the first or subsequent HPV doses, all three HPV doses, Tdap, and meningococcal conjugate.

The study's primary outcome, measured by review of NCIR data, was HPV vaccine at 6 months for 11- and 12-year-olds. The NCIR, a secure, web-based registry, is used by more than 90% of vaccine providers in North Carolina and contains immunization data for almost all adolescents in the state. Mean change in vaccine initiation was calculated from baseline to 3 and 6 months after the training. Intervention groups were matched on timing of trainings and assessments to control for seasonal variation in vaccination.
 

• At 6-month follow-up, clinics in the announcement training group had a greater increase in HPV vaccine initiation among 11- and 12-year-olds in comparison with clinics in the control group (5.4% difference, p=.02).

Additional Findings

• At 3-month follow-up, clinics in the announcement training group had a greater increase in HPV vaccine initiation among 11- and 12-year-olds compared with clinics in the control group (5.1% difference, p=.003).

• At 3- and 6-month follow-up, clinics in the announcement training group had a greater increase in HPV vaccine initiation compared with clinics in the control group among 11- and 12-year-old girls (4.8% difference, p=.004; 4.6% difference, p=.045) and 11- and 12-year-old boys (5.6% difference, p=.003; 6.2% difference, p=.01).

• At 3- and 6-month follow-up, clinics in the conversation training group did not differ from clinics in the control group in HPV vaccine initiation among 11- and 12-year-olds.