Physicians' Communication Style Likely Lowers HPV Vaccinations

Troy Brown, RN

October 27, 2015

Many physicians could do better when communicating the need for their pediatric patients to be vaccinated against human papillomavirus (HPV), and this has likely contributed to low coverage, according to a new study. The American Academy of Pediatrics recommends that all 11- and 12-year-old boys and girls be routinely vaccinated against HPV.

"A provider's recommendation is one of the strongest and most consistent predictors of HPV vaccination, yet providers often miss opportunities to deliver effective recommendations," the researchers write.

Melissa B. Gilkey, PhD, from the Department of Population Medicine, Harvard Medical School, and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, and colleagues report their findings in an article published online October 22 in Cancer Epidemiology, Biomarkers & Prevention.

The researchers emailed survey invitations to 2368 family medicine physicians and pediatricians. Of those, 776 eligible physicians completed the Physician Communication about HPV Vaccination Study survey online in 2014.

The survey evaluated the quality of physicians' vaccination recommendations on the strength of their endorsement (whether or not the physician said it was important), timeliness (recommending the vaccine by ages 11 to 12 years), consistency (recommending the vaccine for all children, and not just for those they felt were at risk), and urgency (recommending vaccination on the same day).

"We were surprised that physicians so often reported recommending HPV vaccination inconsistently, behind schedule, or without urgency. Of the five communication practices we assessed, about half of physicians reported two or more practices that likely discourage timely HPV vaccination," Dr Gilkey said in a news release from the American Association for Cancer Research. "We are currently missing many opportunities to protect today's young people from future HPV-related cancers. Helping providers communicate about the HPV vaccine effectively is a promising strategy for getting more adolescents vaccinated."

The researchers adjusted for potential confounders, including the physician's medical specialty, the physician's sex, percentage of vaccines given through the Vaccines for Children program, whether or not the physician's practice stocked the HPV vaccine, parent's perceived belief about the vaccine's importance, whether or not the physician was comfortable discussing sexually transmitted infections and the HPV vaccine, how the physician initiated the conversation about the vaccine, and how many HPV-caused cancers the physician discussed with the parents.

Consistency, Urgency Lacking

Physicians most often fell short in the areas of consistency and urgency. A majority (59%) recommended the vaccine only to children they perceived as being at risk for the infection. This approach likely excludes many children who might benefit from it, as one third of all older adolescent girls carry the virus, the authors warn.

Almost half (49%) of physicians failed to recommend same-day vaccination.

A sizable number of physicians reported they did not recommend the vaccine in a timely manner (ie, for 11- and 12-year-old children) for boys (39%) or girls (26%), and 27% reported that the strength of their endorsement of the vaccine's importance was weak.

Almost half of the physicians (47%) said they believed parents felt the vaccine was not important or was only slightly important for their 11- and 12-year-old children. One third of physicians felt the conversation about the vaccine (34%) or sexually transmitted infections (32%) would be an uncomfortable one.

Recommendation quality was lower for physicians who believed parents saw the vaccine as not important or not very important (multivariable odds ratio [OR], 0.60; 95% confidence interval [CI], 0.43 - 0.84) and for physicians who felt the conversation about a sexually transmitted infection or about the HPV vaccine would be uncomfortable (multivariable OR, 0.45; 95% CI, 0.31 - 0.65).

Setting the Stage

Most physicians initiated the conversation about HPV vaccination by presenting information (34%), saying the child was due for HPV vaccination (30%), or suggesting the child be vaccinated (29%). Only 1% of physicians started the conversation by telling the parent they would administer the vaccine at the end of the child's visit.

Recommendation quality was higher for physicians who began conversations about the vaccine by saying the child is due for the vaccine compared with those who began these conversations by giving information (multivariable OR, 0.12; 95% CI, 0.08 - 0.18), suggesting the vaccine (multivariable OR, 0.26; 95% CI, 0.17 - 0.40), or asking whether the parent had questions (multivariable OR, 0.13; 95% CI, 0.06 - 0.29).

A majority of physicians told parents the HPV vaccine prevents cervical cancer (99%), genital warts (84%), or other cancers (55%).

Recommendation quality was higher for physicians who informed parents that the HPV vaccine prevents cervical cancer, other cancers, and genital warts compared with those who said it prevents cervical cancer and genital warts (OR, 0.56; 95% CI, 0.38 - 0.82), or cervical cancer alone (OR, 0.36; 95% CI, 0.20 - 0.64).

Better Understanding of HPV Risk Needed

Physicians who used a risk-based approach to recommending the vaccine most often believed sexually active adolescents (71%) and those who have had a sexually transmitted infection (60%) were at higher risk for HPV infection. Fewer than half knew that gay and bisexual males (43%) and older adolescents (39%) are at increased risk for HPV infection.

"Physicians have a lot of influence on whether adolescents receive the HPV vaccine. Our findings suggest that physicians can improve their recommendations in three ways: by recommending HPV vaccination for all 11- to 12-year-olds and not just those who appear to be at risk; by saying the HPV vaccine is very important; and by suggesting vaccination on the day of the visit rather than at a later date," Dr Gilkey said in the American Association for Cancer Research news release.

One coauthor reports receiving commercial research grants from Merck, Pfizer, and GSK; speaker honoraria from Merck; and consultant/advisory board membership for Merck. The other authors have disclosed no relevant financial relationships.

Cancer Epidemiol Biomarkers Prev. Published online October 22, 2015. Abstract

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