'Announcements' Beat Conversations for HPV Vaccine Uptake

Beth Skwarecki

December 07, 2016

Human papillomavirus (HPV) vaccination rates were higher among children aged 11 and 12 years when clinicians announced it was time for HPV vaccination, rather than starting conversations with parents about their concerns, results of a randomized controlled trial show.

"We speculate that announcements normalize HPV vaccination for both providers and parents, making providers more likely to raise the topic and parents more likely to consent to vaccination," Noel T. Brewer, PhD, professor in the Department of Health Behavior at the University of North Carolina in Chapel Hill, and colleagues write. The results were published online December 5 in Pediatrics.

The study allocated 30 primary care clinics to receive the "announcement" training (n = 10), the "conversation" training (n = 10), or no training (n = 10). All the clinics had at least 100 patients aged 11 or 12 years in the North Carolina Immunization Registry, and the researchers used this registry to determine outcomes in vaccination rates.

The primary outcome was the change in receipt of at least one dose of HPV vaccine between baseline and 6 months after the training among children aged 11 and 12 years (n = 17,173). At 6 months, vaccination rates increased by 5.4% among clinics where clinicians received the "announcement" training (95% confidence interval [CI], 1.1% - 9.7%). Vaccination rates increased among both 11- and 12-year-old girls (4.6% difference; 95% CI, 0.1% - 9.0%) and boys (6.2% difference; 95% CI, 1.5% - 11.0%).

The difference was also detectable among 11- and 12-year-old children at 3 months after training (5.1% difference; 95% CI, 2.0% - 8.2%).

There was no difference between the conversation training and the no-training group. In addition, the authors saw no differences among interventions for adolescents aged 13 to 17 years.

Providers who received the "announcement" training were instructed to bring up the child's age and state that the child was due for three vaccines that day, putting the HPV vaccine in the middle of the list to de-emphasize it. (The other vaccines were meningococcal and Tdap vaccines.) The clinicians were instructed to then say they would be vaccinating that day. The discussion would only continue if the parent raised concerns.

If the parent expressed concerns, the provider was taught to address the main concern and end with a recommendation to receive the vaccine that day.

In contrast, the conversational approach advised the provider to name the three vaccines recommended for children this age, discuss the health benefits, and ask the parent whether they have questions. In this approach, the provider saves their recommendation for later in the conversation.

Both trainings included a presentation on current evidence of the vaccines' effectiveness, safety, and the rationale for targeting younger adolescents. The clinicians were also given advice for addressing common concerns. "For instance, if parents associated the vaccine with sex, we suggested providers redirect the conversation to be about cancer prevention," the researchers write. Clinicians asked parents who did not agree to vaccination to return in 2 months.

As part of the training, clinicians used role-play to practice putting the recommended approach into their own words, and discussed with colleagues how they planned to implement the strategy in their practice.

The authors note that although the clinics studied were in both urban and rural areas, all were in one state and within a 2-hour drive of Chapel Hill, North Carolina. They may also represent clinics whose staffs were more motivated than average, as many of the eligible clinics did not respond to an invitation to join the study.

The investigators did not review medical records or evaluate clinicians' adherence to the strategies they were taught in the training. They also did not evaluate how parents and patients responded to the approaches. "Although our evaluation focused on how best to first raise the topic of vaccination," they write, "research is also needed on effective ways to ease concerns that parents may express."

The study was supported by an unrestricted educational grant from Pfizer and training grants from the National Cancer Institute. Dr Brewer reports receiving commercial research grants from Merck, Pfizer, and GSK and serving on a paid advisory board for Merck. Dr Brewer did not use Merck resources to support this trial. The other authors have disclosed no relevant financial relationships.

Pediatrics. Published online December 5, 2016. Full text

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