A Mixed-Methods Examination of Factors Related to HPV Vaccination Promotion in Private Dental Settings, Iowa, 2019

Natoshia Askelson, MPH, PhD; Grace Ryan, MPH; Susan McKernan, MS, DMD, PhD; Aaron Scherer, MA, PhD; Eliza Daly, BA; Lejla Avdic, BA

Disclosures

Prev Chronic Dis. 2021;18(3):e26

Abstract and Introduction

Abstract

Introduction: Human papillomavirus (HPV)-associated oropharyngeal cancer rates are rising, particularly in males, although rates of other HPV-related cancers are decreasing. Although the HPV vaccine is safe and effective, vaccination rates remain below the Healthy People 2030 goal of 80% coverage. Engaging dental providers, who have experience with patient education and oropharyngeal cancer, may prove useful in efforts to increase vaccination rates. Our research explores dental providers' (dentists, dental hygienists) willingness to participate in continuing education about HPV, educate parents of adolescents, recommend the vaccine for adolescents, and refer parents to medical providers.

Methods: We used a mixed-methods approach and conducted a survey with dental hygienists and semistructured interviews with dental providers. We produced frequencies and descriptive statistics for all variables and used regression modeling to explore factors related to willingness to promote the HPV vaccine. We used a deductive approach to code interview transcripts.

Results: Regression models using survey data (n = 470) showed that after controlling for demographic and practice-level characteristics, higher levels of willingness were associated with thinking that parents would act on a recommendation and thinking that engaging in HPV promotion is within the scope of practice. Interview data reflected willingness of dental providers to work on HPV vaccination, but revealed barriers (eg, time, knowledge) that need to be addressed.

Discussion: Overall, dental providers expressed a willingness to participate in HPV vaccine promotion, and future efforts should focus on addressing barriers to doing so. Engaging dental providers in HPV vaccine recommendation and referral can help prevent future HPV-related cancers.

Introduction

Human papillomavirus (HPV) causes an estimated 34,800 cases of cancer annually in the United States.^[1] Although rates of HPV-associated cervical cancers have fallen, HPV-associated oropharyngeal cancer rates are increasing. Males are disproportionately affected, experiencing an increased rate of 2.7% per year between 1999 and 2015.^[2] In 2020, the Food and Drug Administration (FDA) expanded its approval of the HPV vaccine to include prevention of HPV-related oropharyngeal cancer.^[3] The HPV vaccine prevents multiple types of cancer; however, uptake falls short compared with other adolescent vaccines, particularly for males,^[4] and rates remain below the Healthy People 2030 goal of 80% completion.^[5]

The increase in HPV-associated oropharyngeal cancer and little progress in vaccination rates raises questions about current approaches to vaccine promotion and highlights the need to seek new partners. Dental hygienists and dentists (collectively called dental providers) have been identified as a group to enlist in HPV vaccine promotion.^[6,7] The American Dental Association (ADA) released a statement that "urges dentists, as well as local and state dental societies, to support the use and administration of the HPV vaccine".^[8] Moreover, dental providers have long been essential in providing preventive health care, with documented success helping patients understand diabetes management^[9] and tobacco cessation.^[10]

Despite these professional recommendations, most dental providers lack the formal education or experience to ensure that they can be successful partners in vaccine promotion.^[11,12] We designed our study to expand our understanding of the factors that contribute to dental providers' willingness to implement routine HPV vaccine promotion. We used a mixed-methods approach to answer the following formative research questions about dental providers in private practice: 1) In what HPV vaccine promotion activities do dental providers currently engage? 2) How willing are dental providers to engage in HPV vaccine promotion? 3) What factors are related to dental providers' willingness to engage in HPV vaccine promotion?

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Abstract and Introduction
Methods
Results
Discussion
References
Sidebar

Table 1. Dental Hygienist Survey Items and Regression Coefficients from Model 3 (N = 470), Iowa, 2019
Variable			Willingness
Variable			To participate in CE	To educate parents	To recommend vaccine to parents	To refer patients
Characteristics	n (%)	Mean (SD)	β (SE)	β (SE)	β (SE)	β (SE)
Age, y
18–26	NA		−.616 (.329)^a	−.230 (.292)	−.140 (.293)	−.128 (.312)
27–39	1 [Reference]		[Reference]	[Reference]	[Reference]	[Reference]
40–59	NA		−.348 (.169)	−.007 (.150)	−.093 (.150)	−.014 (.160)
≥60	NA		−.064 (.269)	−.008 (.239)	−.124 (.240)	−.063 (.256)
How many years have you been employed as a dental hygienist?	NA	18.64 (11.20)	−.004 (.008)	−.013 (.007)	.002 (.007)	.006 (.007)
How would you describe your political views? (very conservative, 1 to very liberal, 5)	NA	2.66 (0.88)	−.021 (.068)	.002 (.060)	.058 (.061)	.030 (.065)
How religious are you? (not at all, 1 to very religious, 7)	NA	4.92 (1.54)	−.031 (.039)	.009 (.034)	.006 (.034)	.017 (.037)
Previous experience (yes)
Have you or anyone you know been diagnosed with an HPV-related cancer?	77 (16.4)	NA	.106 (.142)	.026 (.126)	.078 (.127)	.134 (.135)
Have you received at least 1 dose of HPV vaccine?	95 (20.4)	NA	−.001 (.151)	.075 (.134)	.255 (.135)	.184 (.144)
Have you completed a continuing education course on either HPV or HPV vaccination?	109 (24.4)	NA	−.028 (.083)	−.073 (.064)	−.104 (.074)	.018 (.079)
Have you completed a continuing education course on oral cancer?	414 (88.5)	NA	−.164 (.343)	−.156 (.153)	−.123 (.154)	−.042 (.164)
Current behavior (yes)
Discuss HPV vaccination as oral cancer prevention with parents of adolescent patients	113 (24.0)	NA	−.291 (.121)	−.128 (.166)	−.216 (.167)	−.268 (.177)
Discuss the HPV vaccine as oral cancer prevention with adolescent patients	97 (20.7)	NA	.396 (.197)^a	.116 (.175)	.244 (.176)	.247 (.187)
Attitudes (strongly disagree, 1 to strongly agree, 5)
Parents would act on a recommendation from me to vaccinate their adolescent against HPV	NA	2.90 (0.80)	.169 (.072)^a	.250 (.063)^c	.244 (.064)^c	.258 (.068)^c
It is within a dental hygienist's scope and role to recommend the HPV vaccine	NA	2.94 (0.95)	.193 (.064)^b	.333 (.056)^c	.543 (.057)^c	.473 (.061)^c
Local stigma plays a role in discussing HPV and the HPV vaccine in the dental office	NA	3.28 (0.97)	.022 (.057)	−.030 (.051)	−.010 (.051)	.007 (.054)
There are no established professional guidelines pertaining to hygienists recommending the HPV vaccine	NA	3.79 (0.76)	.133 (.073)	.075 (.064)	−.040 (.065)	−.015 (.069)
Clinic characteristics
Accepting new Medicaid patients	101 (21.5)	NA	.017 (.127)	.151 (.113)	.012 (.113)	.214 (.121)
Percent of adolescent patients seen	NA	NA	−.003 (.004)	−.001 (.003)	.000 (.003)	.000 (.004)
Someone hands out info about HPV vaccine to adolescent parents	7 (1.5)	NA	−.119 (.535)	.078 (.474)	.204 (.477)	.308 (.507)
Health history form includes question about HPV	32 (6.8)	NA	−.313 (.220)	−.073 (.195)	−.417 (.196)^a	−.155 (.208)
Patient waiting area has info about HPV vaccine	10 (2.1)	NA	.029 (.415)	.024 (.368)	−.075 (.369)	.473 (.393)
Dental professionals or staff recommend HPV vaccine to adolescent patients or parents	15 (3.2)	NA	.112 (.309)	.369 (.274)	.316 (.275)	.269 (.293)
Willingness (very unwilling, 1 to very willing, 5)
To educate your patients about HPV and oral cancer, if trained	NA	3.87 (1.00)	NA	NA	NA	NA
To recommend the HPV vaccine to the parents of your adolescent patients	NA	3.43 (1.09)	NA	NA	NA	NA
To refer eligible patients to receive the HPV vaccine with their primary care providers, if trained	NA	3.50 (1.11)	NA	NA	NA	NA
To participate in continuing education about HPV and oral cancer	NA	4.23 (1.03)	NA	NA	NA	NA

Abbreviations: CE, continuing education; HPV, human papillomavirus; NA, not applicable.
^a P <.05.
^b P <.01.
^c P <.001.

Table 2. Characteristics of Interview Participants in HPV Vaccination Promotion Study, Iowa, 2019
Characteristics	Dental Hygienist Survey (n = 470)		Dental Hygienist Interviews (n = 19)		Dentist Interviews (n = 20)
Characteristics	n/mean	%/SD	n/mean	%/SD	n/mean	%/SD
Male	NA	NA	0	0	12	60
Female	NA	NA	19	100	8	40
Age, y
18–26	14	3.0	0	0	1	5
27–39	176	37.4	3	15.8	8	40
40–59	228	48.5	12	63.2	3	15
≥60	52	11.1	4	21.0	8	40
Hygiene certificate	213	45.3	2	10.5	NA	NA
Associate's degree	316	67.2	11	57.9	NA	NA
Bachelor's degree	147	31.3	6	31.6	NA	NA
≥Master's degree	5	1.1	0	0	NA	NA
Average % adolescent patients	23.85	12.32	23.16	18.92	20.19	9.91

Table 3. Themes and Representative Quotes From Interviews With Dental Providers, Iowa, 2019
Theme	Subtheme	Group	Example Quote
Currently discussing HPV vaccination in clinic	NA	Dental hygienist	"I don't typically think about discussing [it] with my dental patients" (hyg_4.2.2019_EB) "To be honest it's not something we've talked about or addressed at all, but it is something that we're starting to hear more information about, that we're talking about [it] as a[n] office [and] communicating more about. We just have a new dentist in the practice so there's a lot of changes going on, so that hasn't been implemented yet" (hyg_7.12.2019_LA)
Currently discussing HPV vaccination in clinic	NA	Dentists	"it's not on my radar" (dentist_7.17_2019_ED2) "I do not know much about the HPV vaccination or what is the recommendation for it" (dentist_8.8.2019_EB1)
Willingness to engage in HPV vaccine promotion	Overall willingness	Dental Hygienist	"You know, I would think likely, or somewhat likely, considering we are considered the health field… . So, I mean I would assume likely or somewhat likely" (hyg_3.29.2019_EB) "Well, because we do oral cancer screens on all ages, children and adults, so as we're talking about it I feel like if there's concern or if there [is] talk about the topic of the vaccination that we should just bring up in general, it's something that would be" (hyg_7.12.2019_LA)
	Barriers to participation	Dental Hygienist	"I don't feel I have enough background information on it" (hyg_4.5.2019_WB) "People aren't gonna understand or…they're not gonna see [hygienists] as a provider-type" (hyg_4.1.2019_EB) "Because I realize that it shows up in the mouth and that if the kids are sexually active, that could happen. But I don't know. I would have to say I'm not comfortable with telling somebody they need to get vaccinated for HPV" (hyg_5.3.2019_FP)
	Barriers to participation	Dentist	"I know that because a lot of [hygienists] have so much to do during the appointments as well, so sometimes adding one more thing for them to do can be tough for them to adapt to" (dentist_8.8.2019_EB2) "Well, just my ability to answer questions about it, you know, I would probably be less likely to talk about it if I felt like I didn't know a whole lot about it, but a simple educational brochure could take care of that" (dentist_8.27.2019_LA)
	Willingness of parents to act on dental professionals' recommendations	Dental Hygienist	"My patients would definitely feel very comfortable asking me about recommendations because I have a good rapport with my parents and patients" (hyg_7.12.2019_ED).
		Dentist	"It's an easy sell. Patients are very concerned about cancer" (dentist_7.19.2019_LA) "Hygienists just have these really nice, established relationships with [their] patients" (dentist_8.9.2019_LA) "I do think that people's response to this issue is going to be somewhat significantly impacted by the level of relationship and therefore trust that exists" (dentist_8.2.2019_LA3)
	Role of dental professionals in HPV promotion	Dental Hygienist	"I think it's more of a medical [matter]. I was in private practice for almost 30 years, and we never brought that up, or educated the person on it. I think most dentists would think that's for the medical provider" (hyg_3.27.2019_WB) "Well, we educate our patients on overall health. That could definitely be incorporated into that" (hyg_6.10.2019_WB)
	Role of dental professionals in HPV promotion	Dentist	"Hygienists probably [have a] smaller role than the dentist" (dentist_7.18.2019_LA) "I hadn't thought about it a lot until recently, but it should be a bigger role" (Dentist_7.18_2019_LA).