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


Prev Chronic Dis. 2021;18(3):e26 

In This Article



We received 597 surveys resulting in a 30.4% overall response rate, but 127 of those participants did not work in a private practice, setting our final sample for which we report results for 470 dental hygienists, a response rate of 22.6%. We completed 19 dental hygienist interviews and 20 dentist interviews. Individual demographic information and practice characteristics for both survey and interview participants are reported (Table 2).

Current Practices and Perceived Importance of HPV Vaccination Promotion by Dental Hygienists

Few hygienists reported that their practices currently incorporated HPV vaccine promotion (Table 1). For these questions, we coded our data so that if a participant reported that at any point they performed the activities in question, we coded their response as a "yes" to the activity. The most commonly performed activities were discussing the HPV vaccine as oral cancer prevention with adolescent patients (20.6% of participants) or their parents (24.0%). Fewer participants reported that their practice included a question about HPV vaccination on their health history form (6.8%), or had HPV informational materials in the waiting room (2.1%) or available to hand to patients (1.5%).

Qualitative data from the interviews also reinforced survey results that dental practices are not currently engaged in HPV vaccine promotion efforts and that HPV vaccination was perceived as a relatively low priority (Table 3). Many dental hygienists thought that the HPV vaccine was important, but potentially not important enough to discuss in a dental setting. Dental hygienists identified their top priorities with adolescent patients as oral hygiene, diet, and brushing habits.

For the most part, dentists echoed dental hygienists' observations that although HPV is important, it is not a priority to discuss with patients in their practices. Several dentists reported that they did not know much about the vaccine or current guidelines about administering it. Dentists similarly identified their top priorities for adolescent patients as oral hygiene, tooth decay or caries, nutrition, and brushing habits.

Overall, dental hygienists reported being willing to engage in a variety of HPV vaccine promotion strategies, including participation in CE (mean = 4.23, SD = 1.03), educating parents (mean = 3.87, SD = 1.00), recommending the vaccine (mean = 3.43, SD = 1.09), and referring eligible patients to receive the vaccine (mean = 3.50, SD = 1.11 (Table 1). We also explored what factors were related to their willingness to engage in each activity. After controlling for demographic and practice-level characteristics, higher levels of willingness were most associated with thinking that parents would act on a recommendation from their dental hygienist and thinking that engaging in HPV promotion is within the scope of practice for a dental hygienist (Table 1). Because the hierarchical models did not differ significantly, we only report the final model for each activity.


Dental Hygienists. Results from our interviews helped to contextualize findings from the quantitative analyses. We asked hygienists about their willingness to either educate parents about the HPV vaccine or refer parents to a medical provider to get the vaccine. In general, dental hygienists reported a high willingness to educate parents, but lower willingness to refer parents. Those who reported being willing to educate parents gave several reasons. Several dental hygienists identified this as an important issue because of HPV's connection with oropharyngeal cancer. Several others reported that they may be willing to educate parents but would need more information and specific training on how to do this.

Dental hygienists who reported being unwilling to refer patients cited various barriers. Several dental hygienists thought that this kind of activity would be outside their scope of practice. Other participants cited issues related to the time available during a visit to discuss the vaccine or feeling uncomfortable discussing it. Only 1 participant reported that the barrier would be their perceived discomfort with the relationship between HPV and sexual activity. Finally, despite these barriers, several dental hygienists reported that they thought parents would act on their recommendation. In many cases, dental hygienists reflected on the good rapport they have established with parents of patients and thought that parents respect them.

Dentists. We asked dentists about the possibility of either themselves or dental hygienists participating in the described activities in the workplace. Dentists had mixed opinions about how much of a role hygienists could play in vaccine promotion. Some dentists envisioned that vaccine promotion would either need to be a collaborative effort or that hygienists might have a larger role to play than dentists. Those who thought the dental hygienist could have a critical role in promotion activities cited the fact that dental hygienists often have the most uninterrupted time with patients and are the ones with stronger connections to patients and their parents.

Overall, dentists were willing to have dental hygienists educate parents and refer patients for the vaccine, and to send dental hygienists to CE opportunities related to HPV vaccination and promotion. Only a few dentists expressed that they thought dental hygienists may hesitate because of their own personal beliefs about vaccination. Beyond that, dentists reiterated what dental hygienists reported about needing tools and additional training. Overall, dentists thought that CE opportunities would benefit dental hygienists, that information about HPV and its vaccine was important, and that the topic is relevant to their job duties. Finally, dentists had mixed views about how receptive parents would be to a vaccine recommendation from a dental hygienist; however, the majority expressed confidence that dental hygienists would be able to deliver effective messages.