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


The recent announcement from the FDA regarding the use of the HPV vaccine to prevent head and neck cancers affirms the need to engage dental providers in vaccine promotion efforts. Similar to recent research, our study found low levels of current activities to promote the HPV vaccine in dental offices;[11,12] however, willingness was high among our participants to engage in HPV vaccine efforts. Given previous successes of engaging dental professionals in health promotion work (eg, tobacco cessation[10] and diabetes management[9]), we think that this workforce could help make significant strides in HPV vaccine promotion in the short term and the prevention of HPV-related cancers in the long term.

Several themes emerged to help shed light on how best to work with dental providers on HPV vaccination. First, our interviews with dental providers highlighted the crucial role that dental hygienists may have. Dentists pointed to the fact that, because of the amount of uninterrupted time dental hygienists have with their patients, they often have much stronger relationships with adolescents and their parents than dentists do. These relationships could be leveraged to have dental hygienists provide information and education to this patient population. Not only did dentists convey that dental hygienists who supported their practice would be well-positioned to take on this role, but dentists also did not cite many barriers to this work. Most dentists believed that dental hygienists would be open and willing to participate in HPV vaccine promotion activities; however, one did cite a worry that dental hygienists may not want to participate because of their personal beliefs. Moreover, dental hygienists echoed sentiments that they are willing to participate and reported having a good rapport with patients.

Dentists' willingness to participate in HPV vaccine–focused activities was echoed in results from dental hygienists. Across the 4 regression models that explored factors related to willingness to participate in different types of HPV vaccine promotion activities, the factors with the largest associations were thinking that discussing the HPV vaccine is within their scope of practice and believing that parents would act on a recommendation to vaccinate their adolescents. The belief that parents would act on their recommendation suggests that, for dental hygienists to engage in these behaviors, there must be high levels of response efficacy — the belief that an action will result in the desired outcome.[22] In another study examining providers' knowledge and beliefs about the HPV vaccine and the role of the dental provider, researchers found that higher levels of knowledge about the vaccine were correlated with a belief that providers' recommendations to parents to vaccinate their children would be effective.[23] Dental providers' beliefs that parents will be open to their recommendations on the HPV vaccine is an important part of future work in leveraging the role of providers.

Two major strengths exist in our study. The first is using mixed-methods data collection and recruiting both dentists and dental hygienists to participate. The results from our survey and interviews complement each other and give validity to our results. Second, although many studies focused only on collecting data from either dentists or dental hygienists, we have gained important insights into how best to work with dental practices on HPV vaccine promotion efforts overall by recruiting from both groups. Additionally, recognizing the limitations of our study and how they influence our results is important for understanding.

Our study had some limitations. First, our relatively low initial response rates for interview recruitment led us to rely on alternative recruitment methods. Although this was useful in boosting the number of participants, it is possible that it also led to a certain level of response bias. Additionally, we only recruited within Iowa with the goal of developing an intervention for this population; therefore, our results reflect those interviewed and are not generalizable beyond the state or the context. Despite these limitations, however, we believe this work offers key insights into how best to work with private practice dental clinics on HPV vaccine promotion.

Engaging dental providers in the fight against oropharyngeal cancer is not a new idea;[24,25] however, risk factors for oropharyngeal cancer have changed dramatically, shifting from tobacco use toward HPV infection.[26] In light of the current decline in adolescent vaccinations due to the COVID-19 pandemic,[27] finding new ways to promote vaccination within this population is essential. Dental providers' willingness to be partners in HPV vaccine promotion came across strongly in both surveys and interviews, and our data point to several areas where dentists and dental hygienists can be effective partners. Dental hygienists should be the focus of future training as they have strong relationships with patients and families, reporting high willingness to refer patients and, with proper training, recommend the vaccine. We plan to use these results to design an intervention for private practice settings that will increase these activities in the short term and hopefully support other health care providers in their efforts to vaccinate adolescents and close the gap created by COVID-19. Given the strong evidence that provider recommendation results in higher HPV vaccination rates,[28,29] engaging this additional group of providers will continue to increase rates, as parents receive needed information from several sources.