HPV Vaccine Hesitancy
HPV Vaccine Hesitancy
Despite national guidelines for routine HPV vaccination of 11- to 12-year-olds, nearly one out of four health care providers in our statewide sample indicated that they are not routinely recommending the vaccine for girls, and more than half reported not doing so for boys, even 18 months after the release of guidelines recommending routine vaccination of males. Although such gender-based differences are not surprising given the initial rollout of the vaccine for girls only, they are concerning. If trends in vaccine uptake among females provide an indication of trajectories for males, vaccine coverage may increase but remain below targets. Furthermore, our findings suggest that the recommendations that providers do deliver may be ambiguous; most respondents reported preferring to offer the vaccine as optional, and a significant minority indicated that they do not recommend HPV vaccine as strongly as other adolescent vaccines. Because receiving a provider's recommendation is one of the strongest correlates of HPV vaccination, our findings lend support to a growing body of literature that highlights the importance of increasing the frequency and quality of recommendations (Allen et al., 2010; Reiter et al., 2009; Rosenthal et al., 2011; Vadaparampil et al., 2011). Improving HPV vaccine recommendations may be especially important for raising coverage among boys because parents are less likely to know that the vaccine is available for their sons (Gilkey, Moss, McRee, & Brewer, 2012).
Health care providers in our sample perceived parental HPV vaccine hesitancy to be common; about half of respondents reported that parents frequently request to delay or sometimes wish to refuse HPV vaccination. The high frequency of perceived hesitancy is concerning and, in aggregate, may constitute a substantial burden for providers, who experience vaccine hesitancy as a frustrating and time-consuming problem (Kempe et al., 2011). Importantly, our findings suggest that perceptions of parental hesitancy may discourage providers from delivering recommendations according to guidelines. This finding is particularly a cause for concern because recent research suggests that providers are overestimating parental concerns with regard to HPV and flu vaccines (Healy, Montesinos, & Middleman, 2014). Providers may be reassured to learn that parental concerns about adolescent vaccines are not as frequent or severe as they suspect. Indeed, consistent with previous findings on HPV vaccine recommendations for females (Daley et al., 2010), providers in this sample who reported more frequently encountering parental responses of refusal or delay were less likely to routinely recommend HPV vaccination to either female or male adolescents.
Our findings suggest that providers' self-efficacy to address parental HPV vaccine hesitancy and their outcome expectations may also influence their recommendation practices. We found that respondents with lower levels of confidence in addressing concerns and who believed that they were not influential or able to convince parents to get the vaccine were less likely to routinely recommended HPV vaccination to either males or females. Although the cross-sectional nature of our data preclude drawing conclusions about the directionality of this relationship, prior research supports the hypothesis that providers' self-efficacy and outcome expectations are associated with adherence to clinical guidelines (Cabana et al., 1999). Improving providers' self-efficacy to address parental concerns may be important for supporting recommendation practices and ultimately improving HPV vaccine uptake in the target age group.
Respondents in our sample perceived parents' association between HPV vaccine and sexual activity to be an especially common source of hesitancy. Provider training or other tools may be particularly helpful if they are aimed at helping to convey that HPV vaccination is most beneficial before the onset of sexual activity and that HPV is highly prevalent. In addition, identifying ways of discussing HPV vaccine in a manner that helps providers navigate discomfort with discussing sexual activity may also be important, because these topics may not be adequately addressed in vaccine conversations (Perkins & Clark, 2013), and providers may be less likely to recommend HPV vaccine if they believe they must broach sexuality in the context of HPV vaccine discussions (Daley et al., 2010). Our finding that very few health care providers perceived that parents react to HPV vaccine recommendations by being offended or angry may give providers more confidence in initiating these discussions.
To effectively communicate with vaccine-hesitant parents, health care providers need to understand parents' specific concerns. However, a quarter of providers in our sample reported that they only sometimes or rarely ask questions to explore parents' reasons, and many indicated lacking time to address parental hesitancy. Effective and efficient ways of assessing and addressing parents' vaccine concerns are needed, and many providers in this study indicated that a screening questionnaire to identify parental concerns would be helpful for counseling HPV-vaccine hesitant parents. Research suggests that such tools can be a reliable and valid way to identify parents who are hesitant to get their young children vaccinated (Opel et al., 2011), although to date, no such screening tool exists for vaccines in an adolescent platform. Most providers also indicated that written information that addresses specific concerns would be helpful. Such targeted information may increase the relevance of information provided to parents (Kreuter & Wray, 2003) and could be an effective and low-burden supplement to the standard written information that the vast majority of health care providers already offer to parents. Beyond didactic information, which alone is unlikely to change parents' intentions to vaccinate (Dempsey, Zimet, Davis, & Koutsky, 2006; Lechuga, Swain, & Weinhardt, 2012), providers in our sample were also interested in an interactive decision aid (Fiks et al., 2013) that could assist parents in making decisions about HPV vaccine before or during a clinical visit (e.g., in the waiting room). Future intervention research should explore these opportunities; available tools for early childhood immunization may offer a starting point for this work.
Study findings highlight differences in HPV vaccine recommendation practices based on provider specialty. In contrast to previous research (Daley et al., 2010; Weiss, Zimet, Rosenthal, Brenneman, & Klein, 2010), we did not find provider type differences in HPV vaccine recommendations for girls. However, we did note differences in recommendations for boys, with fewer family medicine physicians and nurse practitioners routinely recommending the vaccine than pediatricians. These between-type differences may reflect the populations served by different types of providers. For example, in our sample, family medicine physicians and nurse practitioners reported serving fewer adolescents than pediatricians. Although it is possible that pediatric and family nurse practitioners also differ in their HPV vaccine recommendation practices, our data did not allow us to differentiate nurse practitioners by practice specialty. Future research in this area should examine differences among nurse practitioners. Efforts to improve HPV should continue to reach out to health care professionals beyond pediatricians to include all providers who provide preventive care to adolescent patients.
Discussion
Despite national guidelines for routine HPV vaccination of 11- to 12-year-olds, nearly one out of four health care providers in our statewide sample indicated that they are not routinely recommending the vaccine for girls, and more than half reported not doing so for boys, even 18 months after the release of guidelines recommending routine vaccination of males. Although such gender-based differences are not surprising given the initial rollout of the vaccine for girls only, they are concerning. If trends in vaccine uptake among females provide an indication of trajectories for males, vaccine coverage may increase but remain below targets. Furthermore, our findings suggest that the recommendations that providers do deliver may be ambiguous; most respondents reported preferring to offer the vaccine as optional, and a significant minority indicated that they do not recommend HPV vaccine as strongly as other adolescent vaccines. Because receiving a provider's recommendation is one of the strongest correlates of HPV vaccination, our findings lend support to a growing body of literature that highlights the importance of increasing the frequency and quality of recommendations (Allen et al., 2010; Reiter et al., 2009; Rosenthal et al., 2011; Vadaparampil et al., 2011). Improving HPV vaccine recommendations may be especially important for raising coverage among boys because parents are less likely to know that the vaccine is available for their sons (Gilkey, Moss, McRee, & Brewer, 2012).
Health care providers in our sample perceived parental HPV vaccine hesitancy to be common; about half of respondents reported that parents frequently request to delay or sometimes wish to refuse HPV vaccination. The high frequency of perceived hesitancy is concerning and, in aggregate, may constitute a substantial burden for providers, who experience vaccine hesitancy as a frustrating and time-consuming problem (Kempe et al., 2011). Importantly, our findings suggest that perceptions of parental hesitancy may discourage providers from delivering recommendations according to guidelines. This finding is particularly a cause for concern because recent research suggests that providers are overestimating parental concerns with regard to HPV and flu vaccines (Healy, Montesinos, & Middleman, 2014). Providers may be reassured to learn that parental concerns about adolescent vaccines are not as frequent or severe as they suspect. Indeed, consistent with previous findings on HPV vaccine recommendations for females (Daley et al., 2010), providers in this sample who reported more frequently encountering parental responses of refusal or delay were less likely to routinely recommend HPV vaccination to either female or male adolescents.
Our findings suggest that providers' self-efficacy to address parental HPV vaccine hesitancy and their outcome expectations may also influence their recommendation practices. We found that respondents with lower levels of confidence in addressing concerns and who believed that they were not influential or able to convince parents to get the vaccine were less likely to routinely recommended HPV vaccination to either males or females. Although the cross-sectional nature of our data preclude drawing conclusions about the directionality of this relationship, prior research supports the hypothesis that providers' self-efficacy and outcome expectations are associated with adherence to clinical guidelines (Cabana et al., 1999). Improving providers' self-efficacy to address parental concerns may be important for supporting recommendation practices and ultimately improving HPV vaccine uptake in the target age group.
Respondents in our sample perceived parents' association between HPV vaccine and sexual activity to be an especially common source of hesitancy. Provider training or other tools may be particularly helpful if they are aimed at helping to convey that HPV vaccination is most beneficial before the onset of sexual activity and that HPV is highly prevalent. In addition, identifying ways of discussing HPV vaccine in a manner that helps providers navigate discomfort with discussing sexual activity may also be important, because these topics may not be adequately addressed in vaccine conversations (Perkins & Clark, 2013), and providers may be less likely to recommend HPV vaccine if they believe they must broach sexuality in the context of HPV vaccine discussions (Daley et al., 2010). Our finding that very few health care providers perceived that parents react to HPV vaccine recommendations by being offended or angry may give providers more confidence in initiating these discussions.
To effectively communicate with vaccine-hesitant parents, health care providers need to understand parents' specific concerns. However, a quarter of providers in our sample reported that they only sometimes or rarely ask questions to explore parents' reasons, and many indicated lacking time to address parental hesitancy. Effective and efficient ways of assessing and addressing parents' vaccine concerns are needed, and many providers in this study indicated that a screening questionnaire to identify parental concerns would be helpful for counseling HPV-vaccine hesitant parents. Research suggests that such tools can be a reliable and valid way to identify parents who are hesitant to get their young children vaccinated (Opel et al., 2011), although to date, no such screening tool exists for vaccines in an adolescent platform. Most providers also indicated that written information that addresses specific concerns would be helpful. Such targeted information may increase the relevance of information provided to parents (Kreuter & Wray, 2003) and could be an effective and low-burden supplement to the standard written information that the vast majority of health care providers already offer to parents. Beyond didactic information, which alone is unlikely to change parents' intentions to vaccinate (Dempsey, Zimet, Davis, & Koutsky, 2006; Lechuga, Swain, & Weinhardt, 2012), providers in our sample were also interested in an interactive decision aid (Fiks et al., 2013) that could assist parents in making decisions about HPV vaccine before or during a clinical visit (e.g., in the waiting room). Future intervention research should explore these opportunities; available tools for early childhood immunization may offer a starting point for this work.
Study findings highlight differences in HPV vaccine recommendation practices based on provider specialty. In contrast to previous research (Daley et al., 2010; Weiss, Zimet, Rosenthal, Brenneman, & Klein, 2010), we did not find provider type differences in HPV vaccine recommendations for girls. However, we did note differences in recommendations for boys, with fewer family medicine physicians and nurse practitioners routinely recommending the vaccine than pediatricians. These between-type differences may reflect the populations served by different types of providers. For example, in our sample, family medicine physicians and nurse practitioners reported serving fewer adolescents than pediatricians. Although it is possible that pediatric and family nurse practitioners also differ in their HPV vaccine recommendation practices, our data did not allow us to differentiate nurse practitioners by practice specialty. Future research in this area should examine differences among nurse practitioners. Efforts to improve HPV should continue to reach out to health care professionals beyond pediatricians to include all providers who provide preventive care to adolescent patients.
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