HPV and Cervical Cancer Prevention Counseling With Younger Adolescents: Implications for Primary Care

Abstract

PURPOSE Primary care clinicians will continue to play an important role in cervical cancer prevention, particularly with regard to administration of the newly licensed human papillomavirus (HPV) vaccine and continued administration of Papanicolaou tests. Little is known about the factors that infl uence cervical cancer prevention counseling, particularly in the adolescent encounter. We conducted a qualitative study to better understand the implications for counseling about cervical cancer prevention by primary care clinicians who care for adolescents. METHODSWe conducted in-depth interviews with 37 primary care clinicians in New Mexico to understand the context in which they provide anticipatory guidance about sexual health risks as well as their attitudes about counseling for the forthcoming HPV vaccine. RESULTSClinicians identifi ed 4 categories of factors related to their counseling experiences with adolescents about HPV: (1) the need to build rapport with adolescent patients, (2) the presumption that adolescent patients engage in high-risk behaviors, (3) the situational delivery and complexity of HPV counseling, and (4) perceptions of clinician and community receptivity to the HPV vaccine.CONCLUSION Our fi ndings show that conditions of the preadolescent and young adolescent visit pose a challenge to the successful integration of counseling about cervical cancer prevention in primary care. Counseling strategies that are designed to emphasize a preventive focus while including parents in the discussion at the time of vaccination and that are appropriate to populations with different cultural values and beliefs will help to enhance communication about cervical cancer prevention and the particular role of the HPV vaccine. 2007;5:298-304. DOI: 10.1370/afm.723. Ann Fam Med INTRODUCTIONH uman papillomavirus (HPV) ranks as the most commonly acquired sexually transmitted infection in the United States, and infection with HPV is linked to cervical cancer and genital warts.1,2 In June 2006, the fi rst HPV vaccine (Merck) was approved for females aged 9 to 26 years. 3 Shortly after its approval, the National Advisory Committee on Immunization Practices recommended that the vaccine be given to girls aged 11 to 12 years. 4 The approval of the HPV vaccine marks the beginning of a new stage in preventing sexually transmitted diseases (STDs) and their sequelae, in this case cervical cancer. Currently, the hepatitis B vaccine, administered during infancy, is the only existing vaccine that prevents a sexually transmitted disease, although several other STD vaccines are in various stages of development. 3,[5][6] Collectively, these vaccines have the potential to serve as powerful disease prevention weapons against chronic illnesses, including cancer. The availability of these vaccines will have important implicaAndrew L. Sussman, PhD 299CERVIC A L C A NCER PR EVENT ION COUNSELING tions for adolescents who, because they are at higher risk for contracting these diseases, will likely be the targeted recipients for these...

Provider communication about HPV vaccination: A systematic review

“…17,22,27,29,35,38,40,76,81 Second, at the interpersonal level, many providers perceived parents as being unsupportive of HPV vaccination, a view which hindered guideline-consistent delivery of recommendations. 12,29,33,35,[37][38][39] Third, studies consistently documented a challenging policy context, including unclear practice guidelines and a lack of school entry requirements for HPV vaccination. 11,27,34,59,74 Finally, participants across several studies perceived clinical systems as unconducive to communication due to factors such as time constraints and deficiencies in reminder/recall systems.…”

“…32 Studies of providers with higher participation in Medicaid or the Vaccines for Children program found that this participation was associated with more positive HPV vaccine recommendation practices 9,23,30,[33][34][35] or no effect. 29,44,48 Provider recommendations did not vary substantially by national region, 30,[33][34][35]39,44 but providers practicing in urban areas more often reported recommending HPV vaccine than those in rural or suburban ones. 34,37,44,46 Audience Variation in recommendations by patient factors Studies assessing patient factors associated with receiving an HPV vaccine recommendation most often examined patient demographics and providers' perceptions of patients' risk of HPV infection.…”

“…29,35,36 Perceptions of parental hesitancy toward HPV vaccination were also negatively associated with communication; providers who perceived parents as unsupportive less often recommended or intended to recommend HPV vaccine. 12,29,33,35,[37][38][39] Conversely, providers who perceived professional organizations as influential more often recommended or intended to recommend the vaccine. [23][24][25]37,[40][41][42][43] Other frequently studied perceptions included those related to providers' confidence in HPV vaccine and their own abilities to discuss it.…”

“…12,32 Other studies failed to find variation in recommendations by specialty, 23,[34][35][36]40,52,53 but several of these studies did not include pediatricians. 34,52,53 Most studies did not find variation in HPV vaccine recommendations by provider sex, 9,23,30,36,39,44,[47][48][49]54 but those that did most often favored female providers. 24,25,29,33,53 Similarly, most studies did not find variation in HPV vaccine recommendations by provider age or years in practice, 30,33,36,47,49 although a few did with mixed results.…”

Interventions to Improve HPV Vaccine Uptake: A Systematic Review

“…[10][11][12][13][14][15][16][17][18] Although vaccination intent was increased, it was neither sustained nor translated into vaccination behavior. Furthermore, there has been speculation that parents from different ethnic and socioeconomic groups may face different barriers to vaccination and thus require different intervention strategies, 17,19 a critical point in the context of disparate HPV disease outcomes.…”