Missed Opportunities for HPV Vaccination in Adolescent Girls: A Qualitative Study

Abstract

WHAT'S KNOWN ON THIS SUBJECT: Rates of human papillomavirus (HPV) vaccination lag behind other adolescent vaccines. Research indicates that provider recommendation is the key to improving HPV vaccination rates and that most adolescents who are unvaccinated received other vaccines, indicating missed opportunities for HPV vaccination. WHAT THIS STUDY ADDS:This study explores in-depth the content of provider-patient conversations that either create or prevent opportunities for HPV vaccination. Effective and ineffective conversations are presented with the goal of providing practical tools to improve communication regarding HPV vaccines.abstract OBJECTIVE: The goal of this study was to identify the rationale by parents/guardians and providers for delaying or administering human papillomavirus (HPV) vaccination to girls. METHODS:Qualitative interviews were conducted with parents/ guardians accompanying their vaccine-eligible 11-to 17-year-old daughters to medical visits. Interviews were conducted in 1 public clinic and 3 private practice settings to ascertain why girls did or did not receive HPV vaccination. Questions probed vaccine decisionmaking from the point of view of parents/guardians and providers.RESULTS: A total of 124 parents/guardians and 37 providers participated. The most common reasons parents reported for not vaccinating their daughters was the lack of a physician recommendation (44%). Both parents and providers believed that HPV vaccination provided important health benefits, but the timing of vaccination with relation to sexual activity was an important theme related to vaccine delay. Providers with lower self-reported vaccination rates delayed vaccine recommendations in girls perceived to be at low risk for sexual activity, and several parents reported that their providers suggested or supported delaying vaccination until their daughters were older. However, parents/guardians and providers agreed that predicting the timing of sexual debut was extremely difficult. In contrast, providers with high vaccination rates presented HPV vaccination as a routine vaccine with proven safety to prevent cancer, and parents responded positively to these messages. CONCLUSIONS:Although most parents and providers believe that HPV vaccination is important, missed opportunities result from assumptions about the timing of vaccination relative to sexual activity. Routinely recommending HPV vaccination as cancer prevention to be coadministered with other vaccines at age 11 years can improve vaccination rates. Pediatrics 2014;134:e666-e674 AUTHORS:

Provider communication about HPV vaccination: A systematic review

“…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.…”

“…29,32,37,44,45 In contrast, no studies found a correlation between providers' perceptions of HPV vaccine safety and their recommendation behaviors, perhaps because concerns about safety were relatively uncommon. 27,32,36,38,44,45 In terms of providers' perceptions of themselves, self-efficacy to communicate about HPV vaccine was associated with recommending and intending to recommend the vaccine. 12,26,46 Interestingly, providers who viewed themselves as "early adopters" were also more likely to recommend HPV vaccine.…”

“…Studies found that providers prioritized HPV vaccination for subpopulations including sexually active adolescents, males who might have same sex partners, and adolescents of lower socioeconomic status. 19,33,38,44,74 Similarly, some providers based their HPV vaccine recommendations on risk-related factors such as the results of a Pap or HPV test, number of sexual partners, or relationship status. 52,58,75 Ironically, providers in one qualitative study acknowledged that their ability to accurately assess whether adolescents were sexually active was limited.…”

“…52,58,75 Ironically, providers in one qualitative study acknowledged that their ability to accurately assess whether adolescents were sexually active was limited. 38 …”

Parents who refuse or delay HPV vaccine: Differences in vaccination behavior, beliefs, and clinical communication preferences

“…These behaviors constitute important intermediary steps between parents' vaccination intentions and adolescents' vaccination status. Although the qualitative literature suggests that HPV vaccine refusal and delay are common, 7,8 only one study has estimated their national prevalence. 9 In 2010, a special addendum to the National Immunization Survey (NIS)-Teen assessed these behaviors, finding that 20% of parents of adolescent girls reported HPV vaccine refusal while an additional 11% reported delay.…”