Examining Strategies for Improving Healthcare Providers' Communication about Adolescent HPV Vaccination: Evaluation of Secondary Outcomes in a Randomized Controlled Trial

"[I]nterventions aimed at improving providers' communication skills can increase not only perceived rates of HPV vaccine acceptance but also...actual vaccination rates."

As of 2017, only 44.3% and 53.1% of United States (US)' male and female adolescents, respectively, were current on their human papillomavirus (HPV) vaccination series. Previous research has demonstrated the importance of a provider recommendation to increasing HPV vaccination rate. However, sometimes the recommended strategies - a presumptive approach (PA) and use of language that strongly conveys the importance and need for the vaccine at the time of the visit - fail to allay hesitancy or refusal. This article presents the evaluation of secondary outcomes in a multi-component communication-based intervention to improve healthcare providers' communication about HPV vaccination.

As described in a separate paper (see Related Summaries, below), these researchers developed a 5-component provider communication intervention consisting in: (i) communication training encouraging providers to open the HPV vaccine conversation using the PA (assuming that parents will vaccine their child), followed by implementation of motivational interviewing (MI) techniques if vaccine hesitancy was encountered; (ii) customised HPV vaccine fact sheets; (iii) a set of disease images representing potential sequelae of HPV infection; (iv) a paper decision aid for parents unsure of their vaccine decision; and (v) an educational tailored-messaging website for parents about HPV. A randomised controlled trial of the intervention revealed substantial improvement in HPV vaccine series initiation and completion among adolescents in the intervention arm compared to controls.

The present study sought to understand the specific mechanisms by which the intervention impacted provider communication and subsequent vaccination rates. Overall, 108 providers in the intervention group and 79 in the control group completed one or more surveys. Selected findings:

• Of the 4 "tangible" (i.e., not PA or MI) toolkit items assessed among the intervention group, the fact sheet was used most often (vs. the decision aid, disease images, and website). Use of the fact sheet was significantly correlated with high parental acceptance of the HPV vaccine.
• Post-intervention, the intervention group demonstrated higher use of both the PA (78.2% vs. 61.2%, p = .04) and MI than the control group. Of the MI skills measured, use of reflections and affirmations was higher among the intervention group versus control group.
• Post-intervention, more providers in the intervention group reported high parental HPV vaccine acceptance (accepted the HPV vaccine without question most of the time [> 75%]) compared to control (46% vs 29%, respectively); however, the change in parental vaccine acceptance over time was not statistically significant between groups.
• In the intervention group alone, providers' reported use of the PA was significantly associated with greater instances of reported high parental HPV vaccine acceptance at post-intervention (p = .003). Among those in the intervention group who used a PA, 50.8% of providers reported that parents accepted the vaccine "most of the time", versus only 29.4% of providers in the intervention group who did not use a PA.

In short, while both the control and intervention cohorts reported similar increases over time in strongly recommending the vaccine to 11-12 year olds, it appears that among the intervention cohort, the combined use of the PA with all patients, and MI and the fact sheet with vaccine-hesitant parents, is the main mechanism by which the intervention improved HPV vaccination rates.

Reflecting on the findings, the researchers cite a study showing that providers may inconsistently use a PA to communicate HPV vaccine recommendations because they may anticipate hesitancy or pushback from parents. Such disinclination is not surprising, they observe, given that medical training and practice often emphasise "shared decision-making", which may be perceived as counter to the PA style. Yet the present study found that "providers in the intervention group did not have significantly more reported instances of parents appearing 'offended or angry' when HPV vaccines were brought up in this manner. This suggests that for many parents, providers' concerns about using the PA may be unfounded."

The intervention group reported significantly fewer instances of parents expressing concerns about HPV vaccination. To explain this result, the researchers again point to use of the PA, which "is meant to promote vaccine acceptance as the norm, and could therefore increase parents' perceived confidence in the providers' HPV vaccine recommendation."

Notably, "[w]hile those in the intervention group demonstrated higher self-report of patient acceptance of the vaccine, they did not report significantly lower numbers of patient refusal or wish to delay. Thus, although the intervention seems to be efficacious for addressing parent HPV vaccine hesitancies, it may not address HPV vaccine refusal....[F]uture research is needed to identify communication strategies effective for effectively mitigating concerns among parents who refuse the vaccine."

Finally, although providers in the intervention group reported greater use of MI than control providers, they did not report corresponding increases in time spent having conversations about the HPV vaccine with parents who expressed substantial concerns. According to the researchers, this finding underscores the feasibility of implementing this intervention in other settings.