CE/CME

How to Increase HPV Vaccination Rates

Clinician Reviews. 2017 September;27(9):40-46

References

1. Juckett G, Hartsman-Adams H. Human papillomavirus: clinical manifestations and prevention. Am Fam Physician. 2010;82(10):1209-1213.
2. Markowitz LE, Dunne EF, Saraiya M, et al. Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2014;63(RR-05):1-30.
3. Viens LJ, Henley SJ, Watson M, et al. Human papillomavirus-associated cancers—United States, 2008-2012. MMWR Morb Mortal Wkly Rep. 2016;65(26):661-666.
4. American Cancer Society. Cancer facts and figures 2016. Atlanta: American Cancer Society; 2016.
5. Holman DM, Benard V, Roland KB, et al. Barriers to the human papillomavirus vaccination among US adolescents: a systematic review of the literature. JAMA Pediatr. 2014;168(1):76-82.
6. American College of Obstetricians and Gynecologists. Human papillomavirus vaccination. Committee Opinion. Number 704. June 2017. www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/Human-Papillomavirus-Vaccination. Accessed August 17, 2017.
7. Meites E, Kempe A, Markowitz LE. Use of a 2-dose schedule for human papillomavirus vaccination—updated recommendation of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2016;65(49):1405-1408.
8. Mulcahy N. GSK’s HPV vaccine, Cervarix, no longer available in the US. Medscape Medical News. October 26, 2016. www.medscape.com/viewarticle/870853. Accessed June 11, 2017.
9. Reagan-Steiner S, Yankey D, Jeyarajah J, et al. National, regional, state, and selected local area vaccination coverage among adolescents aged 13–17 years—United States, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(29):784-792.
10. Muncie HL, Lebato AL. HPV vaccination: overcoming parental and physician impediments. Am Fam Physician. 2015;92(6):449-454.
11. Bratic JS, Seyferth ER, Bocchini JA Jr. Update on barriers to human papillomavirus vaccination and effective strategies to promote vaccine acceptance. Curr Opin Pediatr. 2016;28(3):407-412.
12. Rahman M, Laz TH, McGrath CJ, Berenson AB. Provider recommendation mediates the relationship between parental human papillomavirus (HPV) vaccine awareness and HPV vaccine initiation and completion among 13- to 17-year-old US adolescent children. Clin Pediatr. 2015;54(4):371-375.
13. Sussman AL, Helitzer D, Bennett A, et al. Catching up with the HPV vaccine: challenges and opportunities in primary care. Ann Fam Med. 2015;13(4):354-360.
14. Clark SJ, Cowan AE, Filipp SL, et al. Parent perception of provider interactions influences HPV vaccination status of adolescent females. Clin Pediatr. 2016;55(8):701-706.
15. Ackerman LK, Serrano JL. Update on routine childhood and adolescent immunizations. Am Fam Physician. 2015;92(6):460-468.
16. Tom A, Robinett H, Buenconsejo-Lum L, et al. Promoting and providing the HPV vaccination in Hawaii: barriers faced by health providers. J Community Health. 2016;41(5):1069-1077.
17. Young JL, Bernheim RG, Korte JE, et al. Human papillomavirus vaccination recommendation may be linked to reimbursement: A survey of Virginia family practitioners and gynecologists. J Pediat Adolesc Gynecol. 2011;24(6):380-385.
18. Thomas R, Higgins L, Ding L, et al. Factors associated with HPV vaccine initiation, vaccine completion, and accuracy of self-reported vaccination status among 13- to 26-year-old men. Am J Mens Health. 2016;1-9.
19. Laz TH, Rahman M, Berenson AB. Human papillomavirus vaccine uptake among 9-17 year old males in the United States: the National Health Interview Survey, 2010. Hum Vaccin Immunother. 2013;9(4):874-878.
20. Perkins RB, Zisblatt L, Legler A, et al. Effectiveness of a provider-focused intervention to improve HPV vaccination rates in boys and girls. Vaccine. 2015;33:1223-1229.
21. Smulian EA, Mitchell KR, Stokley S. Interventions to increase HPV vaccination coverage: a systematic review. Hum Vaccin Immunother. 2016;12:1566-1588.
22. Walling EB, Benzoni N, Dornfeld J, et al. Interventions to improve HPV vaccine uptake: a systematic review. Pediatrics. 2016;138(1).
23. CDC. Overview of AFIX. www.cdc.gov/vaccines/programs/afix/index.html. Accessed August 17, 2017.
24. CDC. Human papillomavirus (HPV). www.cdc.gov/hpv/. Accessed August 17, 2017.
25. Fu LY, Bonhomme LA, Cooper SC, et al. Educational interventions to increase HPV vaccination acceptance: a systematic review. Vaccine. 2014;32(17):1901-1920.
26. Kennedy A, Sapsis KF, Stokley S, et al. Parental attitudes toward human papillomavirus vaccination: evaluation of an educational intervention, 2008. J Health Commun. 2011;16(3):300-313.
27. Spleen AM, Kluhsman BC, Clark AD, et al; ACTION Health Cancer Task Force. An increase in HPV-related knowledge and vaccination intent among parental and non-parental caregivers of adolescent girls, ages 9-17 years, in Appalachian Pennsylvania. J Cancer Educ. 2012;27(2):312-319.
28. Conroy K, Rosenthal SL, Zimet GD, et al. Human papillomavirus vaccine uptake, predictors of vaccination, and self-reported barriers to vaccination. J Womens Health (Larchmt). 2009;18(10):1679-1686.
29. National Vaccine Advisory Committee. Overcoming barriers to low HPV vaccine uptake in the United States: recommendations from the National Vaccine Advisory Committee. Public Health Rep. 2016;131(1):17-25.
30. Aragones A, Bruno DM, Ehrenberg M, et al. Parental education and text messaging reminders as effective community based tools to increase HPV vaccination rates among Mexican American children. Prev Med Rep. 2015;2:554-558.
31. Chao C, Preciado M, Slezak J, Xu L. A randomized intervention of reminder letter for human papillomavirus vaccine series completion. J Adolesc Health. 2015;56(1):85-90.
32. Community Preventive Services Task Force. The community guide—guide to community preventive services: increasing appropriate vaccinations. Atlanta, GA: Community Preventive Services Task Force; 2016
33. Kelminson K, Saville A, Seewald L, et al. Parental views of school-located delivery of adolescent vaccines. J Adolesc Health. 2012;51(2):190-196.

BARRIERS TO VACCINATION

Impediments that prevent adolescents and young adults from receiving the HPV vaccine exist throughout the vaccination process, with providers, parents, and the medical system itself contributing to low rates. Barriers to vaccination include fear and misconceptions, costs and socioeconomic status, lack of understanding and education, and logistic obstacles to completing the full series.⁵ Understanding these barriers, as well as discussing methods to overcome them, is key to increasing HPV vaccination rates and preventing the spread of this cancer-causing infection.

Health care provider barriers

Even though accredited national institutions and committees such as the CDC, ACIP, and ACOG strongly recommend vaccination based on current evidence, some health care providers still do not recommend the HPV vaccine to parents and patients.^2,6,7,11 Lack of provider recommendation and the resulting lack of parental awareness of the vaccine account for many adolescents not receiving the vaccination.^10,12

Providers do not recommend the vaccine for a number of reasons. Some have limited knowledge or conflicting ideas about the specific disease protection of the HPV vaccine, while others are hesitant to administer the vaccine before the onset of sexual activity, because they feel the suggested age for vaccination (11 to 12 years) is too young.^10,11 Still other providers report difficulty approaching parents who they perceive as having concerns about the vaccine’s association with a sexually transmitted infection or believing that it might promote sexual activity.¹⁰

Some professionals simply claim that they forget to address the HPV vaccine at health visits, or that they propose it as optional and up to the parent’s discretion.^5,10 Many providers do recommend and administer the initial dose of the vaccine, but have difficulties ensuring that patients complete the full multidose series.¹³ Evidence has shown that a strong provider recommendation is one of the most important incentives for parents and patients to accept vaccination.¹⁴

Parental and caregiver barriers

Lack of knowledge about the HPV vaccine and lack of recommendation from providers are two top reasons parents and caregivers cite for not vaccinating their children.^5,10,14,15 In a national survey, almost all parents whose daughters completed the full vaccination series reported being counseled by their provider on the appropriate age for vaccination and the timeline of the series.¹⁴

Fears and apprehensions about side effects, especially with newer vaccines, can prevent some parents from having their children vaccinated.¹⁵ Although there is some stigma related to the vaccine’s association with the sexually transmitted HPV, this is a much less significant barrier than lack of provider recommendation or knowledge about the vaccine.^5,11

Health care system barriers

Both providers and parents agree that system-level issues such as access, follow-up, and cost are barriers to initiating or completing the vaccination series.^11,13 Many adolescents have few opportunities to receive the vaccine because they do not have a primary care provider.¹¹ For those with access to primary care, visits are often problem-focused and frequently do not include a review of immunization history.¹³ Health care professionals also report challenges with scheduling follow-up visits for the second and third doses to complete the series within the recommended timeframe.¹³

Cost, insurance coverage, and reimbursement pose additional hurdles for both providers and patients, with some providers citing concerns about the cost of stocking the vaccine.¹⁶ Providers, both family practice providers and gynecologists, agree that reimbursement for administering the HPV vaccine in office poses a barrier when recommending the vaccine to patients.¹⁷ Lack of insurance coverage and type of insurance also pose barriers, with Medicaid patients more often completing the full series compared to those with private or no insurance, because Medicaid covers the cost of vaccination for men up to age 19.^9,18 A national survey of males ages 9 to 17 found that the percentage of HPV vaccine initiation was double for those with public insurance compared to those with private insurance.¹⁹Changes at the system-level, such as participation in the VFC program, in coordination with better provider recommendation should help increase HPV vaccination rates.^9,11

STRATEGIES TO IMPROVE VACCINATION RATES

Many strategies for increasing HPV vaccination acceptance, decreasing barriers to access, and improving compliance with vaccine completion have been reported in the literature, with some strategies achieving more success than others. This section discusses interventions and strategies designed to help overcome provider-, parent-, and system-related barriers that have been shown to be effective (see Table 3).

How to Increase HPV Vaccination Rates

References

BARRIERS TO VACCINATION

Health care provider barriers

Parental and caregiver barriers

Health care system barriers

STRATEGIES TO IMPROVE ­VACCINATION RATES

Pages

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STRATEGIES TO IMPROVE VACCINATION RATES