Communicating with Families About HPV Vaccines

Despite the potential of HPV vaccines to drastically reduce the incidence of HPV-related cancers and other diseases, these vaccines are not being as widely used in the United States as was hoped. The most recent national data from 2015 demonstrates that only 41.9% of girls and 28.1% of boys have received all 3 doses recommended in the HPV vaccine series [16]. This level of vaccine utilization is significantly lower than the Healthy People 2020 goal of 80% coverage [17], and also significantly lower than that of other developed countries such as Australia and the United Kingdom, which have achieved vaccination levels of ~70% among their target adolescent populations [18,19]. In the future, these low vaccination levels will likely be mitigated somewhat by the recent approval from the FDA and recent recommendation from the Advisory Committee on Immunization Practices (ACIP) for only 2 doses of the 9-valent HPV vaccine (spaced 6 to 12 months apart) for adolescents less than 15 years of age [20,21]. Three doses are still recommended for those aged 15 to 26 years.

Provider Communication About HPV Vaccines

How providers communicate with parents and patients about HPV vaccines is a key influential factor driving current U.S. adolescent HPV vaccination levels [22,23]. Numerous studies demonstrate that a provider’s recommendation generally has the largest impact on whether or not an adolescent receives the vaccine, even above that of parent factors such as attitudes and beliefs about the vaccine and patient characteristics such as age and insurance status [23–31]. Moreover, parents consistently cite their adolescent’s provider as one of the most trusted and impactful resources for obtaining vaccine information [22,32].

Unfortunately, research also shows that providers often fail to adequately recommend the HPV vaccine for their patients, especially for 11 to 12 year olds for whom the vaccine is preferentially recommended [33,34]. For example, in a national study of parents done in 2013, not being recommended by a provider was one of the top 5 reasons parents of males and of females aged 11 to 17 gave for not getting their adolescent vaccinated against HPV [35]. Supporting this also is a 2014 study of 776 pediatricians and family medicine providers nationally, in which Gilkey and colleagues found that more than 1 out of 4 providers did not highly endorse the HPV vaccine for 11 to 12 year olds despite this having been the recommended practice from ACIP for the prior 8 years for girls and 4 years for boys. This is in comparison to the other adolescents vaccines that were reported in the same study as being endorsed highly by these providers > 95% of the time [36].

Recognizing that providers’ HPV vaccine recommendations are often suboptimal, researchers have begun to define what components comprise “high-quality” HPV vaccine recommendations. This has been operationalized by one research group as (1) timeliness—routinely recommending the vaccine starting when the patient is ≤ 12 years; (2) consistency—recommending the vaccine for all eligible adolescents as opposed to an approach based on providers’ perception of their patients’ risk for HPV infection; (3) urgency—recommending that the vaccine be given on the same day the vaccine is being discussed, rather than offering the option of getting it at a future visit; and (4) strength—using language that clearly conveys that the provider believes the vaccine is very important for the adolescent to receive. A national study of primary care providers done in 2014 examined how frequently these quality components were implemented [37]. The results were startling and discouraging. Nearly half of providers (49%) reported they usually recommended that 11 to 12 year olds get the vaccine at a later visit, 41% used a risk-based approach for deciding when to recommend the vaccine, 27% did not tell the parents the vaccine was “very or extremely important,” and a large proportion did not start routinely recommending the vaccine before the age of 13 (39% for male patients and 25% for females) [37].