Although the human papillomavirus (HPV) vaccine was first licensed in the U.S. in 2006, by 2014 only 34 percent of girls and 21 percent of boys aged 13 to 15 had completed the three-dose series—levels far short of the Healthy People 2020 goal of 80 percent coverage. According to a new study, a brief physician training in recommending the vaccination using presumptive announcements instead of participatory conversations produced a measurable increase in vaccine initiation in girls and boys.
The study, published in Pediatrics, looked at a parallel-group randomized clinical trial involving 30 pediatric and family medicine clinics in central North Carolina. The clinics were randomized to receive announcement training or conversation training, while the control group got no training. A physician led each one-hour, in-clinic training, and the North Carolina Immunization Registry provided data on the six-month coverage change in HPV vaccine initiation for adolescents aged 11 or 12 years.
Presume or participate?
In the announcement training—also called the presumptive approach—physicians were instructed to first announce that the child is due for three vaccines to be given that day. This step also involved mentioning the child’s age, announcing the child is due for three vaccines recommended at this age, placing the HPV vaccine in the middle of the list and saying they will vaccinate today.
If parents raised a concern about HPV vaccine, physicians would address the main concern and strongly recommend same-day HPV vaccination. They would also offer a motivational statement that ended with a strong “I recommend” utterance, encouraging parents to have the HPV vaccine initiated right away.
The conversation training, or participatory model, differed primarily in the first step. Physicians were instructed to start the conversation with a statement about three adolescent vaccines, again placing the HPV vaccine in the middle of the list but also discussing the health benefits of these vaccines and inviting parents’ questions. The recommendation was saved for later in the conversation.
Avoid sex talk, but invite questions
Six-month increases in HPV vaccination coverage were 5.4 percent higher for patients in clinics that received announcement training than those in control clinics—4.6 percent for girls and 6.2 percent for boys. Coverage rates for patients in clinics receiving conversation training, on the other hand, did not differ from those in control clinics.
“By achieving a clinically meaningful improvement in HPV vaccine initiation coverage, the announcement training fills an important gap,” wrote the authors, a team of researchers from the University of North Carolina, Chapel Hill, the North Carolina Immunization Branch, Harvard Medical School and Harvard Pilgrim Health Care Institute. “Providers describe needing a brief recommendation approach that avoids discussing sex and gives parents an opportunity to ask questions should they wish to, issues that our trainings addressed.”
The authors noted that additional research is needed to better understand how trainings can improve vaccination coverage and the extent to which physicians routinely use announcements in clinical practice, and how parents and adolescent children respond to announcements.
“Although our trial was conducted in larger clinics in urban and rural areas of one southeastern U.S. state, we do not know whether the findings will generalize to other areas of the U.S., to large managed-care organizations, to smaller clinics or to clinics that do not use immunization registries,” they added. “Trial findings may represent more motivated clinics as many eligible clinics were unreachable or declined.”
About 79 million Americans are currently infected with HPV, which causes more than 30,000 cases of cancer in women and men each year, according to the U.S. Centers for Disease Control and Prevention (CDC). Around 12,000 women develop cervical cancer and some 4,000 die from the disease annually.
The CDC’s Advisory Committee on Immunization Practices recently recommended 11- and 12-year-olds receive two doses of HPV vaccine at least six months apart rather than the previously recommended three. Teens and young adults who start the series at ages 15 through 26 years will continue to need three doses.
The AMA has policy urging physicians to educate patients about HPV vaccination and cervical cancer screening, supporting insurance coverage for the vaccine and backing curricula to inform high-school students about HPV, its relationship to genital lesions and cervical cancer, and the vaccine.
