Communicating with Families About HPV Vaccines

Focusing Communication on Cancer Prevention

HPV vaccines are unique in that they are only 1 of 2 vaccines for cancer prevention (the other being hepatitis B). Provider and parent surveys suggest that while most providers do mention cancer prevention when discussing HPV vaccines [40,88,89], this may be more commonly done with female patients than males [22]. Focusing on cancer prevention rather than sexual transmissibility is a communication technique suggested by the Centers for Disease Control and Prevention (CDC) as many parents cite this aspect of the vaccine as one of the most compelling reasons for vaccinating [45,90]. CDC’s “You are the Key” program [91] uses cancer prevention as a central theme in their physician and patient communication materials, based on significant prior market research on the acceptability and impact of such messages among parents and providers. In 2016 Malo and colleagues tested the potential impact of brief messages related to HPV vaccination, including cancer prevention messages, among a national sample of 776 medical providers and 1504 parents of adolescents [92]. In addition to their potential to motivate parents to vaccination, associations between parental endorsement of each message and their adolescent’s vaccination status were also examined. The cancer prevention messages were among those most highly endorsed by both parents and providers as being motivating for parents to get their adolescent vaccinated. More importantly, among parents these endorsements were associated with a significantly higher likelihood of the adolescent having been vaccinated against HPV. Interestingly, one of the briefest messages in the study, “I [the physician] strongly believe in the importance of this cancer preventing vaccine for [child’s name],” was perceived as the most persuasive message by parents.

Further support for the positive impact of framing HPV vaccines primarily as cancer prevention comes from another national study of 1495 parents of 11 to 17 year olds that examined 3 measures of quality of their adolescent provider’s HPV vaccine recommendation, and the relationship between recommendation quality and likelihood of adolescent HPV vaccination [40]. The 3 quality indicators assessed included providing information about cancer prevention, encouraging the vaccine “strongly,” and recommending it be given on the same day as it was being discussed. While 49% of parents reported receiving no HPV vaccine recommendation from their adolescents’ provider, of those that did, 86% received a cancer prevention message. Parents who had been given high quality recommendations that included either 2 or 3 of the quality indicator measures had over 9 times the odds of vaccine series initiation and 3 times the odds of vaccine series follow through than those who had not received any recommendation, and also significantly higher odds of vaccination than parents who had received low quality recommendations (ie, included only 1 indicator). Taken together, these results suggest that focusing discussions about HPV vaccines on their ability to prevent cancer is likely to be persuasive for some parents.

Strategies That Are Promising But Not Thoroughly Tested

Helping Parents Create Vaccination Plans

A recent commentary suggested that instead of focusing on changing beliefs or “educating” parents and patients about the need for a given vaccine, perhaps a better way to craft interventions for increasing vaccination is to focus on structuring the environment to make vaccination “easy” [93,94]. Examples of this include strategies such as extended office hours and making the vaccine available in other locations such as schools and pharmacies, both of which have been shown in some populations and settings to improve vaccine utilization [48,95]. One aspect of structuring a vaccine-conducive environment that relates to provider communication is helping parents create “implementation intentions” for future vaccination visits. In its most obvious form, this would mean providers provide office resources that facilitate making an appointment for the next dose in the HPV vaccine series during a clinic visit where the first dose was provided. But such an approach could also potentially extend to parents who are on the fence about the vaccine—to make an appointment before the parent leaves the office with an unvaccinated child to either re-discuss the vaccine in the future or to actually start the vaccine series. Support for such a strategy comes primarily from the social sciences, which suggest that implementation intentions work by increasing attention to specific cues to action, making it more likely that that the cue will be acted upon [96–98]. Creating implementation intentions has been shown to be helpful for improving adherence with a variety of health behaviors [99–105], and there is a growing evidence base related to how implementation intentions may facilitate vaccination specifically. For example Vet and colleagues performed a randomized controlled trial among 616 men who have sex with men with either strong or weak intentions to receive the hepatitis B vaccine [106]. Half of the participants were asked to create an implementation intention plan where they described when, where and how they would obtain the vaccine. Those in the control arm were not given this prompt. Regardless of whether their initial vaccination intention was weak or strong, those who had been asked to create an implementation plan had more than double the likelihood of actually getting the vaccine than participants who did not receive the implementation plan prompt. Similarly, a study of influenza vaccination rates among corporate employees found that those who were asked to write down the day and time they planned to go to employee health to get the free vaccine were somewhat more likely (4% higher) to be vaccinated than those who did not receive this prompt [107]. In addition, a study of elderly individuals found that influenza vaccination rates were significantly higher among those who had received “action instructions” on how, when and where to get the vaccine than those who did not [108]. These studies suggest that helping parents craft a definitive follow-up plan regarding vaccination could have a significant impact on vaccination rates—particularly for vaccines like HPV that require multiple doses.

Treating all Adolescent Vaccines the Same

Prior research has demonstrated that providers often communicate differently about HPV vaccines than other adolescent vaccines such as the tetanus-diphtheria-pertussis (Tdap) and meningococcal (MCV) vaccines [22,36]. Providers often tend to discuss the HPV vaccine last among these 3 vaccines, provide weaker endorsements of the vaccine, and pre-emptively give much more detail about the HPV compared to the other vaccines, even in the absence of a parent’s request for additional information [36,39,41]. The CDC and the American Academy of Pediatrics now suggest putting HPV at the beginning or middle of the list of vaccines recommended to the adolescent (ie, “HPV, Tdap and MCV”), and treating all recommended vaccines equivalently in terms of the level of detail provided to parents in the absence of a parent’s request for more information [109,110]. Through these suggestions have face validity, their specific impact on HPV vaccination rates, and on patient and provider satisfaction with the visit have yet to be evaluated.

Strategies that Probably Don’t Work

Presenting Myths and Facts

Research related to promoting other vaccines provides insight into communication activities that probably would not work well for promoting HPV vaccination. A 2012 study by Nyhan and colleagues examined the impact of 2 different messages related to influenza vaccines on participants’ beliefs about the vaccine’s safety and intentions to get vaccinated [111]. One group received information to correct the commonly held belief that influenza vaccine can cause the flu while the other received information about the risks associated with contracting an influenza infection. While the correction of myths did improve participants’ perceptions of the vaccine’s safety, information about influenza dangers did not. Neither message impacted intentions to vaccinate in the study subjects overall. However, in sub-analyses the correction of myths actually decreased intentions to vaccinate among those with high baseline levels of concern about the vaccine’s side effects—that is, among those most concerned that the flu vaccine can give someone the flu, correcting this myth actually decreased the likelihood that they would receive the vaccine. Similar findings have been reported in other studies related to vaccination [112–114], and suggest that the “threat” generated by providing information opposing a person’s beliefs may actually entrench these beliefs further as part of the threat response—a phenomenon known as attitude polarization [115]. These results also are consistent with the concept of negativity bias, which posits that negative information influences people’s risk perceptions more than positive information, and that the more strongly a risk is attempted to be negated, the lower the effectiveness and perceived trust of the information [116].