Communicating with Families About HPV Vaccines

Despite the potential of human papillomavirus (HPV) vaccines to reduce the incidence of HPV-related cancers and other diseases, these vaccines are not being as widely used in the United States (US) as was hoped. How providers communicate with parents and patients about HPV vaccines is a key factor driving current US adolescent HPV vaccination levels. With a focus on interpersonal communication, this review highlights some innovations in provider HPV vaccine communication and describes 4 provider communication strategies that have been found to improve adolescent vaccination rates in rigorous scientific studies. Also described here are 2 promising strategies for which additional research is needed and 2 strategies that probably do not work.

Research cited here 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. Issues that have been shown to impact whether and how providers communicate about HPV vaccination during clinical visits include: providers' own knowledge about HPV-related diseases, personal beliefs about the vaccine's safety and necessity, concern that a discussion about the vaccine will necessitate a discussion about adolescent sexuality with the parent, belief that parents will not want their child vaccinated if asked, perceptions that a provider can adequately select those patients most "in need" of HPV vaccination, and worry that raising the vaccine discussion with vaccine-hesitant parents will result in prolonged discussions.

Recognising that providers' HPV vaccine recommendations are often suboptimal, researchers have begun to define what components comprise "high-quality" HPV vaccine recommendations. This has been operationalised 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 adolescent; (3) urgency: recommending that the vaccine be given on the same day the vaccine is being discussed; and (4) strength: using language that clearly conveys that the provider believes the vaccine is very important.

Interpersonal communication strategies between a provider and a patient or his or her parent that have been tested and found useful for HPV specifically include:

• Adopting a presumptive communication style: Assuming that parents would agree to vaccination and presenting the vaccines as routine - a paternalistic approach in which the clinician makes the vaccination decision and communicates this to the family - has been found to have the most success in convincing parents to vaccinate. Research demonstrates that learning and implementing a presumptive/paternalistic HPV vaccine recommendation style is easy for primary care providers to do and is perceived as often shortening the time taken during clinical visits to discuss the vaccine. Thus, it is recommended here that providers consider opening the HPV vaccine conversation using this approach and then turn to some of the other communication techniques described in the article when met with parental resistance or questions.
• Using motivational interviewing: This is a communication technique in which the provider leverages a parents' or patients' intrinsic motivation to engage in a preferred health behaviour. The evidence base supporting use of this technique includes, for example, a large, cluster-randomised controlled trial of 16 paediatric and family medicine clinics to examine the impact of a provider communication "toolkit" on adolescent HPV vaccine series initiation and completion. The toolkit consisted of motivational interviewing training for providers related to HPV vaccination and training on 3 tangible resources providers could also use with parents: an HPV fact sheet, an HPV vaccine decision aid, and an educational website. Motivational interviewing was the toolkit component most widely utilised by providers and was also perceived as being the most useful, and HPV vaccine series initiation levels were significantly higher among adolescents in practices receiving the toolkit than in control practices.
• Personalising communication: Considering that parents' reasons for not having their adolescent vaccinated against HPV are often complex and multifactorial - but that clinical visits are limited in terms of time - web-based interventions that use software to tailor materials to each individual's unique informational needs have been found to hold promise in increasing adherence to health behaviours such as HPV vaccination.
• Focusing on cancer prevention: Results from various studies suggest that focusing discussions about HPV vaccines on their ability to prevent cancer is likely to be persuasive for some parents.

Strategies that have been tested and found useful for other vaccines, but not tested for HPV specifically, include:

• Helping parents create specific plans for vaccination: 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.
• Treating all vaccines discussed 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. Providers are encouraged to treat all recommended vaccines equivalently in terms of the level of detail provided to parents (rather than, say, providing much more detail about the HPV vaccine).

Strategies that have been tested for other vaccines but not found useful:

• Presenting myths and facts: Negativity bias 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.
• Fear appeals: Using scare tactics to promote vaccination can actually have a negative effect on vaccination intentions.

Untested possibilities for the future:

• Leveraging the power of technology and the internet, including using social media, mobile technologies, and online interventions to augment the provider/parent interaction that occurs during the clinical visit.
• Identifying psychological "levers" such as parents' values (e.g., protecting my child from harm) and using them as an intervention target rather than beliefs or attitudes.
• Creating "serious" video games to train and educate users in an engaging way about specific vaccine-preventable diseases and the need for vaccination.

In conclusion: "the most effective interventions for HPV vaccination in the future are likely to be multicomponent, including not only provider communication strategies but also clinic-, community-, and parent-level interventions."