Understanding the Factors Influencing Health Care Provider Recommendations about Adolescent Vaccines: A Proposed Framework

"Given the strong correlation between a provider recommendation and vaccine receipt, identifying or improving existing interventions to improve provider recommendations has been emphasized by many experts as a priority in adolescent health..."

A high-quality healthcare provider (HCP) recommendation for vaccination is an important predictor of vaccine receipt, including among adolescents. However, there is wide variation in the strength, timeliness, and consistency of the delivery of recommendations for adolescent vaccines. HCPs are influenced by their own attitudes and beliefs about a vaccine, by the patient they are treating, by the community in which they practice, and by state- and national-level vaccine policy. With the ultimate goal of fostering development of interventions to improve uptake of adolescent vaccines in the United States (US), this paper proposes a multi-level framework for understanding the factors that influence HCPs' recommendations at the individual, interpersonal, and community levels.

The multi-level framework includes:

Individual-level factors: These factors pertain to the HCP's knowledge, attitudes, and beliefs regarding adolescent vaccines - for example:

• Knowledge: Research has shown that a perceived lack of knowledge among HCP about human papillomavirus (HPV) vaccines can lead to a lack of confidence in discussing the vaccine. One study found that, for physicians who expressed concerns about the efficacy or safety of the HPV vaccine, vaccine initiation among their patients was lower. Although most research has focused on the HPV vaccine, a study found a wide variety in knowledge and interpretation of recommendations for meningococcal vaccines (MenACWY and MenB) and for prescribing habits among a sample of HCP.
• Personal beliefs and biases: Cognitive biases, which are mental shortcuts that can result in errors in uncertain situations, can influence recommendations. For example, in a qualitative study, clinicians discussed how the anticipation of an uncomfortable discussion around the HPV vaccine or perceptions about the lack of urgency for the HPV vaccine influenced decisions either to delay recommending the vaccine or to recommending the vaccine less enthusiastically. Similar findings have been confirmed in quantitative studies.

Interpersonal-level factors: These factors encompass how the characteristics and attitudes of the patient and/or parent can influence an HCP's recommendation practices. For example:

• Perceived parent attitudes and concerns: In one study, perceived parent vaccine hesitancy by providers was significantly associated with lower provider confidence in vaccine safety, lower outcome expectations for the discussion, and lower self-efficacy. Another study showed that, when parents express a desire to reject the HPV vaccine, providers may in turn recommend delaying the vaccine to a later visit.
• Perceived patient and/or parent characteristics: In both qualitative and quantitative studies, providers who make judgments about sexual maturity of the adolescent have been found to be less likely to make strong recommendations for the HPV vaccine. In addition, reports of provider recommendations vary by sociodemographic characteristics, such as poverty status, sex of the adolescent, and maternal education.

Community-level factors: The environment and community in which the HCP practices can influence recommendation practices. This context includes clinic-level factors, the presence of tools like provider prompts and reminder-recall systems, the characteristics of the broader community in which the provider practices, and peer influences. As an example of the latter: Providers who were characterised in one study as "ambivalent HPV recommenders" were less likely to perceive their peers as thinking the HPV vaccine was important for adolescents or strongly recommending the vaccine.

Policy-level factors: These factors include financial policies such as insurance coverage, initial vaccine costs and reimbursement practices, and vaccine requirement policies, such as school entry requirements or vaccine mandates. For example, one qualitative study found that lack of school entry requirements for the HPV vaccine influenced HCPs' framing of the HPV vaccine as "non-urgent".

The researchers explore the current state of HCP-centred interventions to improve uptake, noting that most have focused on either the individual level (e.g., educational interventions focused on improving provider knowledge about the vaccine) or the community level (e.g., clinic-focused interventions such as reminder-recall systems or electronic decision supports). However, they argue, a promising class of provider-focused interventions are those that incorporate HCP communication training at the interpersonal level. For illustrative purposes, they describe three such interventions. For example, in one instance involving HCP communication training, HCPs were instructed to open conversations with parents using a presumptive approach (similar to an announcement approach) and to proceed to motivational interviewing techniques (e.g., asking the parent if it is OK to share what they know about the recommended vaccines) if the parent presents any resistance to the recommendation. In one such study (Dempsey et al., 2018), there was a 9.5-percentage-point increase in the proportion of adolescents initiating the HPV vaccine series among intervention clinics (p < 0.001).

One potential avenue for increasing the effectiveness of provider communications is to view them through the lens of the framework proposed in this article, including identifying areas where a multilevel intervention could be implemented. Using this framework, they identify factors in the aforementioned three interventions that are adequately addressed, as well as those that may be contributing to disparities in provider recommendations but are not fully addressed in the intervention. Through this analysis, one can see, for example, that, "In future studies, it may be beneficial to incorporate training that is more targeted towards identifying and combatting cognitive biases in provider recommendation practices." The researchers also suggest that "Future exploration of the disconnect between provider report of recommendations and parental recollection of recommendations and the potential association between provider recommendations and patient/parent characteristics could provide information on how to better achieve universal strong recommendations."

Going forward, the researchers call for additional research on the factors influencing HCP recommendations of adolescent vaccines beyond the HPV vaccine, which has been the focus to date. This call is especially timely, they contend, due to the role HCPs will play in ensuring that those adolescents who missed opportunities for routine administration of vaccines during the COVID-19 pandemic are brought up to date. In addition, with the expansion of COVID-19 vaccine recommendations to include 5- to 11-year-olds (in the US), there is a need to understand provider recommendation practices for the COVID-19 vaccines in the adolescent population, according to the researchers.

In conclusion: "Improving uptake of recommended adolescent vaccines is an important public health priority and optimizing provider communication and incorporating provider-focused interventions into multi-level intervention packages is one of the most promising paths forward....By utilizing the framework proposed within, we can not only expand our understanding the of the factors that influence provider recommendations of adolescent vaccinations but also apply this model to designing or improving provider communication interventions."