HPV vaccine recommendation profiles among a national network of pediatric practitioners: understanding contributors to parental vaccine hesitancy and acceptance

Figures & data

Table 1. Respondent demographics and practice characteristics.

	N = 470
Mean age of respondent (SD*)	53 (10)
Mean years in practice (SD*)	22 (10)
Practitioner gender, %
Female	62%
Male	38%
Practitioner race/ethnicity, %
Caucasian	80%
Asian	8%
Hispanic	6%
Black	4%
Hawaiian/Pacific Islander	1%
Other race	1%
% Medicaid-insured patients
> 25%	64%
≤ 25%	36%
Practice setting, %
Suburban	42%
Urban non-inner-city	26%
Urban inner-city	13%
Rural	19%
US states represented in survey	47

*SD = standard deviation

Table 2. Parameter estimates for a 3-class model describing Practitioner HPV vaccine recommendation profiles (N = 470).

	Ambivalent Recommenders	Protocol Followers	Engagers
Latent Class Prevalence	28% (N = 138)	20% (N = 85)	52% (N = 245)
Probability of a “Yes” response (ρ parameter)
Strongly recommend	.02	.93	.88
Recommend same day	.63	.99	.97
Recommend 3 adolescent vaccines at the same time	.61	.72	.93
Benefits of vaccination: cancer protection	.85	.48	.99
Benefits of vaccination: genital wart protection	.52	.10	.76
Benefits of vaccination: antibody argument	.37	.09	.78
Positive tone	.44	.21	.89
Peers strongly recommend	.15	.67	.61
Peers view HPV as important	.16	.50	.53
Sexual maturity judgment	.89	.45	.49

Item response probabilities (i.e., ρ parameter estimates) range between 0 and 1. Estimates that are close to 0 or 1 (e.g., .99) reflect a high degree of certainty that the response pattern is highly characteristic of this class.

Table 3. Description of practitioner profile characteristics*.

	Ambivalent Recommenders (28%)	Protocol Followers (20%)	Engagers (52%)	p value
Total # practitioners	138	85	245
Practitioner characteristics
Mean age	53	53	53	.98
Mean years in practice	22	22	22	.98
% Female practitioners	59% (77/131)	54% (45/84)	67% (163/245)	.07
% Caucasian practitioners	87% (113/130)	78% (65/83)	89% (217/245)	.06
Practice characteristics
Suburban location	53% (70/132)	34% (29/85)	39% (95/243)	p < .001
Rural location	17% (23/132)	21% (18/85)	20% (49/243)	.75
>25% Medicaid patients	52% (68/132)	81% (68/84)	64% (157/244)	p<.001
Located in a CDC designated disparity state	42% (53/127)	55% (45/82)	52% (121/234)	.11
HPV vaccine survey responses
Ranked HPV vaccine as most important relative to other adolescent vaccines	2% (3/132)	13% (11/85)	9% (22/245)	p < .001
Usually discuss HPV vaccination at mild sick, non-febrile visits with 11–12 year olds	28% (37/132)	58% (49/85)	62% (152/245)	p < .001
Reported Paid for Performance (Financial incentive)	14% (18/132)	11% (9/85)	11% (28/245)	.48
Reported reimbursement (Financial incentive)	17% (23/132)	14% (12/85)	17% (42/245)	.48
Reported generate profit (Financial incentive)	17% (22/132)	13% (11/85)	17% (42/245)	.42
Reported financial incentive doesn’t apply	60% (80/132)	72% (61/85)	63% (155/245)	.31
Reported HPV vaccination financial barriers in practice	12% (16/132)	15% (13/85)	10% (24/245)	.38

*Note that some covariates have missing data, and number of respondents within those cells do not always equal the total number of practitioner respondents within a specific profile.

Table 4. Multinomial logistic regression model of covariates predicting practitioner HPV vaccine recommendation profiles.

	Ambivalent Recommenders	Protocol Followers
	OR (95% CI)*	OR (95% CI)*	Engagers (reference)	p-value
Practitioner age	1.0 (0.9, 1.02)	1.0 (0.9, 1.02)	1.0	.71
Practitioner gender (female)	0.7 (0.4, 1.2)	0.6 (0.3, 1.02)	1.0	.13
Practitioner race/ethnicity (Caucasian)	0.64 (0.3, 1.4)	0.4 (0.2, 0.8)	1.0	.05
Suburban location	2.2 (1.1, 4.1)	0.9 (0.4, 2)	1.0	.03
Rural location	1.5 (0.6, 3.2)	1 (0.3, 1.4)	1.0	.20
Located in CDC disparity state**	0.7 (0.4, 1.2)	1.1 (0.6, 2)	1.0	.27
See >25% Medicaid patients	0.7 (0.4, 1.2)	3.1 (1.4, 6.9)	1.0	p < .001
Report financial barriers in practice	1.2 (0.5, 2.5)	1.5 (0.6, 3.6)	1.0	.67

*CI = confidence interval; OR = odds ratio

**CDC designates a US state that has less than 60% of adolescents vaccinated for HPV as a disparity state. Twenty-three states are currently designated as a disparity state.¹⁷

Table 5. Communication, peer norm, and risk-based indicators for the latent class model of practitioner HPV vaccine recommendation profiles.

Indicators	Response Options
COMMUNICATION
Recommendation Strength	0 = includes (a) would not mention (b) would recommend waiting (c) would recommend but not push 1 = I would strongly recommend HPV vaccination
Timeliness	0 = Vaccinate at a future encounter 1 = Vaccinate today
Recommend all 3 adolescent vaccines same time	0 = no 1 = I would normalize HPV vaccination (e.g., by offering and recommending it at the same time as the other required adolescent vaccines Tdap and MCV4
Emphasize cancer protection	0 = no 1 = I would emphasize the importance of the HPV vaccine including discussing the cancers and diseases that it protects against
Emphasize genital wart protection	0 = no 1 = I would mention the vaccine protects against genital warts
Emphasize strong antibody response when vaccinating at younger age	0 = no 1 = I would mention that vaccinating at a younger age results in a stronger antibody response
Use positive tone when recommending HPV vaccine	0 = no 1 = I would talk with the parent in an enthusiastic and hopeful tone mentioning that it’s exciting to have a vaccine that protects against cancer
PEER NORMS
Peer Descriptive Norms “peer practitioner HPV vaccine recommendation practices”	0 = includes (a) Most of the practitioners in our clinic would not mention/discuss the HPVvaccine; (b) Most of the practitioners in our clinic would not recommend HPV vaccinationroutinely; (c) Most of the practitioners in our clinic would recommend the HPV vaccine, butbe neutral/noncommittal 1 = Most of the practitioners in our clinic would strongly recommend HPV vaccination
Peer Injunctive Norms “peer practitioner HPV vaccine recommendation views”	0 = includes (a) Unimportant; (b) Not essential nor unessential for good health; (c) Important but not essential (for good health) 1 = includes (a) Absolutely essential (for good health) and (b) Essential for continuing to be seen as a patient in the practice
RISK BASED APPROACH
Using clinical judgment about whether patient will become sexually active in the next 2 years to adjust HPV vaccine recommendation	0 = Unlikely or very unlikely to adjust HPV vaccine recommendation based on judgment about whether child will become sexually active in next two years 1 = Very likely or likely to adjust HPV vaccine recommendation based on judgment about whether child will become sexually active in next two years

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