Effect of a multi-component intervention on providers’ HPV vaccine communication

Figures & data

Table 1. Qualitative themes identified in provider interviews

Theme	Illustrative Quotes
Changes in Provider Communication
Shift from elective to indicated HPV vaccine presentations	I’m just like, okay, we do these three shots now. And then if there’s sort of objections, we talk about those, and I maybe go over why it would, you know, if you can stand it, it’s good to get all three of them now. (Provider 16)
Increased knowledge leading to greater confidence in presenting and discussing the HPV vaccine	I think I felt a little better equipped to say to people, well, yeah, it really works, and we should just do it. (Provider 21) I think it increased my awareness of the severity – not the severity of the cancers but the prevalence of them, and I also think it increased my understanding of why the early vaccination is important, and made me push harder for people who have younger children in the nine to thirteen range to do it. (Provider 15)
Increased persistence when faced with reluctant parents or patients	I just revisit it and then just mention that, ‘The last time you had some reservations, and you’ve had some time to talk about it with your family and read some literature, and I just kind of wanted to see where you’re at and if you’re interested in getting it today,’ and just take it from there. (Provider 20) I think also helped me to sort of like re-prioritize it in terms of when we were offering it, and how comfortable I was sort of encouraging parents who initially were maybe a little bit more ambivalent. (Provider 24)
Concrete Tools for Communicating with Parents and Patients
Facts about HPV-related cancers and cancer prevention	So hearing her [provider educator] talk about someone in her thirties who died of cervical cancer that had a big impact on me, personally. I was able to say that to parents and I had a few instances where people were sort of reluctant and then I was able to sort of tell that anecdote that this actually really is related to prevention of cancer. And it changed people’s minds. (Provider 1) The information about the oropharyngeal cancers, that helped me understand ways that I can use to promote it with my male patients. (Provider 25)
Improved understanding of HPV transmission	I wasn’t ever saying, ‘Oh this is all STD,’ but one of the things that [provider expert] talked about is that you can get it from non-sexual contact. I say, ‘Well yes, it’s an STD but you can also get it other ways.’ (Provider 12)
Information on the increased effectiveness of vaccination at younger ages	So I tell them we are starting earlier because the goal is that by eleven, the child would be fully immunized and that we guarantee that they would be protected and also it will be only two shots instead of three. (Provider 2)
Impact of repeating the recommendation every year	Mom, you remember last year I gave you information with this about the reasons of HPV, HPV vaccine is safe, I know that you have read many, many things but we have now the luxury to protect against cancer. (Provider 2)
Other Effective Strategies for Communication
Personal stories, cultivating relationships with patients, using simple language to discuss the vaccine	I say, ‘So your daughter is due for the HPV vaccine today.’ And I say that it is for a nine year old ….I say ‘Mom, do you get your pap smear every year?’ and they say yes or no. I say, ‘Has your test ever come back with anything positive in there? And they say yes. ‘That virus, mom, that you had to go to this and this, is the one that we are preventing with these. That disease is what we are preventing with this vaccine.’ (Provider 2)

Table 2. Demographic characteristics and survey responses of providers surveyed (pre- and post-intervention)

Demographic information
Provider Race	Non-Hispanic White		16 (80%)
	Hispanic/Latino		1 (5%)
	Asian		3 (15%)
Provider Sex	Female		19 (90.5%)
	Male		2 (9.5%)
Professional Training	Physician		15 (75%)
	Nurse Practitioner		5 (25%)
Clinical Specialty	Family Medicine		8 (40%)
	Pediatrics		12 (60%)
Survey responses
	Pre-Intervention n (%)	Post-Intervention n (%)	P-value (chi square or Fisher exact)
I believe that HPV vaccine is one of the most Important vaccines that I give to patients. Agree/Strongly Agree Disagree/Strongly Disagree	15 (71.4%) 6 (28.6%)	21 (100%) 0	0.02
I feel more comfortable offering HPV vaccine to adolescents age 13 and over compared to those younger than 13. Agree/Strongly Agree Disagree/Strongly Disagree	6 (28.6%) 15 (71.4%)	0 21 (100%)	0.02
Time pressure is a barrier to providing HPV vaccination. Likely Unlikely	6 (28.6%) 15 (71.4%)	4 (19.0%) 17 (80.9%)	0.72
Parents believe the HPV vaccine is: Extremely/Very Important Somewhat/Not important	1 (4.8%) 20 (95.2%)	9 (42.8%) 12 (57.1%)	0.01
Parental Reluctance to have children immunized against an STI is a barrier to HPV vaccination. Likely Unlikely	12 (57.1%) 9 (42.8%)	8 (38.1%) 13 (61.9%)	0.35

*1 missing value each for race, profession, and clinical specialty.

Table 3. Parent-patient demographic characteristics, parent-reported likelihood of vaccine acceptance, and provider vaccine recommendation style for audio-recorded clinical interactions (pre- and post-intervention)

		Pre-Intervention Survey (N = 64) n (%)	Post-Intervention Survey (N = 65) n (%)	P-value (chi square or t-test)
Parent Race	Non-Hispanic White	15 (23.4%)	10 (15.2%)
	Hispanic/Latino	22 (34.4%)	25 (37.9%)
	Non-Hispanic Black	21 (32.8%)	24 (36.4%)
	Other	6 (9.4%)	7 (10.6%)	0.70
Parent Sex	Female	48 (75%)	52 (80%)
	Male	16 (25%)	13 (20%)	0.50
Parent Age	Mean (Standard Deviation)	41.86 (7.85)	40.14 (7.19)	0.21
Parent Highest	Less than High School	14 (22.2%)	11 (16.9%)
Educational	High School or GED	14 (22.2%)	23 (35.4%)
Attainment*	Some College	11 (17.5%)	13 (20.0%)
	Associates, Bachelors, or Graduate degree	24 (38.1%)	18 (27.7%)	0.31
Annual Household	<$25,000	24 (44.4%)	28 (43.1%)
Income*	$25,001-$50,000	18 (18.5%)	22 (33.9%)
	$51,001-$100,000	14 (25.9%)	9 (13.9%)
	>$100,000	6 (11.1%)	6 (9.2%)	0.18
Parental pre-visit likelihood of vaccination score**	Mean (standard deviation)	3.23 (1.05)	3.49 (1.21)	0.20
Child Race	Non-Hispanic White	13 (20.3%)	10 (15.4%)
	Hispanic/Latino	23 (35.9%)	26 (40.0%)
	Non-Hispanic Black	21 (32.8%)	18 (27.7%)
	Other	7 (10.9%)	11 (16.9%)	0.64
Child Sex	Female	31 (48.4%)	35 (53.8%)
	Male	33 (51.6%)	30 (46.2%)	0.54
Child age	Mean (Standard Deviation)	12.02 (1.81)	10.77 (1.50)	<0.001
Vaccine recommendation style	Indicated Elective	40 (62.5%) 24 (37.5%)	51 (79.6%) 14 (20.4%)	0.047

*1 missing value for educational attainment and 2 missing values for household income in the pre-intervention period

**Parents expressed their likelihood of accepting HPV vaccine for child on a Likert scale from 1 (very unlikely) to 5 (very likely)

Table

HPV	Human Papillomavirus