https://orcid.org/0000-0002-0158-8841
ABSTRACT
Including dental health providers in human papillomavirus (HPV) vaccination could reduce rising rates in HPV-associated oropharyngeal cancer (HPV-OPC). This study assessed Utah dentists’ perspectives on providing HPV vaccination education and services in the dental setting. A cross-sectional, 70-item self-administered survey was conducted among a convenience sample of N = 203 practicing Utah dentists. Statistical analyses included Chi Square tests of independence, scaled scores and Cronbach’s alpha coefficients. Majority of Utah dentists surveyed perceived that discussing the link between HPV and OPC and recommending the HPV vaccine is within their scope of practice, but not administration of the HPV vaccine. Dentists with >10 minutes of patient education per week were less likely to be concerned about the cultural, social norms or religious ideology of discussing HPV with their patients (p = .024). Rural dentists were more concerned about the safety and liability of the HPV vaccine (p = .011). Good internal consistency was observed survey items regarding barriers and willing to engage in HPV vaccination practices. Dental providers were interested in HPV training and patient education brochures as strategies, but less interested in administering the HPV vaccine. Dental associations support dentists’ engagement in HPV education and HPV-OPC prevention. This is the first study in Utah to examine dentists’ perspectives on HPV vaccination. Findings have implications for program planning, intervention development, and future research.
Introduction
Human Papillomavirus (HPV) infection is the most common sexually transmitted infection in the world.Citation1 In the US, nearly 79 million Americans are infected with 14 million new infections each year.Citation1 HPV is the causative agent in the majority of cervical, anal, vulvar, vaginal, penile and oropharyngeal cancers.Citation2 Oropharyngeal cancers have now surpassed cervical cancers as the most common type of cancer caused by HPV.Citation3
In 2019, it is estimated that approximately 53,000 people will get oral cavity cancer (OC) or oropharyngeal cancer (OPC) and 10,860 people will die in the United States.Citation4 The five year survival rate for OPC is 65.3%.Citation4 HPV is the causal agent in approximately 70% of all cases.Citation5 Males are twice as likely as women to be diagnosed with an HPV related OC or OPC with more than 37,000 cases in males and 14,000 cases in females in 2018.Citation4 The median age for diagnosis is 62 years for women and 61 years for men, however the greatest increase in OC and OPC diagnoses is in the 35–55 age group.Citation6 White and African Americans have high rates of HPV-OPC than other races including Native American and Asian/Pacific Islanders.Citation7
Of the more than 100 types, HPV 16 is the most causative viral type of oropharyngeal cancers (OPC).Citation8 Transmission occurs via sexual contact and greater than six lifetime oral sexual partner increases the risk of an HPV related OPC sixfold.Citation9 Although 90 percent of individuals can clear an infection within two years,Citation10 the HPV virus has the ability to integrate its DNA into the host DNA where it can remain dormant and potentially undetectable for decades.Citation10 Currently, there are no FDA approved tests to detect HPV in the oral cavity.Citation10
The Advisory Committee on Immunization Practices (ACIP) recommend HPV vaccination at age 11–12 with a two-dose series given six-twelve months apart or a three-dose series if initiated after age 15.Citation11 Catch up vaccination is recommended in females aged 13 through 26 years and males aged 13 through 21 years not adequately vaccinated previously.Citation11
The Healthy People 2020 objective for 80% of young women and men to receive 2 or 3 vaccinations between ages 13–15.Citation12 In 2017, 48.6% of all adolescents were up to date, including 53.1% of females and 44.3% of males.Citation13 The state of Utah ranks 47th in the nation with only 42.1% of female adolescents up to date and 44th in the nation for male adolescents with 32.9% up to date.Citation14 Reasons for low HPV vaccine uptake include lack of healthcare provider recommendations and low parental motivation to have their adolescent receive the HPV vaccine.Citation15 A strong healthcare provider recommendation on vaccination has been shown to have a positive effect of receiving a vaccine.Citation16 Implementing HPV and HPV cancer education and HPV vaccination strategies into non-traditional alternative venues may represent a new and innovative strategy to increase HPV vaccination among eligible adolescents and young adults.
Dentists earn a doctorate degree in dental surgery (DDS) or medicine (DMD) and provide primary and specialty oral health care. They traditionally screen for signs or symptoms of oral cancers, but have not been involved in prevention with HPV education or vaccination.Citation17 In October of 2018, an American Dental Association adopted a policy that “encourages dentists to support the use and administration of the HPV vaccine.”Citation18 Strauss et al estimated that in 2008 approximately 19.5 million people who visited their dentist, but not a primary care medical provider.Citation19 The involvement of dental providers in the efforts to increase HPV vaccination has the potential of capturing patients who may not visit their medical primary care providers, but do visit their dentists, yet to date, the perspectives, barriers, and willingness to engage in HPV vaccine practices in the dental setting has been unexplored in Utah.
The purpose of this study is to assess Utah and examine the relationship between dental provider’s perspectives about their scope of practice, barriers, and willingness to engage and collaborate in HPV vaccination practices in the dental setting A secondary aim of this study was to assess the internal consistency of survey items for scale development in future studies. We also assessed if perspectives, barriers and willingness to engage and collaborate in HPV vaccination practices differed by dentists’ characteristics.
Results
The demographic and clinical characteristics of the sample are reported in . There was a total of N = 203 respondents in this study. The majority of participants were under 64 years old (90%), white (93%), male (95%) general dentists (83%) practicing in an urban location (85%). Approximately 60% of respondents had less than 21 years of experience, most worked more than 30 hours a week and saw more than 51 patients a week. More than 90% of respondents reported a practice with >50% of patients between the ages of 11–26. The majority (64%) spent less than 10 minutes on patient education.
Table 1. Demographic characteristics of participants (N = 203).
Perspectives on scope of practice
The vast majority (90.6%) of respondents felt that discussing the link between HPV and OPC and recommending the HPV vaccine (69.4%) fell within the scope of the dental professional, however only 23.1% of respondents believed that administering the vaccine was within their scope of their practice (). The Cronbach’s alpha for the three items was negative, suggesting a very weak correlation. Due to the poor internal consistency of the items, these items were not used as a scale in the analyses. Discussing (item 1), recommending (item 2), and administering (item 3) the HPV vaccine did not significantly differ by dentists’ age group, rurality, time spent on patient education, or length of dental experience.
Table 2. Perceptions of scope of practice and barriers of HPV vaccination in the dental setting.
Barriers
Multiple barriers to discussing HPV in the dental setting were assessed. More than half (53.2%) of dentists surveyed did not feel comfortable discussing sexual topics with their patients, felt that social and cultural norms (65.5%), and religious ideology played a role in discussing HPV and HPV vaccines in dental offices (). Dentists’ barriers differed by practice and demographic characteristics. In a univariate analysis, significantly higher proportions of dentists who spent less than 10 minutes in patient education were observed to express that social and cultural norms (n = 184, p = .024) and religious ideology (n = 178, p = .038) played a role in discussing HPV and HPV vaccines in the dental office compared with dental providers who spent greater than 10 minutes in patient education. (). A significantly higher proportion of Urban Utah dentists disagreed that they were concerned about the safety of the HPV vaccine (n = 141, 73.43%, p = .011), or that they were concerned about the liability related to the HPV vaccine (n = 103, 53.34%, p = .004) were compared with rural dental providers (n = 13, 6.77%; n = 13, 6.77%; ).
Table 3. Associations between practice and barriers of HPV vaccination items in the dental setting.
Table 4. Associations between geographical factors and barriers HPV vaccination items in the dental setting.
The Cronbach’s alpha for the nine items assessing dental providers’ barriers toward HPV vaccination in the dental setting was 0.78, indicating acceptable internal consistency of these items. The mean barriers scores of participants was 19.45 out of a possible 36 (SD = 5.90, 0–35). Barriers scores did not differ significantly with dentists’ age group, rurality, length time in patient education, or length of experience working in the dental setting.
Willingness to engage in HPV vaccination practices
More than two-thirds of respondents were willing to participate in a training (66.2%) and educate patients (70.2%) about HPV and OPC (). The Cronbach’s alpha for this scale was 0.9, indicating excelling internal consistency. The mean willingness score was 15.46 out of a possible 32 (SD = 4.79, range = 0–24). The mean willingness score was not significantly different across dentists’ age group, rurality, length of time spent in patient education, and length of experience in dentistry.
Table 5. Dentists’ willingness to engage in HPV vaccination practices and collaborate with primary care providers.
Willingness to collaborate with primary care providers in HPV vaccine promotion
The majority of dental providers were willing to participate in a referral program by having their front desk staff refer eligible patients to primary care (57.8%) and provide patients with educational materials on HPV and OPC (73.3%), but most did not want to identify eligible patients (60.0%), counsel patients (62.2%), or take part in the scheduling (77.2%), or reminders (82.8%; ).
The eight items in this scale had a Cronbach’s alpha of 0.69. When item eight was eliminated, the Cronbach’s alpha increased to 0.79 indicating an acceptable to good internal consistency. Overall Willingness to Collaborate scores were not significantly different by rurality, age group, time spent educating patients, or length of experience working in the dental setting.
Correlation between scale scores
To assess for concurrent validity among scales, Pearson’s correlations between the Perceptions of Scope of Practice items and the scales were conducted. Perceiving that discussing the HPV vaccine was within the dentist’s scope of practice was positively associated with perceiving that recommending (r = 0.64, p = .000) and administering (r = 0.44, p = .000) were within the dentist’s scope of practice. Pearson’s correlations showed moderate positive associations between the perceptions that discussing (r = 0.54, p = .000), recommending (r = 0.51, p = .000), and administering the HPV vaccine (0.64, p = .000) were within scope of practice and overall scores for Willingness to Engage in HPV Vaccine Practices. Low positive associations were also observed between the perceptions that discussing (r = 0.37, p = .000), recommending (r = 0.44, p = .000), and administering (r = 0.43, p = .000) were within the dentist’s scope of practice and dentists’ overall Willingness to Collaborate with Primary Care Providers. Low negative associations were observed for the three Perspectives of Scope of Practice items and the overall Barriers scores. The correlations are reported in .
Table 6. Correlations between perceptions of scope of practice and scales.
Discussion
Given the rising rates of HPV associated OPC and low rates of HPV vaccination in the US, the role of discussing the association of HPV and OPC and HPV vaccination is expanding to include the dental profession. The American Dental Association’s (ADA) and American Pediatric Dental Association’s (APDA) current recommendations support the education of patients and parents on HPV and its relationship to OPC and recommend HPV vaccination in accordance with Centers for Disease Control guidelines.Citation18,Citation20 These new guidelines require a better understanding of dental providers’ perspectives of the scope of practice, barriers, and the willingness to engage in HPV vaccination practices. This study is the first of its kind to examine Utah dentist’s perceived role in HPV vaccination practices.
This paper assessed the internal consistencies of scales to assess dentists’ perspectives on their scope of practice, barriers, and willingness to engage in HPV vaccination practices, and willingness to collaborate with primary care providers to increase HPV vaccination among their patient population. The analyses found acceptable to excellent internal consistencies for three scales,Citation21 suggesting their potential to be used as measure in future studies. The moderate to strong positive correlation between willingness to engage and willingness to collaborate and the correlations of these scales to items assessing Perspectives on Scope of Practice supports the concurrent validity of these scales, which may aid in future model development. Future studies should evaluate and validate the psychometrics of these scales in other dental professional populations such as dental hygienists, dental staff, faculty, and dental professionals in other geographic regions.
Kline et al, in a mixed methods study including focus groups and a survey for dentist and dental hygienists, found that dental providers acknowledged their role in discussing HPV prevention of OPC cancers.Citation22 However, in their study dentists identified their role as secondary prevention, while dental hygienists felt they were “prevention specialists” responsible for education and oral screening.Citation22 This suggests that the constructs related to Perspectives on Scope of Practice items could be further developed to include items that address clinic practices such as prevention and detection of HPV-related oropharyngeal cancers to improve the utility of the Perspectives on Scope of Practice items as a scale.
Utah dentists surveyed in this study had higher overall positive perceptions that discussing and recommending the HPV vaccine was within the role and scope of a dental professional, however, overall perceptions that administering the HPV vaccine in the dental setting was within the dental scope of practice was less positive. This may be because Utah dentists believe that secondary prevention of HPV associated OPC is part of their role, but that primary prevention is the responsibility of primary care providers, which was supported by some responses in the write-in portion of the survey with providers questioning the role of dental providers in HPV education. As a strong physical recommendation highly influential in motivating patients to accept the HPV vaccine,Citation23 this finding suggests that in order for HPV vaccination practices to be acceptable in the dental setting, dentists’ need to be comfortable with their role in primary HPVOPC prevention in addition to secondary prevention. While there may be initial resistance to administration of the HPV vaccine in the dental practice, potentially more acceptable practices to engage dentists in HPV primary prevention may be to provide patients with educational materials and engaging dental practices in referral programs. identified areas of need that would assist in facilitation of HPV discussion for dental providers including increasing patient awareness, patient education materials, improving health literacy, and professional education.Citation22,Citation24 These strategies may be included as components of clinic-based interventions and should be evaluated for feasibility and acceptability.
This study also found that overall perceptions of scope of practice, barriers to HPV vaccination practices, willingness to engage and willingness to collaborate did not differ by age group, rurality, length of time spent in patient education, and length of experience in dental practice. However, when dichotomizing responses to “agree” and “disagree”, we found that significantly higher proportions of Utah dentists who performed less education (<10 min) reported that social, cultural norms and religious ideology played a role in HPV discussion compared to dentists performing more than 10 minutes of education. This possibly could be because dentists who routinely spend more time educating patients may be more comfortable teaching about potentially sensitive subjects. Other barriers ranked highly by Utah dentists included discomfort in discussing sexual topics with patients and lack of time during appointments, which is supported in other studies with dental professionalsCitation25,Citation26 but also needs be explored for future research. A recent literature review by Walker et al. found that dental providers’ discomfort talking about the HPV vaccine to patients included lack of knowledge, the discomfort talking about sexually transmitted infections, perceiving that parents would be uncomfortable, or that patients were lower risk, highlighting the importance for communication training for dental professionals in patient education about the HPV vaccine.Citation27
Additionally, we found that rural Utah dentists were significantly more concerned about the safety and liability of the HPV vaccine than urban dentists. This may be secondary to lack of knowledge and increased opposition to HPV vaccination.Citation25,Citation28 Studies have demonstrated that rural medical providers are less likely to provide a strong recommendation for HPV vaccination which results in more missed opportunity visits and lower vaccination rates.Citation29,Citation30 Educational approaches have been useful in improving the comfort in patient education of HPV among dental professionals, and may be particularly important for rural providers.Citation28 This is particularly important given rural residents often also have decreased access to cancer screening and treatment and increased mortality.Citation31 Targeting all rural providers, medical and dental, as well as rural residents with culturally sensitive HPV vaccine education focusing on cancer prevention is essential.
We found that higher overall scores in Barriers was associated with lower willingness to engage and willingness to collaborate in HPV vaccination practices, as well as more negative perceptions that discussing, recommending, and administering the vaccine was within the dental scope of practice. The related nature of these concepts suggests that future models for studying dental professionals’ attitudes toward HPV vaccination practices could incorporate these constructs and highlights the importance of addressing dentists’ perceived barriers to HPV vaccination and the need for greater advocacy efforts to include dentists in the education and administration of the HPV vaccine.
The limitations of this study include its lack of generalizability to other regions of the country given only Utah dentists were surveyed which may not be representative of other regions. It is important to note that this survey was just prior to the ADA and APDA recommendations for dentists to perform HPV education and thus views of dentists may have changed. The study had a low response rate of 10.1% which lends itself to nonresponse bias. In addition, although, we demonstrated a significant difference between rural and urban providers, the number of rural providers who responded was quite low. Although only approximately 5% of our sample were female dentists, this is reflective of the Utah dentist population – Utah has lower proportions of female dentists compared to national proportions (Utah- 2.5%; US-30.9%).Citation32,Citation33 Moreover, we included dentists from various types of practices (i.e. general practice, endodontist, pediatric, orthodontists, and oral surgeons), which may have improved the generalizability of our findings.
Finally, this study did not assess other potential predictors of attitudes regarding HPV vaccination practices among dentists, such as HPV knowledge, which would be useful in building models for assessing HPV vaccination attitudes among dental professionals. Assessing HPV knowledge and other predictors of HPV vaccination attitudes was not part of the scope of this study and should be explored in future studies. Nevertheless, this is one of the first studies in Utah to explore the perceptions, barriers, and facilitators of HPV vaccination practices for the dental setting.
Conclusion
As OPC rates continue to rise in the US and HPV vaccination rates remain low, we need dental providers to take up the call to educate their patients about HPV and its link to OPC and HPV vaccination. The majority of Utah dentists support role in HPV education with direct patient counseling and brochures but are not interested in providing the vaccine. Launching a campaign with dental provider trainings on HPV and communication tools around HPV vaccination, public service announcements and patient educational materials might increase the dialogue both in the community and at the dental offices. Additional education and support is needed in Utah’s rural areas given the greater concern about vaccine safety and liability. Dental schools need to provide their trainees not only with HPV education, but also communication skills for discussing sensitive topics to increase dentists comfort in teaching patients and parents about HPV. Additionally, further studies are needed examining the roles and training of the dental hygienist in HPV education. We hope that the dental providers will join medical providers and HPV advocates in educating their patients and parents about the link between HPV and OPC and the HPV vaccine to decrease the rates of HPV related cancers.
Materials and methods
Study population and design
This cross-sectional study was approved by the University of Utah Institutional Review Board. The study analyzed 39 items from a larger self-administered survey (three items- Perceptions about Scope of Practice; nine items- Barriers related to recommending and administering the HPV vaccine; eight items-Willingness to Engage in HPV Vaccination Practices; eight items- Willingness to Collaborate with Primary Care Providers in HPV Vaccination Promotion; 11 items- demographics and clinical practice-related). Eligible participants were dentists who were in current practice above the age of 18 years in Utah. Participants who were ineligible included retirees. Recruitment was conducted from a statewide dental association database (n = 180) using mailed surveys and reminders with the option for completing a pencil-and-paper or an online survey, and an in-person convenience sampling approach to recruit practicing dentists, directly from clinics, from two academic institutions, and at professional meetings (n = 23).
Data collection
Recruitment was conducted between February 2017 and April 2018. Members registered with the largest dental association in the state were screened to make sure that they were in current practice in the state. A total of N = 1786 mailed surveys and QR codes and links to an online REDCap survey were sent to the screened member list. Participants either completed the survey online or mailed back their completed paper-and-pencil survey if they preferred. Dentists registered with rural zip codes were oversampled – two mailed reminder postcards were sent to increase the response rate of the rural sample. The overall response rate was 10.10%. Participants recruited through other strategies were approached in-person during presentations during faculty or organization meetings and at informational booths at professional meetings.
Measures
Perspectives on scope of practice
Three questions assessed dentists’ perceptions about their scope and role regarding discussing the link between HPV and oropharyngeal cancer, recommending HPV vaccination, and administering the HPV vaccine in the dental office. Responses were assessed on a five-point Likert scale ranging from 0 = strongly disagree to 4 = strongly agree.
Barriers
Participants were asked to indicate how strongly they agreed with the following statements, 1) I do not have enough information about the HPV vaccine, 2) I am concerned with the safety of the HPV vaccine, 3) I am concerned about liability reasons related to the HPV vaccine, 4) There are no established professional policies/guidelines pertaining to recommendation of the HPV vaccine, 5) There is not enough time to discuss this during appointments, 6) I am not comfortable discussing sexual history/topics with patients, 7) Politics play a role in discussing HPV and the HPV vaccine in the dental office, 8) Social and cultural norms play a role in discussing HPV and the HPV vaccine in the dental office, and 9) A patient’s religious ideology plays a role in discussing HPV and the HPV vaccine in the dental office. Participants provided their response on a five-point Likert scale ranging from 0 = strongly disagree to 4 = strongly agree (higher scores relate to greater perceived barriers to HPV vaccination). Questions were developed and piloted in a previous study conducted by Rutkoski et alCitation34
Willingness to engage in HPV vaccine practices
Providers’ intention to participate to be engaged in HPV vaccination practices were assessed with the following questions developed for this study, 1) “How willing would you be to participate in a training about HPV and oropharyngeal cancer?”, 2) “If trained, how willing would you be to educate your patients about HPV and oropharyngeal cancer?”, 3) “How willing would you be to participate in a referral program with a primary care provider to refer eligible patients for the HPV vaccine?”, 4) “If trained, how willing would you be to refer eligible patients for the HPV vaccine with their primary care providers?” 5) “How willing would you be to participate in a training to administer the HPV vaccine in your dental practice?”, and 6) “If trained, how willing would you be to administer the HPV vaccine in your dental office?” Question responses ranged from 0 = very unwilling to 4 = very willing on a five-point Likert scale.
Willingness to collaborate with primary care providers in HPV vaccine promotion
Willingness to collaborate with primary care providers was assessed with yes/no questions developed for this study. Participants were asked to check all that apply for the following collaborative activities, 1) having office staff identify age-eligible patients for the HPV vaccine, 2) provide HPV vaccine educational materials to patients, 2) counsel eligible patients for the HPV vaccine, 3) have office staff refer eligible patients to the primary care provider, 4) have office staff schedule the HPV vaccine for patients with their primary care provider, 5) have office staff schedule the HPV vaccine with their primary care provider, 6) share their clinics’ electronic health record to facilitate HPV vaccine referral, 7) have clinic staff send reminders for the follow up shot to patients, and 8) other strategies (check box and free text).
Statistical analysis
Paper surveys were logged in a REDCap database and exported to IBM SPSS Version 24 for analysis. Descriptive statistics and chi-square tests of independence were conducted. Frequencies, proportions and p-values are reported. Cronbach’s alphas were calculated for the Perspectives on Scope of Practice, Barriers, Willingness to Engage in HPV Vaccination Practice items, and Willingness to Collaborate with Primary Care Providers in HPV Vaccine Promotion items to assess internal consistency. Summed scores were produced for subscales with moderate to good internal consistency. Differences in mean scores by dentists’ characteristics (age group, urban/rural, minutes spent in patient education, and length of experience in dental practice) were examined with one-way analysis of variance and independent samples t-tests for categorical variables and simple linear regression for continuous independent variables (length of experience in dental practice). These variables were selected a priori as potential factors that would be associated with attitudes toward HPV vaccination, comfort with discussing HPV, and experience in patient-provider communication.Citation35,Citation36 Due to the low cell sizes for non-White and female participants, differences in mean scores for race and gender were not examined.
To assess for relationships between the outcomes of interest, Pearson’s correlation coefficients were produced. Significance was set at the p < .05 level.
Disclosure of potential conflicts of interest
No potential conflicts of interest were disclosed.
Acknowledgments
This study was funded by the Huntsman Cancer Foundation, the Dick and Timmy Burton Foundation, the University of Utah’s College of Nursing, and the University of Utah’s Vice President for Research Faculty Research and Creative Grant Program. The REDCap application was funded by grant number 8UL1TR000105 (formerly UL1RR025764) NCATS/NIH) from the National Center for Advancing Translational Sciences of the National Institutes of Health. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the National Institutes of Health.
Additional information
Funding
References
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