https://orcid.org/0000-0003-4706-3482
ABSTRACT
Increasing human papillomavirus (HPV) vaccine uptake remains a challenge. We compared reasons for HPV vaccine acceptance between two Southern California pediatric clinics serving diverse populations: an academically affiliated resident clinic that offered little continuity of care (n = 53) and a private-practice clinic with well-established physician–patient relationships (n = 200). We found strong doctor recommendation and information dissemination about the importance of HPV vaccination were the most important drivers of acceptance across these distinct settings. The top-cited reasons for vaccine acceptance also varied by gender, language (English vs. Spanish), and clinic type. Findings point to the need for (1) robust provider education on vaccines, vaccine-preventable diseases, and vaccine hesitancy and (2) increased efforts to raise public awareness of the importance of HPV vaccination.
To the Editor:
Nearly 44,000 new cases of human papillomavirus (HPV)-associated cancers are diagnosed in the United States annually, 92% of which are preventable by HPV vaccination.Citation1 The Advisory Committee on Immunization Practices recommends two doses of HPV vaccine for all 11–12-year-olds, as early as age 9.Citation2 As of 2019, the most recent year for which U.S. surveillance data are available, 73.2% of adolescent girls and 69.8% of adolescent boys had received at least one HPV vaccine dose, while 56.8% of girls and 51.8% of boys completed the vaccine series.Citation3 Key barriers to HPV vaccine uptake among U.S. adolescents include lack of health provider recommendation as well as parental knowledge gaps, low perceived susceptibility to HPV and need for vaccination, and concerns about vaccine safety and cost.Citation4 Increasing HPV vaccine uptake remains a challenge across the United States, including in California where providers serve a culturally and linguistically diverse population.Citation5
In 2016, we conducted a pilot study in an academically affiliated resident clinic in Southern California, to identify rates of HPV vaccine uptake and parents’ top-cited reasons for HPV vaccine acceptance or refusal for their adolescent children. Our study is built directly on a 2015 study conducted in a private practice clinic by Brown, Gabra, and Pellman.Citation6 The academically affiliated resident clinic we studied differed from the private practice clinic in Brown et al.’sCitation6 study in two important ways. First, most patients at the resident clinic received Medicaid assistance and federally funded HPV vaccination through the Vaccines for Children program,Citation7 while the private practice clinic served predominantly middle-class, privately insured patients. Second, the resident clinic, which housed 7 attendings and 28 residents rotating through each month, offered little continuity of care, whereas the private practice clinic housed 5 full-time pediatricians with well-established physician–patient relationships and good care continuity.
Given health provider communication is robustly associated with HPV vaccine uptake,Citation8 we questioned whether differences in care continuity across both vastly different settings and patient populations would influence vaccination rates. Additionally, we considered gender differences in vaccine acceptance, as previous research suggests health providers are less likely to strongly recommend HPV vaccines to boys and parents may be less clear about the consequences of HPV infection for sons than daughters.Citation9 Finally, we considered whether the reasons for HPV vaccine acceptance differed by survey administration language (English vs. Spanish), given parents who speak Spanish have reported not vaccinating their children against HPV due to weak provider recommendation.Citation10
We obtained the data (N = 200) and survey tool from Brown et al.’sCitation6 study and administered the same paper survey to parents of patients aged 9 to 15 in the resident clinic, immediately after they had decided whether to accept or refuse HPV vaccination for their child. Participants (N = 53) completed the survey anonymously in English (n = 28) or Spanish (n = 25). The survey recorded the child’s age and gender. Parents who agreed to initiate HPV vaccination for their children were asked to select one or more of up to six possible reasons for their decision: (1) My doctor felt it was important to vaccinate to protect against future HPV infection, (2) My insurance covers all or most of the vaccine cost, (3) I have read or heard this is an important vaccine to give my child, (4) I have had or know someone with HPV disease or cervical cancer, (5) I am very pro-vaccine and this is recommended by the American Academy of Pediatrics and the Centers for Disease Control and Prevention, or (6) Other. We calculated descriptive statistics for all variables and performed Pearson chi-square tests to examine differences in acceptance rates and reasons for acceptance by clinic type, gender, and survey language. Reasons for refusal were not analyzed, given a small number (n = 7) of parents in the resident clinic refused HPV vaccination for their child.
Children of parents surveyed in the resident clinic had a mean age of 11.3 years (median = 11 years), which was not significantly different from children of parents surveyed in the private practice (mean = 12.8; median = 12). More parents of girls were surveyed in the resident clinic (56.6%) vs. private practice (38.5%; p = .018). HPV vaccine uptake rates among respondents were similar in the resident clinic (86.8%) and private practice (82.0%). Comparisons of vaccination rates across clinic type by gender revealed similar vaccination rates for boys in the resident and private practice clinics (82.6% vs. 88.6%, respectively), but significantly higher female vaccination rates for girls in the resident vs. private practice clinic (90.0% vs. 71.4%, respectively; p = .041).
We found differences in reasons for HPV vaccine acceptance by setting. In the resident clinic, the top two reasons chosen for HPV vaccine acceptance were “I have read or heard this is an important vaccine to give my child,” (73.9%) followed by “My doctor felt it was important to protect against future HPV infection” (69.6%; see ). The top two reasons chosen in the private practice were the same, albeit in reverse order, with doctor recommendation chosen significantly more often in private practice than in the resident clinic (84.1% vs. 69.6%; p = .026). The third most cited reason for acceptance in the resident clinic was “My insurance covers all or most of the vaccine cost” (37.0%), whereas the third most cited reason in the private practice clinic was “I am very pro-vaccine and this is recommended by the American Academy of Pediatrics and the Centers for Disease Control and Prevention” (45.1%).
Table 1. Reasons for HPV vaccine acceptance by clinic type (N = 210)
Within the resident clinic, reasons for HPV vaccine acceptance varied by gender and survey language (see ). “I have read or heard this is an important vaccine to give my child” was the most-cited reason for acceptance for parents of girls (85.2%) and second most-cited reason for parents of boys (57.9%; p = .038), while “My doctor felt it was important to protect against future HPV infection” (73.7%) was the most-cited reason for parents of boys. Parents surveyed in Spanish overwhelmingly (86.4%) chose “My doctor felt it was important to protect against future HPV infection” as the top reason for vaccine acceptance, while significantly fewer parents surveyed in English chose this reason (54.2%; p = .018). In contrast, the most-cited reason for vaccine acceptance among parents surveyed in English was “I have read or heard this is an important vaccine to give my child” (70.8%).
Table 2. Reasons for HPV vaccine acceptance by survey language and gender at the resident clinic (N = 46)
Our findings suggest that for two very diverse patient and physician practice scenarios, a strong doctor recommendation and information dissemination of the importance of HPV vaccination are most important for vaccine acceptance. Medical education should include robust training on (1) vaccines and vaccine-preventable diseases, so that providers can make strong vaccination recommendations to patients and (2) vaccine hesitancy, including practicing vaccine education in their patient population’s preferred language, to further enhance patient trust and vaccine awareness. While our study did not evaluate whether this was a first or subsequent clinical encounter regarding HPV vaccination, research suggests secondary acceptance of HPV vaccination is still reliant on good physician–patient communication.Citation11 It may be that having trainees and attendings see patients consecutively may reinforce vaccine recommendations and subsequently influence vaccine acceptance, thus this is an important area for future inquiry. While sample size prevented us from examining differences in reasons for vaccine refusal, we would encourage future research to consider differences in refusal across clinic types so that they can be addressed.
Our findings also indicate that in settings such as academic resident clinics, where continuity of care is limited, awareness of the importance of HPV vaccination remains critical. Increasing public awareness of the importance of HPV vaccination may be key for targeting uptake – especially among girls and adolescents from English-speaking families. Future research should explore the effects of public communication on vaccine decision-making to better understand how communication source shapes HPV vaccine acceptance. Previous research demonstrates higher HPV vaccine uptake among adolescent girls (vs. boys)Citation3 and among Hispanic/Latinx adolescents whose parents’ preferred language is Spanish (vs. English),Citation12 while our results suggest gender and language affect reasons for vaccine acceptance. Such differences in reasons for acceptance remain an important area for future study.
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No potential conflicts of interest were disclosed.
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References
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