HPV vaccine knowledge, attitudes, and practices among New York State medical providers, dentists, and pharmacists

ABSTRACT

Healthcare provider vaccine knowledge and attitudes influence delivery of a strong vaccine recommendation. We aim to describe HPV vaccine knowledge, attitudes, and recommendation or discussion practices (KAP) among New York State medical providers, dentists, and pharmacists. A survey to assess providers’ KAP was distributed electronically to NYS members of medical organizations. Descriptive and inferential statistical methods were used to characterize provider KAP. Responses from 1637 surveys were included, from 864 (53%) medical providers, 737 (45%) dentists, and 36 (2%) pharmacists. 59% (509/864) of medical providers responded that they recommend HPV vaccine to patients, with 390/509 (77%) strongly recommending vaccine at 11–12 years. Medical providers were more likely to report recommending HPV vaccine for children ages 11–12 years if they strongly agreed that HPV vaccine prevents cancer 326/391 (83%) vs 64/117 (55%) and responded that HPV vaccination does not increase the risk of unprotected sex (386/494 (78%) vs 4/15 (25%)) (p < .05). Less than 1/3 of dentists reported discussing HPV vaccine with 11–26-year-old females (230/737, 31%) and males (205/737, 28%) at least “sometimes.” Dentists were more likely to answer that they routinely discuss HPV vaccine with children ages 11–12 years if they responded that HPV vaccination does not increase sexual activity (70/73 (96%) vs 528/662 (80%), p < .001). Few pharmacists reported discussing HPV vaccine with 11–26-year-old females (6/36 (17%)) and males (5/36 (14%)) at least “sometimes.” Gaps in HPV vaccine knowledge among providers still exist and may influence vaccine attitudes and recommendation or discussion practices.

KEYWORDS:

• HPV
• human papillomavirus
• vaccine hesitancy
• vaccine knowledge attitudes and practices
• healthcare providers

Introduction

Human papillomavirus (HPV) is associated with more than 47,000 new cancer diagnoses each year among men and women in the United States.¹ Oropharyngeal cancers account for almost half and cervical cancers account for approximately a quarter of these malignancies with vaginal, vulvar, penile, and anal cancers responsible for the rest.¹ In the United States, the nine-valent HPV vaccine is included in the universal immunization schedule for all males and females starting at 11 or 12 years of age. Catch up vaccination is recommended for those individuals not yet vaccinated up to age 26 years. Healthy individuals who receive their first dose of HPV vaccine prior to age 15 years require two doses, while those who start the series at age 15 years or older require a 3-dose series to be considered fully vaccinated.² While the HPV vaccine is safe and effective in preventing HPV infection and its associated malignancies, only 58.6% of US teens ages 13–17 years have completed the vaccine series.³ According to 2021 data from the Centers of Disease Control and Prevention, only 64% of teens in New York State (NYS) completed the HPV vaccine series, leaving more than 1/3 of this cohort fully susceptible to infection and infection-associated cancers.⁴

The factor most often cited in association with adolescent HPV vaccine acceptance is the receipt of a strong vaccine recommendation by a healthcare provider,^5–8 yet the quality and consistency of HPV vaccine recommendation remains lower than that described for other adolescent vaccines.^9–12 HPV vaccine discussion practices are influenced by the provider’s own HPV vaccine knowledge and attitudes.^13–16 For example, providers are less likely to report recommending HPV vaccine to adolescents if they, themselves are uncomfortable talking about sex, or think that discussing sex with their patients is necessary prior to recommending the HPV vaccine, or believe that vaccination increases the likelihood of sexual activity.^13,17 On the other hand, providers who understand that the HPV vaccine can prevent the future development of HPV-associated cancers are more likely to strongly recommend the HPV vaccine for their adolescent patients.^10,18 Understanding healthcare provider HPV vaccine knowledge and attitudes and the various factors that influence their vaccine recommendation practices are essential to the development of effective strategies aimed at improving HPV vaccine coverage rates.

Most children receive their immunizations during visits to their primary care provider, with other healthcare providers, such as dentists and community-based pharmacists, playing increasing roles in promoting and administering vaccines. The 2018 American Dental Association’s HPV vaccination policy urged dentists to support the use and administration of HPV vaccine when counseling their patients.¹⁹ Two years later, the HPV vaccine labeling indication was expanded by the US Food and Drug Administration (FDA) to include prevention of oropharyngeal cancers.²⁰ Dentists are in a prime position to provide patient education regarding HPV infection, complication, and prevention in coordination with their oral cancer screening exams.²⁰ Despite the 2018 American Dental Association’s HPV vaccination policy statement and the 2020 expanded labeling indication for HPV vaccine, very little data are yet available on how or if dentists educate themselves or their patients about HPV vaccines.

Community-based pharmacists represent another large group of professionals with the potential to both educate and administer vaccines. An estimated 90% of the US population lives within 5 miles of a community pharmacy. With their convenient locations and service hours often extending well beyond the typical office hours of primary care medical practices, community pharmacists are among the most accessible healthcare providers in the country.²¹ Legislation regarding pharmacist-driven vaccinations vary by state. In NYS, licensed pharmacists who obtain immunization-specific certification are permitted to administer the influenza and COVID-19 vaccines to children between the ages of 2 and 18 years, and influenza, COVID-19, pneumococcal, meningococcal, tetanus, diphtheria, pertussis, and herpes zoster vaccinations to adults ages 18 years and older. Despite pharmacists not being licensed to administer the HPV vaccine to adolescents in NYS, the delivery of other vaccines leave them well placed for their role in HPV vaccine education for the community. As such, pharmacies have become well-recognized, highly convenient, community resources for vaccine access and advocacy, placing them in a prime position to provide HPV vaccine-related information to their patients. Data regarding HPV vaccine knowledge, attitudes, and discussion practices among community pharmacists are, however, sparse.

The primary objective of this study was to characterize HPV vaccine knowledge, attitudes, and vaccine recommendation and/or discussion practices among medical providers, dentists, and pharmacists practicing in New York State. Outcome measures include the proportion of providers correctly answering the questions assessing HPV vaccine knowledge, proportion of providers with favorable HPV vaccine attitudes, and proportion of providers discussing or recommending the HPV vaccine to their patients, with a specific focus on adolescents ages 11–12 years.

Methods

For this prospective, descriptive study, the team reviewed previously published research,^22–27 then developed a questionnaire (Table 1) designed to assess healthcare providers’ knowledge, attitudes, and recommendation practices regarding the HPV vaccine. The self-administered survey was pilot tested with a convenience sample of 10 individuals of varying healthcare provider professions to ensure clarity of questions and ease of administration. Between September 15, 2021 and January 1, 2022, the questionnaire was distributed electronically to members of the NYS Chapters of the American Academy of Pediatrics, Academy of Family Physicians, Medical Society of the State of New York, the Nurse Practitioner Association, the New York State Dental Association, and Pharmacists’ Society of the State of New York on 4 different dates, each separated by a week. All members of these medical organizations were eligible for inclusion and there were no exclusion criteria for study participation. The study was determined to be exempt from review by the SUNY Upstate Medical University Institutional Review Board (IRB# 1797883).

Table 1. Questions assessing HPV vaccine knowledge, attitudes, and recommendation practices among healthcare providers in New York State.

Questions assessing HPV vaccine knowledge Answer choices: True, False, I do not know
Vaccinating young adolescents against HPV infection increases risk of unprotected sexual activity
Oropharyngeal cancer is the most common HPV-associated cancer
HPV vaccine should be routinely administered to age-eligible males and females
Provider vaccine recommendation is associated with vaccine acceptance
Questions assessing HPV vaccine attitudes Answer choices: Strongly agree, Agree, Neutral, Disagree, Strongly disagree
I am confident in my ability to communicate with vaccine hesitant patients/families
I have a responsibility to ensure that my patients are fully vaccinated
Other providers recognize my role in vaccinating patients
HPV vaccine is effective in preventing HPV-associated cancers
Promoting HPV vaccine is within my scope of practice
Questions assessing HPV vaccine recommendation practices Answer choices: 11–12 years, 13–14 years, 15–18 years, 18+ years, Not applicable to my practice
Age at which you routinely begin strongly recommending HPV vaccine
Medical providers only: Age at which most of your patients who get immunized accept the first dose of HPV vaccine
You routinely recommend HPV vaccine to (Males, Females, Both, Not applicable to my practice)

Participant demographics, including gender, race, ethnicity, county of practice, field of practice, years in practice, healthcare provider role, and community served were collected. Healthcare provider HPV vaccine knowledge assessment comprised of four statements for which the participants responded with “True,” “False,” or “I don’t know.” The questions were given a score, with 1 point added for each correct answer. The denominators presented in the results section represent the number of providers who answered the question(s) described. A cutoff of 75% (answering 3 of the 4 questions correctly) was considered a “good” level of vaccine knowledge. Healthcare provider HPV vaccine attitudes assessment comprised on five items using an ordinal scale questionnaire (strongly disagree, disagree, neutral, agree, strongly agree). For these questions, 1 point was given for strongly disagree, 2 for disagree, 3 for neutral, 4 for agree, and 5 for strongly agree. Higher scores reflect more favorable attitudes. A cut-off of 75% (scoring above 18.75 out of 25) was considered to represent “positive” vaccine attitudes. Healthcare provider HPV vaccine recommendation practices were assessed using questions that were specific to the healthcare provider role. For medical providers, assessment of vaccine recommendation practices included questions regarding the frequency of and age at which the provider begins to strongly recommend the HPV vaccine for their patients. For dental providers and pharmacists, who play a role in promoting vaccination but are not administering vaccine in NYS, assessment of vaccine recommendation practices included questions regarding the frequency of and age at which the provider begins discussing the HPV vaccine with their patients.

Study data were collected and managed using REDCap electronic data capture tools hosted at SUNY Upstate Medical University.^28,29 REDCap (Research Electronic Data Capture) is a secure, web-based software platform designed to support data capture for research studies, providing 1) an intuitive interface for validated data capture; 2) audit trails for tracking data manipulation and export procedures; 3) automated export procedures for seamless data downloads to common statistical packages; and 4) procedures for data integration and interoperability with external sources.

Statistical analysis

Categorial variables were summarized by frequencies and proportions and Likert scale variables were summarized by means and standard deviations. Pearson’s correlation was used to measure the statistical relationship between variables. Chi-square tests were used for comparing categorical variables. Two-sided t-tests were used for comparing Likert scale variables.

Results

Among the 1637 surveys returned and included in the analysis, 864 (53%) were completed by medical providers, 737 (45%) by dental providers, and 36 (2%) by pharmacists. Distribution methods precluded calculation of the response rates. Among individuals who started the survey, 864/934 (93%) of medical providers, 737/742 (99%) of dentists, and 36/38 (95%) of pharmacists completed it. The demographics of the providers who completed the survey are shown in Table 2. Medical providers (43%) were less likely to be male than dental providers (69%) or pharmacists (67%) (p < .05). Dental providers (11%) were less likely to have been in practice for 10 years or less, when compared to medical (27%) or pharmacy (28%) providers (p < .05). Similarly, dental providers (57%) were more likely to have been in practice for at least 31 years, when compared to medical (31%) and pharmacy (25%) providers (p < .05). Dental providers (64%) were more likely to serve suburban communities than medical (52%) and pharmacy (33%) providers (p < .05). On the other hand, pharmacy providers (44%) were more likely to serve rural communities than medical (18%) or dental (14%) providers (p < .05).

Table 2. Demographics of NYS healthcare providers surveyed regarding HPV vaccine knowledge, attitudes, and practices.

	Total respondents	Medical providers	Dentist	Pharmacists
Total respondents	1637	864 (53)	737 (45)	36 (2)
Male	907 (55)	375 (43)	507 (69)	25 (69)
Race
American Indian/Alaskan Native	6 (<1)	4 (<1)	2 (<1)	0
Asian	146 (9)	92 (11)	52 (7)	2 (6)
Black/African American	42 (3)	32 (4)	9 (1)	1 (3)
Native Hawaiian/Pacific Islander	1 (<1)	1 (<1)	0	0
White	1401 (86)	732 (84)	646 (88)	32 (89)
Ethnicity
Hispanic/Latino	55 (3)	29 (3)	25 (3)	1 (3)
Years in practice
< 1	30 (2)	26 (3)	4 (<1)	0
1–10	271 (17)	187 (22)	74 (10)	10 (28)
11–20	265 (16)	158 (11)	96 (13)	11 (31)
21–30	371 (23)	221 (26)	144 (20)	6 (17)
31 +	700 (43)	272 (31)	419 (57)	9 (25)
Communities served
Rural	282 (17)	159 (18)	106 (14)	17 (47)
Suburban	931 (57)	451 (52)	469 (64)	11 (31)
Urban	631 (39)	384 (44)	233 (32)	14 (39)

Medical providers

The majority of medical providers correctly responded that HPV vaccination does not increase the risk of unprotected sexual activity³⁰ (823/864, 95%) and that HPV vaccine is routinely recommended for both males and females by the Advisory Committee on Immunization Practices² (815/864, 94%). In contrast, fewer than one-third of medical providers (273/864, 32%) correctly responded that oropharyngeal cancer is the most common HPV-associated malignancy (Table 3a).¹ Medical providers who correctly reported that oropharyngeal cancer was the most common HPV-associated cancer (265/273, 97%) were more likely than those who did not answer this question correctly (550/590, 93%), p < .05 to know that HPV vaccine should be routinely administered to age-eligible males and females. When compared to male providers, female providers were more likely to correctly respond that HPV vaccination does not increase the risk of unprotected sexual activity (475/488 (98%) vs 347/375 (93%), p = .001). When stratified by field of practice, primary care providers were more likely than subspecialty care providers to correctly respond that HPV vaccine is routinely recommended for both females and males (482/500 (96%) vs 321/351 (91%), p < .05). No other differences were noted for responses to knowledge questions between primary care and subspecialty care providers.

Table 3. Vaccine knowledge, attitudes, and practices among (A) medical providers (B) dental providers and pharmacists across New York State.

	All medical providers (n = 864) N (%)				Primary care providers (n = 500) N (%)				Specialty care providers (n = 351) N (%)
Vaccine knowledge statements	Correct	Incorrect	Unsure		Correct	Incorrect		Unsure	Correct		Incorrect		Unsure
(A)
Vaccinating young adolescents against HPV infection increase risk of unprotected sexual activity	823 (95)	14 (2)	27 (3)		481 (96)	8 (2)		11 (2)	330 (94)		6 (2)		15 (4)
Oropharyngeal cancer is the most common HPV-associated cancer	273 (32)	432 (50)	158 (18)		154 (31)	265 (53)		81 (16)	113 (32)		161 (46)		77 (22)
HPV vaccine should be routinely administered to age-eligible males and females	815 (94)	24 (3)	24 (3)		482 (96)	9 (2)		9 (2)	321 (91)		15 (4)		15 (4)
Provider vaccine recommendation is associated with vaccine acceptance	796 (89)	30 (3)	26 (3)		471 (94)	14 (3)		14 (3)	313 (89)		16 (5)		22 (6)
Vaccine knowledge score above 75%	769 (89)				457 (91)				300 (85)
Vaccine attitude statements	Strong agreement N (%) [mean LOA^a]				Strong agreement N (%) [mean LOA^a]				Strong agreement N (%) [mean LOA^a]
I am confident in my ability to communicate with vaccine hesitant patients/families	323 (37) [4.11]				204 (41) [4.22]				116 (33) [3.97]
I have a responsibility to ensure that my patients are fully vaccinated	448 (52) [4.16]				340 (68) [4.55]				104 (30) [3.62]
Other providers recognize my role in vaccinating patients	321 (37) [3.71]				270 (55) [4.30]				48 (14) [2.88]
HPV vaccine is effective in preventing HPV-associated cancers	599 (69) [4.65]				381 (76) [4.73]				212 (60) [4.54]
Promoting HPV vaccine is within my scope of practice	487 (56) [4.02]				409 (82) [4.68]				70 (20) [3.08]
Vaccine attitudes score above 75%	616 (71)				457 (91)				152 (43)
Vaccine practices statements	N (%)				N (%)				N (%)
Age at which you routinely begin strongly recommending HPV vaccine	509 responses				418 responses				86 responses
11–12 years	390 (77)				329 (79)				57 (66)
13–14 years	68 (13)				52 (12)				15 (17)
15–18 years	26 (5)				17 (<1)				9 (10)
18 + years	25 (5)				20 (5)				5 (6)
Age at which most of your patients who get immunized accept the first dose of HPV vaccine	455 responses				396 responses				57 responses
11–12 years	233 (51)				207 (52)				26 (46)
13–14 years	137 (30)				122 (31)				13 (23)
15–18 years	52 (11)				39 (10)				13 (23)
18 + years	33 (7)				28 (7)				5 (9)
Provider routinely recommends HPV vaccine	612 responses				471 responses				349 responses
Males	3 (<1)				1 (<1)				2 (<1)
Females	25 (4)				16 (3)				9 (3)
Both	584 (95)				427 (91)				152 (44)
Vaccine knowledge statements	Dental providers (n = 737) N (%)								Pharmacists (n = 36) N (%)
Dental providers and Pharmacists	Correct			Incorrect			Unsure		Correct	Incorrect		Unsure
(B)
Vaccinating young adolescents against HPV infection increase risk of unprotected sexual activity	600 (81)			26 (4)			110 (15)		27 (75)	3 (8)		6 (17)
Oropharyngeal cancer is the most common HPV-associated cancer	461 (63)			101 (14)			174 (24)		8 (22)	8 (22)		20 (56)
HPV vaccine should be routinely administered to age-eligible males and females	592 (80)			39 (5)			104 (14)		28 (78)	1 (3)		7 (19)
Provider vaccine recommendation is associated with vaccine acceptance	529 (72)			54 (7)			148 (20)		33 (92)	1 (3)		2 (6)
Vaccine knowledge score above 75%				536 (73)			24 (67)
Vaccine attitude statements	Strong agreement N (%) [mean LOA^a]								Strong agreement N (%) [mean LOA^a]
I am confident in my ability to communicate with vaccine hesitant patients/families	206 (28) [3.84]								32 (89) [4.14]
I have a responsibility to ensure that my patients are fully vaccinated	126 (17) [3.33]								24 (67) [3.89]
Other providers recognize my role in vaccinating patients	57 (8) [2.73]								29 (81) [4.11]
HPV vaccine is effective in preventing HPV-associated cancers	344 (47) [4.33]								32 (89) [4.36]
Promoting HPV vaccine is within my scope of practice	153 (21) [3.22]								17 (47) [3.61]
Vaccine attitudes score above 75%	275 (37)								24 (67)
Vaccine practices statements	N (%)								N (%)
Age at which you routinely begin strongly recommending HPV vaccine	209 responses								2 responses
11–12 years	73 (35)								2 (100)
13–14 years	47 (22)								0
15–18 years	42 (20)								0
18 + years	47 (22)								0

^aLOA: level of agreement.

Among medical providers, more than half reported strong agreement with the statement that the HPV vaccine is effective in cancer prevention (599/864, 69%) [mean level of agreement 4.65, SD 0.589] and that promoting HPV vaccine is within their scope of practice (487/864, 56%) [mean level of agreement 4.02, SD 1.311] (Table 3a). Primary care providers had higher mean levels of agreement than subspecialty care providers with the statement that the HPV vaccine is effective in cancer prevention (4.73 vs 4.54, p < .001). Providers with higher mean levels of agreement with the statement that promoting the HPV vaccine is within their scope of practice were more likely to practice primary care (4.68 vs 3.03, p < .001), to be female (4.22 vs 3.75, p < .001), to serve rural communities (4.22 vs 3.97, p = .03), and to not serve urban communities (4.11 v 3.90, p = .017).

More than half of the medical providers who completed the survey (509/864 (59%)) report recommending the HPV vaccine to their patients, with 390/509 (77%) strongly recommending it for patients 11–12 years of age (Table 3a). Of the 435 medical providers who responded to the question regarding unimmunized individuals aged 19 to 26 years, only 248 (57%) reported routinely recommending or discussing HPV vaccine with this age cohort. When stratified by field of practice, primary care providers were more likely than subspecialty care providers to routinely recommend the HPV vaccine to their patients (418/500 (84%) vs 86/351 (25%), p < .00001). Among those providers who recommend the HPV vaccine to their patients, primary care providers were more likely than subspecialty care providers to do so for patients 11–12 years of age (329/418 (79%) vs 55/82 (67%), p < .01).

Medical providers were more likely to recommend the HPV vaccine at ages 11–12 years if they strongly agreed that promoting HPV vaccine is within the scope of practice (335/408 (82%) vs 55/101 (55%)) and that the HPV vaccine is effective in cancer prevention (326/391 (83%) vs 64/117 (55%) and if they correctly responded that HPV vaccine does not increase the risk of unprotected sexual activity (386/494 (78%) vs 4/15 (25%)) and that the HPV vaccine is routinely recommended for both females and males (385/499 (77%) vs 4/9 (15%)) (p < .05) (Table 4). Correlations between HPV vaccine knowledge, attitudes, and practices are shown in Table 5a.

Table 4. Association of HPV vaccine knowledge and attitudes with the routine recommendation of HPV vaccine at ages 11–12 years among all medical providers.

Vaccine attitude statements	Routinely recommends HPV vaccine at 11–12 years Mean level of agreement (SD)	Does not routinely recommend HPV vaccine at 11–12  years Mean level of agreement (SD)	P^a
It is my responsibility to ensure that patients are fully vaccinated	4.59 (.812)	4.26 (.916)	< .001
Promoting HPV vaccine is within scope of practice	4.79 (.573)	4.41 (.906)	< .001
Other providers recognize my role in vaccinating	4.34 (.974)	3.74 (1.069)	< .001
HPV vaccine is effective in cancer prevention	4.82 (.433)	4.52 (.581)	< .001
Vaccine knowledge statements	Routinely recommends HPV vaccine at 11–12 years Correctly answered (%)	Does not routinely recommend HPV vaccine at 11–12 years Correctly answered (%)	P^b
HPV vaccination increases the risk of unprotected sexual activity	386/390 (99)	108/119 (92)	< .001
Provider vaccine recommendation is associated with vaccine acceptance	376/390 (96)	106/118 (90)	< .01
HPV vaccine is routinely recommended for females and males	385/390 (99)	114/119 (96)	< .05

^atwo-sided t-tests were used to compare the mean level agreement with each of the vaccine attitude statements.

^bChi-square testing was used to compare the number of providers who correctly answered each of the vaccine knowledge statements.

Table 5. Correlations between HPV vaccine knowledge, attitudes, and recommendation practices among (A) medical providers, (B) dental providers, and (C) pharmacy providers.

	HPV vaccine is effective in cancer prevention	Other providers recognize my role in vaccinations	It is my responsibility to ensure patients are fully vaccinated	Promoting HPV vaccine is within my scope of practice	I am confident in my ability to communicate with vaccine hesitant patients	Routinely recommends HPV vaccine at ages 11–12 years
	Pearson correlation (n)	Pearson correlation (n)	Pearson correlation (n)	Pearson correlation (n)	Pearson correlation (n)	Pearson correlation (n)
(A)
HPV vaccine knowledge scores	.331*** (863)	.160*** (862)	.174*** (862)	.230*** (862)	.111** (862)	.163*** (508)
Routinely recommends HPV vaccine at ages 11–12 years	.265*** (508)	.247*** (509)	.163*** (509)	.237*** (509)	.045 (509)
I am confident in my ability to communicate with vaccine hesitant patients	.098* (862)	.301*** (864)	.366*** (864)	.182*** (862)
Promoting HPV vaccine is within my scope of practice	.324*** (862)	.591*** (862)	.484*** (862)
It is my responsibility to ensure patients are fully vaccinated	.292*** (862)	.662*** (864)
Other providers recognize my role in vaccinations	.242*** (862)
(B)
HPV vaccine knowledge scores	.433*** (730)	.065 (730)	.255*** (731)	.328*** (729)	.093* (731)	.139* (208)
Routinely recommends HPV vaccine at ages 11–12 years	.131 (208)	.079 (209)	.128 (209)	.126 (209)	.01 (209)
I am confident in my ability to communicate with vaccine hesitant patients	.055 (734)	.370*** (733)	.455*** (734)	.149*** (733)
Promoting HPV vaccine is within my scope of practice	.321*** (733)	.186*** (732)	.272*** (732)
It is my responsibility to ensure patients are fully vaccinated	.191*** (733)	.518*** (733)
Other providers recognize my role in vaccinations	.074* (732)
(C)
HPV vaccine knowledge scores	.492** (36)	.093 (36)	.298 (36)	.237 (36)	−.02 (36)	.437 (9)
Routinely recommends HPV vaccine at ages 11–12 years	0 (1)	.449 (9)	.09 (9)	.500 (9)	0 (9)
I am confident in my ability to communicate with vaccine hesitant patients	.003 (36)	.467** (36)	.490** (36)	−.137 (36)
Promoting HPV vaccine is within my scope of practice	.346* (36)	.119 (36)	.203 (36)
It is my responsibility to ensure patients are fully vaccinated	.295 (36)	.556*** (36)
Other providers recognize my role in vaccinations	.194 (36)

*represents p < .05, **represents p < .001, ***represents p < .0001.

Dental providers

The majority of dental providers correctly responded that: HPV vaccination does not increase the risk of unprotected sexual activity (600/737, 81%), oropharyngeal cancer is the most common HPV-associated cancer (461/737, 63%), and the HPV vaccine is routinely recommended for both females and males (592/737, 80%) (Table 3b). Dental providers who correctly reported that oropharyngeal cancer was the most common HPV-associated cancer (396/461, 86%) were more likely than those who did not answer this question correctly (197/275, 72%), p < .0001) to know that HPV vaccine should be routinely administered to age-eligible males and females. When compared to male providers, female providers were more likely to correctly respond that the HPV vaccine does not increase the risk of sexual activity (199/227 (88%) vs 398/507 (79%), p = .003) and that oropharyngeal cancer is the most common HPV-associated cancer (172/227 (76%) vs 289/507 (57%), p < .001). Providers who serve urban communities were more likely than those who do not to correctly respond that provider vaccine recommendation is associated with vaccine acceptance (180/230 (78%) vs 349/501 (70%), p = .016) and that the HPV vaccine is routinely recommended for both females and males (196/231 (85%) vs 395/504 (78%), p = .04).

Fewer than one-third of dental providers strongly agree that they are confident in their ability to communicate with vaccine hesitant families (206/735, 28%), they have a responsibility to ensure that patients are fully vaccinated (126/734, 17%), and that other providers recognize their role in vaccinations (57/733, 8%). Less than half of dental providers report strong agreement that the HPV vaccine is effective in cancer prevention (343/735, 47%) (Table 3b). Dental providers had higher mean levels of agreement with the statement that the HPV vaccine is effective in cancer prevention if they correctly answered that the HPV vaccine is routinely recommended for both males and females (4.55 vs 3.71, p < .01) and that oropharyngeal cancer is the most common HPV-associated cancer (4.88 v 4.25, p < .05) (Table 4b). Even fewer dental providers report strong agreement that promoting HPV vaccine was within their scope of practice (153/734, 21%). Just about 30% of dental providers report discussing the HPV vaccine with 11–26-year-old females (230/737, 31%) and males (205/737, 28%) at least as frequently as “sometimes.” When compared to females, male dental providers had higher mean levels of agreement with the statements. It is my responsibility to ensure that patients are vaccinated (3.43 (SD 1.146) vs 3.08 (SD 1.100), p < .001) and that other providers recognize my role in vaccinations (2.86 (SD 1.094) vs 2.46 (SD 1.044), p < .001) and lower level of agreement with the statement, I am confident in my ability to communicate with vaccine hesitant patients (3.67 (SD 1.167) vs 4.50 (SD .674), p = .029).

Dental providers serving urban communities, when compared to those who do not, had higher mean levels of agreement with the statements, promoting HPV vaccine is within my scope of practice (3.47 (SD 1.342) vs 3.11 (SD 1.304), p < .001), it is my responsibility to ensure that patients are vaccinated (3.64 (SD 1.045) vs 3.18 (SD 1.156), p < .001), other providers recognize my role in vaccinations (2.87 (1.065) vs 2.68 (SD 1.101), p = .032), and that HPV vaccine is effective in cancer prevention (4.45 (SD .683) vs 4.27 (SD .773), p = .002).

Dental providers were more likely to routinely discuss the HPV vaccine with patients at ages 11–12 years if they correctly responded that HPV vaccination does not increase the risk of unprotected sexual activity (70/73 (96%) vs 528/662 (80%), p < .001) and that the HPV vaccine is routinely recommended for both females and males (73/73 (100%) vs 517/661 (78%), p < .001). Correlations between HPV vaccine knowledge, attitudes, and practices are shown in Table 5b.

Pharmacy providers

The majority of pharmacy providers correctly responded that HPV vaccination does not increase the risk of unprotected sexual activity (27/36, 75%) and that the HPV vaccine is routinely recommended for both females and males (28/36, 78%). Less than a quarter, however, correctly responded that oropharyngeal cancer is the most common HPV-associated cancer (8/36, 22%) (Table 3b). When compared to male providers, female providers were more likely to correctly identify that oropharyngeal cancer is the most common HPV-associated cancer (6/12 (50%) vs 2/24 (8%), p = .005). Provider serving urban communities were less likely to correctly identify provider vaccine recommendation was associated with vaccine acceptance (22/22 (100%) vs 11/14 (79%), p = .023).

At least one-third of pharmacy providers strongly agreed that they are confident in their ability to communicate with vaccine hesitant families (12/36 (33%)), they have a responsibility to ensure that patients are fully vaccinated (14/36 (39%)), and that other providers recognize their role in vaccinations (14/36 (39%)). Only half of pharmacy providers report strong agreement that the HPV vaccine is effective in cancer prevention (18/36 (50%)). Further, only 11/36 (31%) reported strong agreement that promoting the HPV vaccine is within their scope of practice (Table 3b). Females had higher mean level of agreement than males with the statement, It is my responsibility to ensure that patients are fully vaccinated (4.50 (SD .674) vs 3.67 (SD 1.167), p = .029).

Few pharmacists report discussing HPV vaccine with 11–26-year-old females (6/36 (17%)) and males (5/36 (14%)) at least as frequently as “sometimes.” Correlations between HPV vaccine knowledge, attitudes, and practices are shown in Table 5c. No other associations were observed.

Discussion

Here we describe HPV vaccine knowledge, attitudes, and recommendation or discussion practices among NYS medical, dental, and pharmacy providers, each of whom play a role in promoting community health. We found that just over half of medical providers, less than a third of dental providers, and fewer than a fifth of pharmacists report recommending or discussing the HPV vaccine with eligible patients. Three-quarters of the medical providers who recommend the HPV vaccine to their patients report strongly recommending the HPV vaccine for patients 11–12 years of age. Others have published similar rates on providers responding that they strongly recommend the vaccine as part of their routine practice, with one study reporting a rate of 85%, Despite these encouraging reports, we^17,31 and others^14,32,33 have presented data suggesting that 25%−30% of providers are still not routinely recommending the HPV vaccine to these young adolescents.

In the present study, medical providers were more likely to routinely recommend the HPV vaccine at ages 11–12 years if they were practicing in primary care (compared to subspecialty care providers). Not surprisingly, Rosen et al., also described that primary care providers, specifically those practicing general pediatrics, were more likely to recommend HPV vaccine than any other group.¹⁰ Similarly, Hofstetter found that only half of subspecialists caring for adolescents with complex medical conditions sometimes or always recommended HPV vaccination to their patients, with reported barriers to vaccine recommendations including lack of sufficient vaccine knowledge and limited primary-specialty care provider communication.³⁴ More than one-third of the US population have medical visits predominantly with subspecialists, with half of these individuals not having visited a primary care practice at all during the course of a year.³⁵ This highlights an opportunity for specialty providers to play an increasing role in promoting and ensuring that their patients receive all routinely recommended immunizations, including HPV vaccine. Due to the impact of HPV acquired during adolescence and young adulthood on the oropharyngeal and genitourinary tracts, professionals practicing in a variety of healthcare fields are in a prime position to discuss HPV vaccine for cancer prevention with their patients. Comprehensive HPV vaccine education and updates must continue for pediatricians and family medicine providers but now needs to extend beyond those traditional groups to other stakeholders whose patients are impacted by HPV infection and sequelae.

Dentists, for example, routinely perform oral cancer screening and are encouraged by their national organization to educate patients on the link between HPV and oropharyngeal cancer and counsel them on the benefits of HPV vaccination for cancer prevention. However, we found fewer than one-third of dental providers routinely discuss the HPV vaccine with patients in the target age group (11–26 years). While our findings are disappointing, the rates we have reported here are higher than those reported from dental providers in Vermont, where 78% of those responding to a survey reported that they rarely discuss HPV disease and vaccine with their patients.³⁶ In that report, dental providers did not have strong confidence in their ability to communicate with vaccine hesitant patients and families, stated that they were not generally recognized as having a role in vaccination, but did respond that promoting HPV vaccine was within their scope of practice. The findings support prior observations that dentists generally believe they should talk about HPV complications and prevention but do not have the confidence in their ability to do so.^37,38 While patients and parents report interest in receiving education regarding the link between HPV infection oropharyngeal cancer and the importance of vaccination for cancer prevention by their dentist, few dental providers report being comfortable delivering this information.^37–43 Barriers to discussing the HPV vaccine with patients cited by dental providers include lack of formal training in HPV infection and vaccination, limited skill in communicating with patients, and lack of guidance for their role in vaccinations.^15,36,43 Guadiana found that taking a class on HPV increased vaccine confidence, which was associated with increased likelihood of discussing HPV vaccine with patients.⁴⁴ Guidance from the American Dental Association’s HPV vaccination policy published in 2018 encourages these conversations during patient counseling. It is anticipated that the recent FDA expansion of the HPV vaccine labeling indication to include prevention of oropharyngeal cancers will also lead to increased HPV vaccine-related discussions by dental providers, but further focused interventions, including specific delineation of the role dentists play in HPV vaccine promotion, communication training and providing written patient education (brochures, posters) are needed to optimize this strategy.

Similarly, we found that only 30% to 40% of surveyed pharmacists reported strong agreement that promoting HPV vaccine is within their scope of practice, confidence in their ability to communicate with vaccine hesitant patients and families, and that other providers recognize their role in vaccinations. While the legislation regarding vaccine administration varies by vaccine, patient population, and geographic location, the role of the pharmacist in promoting vaccinations to the community has been long established, particularly with increase accessibility and availability of community pharmacies when compared to medical offices.⁴⁵ While pharmacies are commonly recommending and administering other vaccines (ie: influenza vaccine, herpes zoster vaccine), the majority of pharmacies surveyed by Hastings et al., report not making any HPV vaccine recommendations to eligible patients.⁴⁶ While many pharmacists believe that HPV vaccine promotion is within their professional scope, the lack of education received about the infection and vaccine safety and efficacy has become a barrier to these discussions.^46,47 As pharmacists are uniquely positioned to interact with potential vaccine-eligible clients, increasing their confidence and knowledge regarding HPV vaccine as cancer prevention through educational interventions and reinforcing their role in HPV vaccine promotion can have significant impact on adolescent HPV vaccine uptake.

We also identified gaps in HPV infection and vaccine knowledge among all healthcare providers (medical, dental, and pharmacists), specifically as it relates to the impact of HPV vaccine on the risk of unprotected sexual activity, HPV-associated oropharyngeal cancer disease burden, and the effectiveness of the HPV vaccine to prevent HPV-associated cancers. Higher vaccine knowledge was associated with increased likelihood of recommending HPV vaccine to 11–12-year-old patients. Similar findings have been described among healthcare providers across the country.^{14,36,43,48,49} The data reported here show that 87% of medical and dental providers correctly reported that HPV vaccination does not increase the risk of unprotected sexual activity. Further, providers who correctly answered this question were more likely to recommend or discuss the HPV vaccine with adolescents ages 11–12 years. This finding supports previously published works which found that associating the HPV vaccine with sex or believing that adolescents who receive the HPV vaccine are at an increased risk of sexual activity are factors that reduce the likelihood of delivering a strong vaccine recommendation.^13,17 On the other hand, understanding the effectiveness of the HPV vaccine in prevention of HPV-associated cancers is associated with higher likelihood of delivering a strong provider vaccine recommendation.^10,18 Furthermore, parents report wanting the providers to discuss with them diseases prevented by the HPV vaccine and how effective vaccination is, particularly for cancer prevention.¹³ Future educational interventions for medical and dental providers should include a review of the data showing that HPV vaccination does not impact sexual behaviors as well as data describing HPV-associated cancer burden and effectiveness of vaccination in HPV-associated cancer prevention.

Limitations of this work include the bias that is associated with survey studies. Recall bias may be present with regard to questions about vaccine recommendation and discussion practices. Selection bias, as a result of voluntary study participation, may inadvertently lead to an over-assessment of vaccine confident providers. Religion is known to influence vaccine attitudes, however, the demographic questions on the survey did not address the provider’s religious beliefs. Therefore, we are unable to ascertain the impact of religion on vaccine attitudes among our study population. Overall, a low percentage of respondents were pharmacists. However, we were unable to determine the denominators for the three subgroups and therefore, could not determine whether or not a similar proportion of responses were received from each group. While these data may not be generalizable, they do provide us with some understanding of the HPV vaccine knowledge, attitudes, and self-reported practices among healthcare providers that can be used to identify areas to target when developing interventions to improve vaccine confidence and vaccine uptake.

Gaps in HPV vaccine knowledge among providers in various healthcare roles still exist and may influence vaccine attitudes and vaccine recommendation or discussion practices. Interventions to strengthen provider HPV infection and vaccine knowledge, with a specific focus on the disease burden of HPV-associated cancers and the impact of vaccine in cancer prevention, should be disseminated from national and professional societies to their respective healthcare providers in an effort to improve vaccine knowledge, confidence, and vaccine recommendation or discussion practices. In addition, consideration should be given to incorporating more education within the medical, dental, and pharmacy student curriculum. By providing further training regarding HPV infection and risk of cancer development, vaccine safety and efficacy, and communication strategies with vaccine hesitant patients and families, it can be ensured that future healthcare professionals are armed with the skills and confidence needed to deliver this important preventive care service.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported in part by a research grant from Investigator-Initiated Studies Program of Merck Sharp & Dohme Corp. The opinions expressed in this paper are those of the authors and do not necessarily represent those of Merck Sharpe & Dohme Corp.