Emergency medicine physician attitudes toward HPV vaccine uptake in an emergency department setting

Abstract

A physician's recommendation is the most effective published method of motivating HPV vaccination initiation. The emergency department (ED) is the 'public health safety net', and often the only access to care for underserved populations. Recommendation of the HPV vaccine in the ED is a potential avenue to improve vaccination rates among sub-populations who do not have access to routine medical care. We assessed willingness of EM physicians to recommend the vaccine, target high-risk women, and disclose perceived barriers to vaccination in the ED. A cross sectional study using an 11-item survey, was used to assess physician attitudes toward recommending the HPV vaccine in an ED setting to age eligible patients. 67.4% stated they would recommend the vaccine, 23.9% were neutral, and 8.7% would not recommend the vaccine to age eligible patients in the ED. 41% noted lack of adequate reimbursement for vaccination as a barrier to vaccination in the ED (P < 0.05). Physicians were comfortable targeting women at high risk for cervical cancer for vaccination (P < 0.05). EM physicians are comfortable targeting high-risk women for HPV vaccination in an ED setting. Support of EM physicians in the national effort to improve HPV vaccine uptake is an important step in eradicating a largely preventable yet lethal cancer.

Keywords:

• HPV vaccine
• physician recommendation
• emergency medicine
• young adults
• physician attitudes

Introduction

Physician recommendation of the HPV vaccine is consistently an important predictor of HPV vaccine uptake.^1-14 Preventive care, specifically HPV vaccination, for females are traditionally driven by Pediatricians, Family Physicians, and Obstetricians/Gynecologist (OB/GYN).¹ Professional organizations in these specialties consistently support HPV vaccine uptake; yet, vaccine recommendation rates vary by provider specialty.^1,15 National guidelines suggest HPV vaccine uptake to all females 11–26 y of age; however, physicians reporting recommendation of HPV vaccination among this population ranges from 25.8% to 74.5% (variance was dependent upon age group and physician specialty).¹

Family physicians reported higher intention to vaccinate older adolescents.¹⁶ A strong physician's recommendation of the HPV vaccine resulted in a 4-fold greater chance of HPV vaccination among young adult women 19–26 y.¹³ Research findings found notable predictors associated with provider intent to offer the HPV vaccine to age eligible females, including practice characteristics, provider characteristics, knowledge about HPV, attitudes toward administering the vaccine, and intention to vaccinate their own children.^16-20

Due to the established success of provider recommendation, gaining the support of emergency medicine (EM) providers in the national strategy of improving HPV vaccine initiation and series completion is ideal. EM physicians encounter subsets of the population who likely have no other interactions with health care systems.^21-25 The emergency department (ED) is the national public health safety net^21-25; thus, broadband public health strategies, such as national efforts to improve HPV vaccine uptake and completion, should incorporate EM providers within strategic development efforts.¹⁴

Existing ED based cervical cancer preventions efforts have incorporated pap smears with routine pelvic exams in the ED. Study findings confirm that this effort has the potential to serve an important role in early detection for patients at high risk for HPV infections and cervical cancer.²⁶ Recent research found more low income women received cervical cancer screening during a routine visit to the ED than women seen in the ED, and they were referred for outpatient screening.^27,28 A pilot study is currently underway administering vaccinations and pap smears to uninsured women presenting to the ED.²⁹ These researchers hypothesize that a large number of high-risk women who present to the ED could be targeted for HPV vaccination. HPV vaccination efforts are likely a driver in the future direction of ED based, public health initiatives against HPV infection and cervical cancer.

Research is needed to indicate whether ED physicians would support incorporating HPV vaccination initiation into their clinical practice. Previous researchers suggest the focus should be on strengthening intentions to vaccinate among physicians who serve vaccine eligible populations, in specialties other than family medicine and OB/GYN.²⁰ Previous research confirm that physician immunization practices are associated with their attitudes about vaccination.³⁰ Pediatricians’ and family physicians’ attitudes toward intention to vaccinate have been evaluated, as those attitudes play a major role in their practice. A survey study done with family physicians found that attitudes about vaccination were associated with intent to recommend HPV vaccine.¹⁶ The goal of the current study is to assess the attitudes of ED physicians toward primary cervical cancer prevention through HPV vaccination in the ED. We examined whether ED physicians would: 1) offer the vaccine to age eligible, young adult women, 2) target high-risk women, and/or 3) disclose perceived barriers to HPV vaccination.

Results

A frequency analysis was done for each survey item, stratified by response categories and provider status (Table 1). Similar response trends among faculty and residents were noted regarding comfort level with HPV vaccine administration, comfort targeting high risk women for vaccination, belief that HPV vaccine can prevent genital warts, time for HPV vaccination discussion in an ED setting is perceived as a barrier, and an inability to assess vaccine series completion in an ED setting. Faculty members and residents differed in opinion regarding the belief that HPV vaccine is very effective at preventing cervical cancer (11.1% vs 41.4% respectively), agreed it is necessary to test for HPV prior to HPV vaccination (27.8% vs. 10.3% respectively), strongly agreed that it is necessary to discuss patient's sexual behaviors prior to HPV vaccine recommendation (5.9% vs. 13.3% respectively), and strongly agreed that they would recommend the vaccine to age eligible patients (17.6% vs. 31.0% respectively). Broad response variance among residents related to the necessity of discussion with patients regarding their sexual behavior prior to HPV vaccine recommendation and perceived lack of adequate reimbursement for HPV vaccine as a barrier to ED based vaccination practices (Table 1).

Table 1. Frequency analysis of EM physicians towards cervical cancer prevention and HPV vaccine uptake

Independent Variables	Categories	EM Faculty & Residents,N = 50	%	EM Faculty, N = 19	%	EM Residents, N = 31	%
Comfort Level with HPV vaccine administration
	Very Comfortable	18	38.3	6	33.3	12	41.4
	Comfortable	8	17.0	4	22.2	4	13.8
	Neither comfortable or uncomfortable	14	29.8	6	33.3	8	27.6
	Uncomfortable	6	12.8	2	11.1	4	13.8
	Very Uncomfortable	1	2.1	0	0	1	3.4
Comfort targeting high risk women
	Very Comfortable	19	41.3	6	35.3	13	44.8
	Comfortable	7	15.2	3	17.6	4	13.8
	Neither comfortable or uncomfortable	14	30.4	6	35.3	8	27.6
	Uncomfortable	4	8.7	2	11.8	2	6.9
	Very Uncomfortable	2	4.3	0	0	2	6.9
Belief that HPV vaccine can prevent genital warts
	Very Effective	6	12.8	1	5.9	5	16.7
	Effective	27	57.4	10	58.8	17	56.7
	Neither effective or ineffective	10	21.3	4	23.5	6	20
	Ineffective	4	8.5	2	11.8	2	6.7
Belief that HPV Vaccine can prevent cervical cancer
	Very Effective	14	29.8	2	11.1	12	41.4
	Effective	29	61.7	14	77.8	15	51.7
	Neither effective or ineffective	4	8.5	2	11.1	2	6.9
Testing for HPV prior to HPV vaccination
	Agree	8	17.0	5	27.8	3	10.3
	Neither agree or disagree	10	21.3	3	16.7	7	24.1
	Disagree	21	44.7	8	44.4	13	44.8
	Strongly disagree	8	17.0	2	11.1	6	20.7
Time for HPV vaccination discussion perceived as barrier
	Strongly agree	13	27.7	5	27.8	8	27.6
	Agree	20	42.6	8	44.4	12	41.4
	Neither agree or disagree	9	19.1	4	22.2	5	17.2
	Disagree	3	6.4	1	5.6	2	6.9
	Strongly disagree	2	4.3	0	0	2	6.9
Inability to assess completion of vaccine series in ED setting
	Strongly agree	19	41.3	6	35.3	13	44.8
	Agree	19	41.3	7	41.2	12	41.4
	Neither agree or disagree	5	10.9	3	17.6	2	6.9
	Disagree	3	6.5	1	5.9	2	6.9
Necessary to discuss patient sexual behaviors prior to HPV vaccine recommendation
	Strongly agree	5	10.6	1	5.9	4	13.3
	Agree	9	19.1	3	17.6	6	20.0
	Neither agree or disagree	10	21.3	5	29.4	5	16.7
	Disagree	16	34.0	7	41.2	9	30.0
	Strongly disagree	7	14.9	1	5.9	6	20.0
Perceived lack of adequate reimbursement for HPV vaccination is a barrier to vaccination in ED
	Strongly agree	7	15.2	2	11.8	5	17.2
	Agree	12	26.1	7	41.2	5	17.2
	Neither agree or disagree	14	30.4	4	23.5	10	34.5
	Disagree	9	19.6	2	11.8	7	24.1
	Strongly disagree	4	8.7	2	11.8	2	6.9
Would recommend vaccine to age eligible patients
	Strongly agree	12	26.1	3	17.6	9	31.0
	Agree	19	41.3	8	47.1	11	37.9
	Neither agree or disagree	11	23.9	5	29.4	6	20.7
	Disagree	3	6.5	1	5.9	2	6.9
	Strongly disagree	1	2.2	0	0	1	3.4

An analysis of variance revealed EM faculty members were significantly more comfortable targeting high risk women for HPV vaccination than residents. Faculty and residents collectively perceived lack of adequate reimbursement for HPV vaccination as a barrier to ED based vaccination efforts (Table 2).

Table 2. Analysis of Variance (ANOVA) factored by whether EM physicians would recommend the HPV vaccine to age eligible patients

Dependent variable list	Stratification	F statistic	p-value
Comfort targeting high risk women
	Total	2.27	.080
	EM Faculty	3.87	.038*
	EM Residents	1.12	.372
Perceived lack of adequate reimbursement for HPV vaccination is a barrier to vaccination in ED
	Total	3.85	.01*
	EM Faculty	3.30	.055
	EM Residents	2.69	.057

* - significant at the p < .05 level; Italics – p < .10 and approaches significance at the p < .05 level.

A Pearson's chi-square analysis of relationships with physician recommendation of the HPV vaccine to age eligible patients showed a significant relationship to comfort targeting high risk women. Relationships approaching significance at the P < 0.05 level were with time for HPV vaccination discussion perceived as a barrier and perceived lack of adequate reimbursement for HPV vaccination as a barrier to vaccination in the ED (Table 3).

Table 3. Bivariate Analysis on whether EM physicians would recommend the HPV vaccine to age eligible patients

Independent variable	Stratification	Pearson's α^2	p-value
Comfort targeting high risk women
	Total	26.47	.048*
	EM Faculty	19.66	.020*
	EM Residents	17.39	.361
Time for HPV vaccination discussion perceived as barrier		25.03	.069
Perceived lack of adequate reimbursement for HPV vaccination is a barrier to vaccination in ED		25.36	.064

* - significant at the p < .05 level; Italics −p < .10 and approaches significance at the p < .05 level.

Discussion

Willingness to recommend HPV vaccine uptake to at-risk, young adult women among EM faculty and resident physicians has not been assessed previously; thus, the data presented here is a novel contribution to the existing body of literature. Physician recommendation is the most effective indicator of HPV vaccine uptake among young adult women, and this fact is well established.^1-14 This study showed the potential of using the ED for initiating HPV vaccine uptake and series completion among young women who otherwise would not have health care access for this important preventive intervention.

Targeting individuals at greatest risk for HPV and cervical cancer are supported approaches by researchers in the literature.²⁰ Current study findings support that EM physician faculty members are more comfortable targeting high risk, age eligible women for HPV vaccine uptake than residents. Similarly, older pediatricians were more supportive of HPV vaccination in comparison to younger pediatricians.¹⁵ Previous study findings suggest physicians who work with patients at high risk for HPV-related disease may better understand HPV infections, prompting them to realize the potential health benefits offered by a prophylactic vaccine.^16,31 Pediatricians practicing in urban settings perceive that their adolescent population are sexually active and are at risk for HPV disease.¹⁵ EM physicians are the primary healthcare providers of the nation's public health safety net, the ED. This safety net provides care to a diverse community of vaccine eligible individuals^23,24; thus, buy-in of this group of healthcare providers is important to public efforts aiming to improve HPV vaccine uptake and series completion overall. Previous efforts to increase HPV vaccine uptake have targeted schools and clinics, and both settings allow for repeat visits.^32,33 An ED visit may be the only point of care for women without a primary health care source, who lack adequate insurance, or do not have access to preventive services.³⁴ Willingness of EM physicians to target high risk young adult women for HPV vaccine uptake capitalizes on the opportunity to provide preventive services to a population that may not be linked to a routine health care source.

The time required to implement HPV vaccination recommendations as an ED based prevention efforts was perceived as a barrier by EM physicians. The need to discuss sexuality prior to vaccine recommendation is a reported barrier, as this pre-requirement adds demands on the provider's time.¹⁰ Physicians reporting time constraints in previous studies were less likely to recommend the HPV vaccine to target adolescent females.¹⁰ Established strategies to mitigate this barrier include patient-centered educational material and/or training of mid-level providers to discuss vaccination with patients.¹⁰ By sharing the responsibility with mid-level providers, comprehensive care to the patient is not compromised and the pressure of the physician's time is alleviated.³⁵ The potential public health benefit of incorporating HPV vaccine initiation into the clinical practice of ED healthcare providers is important, and has the chance to provide valuable preventive services to a much larger and more diverse catchment area.

Both EM faculty and residents perceived lack of adequate reimbursement for HPV vaccination as a barrier to ED based vaccination efforts. Pediatricians confirmed vaccine cost, insurance coverage, and reimbursement are critically important to vaccine delivery.¹⁵ Lack of insurance coverage was considered a notable barrier to successfully recommending HPV vaccine to age eligible persons.¹⁵ Cost is an established and dominating barrier to HPV vaccination,^36-43 supporting implementation of a publicly-funded vaccination program for at risk women.³⁶ Cost concerns by providers may be confounded by a lack of perceived value of the vaccine for sexually active women who have likely been exposed to HPV prior to vaccination. In the absence of a publicly-funded vaccination program, the HPV vaccine should be offered to age eligible women seeking care in the ED who have insurance coverage for the vaccine, whether public or private.

Limitations

The primary limitation of the study is the small sample size. In order to establish generalizability of the findings, this pilot study needs to be replicated with a larger sample size in emergency medicine departments at medical schools nationwide. Second, the data was based on self-report. Actual willingness to offer the HPV vaccine among clinicians was not measured; thus, an intervention assessing willingness would substantiate implications of study findings.

Future research

Cervical cancer prevention studies currently exist in the ED setting.⁴⁴ The current study provides supportive data for an ED based intervention. Incorporating a behavioral risk assessment into the intake process for patients would assist the ED provider in discerning high risk sexual activity of patients, with diverse chief complaints, who would benefit from the HPV vaccine. Emphasizing individual and public health benefits of HPV vaccination are key elements of educating provider directed initiatives and designing interventions aimed at modifying provider attitudes toward vaccine uptake.¹⁵ The current literature recommends using any visit to a health care provider as a primary opportunity to encourage HPV vaccine initiation.¹⁴ By adding HPV vaccine uptake to existing ED based cervical prevention efforts, we magnify the public health impact of an ED visit for age eligible young women seeking emergent care. Studies such as this provide insight to ED provider attitudes and intentions toward HPV vaccine uptake, which is useful information when designing HPV vaccine delivery programs utilizing our nation's public health safety net.¹⁶ The survey tool for this pilot study will be used to expand the survey for dissemination to faculty and residents at Emergency Medicine academic programs nationwide via an internet-based survey mechanism. Data gleaned from the full study will provide generalizable insight regarding physician attitudes toward HPV vaccine uptake in an ED setting.

Methods

The study population consisted of EM physician faculty and residents at the University of Texas Health at Houston (UT Health). The EM physicians enrolled in this study are a diverse group of faculty and residents with a singular commitment to educating academic leaders in emergency medicine, and providing quality clinical care with hospital partners. Among participants, the levels of experience, years of practice, and clinical standards/clinical cultural norms are diverse. Subjects were recruited at a monthly faculty meeting and monthly resident conference during October of 2013. Participants were either board certified EM attending physicians or resident physicians. A cross sectional survey study used an 10-item survey, including previously validated survey items used to gauge physician attitudes on HPV vaccination,^16,17 and new study-specific questions developed by investigators. The survey instrument was administered using a clicker audience response system that electronically captured audience response. We allowed a 10–20 min interval for survey implementation and completion. In both cases, the survey was completed by participants within 10 min. The response rate was, at minimum, 93.9% on all questions and as high as 100% on some questions. The rationale for refusals to participate was not assessed. The Center for the Protection of Human Subjects (IRB) approved the study and informed consent was implied by participation in the study (HSC-MS-13–0662). Statistical analysis was performed with IBM SPSS Statistics 21.0 (SPSS Inc. Chicago, IL). A descriptive frequency analysis on each survey measure was generated, followed by a bivariate analysis assessing the primary outcome measure as compared with comfort targeting high-risk women and perceived barriers to vaccination in the ED. Missing data are reported, but were excluded from the analysis, as only valid percent frequencies are reported.

Measures

Dependent variable

The primary outcome measure was whether EM physicians would recommend the vaccine to age eligible women in the ED.

Independent variables

Survey questions assessed physicians’ comfort with: HPV vaccine administration and targeting high risk women; HPV vaccine related beliefs about the vaccine's ability to: prevent genital warts and/or cervical cancer; need based beliefs about the need to test for HPV prior to vaccination and/or the need to discuss patient sexual behaviors prior to vaccine recommendation; perceptions of ED based HPV vaccination as a time related barrier and/or the lack of adequate reimbursement for the vaccine as a barrier; reservations about ED based HPV vaccination due to the inability to assess completion of vaccination series.

Disclosure of Potential Conflicts of Interest

There were no potential conflicts of interest.

Acknowledgment

We acknowledge the following contributors to the research presented: Samuel D. Luber, MD, MPH for providing the data capturing mechanism and lending the survey design expertise to the research team; Misha Granado, MPH, MS facilitated survey implementation and study approval. Erica Evans, MD for survey delivery to resident physicians.