HPV Vaccine Recommendation Profiles among a National Network of Pediatric Practitioners: Understanding Contributors to Parental Vaccine Hesitancy and Acceptance

"Health care clinicians, particularly those in pediatric settings, play a critical role in HPV vaccine uptake but also, in recognizing parental hesitancy..."

Studies have found that a practitioner's recommendation is one of the most consistent predictors of human papillomavirus (HPV) vaccination. The present research investigated patterns of practitioner communication about HPV vaccine recommendation in the United States (US), where rates of vaccination remain suboptimal at 50.4%-65.9%, depending upon geographical area.

The study used a methodological technique called latent class analysis (LCA), a person-oriented approach that, unlike traditional multivariate models, involves studying individuals as a whole on the basis of their response patterns across a number of individual characteristics relevant for a particular phenomenon (e.g., practitioner recommendation patterns).

Four hundred and seventy paediatric practitioners of the American Academy of Pediatrics (AAP)'s Pediatric Research in Office Settings (PROS) national network completed an online survey where they were presented with 5 hypothetical vignettes of well child visits and responded to questions. Questions asked about their use of communication strategies, assessments about the adolescent patient becoming sexually active in the next 2 years for decision-making about HPV vaccine recommendation, and peer norms.

LCA yielded 3 distinct practitioner vaccine recommendation patterns:

1. "Engagers" (52% of respondents) reported being highly engaged with families around HPV vaccination. They had high response probabilities for strongly recommending HPV vaccine initiation to parents of youth, recommending vaccination at today's visit, and recommending HPV vaccination at the same time as other adolescent vaccines. This subgroup of practitioners, more than any other, was inclined to describe the following benefits when talking to parents about HPV vaccination: cancer protection, genital wart protection, and a stronger antibody response when vaccinating at a younger age, and they were more likely to do so using a positive tone. Engagers perceived peer practitioners as also strongly recommending HPV vaccination to parents of youth and were less likely to use a risk-based approach (e.g., assessing whether the patient will become sexually active in the next 2 years).
2. "Protocol Followers" (20%) did report being highly likely to strongly recommend HPV vaccine, perceived peers as strongly recommending HPV vaccination, and showed adherence to national age-based vaccine recommendation guidelines. However, they were less likely to engage families in conversations about HPV vaccine benefits.
3. "Ambivalent Recommenders" (28%) reported a very low probability of strongly recommending HPV vaccine initiation or recommending at all to parents of youth. They were likely to report using judgment about whether the adolescent patient will become sexually active in the next 2 years to decide when to recommend HPV vaccination and were less likely to emphasise the importance of vaccinating against HPV the same day. Ambivalent Vaccine Recommenders did not perceive peer practitioners as prioritising HPV vaccination and did not perceive their peers as strongly recommending HPV vaccine initiation to parents of youth.

Reflecting on the findings, the researchers stress that "[p]eer norms play an underappreciated role in bringing about changes in recommended practice guidelines especially in today's predominantly group practice structures....Physician champions have been discussed in the literature as assuming key roles in nationwide quality improvement initiatives including HPV vaccination....Our results support the importance of targeting peer practice norms as part of communication training."

This study points to a possible contributor to vaccine hesitancy - namely, a sizeable minority or practitioners are communicating ambivalent HPV vaccination recommendations. "While moving toward having all pediatric practitioners make HPV vaccine recommendations routinely and consistently, simply making a recommendation is not sufficient....The specific language the provider uses, the tone, the timeliness and whether they treat HPV vaccination in the same way as other adolescent vaccines to communicate recommendations can have major effects on parents' vaccine attitudes and whether they will have their children vaccinated."

In conclusion, to bolster vaccination rates, future studies could test interventions to address use of effective HPV vaccine recommendation strategies among clinicians who may be Ambivalent Recommenders, as identified in this study. Furthermore, due to the finding that practicing in a suburban office predicted a two-fold higher odds of Ambivalent Recommender practice pattern, suburban paediatric offices in particular may benefit from practitioner training in optimal HPV vaccine recommendation practices.