Parent-Provider Communication of HPV Vaccine Hesitancy

"To reduce the burden of preventable HPV-related cancers, it is critical that providers actively engage in effective discourse with HPV vaccine-hesitant parents."

In the context of inadequate levels of human papillomavirus (HPV) vaccination in the United States (US), and the fact that national data reveal that providers are parents' preferred source of vaccine information, this qualitative study analysed actual provider discussions with undecided parents to explore how parents express hesitancy about the HPV vaccine and how providers respond. The goal was to develop a typology that could provide a framework to identify communication drivers of HPV vaccine decisions.

The researchers audio-recorded 43 visits with unvaccinated adolescents aged 11-17 at 6 paediatric clinics in Dallas, Texas, US, in which parents were undecided about HPV vaccination. They qualitatively coded how parents verbally expressed hesitancy (assertive response, asking a question, or expressing concern) and whether providers responded with acquiescence (agree to defer vaccination) and/or persistence (continue discussion). They described the frequency of parent and provider communication codes and same-day vaccination.

Among the 43 visits, 37 parents expressed hesitancy 1 or more times in many ways. Assertive responses were most common (73% of the 37 visits), and they ranged from clear refusals ("no, not right now") to statements that the parent wanted to delay ("we need to think about that"). Parents who expressed hesitancy by asking questions (43% of 37 visits) said things like, "What are the side effects?" or "How is papilloma transmitted in men?" In 12 visits (32% of 37), parents communicated their hesitancy with an expression of concern ("I'm just nervous about it.") When the first expression of hesitancy was a question or concern, 71% and 75% of adolescents, respectively, received same-day vaccinations, whereas 33% of adolescents who received an initial assertive response were vaccinated.

Just over half (n = 19) of adolescents whose parents made 1 or more hesitancy statements received the HPV vaccine during the visit. Nearly three-fourths of parents whose first hesitancy statement was a question or expression of concern went on to have their child vaccinated during the visit. A third of parents who used an assertive response as their first expression of hesitancy went on to have their child vaccinated.

Providers responded with only persistence in 18 visits, a mix of acquiescence and persistence in 13 visits, and only acquiescence in 6 visits. When providers only used persistence, 17 of 18 adolescents were vaccinated; when providers responded with only acquiescence, no adolescents received the vaccine.

"Conversations involving a mix of persistence and acquiescence, by definition, included a back and forth interaction between providers and parents, and thus took somewhat more time than other discussions. However, the length of these vaccine discussions was not appreciably longer than the discussions with acquiescence only. Findings reveal that providers are able to change the mind of hesitant parents and that it does not take much time to educate parents..."

In this exploratory study, providers largely persisted and continued the immunisation discussion in response to parents' hesitancy. The positive influence of provider persistence was evident even among parents who used an assertive style when expressing hesitation (7 out of 7 adolescents were vaccinated). Furthermore, parental hesitancy provides an opportunity to practice patient-centred communication: Unless a provider understands the source of parental hesitancy, his or her response may not be suitably tailored to counter hesitation.

"Thus, parental expressions of vaccine hesitancy may present a critical opening for providers to respectfully engage parents, endorse the HPV vaccine, and address questions or concerns....[The] findings reveal a potentially important missed opportunity when providers simply acquiesce to parental expressions of hesitation."