Factors Influencing Pediatricians' Intention to Recommend Human Papillomavirus Vaccines

doi:10.1016/j.ambp.2007.05.010

Ambulatory Pediatrics

Volume 7, Issue 5, September 2007, Pages 367-373

https://doi.org/10.1016/j.ambp.2007.05.010 Get rights and content

Objectives

The objectives of this qualitative study were to describe the range of pediatricians' attitudes about human papillomavirus (HPV) vaccines and to explore factors influencing their intention to recommend HPV vaccines, extending the findings of previous quantitative studies.

Methods

A diverse sample of pediatricians participated in semistructured individual interviews to assess attitudes and intentions regarding HPV immunization. Framework analysis was used for qualitative analysis.

Results

The mean age of the 31 participants was 47 years, 17 (55%) were female, 9 (29%) were black, and 4 (13%) were Latino. The efficacy, safety, and potential health impact of vaccination were the primary factors driving participants' decisions about recommending HPV vaccines. Perceived benefits of HPV vaccination included prevention of HPV-related disease and the opportunity to educate adolescents. Perceived barriers included anticipated parental beliefs (eg, parental denial that their child would be at risk) and provider beliefs (eg, reluctance to discuss sexuality with preadolescents). Participants reported high intention to recommend HPV vaccines overall, but intention varied according to patient age, patient gender, and HPV vaccine type. The primary reasons underlying this variation included perceptions about the health impact of vaccination and relevance of HPV vaccines to the provider's patients. The main factors driving intention to recommend HPV vaccines included knowledge, personal and professional characteristics, office procedures, vaccine cost and reimbursement, parental factors, and specific attitudes about HPV vaccination.

Conclusions

These findings provide a framework for understanding pediatricians' decisions to recommend HPV vaccines and may be used to guide the design of interventions to maximize vaccine recommendations.

Section snippets

Methods

Pediatricians practicing in a 3-state region (Ohio, Kentucky, and Indiana) were recruited in 2005 for this study. We used a purposeful sampling strategy to achieve representation of those who were: 1) male and female; 2) non-Latino white, non-Latino African American, and Latino; 3) practicing in primary care and academic settings; and 4) practicing in urban, suburban, and rural areas. We enrolled new participants until we determined that the end points of analysis had been achieved, which

Results

The mean age of the 31 participants was 46.9 years (SD 11.8; range, 30–78 years); 17 (55%) were female, and 14 (45%) were male. Eighteen (58%) pediatricians were white, 9 (29%) were black, 2 (7%) were Asian American, 1 (3%) was American Indian/Alaskan Native, and 1 (3%) was multiracial. Four (13%) were of Latino ethnicity. The majority practiced in urban (45%) or suburban (52%) locations.

Discussion

In this study, we used qualitative methodology to validate, explain, and extend the findings of previous research that has examined pediatrician attitudes about HPV vaccines. Our work provides novel information about 3 areas not explored in previous survey research. The study identified the full range of pediatrician attitudes about recommending HPV vaccines in a diverse sample, provided information about the reasons underlying specific attitudes and intentions, and prioritized factors

Acknowledgment

This study was supported by grant K23 AI50923 to Dr Kahn from the National Institute for Allergy and Infectious Diseases.

Dr Kahn has received honoraria for presenting grand rounds at academic institutions, funded by unrestricted educational grants from industry. She does not receive research funding nor does she serve on advisory boards, speakers' bureaus, or as a consultant for any industry. Dr Zimet has been a speaker for Merck, a consultant and speaker for SciMed (a medical education company

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Dental professionals are encouraged by the American Dental Association (ADA) to recommend the HPV vaccine to eligible patients. To better understand their comfort level in following this recommendation, we conducted a mixed methods study of dentists and dental hygienists. A total of 173 providers were surveyed and 8 interviewed. The majority felt they had an important role in preventing HPV-related OPC and that they should educate their patients and encourage HPV vaccination. However, most providers had low knowledge about HPV and expressed a need to obtain more information on the topic. In particular, they desired information about the HPV vaccine, its connection to cancer and where to refer patients for vaccination. They also wanted access to visual aids to help them bring up the topic. This study demonstrates the need to develop and disseminate educational programs for dental providers so they can assist with efforts to raise HPV vaccination rates.
Educating healthcare providers to increase Human Papillomavirus (HPV) vaccination rates: A Qualitative Systematic Review
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HPV vaccination rates in the United States lag behind other developed countries. Educational interventions are primarily directed at patients and parents rather than healthcare providers (HCPs), despite evidence that provider recommendation is a key determinant of vaccine uptake. The objectives for this review are to synthesize the available evidence related to the knowledge, attitudes, and beliefs of HCPs surrounding HPV vaccination, to summarize provider-specific educational interventions which have been evaluated, and to review existing provider-specific educational resources from national organizations and whether they align with the gaps identified.
A systematic search was performed using PubMed, Web of Science, CINAHL, and ERIC with MeSH terms human papillomavirus, vaccine, education, workshop, training, knowledge, attitude, belief, intention, and healthcare provider. Full text articles were obtained for studies that described the knowledge and attitudes of providers and/or impact of educational interventions. Data extraction was performed by four independent reviewers. Websites of American organizations with an interest in HPV vaccination were manually searched for provider resources.
1066 publications were identified, and 98 articles were fully reviewed with 40 ultimately included. Providers’ knowledge on HPV was generally low with a correspondingly low vaccine recommendation rate. Provider-specific education (e.g., didactic session and communication training) with complimentary interventions demonstrated increased knowledge and vaccine series initiation and completion. Themes identified in descriptive studies highlighted providers’ lack of general HPV and vaccine knowledge, low self-confidence in counselling and addressing parental concerns, and discomfort in discussing sexual issues related to vaccination. Many American organizations have provider-specific resources; however, the effectiveness of these materials has not been established.
HPV knowledge among providers remains low. Educational interventions to improve knowledge and communication appear to be effective. A breadth of resources from national organizations are available but their efficacy and level of utilization is largely unknown. Coordinated efforts are needed to evaluate provider-specific educational resources to improve vaccine uptake in the US.
Florida physicians’ reported use of AFIX-based strategies for human papillomavirus vaccination
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HPV vaccination rates in Florida are low. To increase rates, the CDC recommends clinics adhere to components of their evidence-based quality improvement program, AFIX (Assessment, Feedback, Incentives, and eXchange of information). We explored factors associated with engaging in HPV-specific AFIX-related activities. In 2016, we conducted a cross-sectional survey of a representative sample of 770 pediatric and family medicine physicians in Florida and assessed vaccination practices, clinic characteristics, and HPV-related knowledge. Data were analyzed in 2017. The primary outcome was whether physicians' clinics engaged in ≥1 AFIX activity. We stratified by physician specialty and developed multivariable models using a backward selection approach. Of the participants in the analytic sample (n = 340), 52% were male, 60% were White of any ethnicity, and 55% were non-Hispanic. Pediatricians and family medicine physicians differed on: years practicing medicine (p < 0.001), HPV-related knowledge (p < 0.001), and VFC provider status (p < 0.001), among others. Only 39% of physicians reported engaging in ≥1 AFIX activity. In the stratified multivariable model for pediatricians, AFIX activity was significantly associated with HPV-related knowledge (aOR = 1.33;95%CI = 1.08–1.63) and provider use of vaccine reminder prompts (aOR = 3.61;95%CI = 1.02–12.77). For family medicine physicians, HPV-related knowledge was significant (aOR = 1.57;95%CI = 1.20–2.05) as was majority race of patient population (non-Hispanic White vs. Other: aOR = 3.02;95%CI = 1.08–8.43), daily patient load (<20 vs. 20–24: aOR = 9.05;95%CI = 2.72–30.10), and vaccine administration to male patients (aOR = 2.98;95%CI = 1.11–8.02). Fewer than half of Florida pediatric and family medicine physicians engaged in any AFIX activities. Future interventions to increase AFIX engagement should focus on implementing and evaluating AFIX activities in groups identified as having low engagement in AFIX activities.
Association of Health Insurance Status and Vaccination Coverage among Adolescents 13-17 Years of Age
2018, Journal of Pediatrics
To assess selected vaccination coverage among adolescents by health insurance status and other access-to-care characteristics.
The 2015 National Immunization Survey-Teen data were used to assess vaccination coverage disparities among adolescents by health insurance status and other access-to-care variables. Multivariable logistic regression analysis and a predictive marginal modeling were conducted to evaluate associations between health insurance status and vaccination coverage.
Overall, vaccination coverage was significantly lower among uninsured compared with insured adolescents for all vaccines assessed for except ≥3 doses of human papillomavirus vaccine (HPV) among male adolescents. Among adolescents 13-17 years of age, vaccination of uninsured compared with insured adolescents, respectively, for tetanus toxoid, reduced content diphtheria toxoid, and acellular pertussis vaccine was 77.4% vs 86.8%; for ≥1 dose of meningococcal conjugate vaccine was 72.9% vs 81.7%; for ≥1 dose of HPV was 38.8% vs 50.2% among male and 42.9% vs 63.8% among female adolescents; for 3 doses of HPV was 24.9% vs 42.8% among female adolescents. In addition, vaccination coverage differed by the following: type of insurance among insured adolescents, having a well-child visit at 11-12 years of age, and number of healthcare provider contacts in the past year. Uninsured were less likely than insured adolescents to be vaccinated for HPV (female: ≥1 dose and 3 doses; and male: ≥1 doses) after adjusting for confounding variables.
Overall, vaccination coverage was lower among uninsured adolescents. HPV vaccination coverage was lower than tetanus toxoid, reduced content diphtheria toxoid, and acellular pertussis vaccine Tdap and meningococcal conjugate vaccine in both insured and uninsured adolescents. Wider implementation of effective evidence-based strategies is needed to help improve vaccination coverage among adolescents, particularly for those who are uninsured. Limitation of current federally funded vaccination programs or access to healthcare would be expected to erode vaccine coverage of adolescents.
Human Papillomavirus Vaccination of Adolescents with Chronic Medical Conditions: A National Survey of Pediatric Subspecialists
2017, Journal of Pediatric and Adolescent Gynecology
Many adolescents with chronic medical conditions (CMCs) are at risk of human papillomavirus (HPV) infection, associated complications, and underimmunization and often identify a pediatric subspecialist as their main provider. This study aimed to assess the HPV-related understanding, beliefs, and practices of pediatric subspecialists, which are largely unknown.
National cross-sectional study.
Pediatric endocrinologists, hematologist/oncologists, pulmonologists, and rheumatologists identified using the American Medical Association Physician Masterfile (n = 418).
Subspecialists who care for adolescents with CMCs in the outpatient setting were recruited to complete a Web-based survey on their HPV-related knowledge, attitudes, comfort, and practices.
HPV vaccination recommendation.
Over half of respondents (50.4%; n = 196/389) reported sometimes or always recommending HPV vaccination to adolescent patients with CMCs. Factors positively associated with recommendation included hematology/oncology (adjusted odds ratio [AOR], 4.69; 95% confidence interval [CI], 1.86-11.81) or rheumatology (AOR, 6.55; 95% CI, 1.67-25.74) specialization, seeing more adolescent patients with CMCs (AOR, 1.01; 95% CI, 1.00-1.02), and sometimes or always discussing sexual health (AOR, 2.53; 95% CI, 1.05-6.08) or checking vaccine status (AOR, 3.83; 95% CI, 1.59-9.20) with these patients. Those who thought it was important, but were uncomfortable discussing sexual health when recommending HPV vaccination (AOR, 0.28; 95% CI, 0.12-0.70) or who reported insufficient HPV vaccine information (AOR, 0.45; 95% CI, 0.23-0.88) or lack of primary–subspecialty care provider communication (AOR, 0.38; 95% CI, 0.16-0.93) as barriers to HPV vaccination were less likely to recommend HPV vaccination.
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View all citing articles on Scopus

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Adolescent HealthFactors Influencing Pediatricians' Intention to Recommend Human Papillomavirus Vaccines

Objectives

Methods

Results

Conclusions

Section snippets

Methods

Results

Discussion

Acknowledgment

Lancet

Am J Prev Med

J Adolesc Health

Organ Behav Hum Decis Process

J Adolesc Health

Am J Prev Med

Am J Prev Med

J Pediatr Adolesc Gynecol

J Adolesc Health

J Adolesc Health

Quadrivalent vaccine against human papillomavirus to prevent high-grade cervical lesions

N Engl J Med

Quadrivalent vaccine against human papillomavirus to prevent anogenital diseases

N Engl J Med

Utilization of physician offices by adolescents in the United States

Pediatrics

National health care visit patterns of adolescents: implications for delivery of new adolescent vaccines

Arch Pediatr Adolesc Med

Vaccines against sexually transmitted infections: promise and problems of the magic bullets for prevention and control

Sex Transm Dis

Immunization practices of pediatricians and family physicians in the United States

Pediatrics

Adolescent immunization practices: a national survey of US physicians

Arch Pediatr Adolesc Med

One-year uptake of pneumococcal conjugate vaccine: a national survey of family physicians and pediatricians

J Am Board Fam Pract

Utility of the theories of reasoned action and planned behavior for predicting physician behavior: a prospective analysis

Health Psychol

A national survey of pediatrician knowledge and attitudes regarding human papillomavirus vaccination

Pediatrics

Adolescent Health
Factors Influencing Pediatricians' Intention to Recommend Human Papillomavirus Vaccines