A healthcare provider recommendation is one of the most potent tools for increasing HPV vaccination.¹ Studies show that parents who receive a clear recommendation for their children to get HPV vaccine have around 10 times higher odds of getting their children vaccinated. You would think such recommendations would be common, but they are not. Many parents never receive a recommendation. And, those parents who do, often get a recommendation that is hesitant, unclear or late.² The main reasons for these low-quality recommendations include providers’ tendency to underestimate the value that parents place on HPV vaccination, their expectation that talking about HPV vaccination will be uncomfortable, and their perception that time in the clinic visit is too limited.³

One approach to recommending HPV vaccine is to do more and say more. In line with the tenets of shared decision-making, some providers opt for a conversational approach. These providers may begin by describing the vaccine, including the guidelines, the vaccine’s benefits and its safety. They then ask for questions, expecting an interactive exchange of ideas. The conversation might eventually end with a recommendation or the provider might just leave it to the parent to think over. A problem with this approach is that it presumes medicine is agnostic about whether vaccination is a good idea. Most countries have clear guidelines for HPV vaccine and other vaccines. This means that research clearly indicates what is best for the child’s health, and that providers should give clear direction to parents accordingly.

A promising alternative is to open the topic of HPV vaccination with a presumptive announcement. For example, a provider can say, “I see that Michael is 11. That means he is due for vaccines against meningitis, HPV cancers and whooping cough. We will give those at the end of the visit.” Providers routinely use presumptive announcements for childhood and other teen vaccines. Observational research has found that these presumptive announcements are uncommon, yet highly effective.⁴

Our research group conducted a randomized controlled trial to evaluate which approach to introducing HPV vaccination is most effective. We randomly assigned physicians to: 1) receive training on how to use presumptive announcements to raise the topic of HPV vaccination, 2) receive training on how to use open-ended conversations, or 3) have no training. Compared to no training, presumptive announcement training led to a 5% increase in HPV vaccine initiation among the priority patient group of 11-12 year olds (Figure 1).⁵ The finding was clinically and statistically significant (p < 0.05). Presumptive announcements were equally effective for parents of boys and girls. However, the conversation trainings had no impact on HPV vaccination.

The US Centers for Disease Control (CDC) and Prevention and the American Academy of Pediatrics (AAC) now advocate that providers use presumptive announcements to introduce the topic of HPV vaccination. Many medical training programs in the US and internationally also now include such trainings. Materials for conducting announcement training are available for free online at www.HPViq.org. Materials include the training script, slides, and activities, as well as evaluation tools.

Concerns about the clinical utility of presumptive announcements have not borne out in practice. First, many patients prefer the efficiency of receiving clear direction from their providers. Starting with long conversations uses up time parents may want to spend on more complex health concerns, including those related to nutrition, physician activity, and mental health. Second, if parents have questions, providers can and indeed must carefully listen and address them. Questions can reflect curiosity or uncertainty and are not necessarily a sign of parents’ unwillingness to vaccinate.

References
1. Gilkey MB, Calo WA, Moss JL, et al. Provider communication and HPV vaccination: The impact of recommendation quality. Vaccine 2016;34(9):1187–92.
2. Gilkey MB, Malo TL, Shah PD, et al. Quality of physician communication about human papillomavirus vaccine: findings from a national survey. Cancer Epidemiol Biomarkers Prev 2015;24(11):1673–9.
3. Gilkey MB, McRee AL. Provider communication about HPV vaccination: A systematic review. Hum Vaccin Immunother 2016;2(6):1454–68.
4. Moss JL, Reiter PL, Rimer BK, et al. Collaborative patient-provider communication and uptake of adolescent vaccines. Soc Sci Med 2016;159:100-7.
5. Brewer NT, Hall ME, Malo TL, et al. Announcements versus conversations to improve HPV vaccination coverage: A randomized trial. Pediatrics 2017;139(1):pii:e20161764.