A lot of what we hear or read in the news about vaccination these days has to do with the “anti-vaxxer” movement, in which individuals oppose vaccination based on a thoroughly disproven belief that vaccines are responsible for a range of health problems. But there’s a lesser-known obstacle to children and adolescents receiving the vaccinations they need, one that’s possibly even more concerning: provider communication.
The American Council on Immunization Practices (ACIP) recommends that individuals between the ages of 11-18 receive four vaccines: (1) a TDap booster, which protects against tetanus, diphtheria, and pertussis, (2) a meningococcal booster, which protects against meningitis and sepsis, (3) the full HPV vaccine series which protects against human papillomavirus, and (4) an annual influenza vaccination, a.k.a., a flu shot.
Immunization rates have improved fairly consistently over the past decade for each of these vaccines. In 2014, 88 percent of adolescents received a TDap booster and 79 percent received a meningococcal booster by the age of 17. However, only 60 percent of adolescent girls and 42 percent of adolescent boys received one or more of the three doses of HPV vaccine, and only 38 percent of adolescent girls and 14 percent of adolescent boys received all three doses in the series. Scholars have pointed out that, despite an excellent safety profile, mounting evidence of effectiveness, and national guidelines for routine administration, HPV vaccination rates remain far below the Healthy People 2020 goal of 80 percent vaccination completion.
Researchers like Jennifer Moss at the University of North Carolina and Melissa Gilkey at Harvard Medical School examine why some vaccines are taken up more frequently than others, and they say that health care providers’ advice can make a big difference. Gilkey even co-authored a paper that identified health care providers’ recommendations as one of the strongest and most consistent predictors of vaccination. The Centers for Disease Control and Prevention (CDC) and President’s Cancer Panel both agree. Their strategies for increasing HPV vaccine coverage include efforts to improve providers’ communication to parents and families.
Unsurprisingly, vaccination rates are higher in instances in which the health care provider explicitly recommends vaccination. The more interesting findings, though, have to do with the quality of these recommendations and the provider’s communication style.
The quality of a recommendation for vaccination is based on four factors: (1) strength of endorsement (saying a vaccine is important), (2) consistency (recommending a vaccine universally versus using a risk-based approach), (3) urgency (recommending same-day vaccination), and (4) timeliness (recommending a vaccine by ages 11-12).
A survey of parents of adolescents indicated that when they got a high-quality recommendation, adolescents were more than nine times more likely to receive at least one dose of HPV vaccine, and nearly four times more likely to complete the three-dose series, compared to those receiving no recommendation. Teens whose parents received low-quality recommendations were about four times more likely to initiate the series, but were not more statistically likely to complete the vaccine series than those who received no recommendation.
The four quality dimensions vary by vaccine, however. One survey of physicians indicated that, while 95 percent reported highly endorsing the Tdap vaccine for their 11- and 12-year-old patients and 87 percent reported highly endorsing meningococcal vaccines, only 73 percent reported highly endorsing the HPV vaccine. Further, 70 percent of physicians who discussed these three vaccines in a particular order reported discussing HPV last. Another study indicated that a majority (59 percent) of physicians surveyed used a risk-based approach to recommending the HPV vaccine rather than a universal recommendation, and about half (49 percent) did not usually recommend same-day vaccination. Reports regarding the timeliness of the recommendation varied by sex: 74 percent recommended HPV vaccine at or before age 12 for girls, though only 61 percent did so for boys.
The other important element of vaccine recommendation is the health care provider’s communication style. One recent investigation contrasted three styles of patient-provider communication. In informed (or “patient-driven”) communication, information flows exclusively from provider to patient, but deliberation and decision-making are left to the patient. Efficient (or “provider-driven”) communication involves a similar information flow, but deliberation and decision-making are solely the provider’s responsibility. Shared communication involves a two-way exchange of information, and joint deliberation and decision-making.
The results of this study indicated that efficient communication, though rarely used, was highly effective in encouraging all three adolescent vaccines, particularly HPV vaccination among female adolescents, for whom uptake reached 90 percent. The researchers noted that “when providers made decisions about routine adolescent vaccination, either alone or in conjunction with adolescents’ parents, vaccine uptake was higher.” They theorize that this style may reassure parents about the safety and effectiveness of these vaccines, and imply that vaccination is a normative standard or expectation.
Why is HPV Vaccine Different?
Why do vaccine recommendation quality and provider communication style differ across vaccines? One possibility is the lack of school-entry requirements for HPV vaccination. Most school districts in the United States require Tdap and meningococcal vaccination, but only Washington, D.C., Virginia, and Rhode Island require that students receive HPV vaccine by the seventh grade. Another obstacle is the fact that HPV is transmitted sexually and some parents may believe vaccination promotes adolescent sexual activity. The difference in HPV vaccination rates between girls and boys may be due to the fact that Gardasil (the first FDA-approved HPV vaccine) was not officially approved for administration to males until more than three years after it was approved for females. Because of these and other factors, many providers believe that parents view HPV vaccination as less important than other vaccines, and often anticipate uncomfortable conversations about it.
How to Improve
In order for the nation to meet the Healthy People 2020 goal of 80 percent HPV vaccine completion, health care providers must take advantage of every opportunity to recommend and deliver HPV and other vaccines. Providers often miss prime opportunities for recommending HPV vaccination. For instance, even though the CDC indicates that mild illnesses should not be a reason for delaying vaccination, only 41 percent of physicians reported discussing vaccination during sick visits.
Second, providers should deliver strong, consistent, urgent, and timely recommendations, and do so with authority. CDC’s AFIX approach is a step in the right direction, but improved education, training, and professional development for health care providers will also greatly improve the quality of their vaccine recommendations and communication styles.
Additional research will also help expand vaccine coverage. Given that efficient patient-provider communication was associated with increased HPV vaccine initiation in adolescent females, it may also improve completion of the three-dose series as well. Future studies should examine this possibility and other elements of the patient-provider dynamic.
Maryjo Oster, Ph.D., Research Scientist
 I’ll be focusing on the first three vaccines here, since influenza vaccine is recommended for individuals annually throughout the life course, not solely during childhood or adolescence.