A Brief Provider Training Video Improves Comfort With Recommending the Human Papillomavirus Vaccine

Abstract

The American Academy of Pediatrics California Chapter 3 created a 20-minute training video targeting barriers to strong provider recommendation of the human papillomavirus (HPV) vaccine. The video included clinical vignettes featuring pediatricians modeling counseling techniques with vaccine-hesitant families. Ninety-six multidisciplinary providers (including pediatric residents) at 6 sites viewed the video and completed baseline and posttest questionnaires assessing their vaccine knowledge, attitudes toward vaccination, and comfort with skills needed to facilitate vaccination. Following the intervention, providers had substantial and statistically significant (P < .05) improvements in multiple areas assessed, particularly knowledge of the burden of HPV-related disease in males and changes in vaccine response with age; likelihood of “strongly agreeing” that vaccination should not be delayed beyond preadolescence and that HPV vaccine is safe; and feeling “very comfortable” counseling vaccine-hesitant parents and facilitating vaccine completion. This cost-effective and easily disseminated training modality shows promise in increasing provider comfort with HPV vaccine counseling.

Keywords

human papillomavirus vaccines vaccination refusal counseling primary health care adolescent health medical education

Introduction

Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States. At any given time, the prevalence of genital HPV among American adults aged 18 to 59 years is almost 50%.¹ Nononcogenic HPV strains cause genital warts and substantially reduce quality of life.² Oncogenic HPV strains cause over 30 000 cancers per year in the United States, most commonly cervical and oropharyngeal but also penile, vulvovaginal, and anorectal cancers.³ Each year, over 4000 American women die of cervical cancer and an additional 12 000 are newly diagnosed.⁴ However, almost 40% of all HPV-related cancers occur in men, most of which are oropharyngeal.³

The 9-valent HPV vaccine protects against ~80% to 85% of cervical cancers and ~90% of genital warts.⁵ The Centers for Disease Control and Prevention Advisory Committee on Immunization Practices, with approval from the American Academy of Pediatrics (AAP), the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, and the American Cancer Society, recommends routine vaccination of all boys and girls aged 11 to 12 years with the 9-valent vaccine.^6,7 The World Health Organization also recommends that “all countries proceed with nationwide introduction of HPV vaccination.”⁸ At this time, many countries, including Canada, Australia, and the United Kingdom, routinely administer HPV vaccine in schools during early adolescence.^9-11

Despite this, most American adolescents have not completed their HPV vaccine series. In 2016, 65% of girls and 56% of boys aged 13 to 17 years had received at least one vaccine dose; only 49.5% of girls and 37.5% of boys had completed the series.¹² One contributor to low HPV vaccination rates is parental vaccine hesitancy, which may come from fear of vaccine side effects, low perceived risk of HPV in one’s child, uncertainty about vaccine effectiveness, and social influences.^13-17 Cost and lack of access to preventive health care are other important contributors.^13-17 However, one of the most commonly cited reasons for low vaccination rates is lack of a strong provider recommendation for vaccination.^13-17 A national study demonstrated that only 67% of pediatricians routinely discuss HPV vaccination at the 11- to 12-year-old well-child visit; of these, only 60% strongly recommend the vaccine for girls while 52% strongly recommend it for boys.¹⁸

A recent meta-analysis explored barriers to strong provider recommendation of the HPV vaccine.¹⁷ These included poor knowledge of HPV-related disease (particularly in males), failing to perceive HPV as a pediatric health threat, and concerns about time constraints when discussing the vaccine. The study found that providers tended to use a risk-based approach to recommending vaccination based on perceptions of whether patients are sexually active or likely to suffer consequences from HPV infection. Therefore, they offered the vaccine less to younger adolescents or males. Providers often perceived that the decision to vaccinate was beyond the provider’s control, and that parental concerns about the vaccine could not be overcome. Rutten et al¹⁹ demonstrated that greater perceived parent-related barriers among providers was associated with lower vaccination rates. This was corroborated by Allison et al,¹⁸ who found that almost 30% of pediatricians who failed to discuss HPV vaccine at the 11- to 12-year-old visit did not raise the subject because they expected parents to refuse, and 12% of pediatricians would not offer HPV vaccination again to a parent who had previously declined it.¹⁸ Other research suggests that providers tend to underestimate the value that parents assign to HPV vaccination.²⁰

Video-based modeling of clinical techniques have been shown to increase skill adoption²¹ and clinical confidence^22,23 among physicians and trainees, and is valued by learners for its ease of dissemination, accessibility, and efficacy.^23-25 The purpose of this study was to create a short pediatric provider training video addressing provider-related barriers to HPV vaccination identified in previous literature, incorporating modeling of helpful counseling strategies, and to assess the feasibility and efficacy of this modality in improving provider-related barriers to HPV vaccination.

Methods

Intervention

A 20-minute training video was created by the American Academy of Pediatrics California Chapter 3 (AAPCA3) in collaboration with adolescent medicine (MK), general pediatrics (EB), and pediatric infectious disease physicians (MS) at the University of California San Diego (UCSD) School of Medicine. Content was chosen to address previously reported provider-related barriers to HPV vaccination^13-20 including the following:

Lack of knowledge related to the burden of HPV-related disease, particularly in males

Lack of knowledge of the superior response to vaccination in early adolescence

Belief that HPV vaccine is less important than Tdap (tetanus, diphtheria, and pertussis) or meningococcal vaccine in preadolescence

Belief that it is acceptable to delay HPV vaccination until closer to sexual debut

Discomfort with addressing concerns of vaccine-hesitant parents, such as short-term and long-term vaccine safety, safety of giving multiple vaccines at the 11- to 12-year-old well-child visit, need for vaccinating boys, and need for vaccinating preadolescents

The video included didactic teaching (narrated by author MK) outlining the burden of HPV-related disease in males and females, information regarding vaccine efficacy and administration, misperceptions about vaccine safety and delaying vaccination, and specific strategies for counseling vaccine-hesitant parents. This was interspersed with 7 clinical vignettes featuring local pediatricians modeling counseling techniques and volunteer actors playing vaccine-hesitant parents and adolescent patients. Scenarios modeled in the vignettes included the following:

Parent and patient concerned about short-term side effects (eg, syncope)

Parent concerned about long-term vaccine safety

Parent wondering if vaccination can be delayed for his/her preteen child

Parent unsure if his/her son requires HPV vaccination

Eleven-year-old patient who does not want 3 vaccines at once

Sexually active adolescent wondering if it is too late for HPV vaccination

Parent who declines HPV vaccination despite strong provider recommendation

Setting and Participants

From February to May 2016, the short training video was shown by AAPCA3 representatives to a convenience sample of providers attending staff meetings at 4 large pediatric practices in San Diego County, a UCSD pediatric residency seminar, and the annual meeting of the San Diego Immunization Coalition. These groups were chosen as they encompassed diverse practice settings (private practices, health maintenance organizations, public health settings, federally qualified health centers, and academic practices) and included multidisciplinary providers including trainees. One hundred and nine providers attended these sessions. Thirteen providers did not complete either the baseline or postintervention study measures and were excluded, leaving 96 subjects in the final analysis. This study was exempted from review by the UCSD Institutional Research Board.

Measures

Viewers completed baseline and postintervention questionnaires, which included identical questions. The questionnaire items were created by the authors and targeted provider-related barriers to vaccination identified in the existing literature. They included 6 true/false questions assessing knowledge of HPV-related disease and the HPV vaccine, 9 items assessing attitudes and beliefs about HPV vaccination using a 5-point Likert-type scale (1 = strongly disagree to 5 = strongly agree), and 8 items assessing comfort with vaccine counseling and delivery using a 5-point Likert-type scale (1 = very uncomfortable to 5 = very comfortable). Knowledge questions addressed common misperceptions around HPV and the vaccine (eg, vaccine efficacy does not vary with age). Attitude and belief questions centered on provider perceptions of the importance of HPV vaccination in boys compared with girls, acceptability of delaying HPV vaccination in preadolescence, and vaccine safety. Finally, 8 items assessed comfort with skills required to facilitate HPV vaccination, such as counseling parents around commonly reported reasons for vaccine hesitancy, offering vaccination again after a parent has declined it, and facilitating completion of all required vaccine doses. Questionnaire items are listed in Tables 1 to 3.

Table 1.

Changes in Knowledge About HPV Vaccination Among Pediatric Providers at Baseline and After Viewing a Training Video (% Who Gave Correct Responses).

Question	Baseline	Posttest	P
1. HPV only affects a minority of sexually active people. (FALSE)	86.5%	97.9%	<.01
2. In the United States, HPV-related cancer occurs far more frequently than meningococcal disease. (TRUE)	90.6%	96.9%	.11
3. Though genital warts affect men and women equally, less than 10% of HPV-related cancers occur in men. (FALSE)	38.5%	67.7%	<.01
4. HPV catch-up vaccination can be offered up to age 26 years for men and women. (TRUE)	87.5%	95.8%	.02
5. The 9-valent HPV vaccine covers approximately 85% of cancer-causing strains. (TRUE)	86.5%	91.7%	.27
6. Up to age 18 years, HPV vaccine efficacy does not vary with age. (FALSE)	49.0%	88.5%	<.01

Abbreviation: HPV, human papillomavirus.

Table 2.

Changes in Attitudes Toward HPV Vaccination Among Pediatric Providers at Baseline and After Viewing a Training Video.

Question (Likert-Type Score for Strongly Pro-Vaccine Attitude)	Proportion With Strongly Pro-Vaccine Attitude
	Baseline (%)	Posttest (%)	P
1. It is important to vaccinate girls against HPV. (5 = strongly agree)	92.7	100.0	—
2. It is important to vaccinate boys against HPV. (5 = strongly agree)	91.7	95.8	.34
3. It is acceptable to delay HPV vaccination in a child or adolescent who is not yet sexually active. (1 = strongly disagree)	50.0	70.8	<.01
4. It is more important to offer Tdap and MCV vaccines at the age 11 well-visit than the HPV vaccine. (1 = strongly disagree)	42.7	63.5	<.01
5. I think of the HPV vaccine as a cancer-prevention vaccine, not a wart-prevention vaccine. (5 = strongly agree)	55.2	68.8	.01
6. I have concerns about the short-term side effects of the HPV vaccine. (1 = strongly disagree)	64.6	78.1	.01
7. I have concerns about the long-term safety of the HPV vaccine. (1 = strongly disagree)	65.6	76.0	.02
8. Offering HPV vaccination to young adolescents may encourage sexual risk-taking. (1 = strongly disagree)	87.5	87.5	1.0
9. It is difficult to talk to parents about the HPV vaccine because HPV is sexually transmitted. (1 = strongly disagree)	27.1	47.9	<.01

Abbreviations: HPV, human papillomavirus; Tdap, tetanus, diphtheria, and pertussis; MCV, meningococcal vaccine.

Table 3.

Changes in Comfort With Skills Required to Recommend HPV Vaccine Among Pediatric Providers at Baseline and After Viewing a Training Video (Goal Likert-Type Scale Score Is 5 = “Very Comfortable” With the Skill).

Question	Proportion Reporting They Feel “Very Comfortable” With the Skill (Likert-Type Scale Score of 5)
Question	Baseline (%)	Posttest (%)	P
1. Counseling about the rationale for routinely giving the HPV vaccine at age 11 to 12 years.	49.0	79.2	<.01
2. Counseling about the need to routinely vaccinate boys against HPV.	51.4	79.2	<.01
3. Addressing parental concerns about HPV being sexually transmitted, and the need to vaccinate prior to sexual debut.	51.0	77.1	<.01
4. Addressing parental concerns about the safety and side effects of the HPV vaccine.	39.6	78.1	<.01
5. Presenting the HPV vaccine as a cancer prevention vaccine.	74.0	87.5	.01
6. Facilitating completion of the 3-dose vaccine series once initiated.	49.9	68.8	<.01
7. Making a strong recommendation for HPV vaccine.	67.7	84.4	<.01
8. Discussing HPV vaccination again with a family who has previously declined it.	56.3	72.9	<.01

Abbreviation: HPV, human papillomavirus.

On completion of the posttest questionnaires, providers were invited to provide free text written feedback about the video.

Analysis

Means and frequencies were used to describe the sample. Likert-type scale responses for attitude and skill questions were dichotomized to assess those who “strongly agreed” (items 1, 2, and 5 in Table 2), “strongly disagreed” (items 3, 4, and 6-9 in Table 2), or were “very comfortable” (all items in Table 3) with the item. The McNemar test was used to determine differences between baseline and postintervention responses. P < .05 was considered statistically significant. Analyses were performed using SAS v9.4.

Results

Of the 96 subjects included in the final analysis, 50 (52.1%) were physicians, 17 (17.7%) were nurses, 6 (6.3%) were pediatric residents, and 23 (23.9%) were other allied health professionals (eg, nurse practitioner, physician assistant, or medical assistant).

Baseline and posttest assessments of knowledge are summarized in Table 1. There were significant postintervention increases in the proportion of providers correctly answering most of the questions (#1, 3, 4, and 6). At baseline, most providers underestimated the prevalence of HPV-related disease in males and failed to recognize that HPV vaccine efficacy varied with age during adolescence. Following the intervention, the largest improvements in correct responses were seen in these 2 areas.

Baseline and posttest attitudes toward HPV vaccination are summarized in Table 2. At baseline, most providers strongly agreed that HPV vaccination was important for both boys and girls. However, only about half of the respondents strongly believed that it was unacceptable to delay HPV vaccination until sexual debut or that HPV vaccination was as important as Tdap and meningococcal vaccination in preadolescence. The proportion who strongly held these beliefs increased significantly after the intervention. Increases were also seen among the proportion of providers who strongly believed that there were no significant concerns about short- or long-term vaccine side effects. Following the intervention, more providers strongly disagreed with the idea that HPV’s sexual transmission made it more difficult to discuss the vaccine.

Baseline and posttest comfort with skills needed to facilitate vaccination are summarized in Table 3. At baseline, only about half of providers were “very comfortable” addressing common concerns of vaccine-hesitant parents, including the need to vaccinate boys, importance of routinely vaccinating at age 11 to 12 years, and rationale for vaccinating prior to sexual debut. About half of the providers were also not “very comfortable” discussing the vaccine again with a family who had previously declined it or facilitating completion of all vaccine doses. Less than 40% were “very comfortable” counseling about vaccine safety. Following the intervention, there were significant improvements in the number of providers who self-reported that they were “very comfortable” with all skills assessed.

Feedback offered by viewers was generally positive, with particular appreciation of the use of vignettes to model helpful counseling strategies.

Discussion

While most providers felt at baseline that HPV vaccination was important for boys and girls, the training video significantly improved provider comfort with counseling parents about vaccine safety, the importance of vaccinating boys, and the rationale for vaccinating 11- to 12-year-old children prior to sexual debut. Providers also reported improved comfort with facilitating completion of all vaccine doses and recommending vaccination again to a family who had previously declined it. Improved comfort with facilitating vaccination may be related to the improvements in vaccine knowledge and changes in beliefs demonstrated by providers after viewing the video, particularly related to vaccinating preadolescents and boys. These areas of improvement have been previously identified as important provider-related barriers to vaccination.^13-20

The video was low-cost to produce ($5350) and easily disseminated. Following study completion, the video was disseminated by the AAP through chapter websites in several states, Facebook, and YouTube, where it could be viewed at no cost. The video received positive feedback from the viewing providers, particularly about the use of clinical vignettes to model helpful counseling strategies.

It is noteworthy that even after viewing the training video, less than half of the providers strongly disagreed that HPV’s sexual transmission makes it more difficult to discuss the vaccine with parents. Other modalities of training, such as those involving role play, may be more effective than video-based training in facilitating experiential learning.

This study had several limitations. The study was conducted in San Diego County with a convenience sample of motivated providers, and the results may not be generalizable elsewhere. Learning needs may be different for different types of providers from different practice environments, but our subgroups were too small to conduct separate analyses of their responses to the video.

Importantly, it is unknown whether the intervention changed actual provider behavior; this study used a convenience sample of providers and did not permit assessment of provider vaccination rates, either immediately following the intervention or over time. However, our assessment of this video is an important first step in the development of an evidence-based provider training program. Future studies should include both immediate and longitudinal evaluations, conducted in providers’ practice settings, to determine whether video-based training changes provider behavior, and how changes can be sustained.

Following study completion, HPV vaccine recommendations changed to permit a 2-dose rather than a 3-dose series in immunocompetent adolescents initiating vaccination before age 15 years. Patient-friendly changes in HPV vaccine recommendations may independently improve provider attitudes and comfort with facilitating vaccination.

In summary, this brief and inexpensive training video significantly improved pediatric provider knowledge of the HPV vaccine, pro-vaccine attitudes, and self-reported comfort in recommending HPV vaccination. Similar videos may be a cost-effective way to increase provider comfort with recommending the HPV, or other, vaccines. Additional studies are needed to determine whether video-based training translates to sustained changes in provider behavior and increased vaccination rates over time.

Author Contributions

Conception and design of study: MMK, EGB, MHS, MK. Acquisition of data: MMK, EGB, MK. Analysis and interpretation of data: MMK, EGB, CW, KER. Drafting of manuscript: MMK. Critical revision of manuscript: MMK, EGB, MHS, MK, CW, KER. Approval of final version of manuscript: MMK, EGB, MHS, MK, CW, KER.

Footnotes

Acknowledgements

The authors would like to acknowledge the physicians and families who volunteered to act in the video without whom this initiative would not have been possible.

Authors’ Note

The study sponsors played no role in study design, in the collection, analysis or interpretation of data, in the writing of the manuscript, or in the decision to submit the article for publication.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by a 2015 Adolescent Vaccinations and Wellness Grant (Primary Investigator: Dr Eyla Boies) awarded by the national American Academy of Pediatrics with support from Merck.

ORCID iD

Maya M. Kumar

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