Identifying the Roles of Medical Providers when Addressing Barriers to HPV Vaccination Rates in Rural NE Clinics

Background: Although many interventions to address vaccine hesitancy until now have operated on the presumption that misperceptions are due to a lack of knowledge about HPV and the vaccine, this may not always be the reason behind vaccine hesitancy. Nyhan et. al found [1] that correcting myths about vaccines- such as autism links or vaccine side effects- do not increase vaccine rates among adolescents. Medical providers play a crucial role on influencing parents’ decision to vaccinate. In a study exploring how vaccination coverage among children 19-35 months old is associated with health care providers' influence on the parents' decision to vaccinate, parents who report their providers as being influential in the study are twice as likely to respond that vaccines are safe for children [2]. In the 2016 Clinical Report on Countering Vaccine Hesitancy by the American Academy of Pediatrics, motivational interviewing is listed as a potential communication technique that may be useful as pediatricians discuss vaccines with vaccine-hesitant parents. Research Question: The research attempting to find the best approaches to reverse the increasing rates of unvaccinated minors is limited and inconclusive. This project addressed the impact of medical providers’ attitudes of HPV vaccination on their early adolescent patient populations. Methods: Our cohort prospective study first examined medical providers’ baseline attitudes and approaches of HPV vaccination in privately insured clinics in rural areas of Nebraska. A survey was sent to eleven Phase III patient centered medical home (PCMH) NE clinics. The survey assessed medical staffs’ attitudes and approaches to HPV vaccination, particularly among specific patient age groups. In addition to each clinic’s collective survey responses, baseline HPV vaccination data was collected at eleven Phase 3 PCMH rural clinics in Nebraska for pediatric patients 11-15-years-old. The follow-up intervention implemented educational interventions in the clinics to increase HPV vaccination rates for pediatric patients 9-15-years-old. Our educational outreach program at the selected 10-13 clinics will serve as these rural clinics’ first efforts to selectively work toward improving HPV vaccination rates. Results: America’s Health Rankings (2017) found 42.4% of adolescents living in rural areas compared to 52.4% in urban areas are up-to-date on their HPV immunizations. The eleven rural clinics selected for the study show only a 0.9% completion of the vaccine series for 9-11-year-old patients (n=855), and 25.0% completion of the series for 12-15-year-old patients (n=1268) as of 2019. This implies a pressing health disparity that needs addressing in rural Nebraskan communities. 92.6% of all respondents chose the 12-15 age range as the patient population the clinics would typically ask about the vaccine versus 59.6% who chose the 9-11 age range. The most chosen reason for not mentioning the HPV vaccine is “parents previously voiced vaccine hesitancy” (33.3%) followed by “not enough clinic time” (22.2%). The most popular reason contributing to parental hesitancy is “they have concerns the vaccine is not safe for their child” (70.4%). The greatest benefit of the HPV vaccine was listed as “prevention from multiple forms of cancer” (33.3%) and the greatest drawbacks were both “multiple dose series completion” (40.7%) and “difficulty in convincing parents to vaccinate minors” (40.7%). The 9-11 age range was chosen as the most difficult age group to vaccinate (33.3%). The most difficult scenarios when addressing HPV vaccination concerns were “lack of vaccine education” (55.6%), “religious reasons against the vaccine (44.4%), and “language/cultural barriers” (37%). Qualitative results were also analyzed separately and focused on each individual clinic’s strengths and weaknesses regarding vaccination encouragement. Discussion: The baseline patient data show that clinics selected for the study exhibit a large disparity of HPV vaccination rates among a vulnerable age group. Survey responses show both a clinical observation regarding parents’ low-level education levels about the HPV vaccine as well as a lack of comfort engaging in open dialogue between patients and healthcare personnel. Focusing on these two variables alone could help increase rates of vaccination significantly. Survey results ultimately illustrate the urgent need for empirically-supported educational resources that will enhance communication- both within individual clinics among staff as well as between medical staff and patients’ families- to sustainably increase HPV vaccination rates across rural clinics.