Cognitive Bias in Clinicians’ Communication about Human Papillomavirus Vaccination

Abstract

National guidelines recommend human papillomavirus (HPV) vaccination for all 11-12-year-olds, but uptake among United States adolescents remains low. A major barrier to greater uptake is the lack of effective recommendations for HPV vaccine from clinicians. One potential influence on clinicians' recommendations for HPV vaccine that has been relatively unexplored is that of cognitive biases, or errors in judgement that result from 'mental shortcuts' used to make decisions under uncertainty. Therefore, we analyzed qualitative data from interviews with 32 pediatric clinicians using a framework of nine cognitive biases relevant to HPV vaccination: omission bias, ambiguity aversion, present bias, availability bias, optimism bias, naturalness bias, protected values, anchoring bias, and confirmation bias. We used a directed content analysis approach to iteratively code and analyze all transcripts in the dataset. We found evidence for several cognitive biases that were related to weaker recommendations for HPV vaccine. Commonly identified biases included anchoring bias (perception that vaccination unnecessary due to age/pubertal status); present bias (perception of burdens related to discussing vaccination), and optimism bias (belief that patient at low risk for HPV acquisition). We found less frequent evidence for ambiguity aversion (perception of missing information regarding vaccination) and omission bias (deferring vaccination). Other biases were identified infrequently or not at all. Our findings suggest that several cognitive biases may be an influence on clinicians' communication about HPV vaccine. Raising awareness of cognitive biases related to making HPV vaccine recommendations could help to strengthen the recommendations that clinicians provide.

Understanding the Factors Influencing Health Care Provider Recommendations about Adolescent Vaccines: A Proposed Framework

“…In addition to knowledge about the vaccines, personal beliefs and biases can influence provider recommendation practices, both consciously and subconsciously. Cognitive biases, mental shortcuts that can result in errors in uncertain situations, have also been proposed as a framework for understanding HCP hesitancy (Hansen et al, 2020 ; Niccolai & Pettigrew, 2016 ). In a qualitative study, clinicians discussed how the anticipation of an uncomfortable discussion around the HPV vaccine or perceptions about the lack of urgency for the HPV vaccine influenced decisions either to delay recommending the vaccine or to recommending the vaccine less enthusiastically, examples of optimism bias and present bias (Hansen et al, 2020 ).…”

“…Cognitive biases, mental shortcuts that can result in errors in uncertain situations, have also been proposed as a framework for understanding HCP hesitancy (Hansen et al, 2020 ; Niccolai & Pettigrew, 2016 ). In a qualitative study, clinicians discussed how the anticipation of an uncomfortable discussion around the HPV vaccine or perceptions about the lack of urgency for the HPV vaccine influenced decisions either to delay recommending the vaccine or to recommending the vaccine less enthusiastically, examples of optimism bias and present bias (Hansen et al, 2020 ). Similar findings have been confirmed in quantitative studies—two national surveys of pediatricians found that about one third of respondents anticipated uncomfortable conversations about the HPV vaccine and one found that about half of respondents did not recommend same day vaccination for the HPV vaccine (Gilkey et al, 2015 ; Kempe et al, 2019 ).…”

“…Conversely, providers may also preferentially recommend the HPV vaccine to adolescents who they perceive as sexually active. In both qualitative and quantitative studies, providers who make judgments about sexual maturity of the adolescent are less likely to make strong recommendations for the HPV vaccine (Hansen et al, 2020 ; Henrikson et al, 2016 ; Hopfer et al, 2019 ). Additionally, reports of provider recommendations vary by sociodemographic characteristics, such as poverty status, sex of the adolescent, and maternal education (Mohammed et al, 2016 ).…”

“…Portions of these three interventions could potentially be addressing these biases, even if that was not the intention of the intervention. For example, all three interventions emphasize same-day vaccination either as part of the presumptive/announcement communication approach or as part of providing an effective recommendation, which could combat present bias (i.e., the HPV vaccine is not urgent, it could be delayed) (Brewer, Hall, et al, Brewer, Hall, et al, 2017 ; Dempsey et al, 2018 ; Hansen et al, 2020 ; Niccolai & Pettigrew, 2016 ; Szilagyi et al, 2021 ). In future studies, it may be beneficial to incorporate training that is more targeted towards identifying and combatting cognitive biases in provider recommendation practices.…”

Behavioral Economics as a Model to Improve Adolescent and Adult Vaccination

“…Cognitive biases undermine many health decisions, including vaccination decisions of adults and parents of adolescents. [18][19][20] The principles of behavioral economics have been used to understand how cognitive biases impact health behaviors, such as vaccination, and to shift such behaviors toward improved health outcomes. 1 Behavioral economics is a strategy to help overcome cognitive biases and encourage vaccination, especially for recommended vaccines that do not benefit from mandates.…”