Lack of School Requirements and Clinician Recommendations for Human Papillomavirus Vaccination

Abstract

BackgroundA strong recommendation from a clinician is one of the best predictors of human papillomavirus (HPV) vaccination among adolescents, yet many clinicians do not provide effective recommendations. The objective of this study was to understand how the lack of school entry requirements for HPV vaccination influences clinicians’ recommendations.Design and MethodsSemi-structured interviews with a purposive sample of 32 clinicians were conducted in 2015 in Connecticut USA. Data were analysed using an iterative thematic approach in 2016-2017.ResultsMany clinicians described presenting HPV vaccination as optional or non-urgent because it is not required for school entry. This was noted to be different from how other required vaccines were discussed. Even strong recommendations were often qualified by statements about the lack of requirements. Furthermore, lack of requirements was often raised initially by clinicians and not by parents. Many clinicians agreed that requirements would simplify the recommendation, but that parents may not agree with requirements. Personal opinions about school entry requirements were mixed.ConclusionsThe current lack of school entry requirements for HPV vaccination is an important influence on clinicians’ recommendations that are often framed as optional or non-urgent. Efforts are needed to strengthen the quality of clinicians’ recommendations in a way that remains strong and focused on disease prevention yet uncoupled from the lack of requirements that may encourage delays. Additionally, greater support for requirements among clinicians may be needed to successfully enact requirements in the future.Significance for public healthMore than a decade after its introduction, human papillomavirus (HPV) vaccination coverage remains low in the United States despite a robust record of safety and effectiveness. A strong recommendation from a clinician is one of the most important determinants of uptake, yet clinicians often fail to provide effective recommendations. One potential barrier to effective recommendations by clinicians that has not been explicitly studied is the widespread lack of school entry requirements for HPV vaccination. In this qualitative study, we found the lack of requirements to be an important reason for clinicians’ framing HPV vaccination recommendations as optional and non-urgent. Efforts are needed to strengthen the quality of clinicians’ recommendations in a way that is focused on disease prevention and uncoupled from requirements. Additionally, greater support for HPV vaccination requirements among clinicians may be needed to successfully enact requirements in the future.

<p>Knowledge and Acceptability of Human Papillomavirus Vaccination and Text Message Reminders for Adolescents in Urban Emergency Departments: A Pilot Study</p>

“…10 It was interestingly noted in a recent study that the lack of school entry requirements for HPV vaccination may contribute to decreased vaccine uptake. 30 Conflicting messages were given by the clinicians interviewed with strong recommendations given by emphasizing the importance of the vaccine for cancer prevention degraded by the lack of urgency suggested by stating that the vaccine is not needed to attend school. Only three states have school entry HPV vaccine requirements and for two out of the three the requirements are only for female adolescents.…”

Individual, systemic and state factors associated with provider recommendation of HPV vaccination: Findings from NIS-Teen, 2020

“…The prioritization of immunization and sexually transmitted disease preventive services at such facilities (STD clinics and school-based health centers) may partly explain the high HPV vaccination recommendation rate seen., This finding is also pertinent given that most U.S. states currently do not require or mandate HPV vaccination for school enrollment, a policy that has negatively influenced providers’ recommendation of HPV vaccination. 49 , 50 Worthy of note is that Rhode Island, where HPV vaccination is required before seventh grade, has the highest HPV vaccination rates in the U.S. 51 HPV vaccination interventions would need to be developed to mitigate the particular challenges in states with and without HPV vaccine mandates. In such jurisdictions where HPV vaccination is mandated, interventions should address barriers to accessing care and increase routine well-visits at ages 11–12 to enhance compliance rates.…”

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

“…Only four states currently have HPV vaccine mandates in place, but a vast majority have school entry requirements for the Tdap and MenACWY vaccines (Elam-Evans, 2020 ). One qualitative study found that lack of school entry requirements for the HPV vaccine influenced provider’s framing of the HPV vaccine as “non-urgent” (Niccolai et al, 2018 ). Another study conducted among stakeholders in Florida found a belief among stakeholders that physicians view the HPV vaccine as less important because there is no mandate in place (P. Lake et al, 2019a , 2019b ).…”