Primary care providers human papillomavirus vaccine recommendations for the medically underserved: A pilot study in U.S. Federally Qualified Health Centers

Abstract

Introduction In the United States, Federally Qualified Health Centers (FQHCs) are safety-net clinics that provide cervical cancer screening and human papillomavirus (HPV) vaccination to medically underserved women, some of whom may be at risk for developing cervical cancer. National guidelines recommend against using screening test results or sexual history to determine vaccine eligibility. Documenting HPV vaccine recommendations and beliefs of primary care providers in FQHCs may aid in promoting evidence-based practices and prioritizing health interventions for vulnerable populations. Methods Between 2009 and 2010, we collected data from 98 primary care providers in 15 FQHC clinics in IL, USA using a cross-sectional survey. Questions assessed provider and practice characteristics, HPV vaccine recommendations, and provider’s belief about whether their screening and management procedures would change for women who were vaccinated. Results 93% of providers recommended the HPV vaccine, most frequently for females aged 13–26 years (98%). Some providers reported sometimes to always using HPV test results (12%), Pap test results (7%), and number of sexual partners (33%) to determine vaccine eligibility. More than half of providers (55%) reported they will not change their screening and management practices for vaccinated females, yet believe vaccination will yield fewer abnormal Pap tests (71%) and referrals for colposcopy (74%). Conclusion Study providers routinely recommended the HPV vaccine for their patients. However, providers made fewer recommendations to vaccinate females ages 9–12 years (which includes the target age for vaccination) compared to older females, and used pre-vaccination assessments not recommended by U.S. guidelines, such as screening test results and number of sexual partners. In order to maximize the public health benefit of the HPV vaccine to prevent cervical cancer, adherence to guidelines is necessary, especially in settings that provide care to medically underserved women.

Primary Care Physicians' Adherence to Expert Recommendations for Cervical Cancer Screening and Prevention in the Context of Human Papillomavirus Vaccination

“…5,6 We also found that about 66% of physicians reported they often or always recommended HPV vaccination to patients with an abnormal Pap test result, compared to 79–85% who sometimes to always did so in previous research. 5,6 Differences in analyses may have accounted for the lower proportion of physicians adhering to this practice recommendation in our study. In our study, we did not consider a sometimes response to reflect sufficiently consistent adherence to practice guidelines.…”

“…1 ACIP does not recommend using prevaccination assessments to determine the appropriateness of HPV vaccination; 2,3 thus, physicians should not use Papanicolaou (Pap) or HPV test results to determine whether to offer HPV vaccination, nor should they use vaccine receipt to inform cervical cancer screening practices. Yet, available studies suggest many providers who deliver cervical cancer screening services for women report intended 4 or actual 5,6 practices inconsistent with ACIP recommendations, including failing to recommend HPV vaccine for females with a history of an abnormal Pap test or positive HPV test.…”

Provider communication about HPV vaccination: A systematic review

“…52,63 Provider communication was consistently associated with patients' sex such that providers' recommendation intentions and behavior were more supportive of HPV vaccination for girls versus boys. 10,12,24,25,29,33,37,44,55,57,58,60,64,65 For example, the 2014 NIS-Teen found that 64% of age-eligible girls had received a provider recommendation compared to just 42% of boys. 10 All but one study examining patients' race/ethnicity suggested disparities in provider communication with parents of African American and Hispanic adolescents less often discussing HPV vaccine with a provider or receiving HPV recommendations than parents of non-Hispanic White adolescents.…”

“…19,33,38,44,74 Similarly, some providers based their HPV vaccine recommendations on risk-related factors such as the results of a Pap or HPV test, number of sexual partners, or relationship status. 52,58,75 Ironically, providers in one qualitative study acknowledged that their ability to accurately assess whether adolescents were sexually active was limited. 38 …”

Society of behavioral medicine supports increasing HPV vaccination uptake: an urgent opportunity for cancer prevention

“…Three important factors that contribute to poor vaccine uptake are amenable to change. Many healthcare providers miss opportunities to recommend and administer the vaccine, [22][23][24] in part due to absent or low-quality recommendations [25]. Significant parental barriers exist, including parents' concerns about vaccine safety and cost, lack of knowledge, and failure to receive a provider recommendation [26][27][28].…”