Effect of a Health Care Professional Communication Training Intervention on Adolescent Human Papillomavirus Vaccination: A Cluster Randomized Clinical Trial

"A health care professional communication intervention significantly improved HPV vaccine series initiation and completion among adolescent patients."

Effective human papillomavirus (HPV) vaccines have been available in the United States (US) for several years but are underused among adolescents, the intended population for vaccination. The President's Cancer Panel has indicated that interventions to improve healthcare professionals (HCPs)' communication about adolescent HPV vaccination are needed. Thus, a group of researchers developed a 5-component HCP communication intervention and, in the present study, tested the hypothesis that implementation of the intervention increases practices' adolescent HPV vaccine uptake compared with providing usual care.

The final cohort for randomisation included 16 practices (4 family medicine and 12 paediatrics) in the Denver, Colorado, US metropolitan area. Participants included 188 medical professionals and 43,132 adolescents. Differences between control and intervention changes over time (i.e., difference in differences between the baseline and intervention period cohorts of patients) in HPV vaccine series initiation (1 or more doses) and completion (3 or more doses) were measured among patients aged 11 to 17 years seen at the practices between February 1 2015 and January 31 2016.

Intervention practices (n=8) received a 5-component intervention that was designed based on the precaution-adoption-process model, which distinguishes between various stages of the decision-making continuum (e.g., unaware, aware but unengaged, undecided). It was developed to provide tools and training that could be used before, during, or at the end of the clinical encounter. The intervention included: (i) a fact sheet library that practices used to create practice-specific fact sheets about HPV infection and vaccination, (ii) a parent education website called "iVac" (no longer in operation) that created individually customised information about HPV vaccination, (iii) a series of disease images depicting diseases associated with HPV, (iv) a decision aid for HPV vaccination, and (v) communication training to improve HCPs' vaccine recommendation practices. The latter consisted of a self-guided, 30-minute webinar, plus 2 in-person, group training sessions that lasted 1 hour each. These sessions focused on opening the HPV vaccine conversation with a "presumptive approach", which assumes parents will vaccinate their children, followed by the use of motivational interviewing techniques for parents perceived as resistant to vaccination. Each intervention practice chose a study champion to help facilitate the study activities. Practices in the control arm (n=8) continued usual care with regard to communication about HPV vaccines.

The study found that adolescents in the intervention practices had significantly higher odds of HPV vaccine series initiation (adjusted odds ratio (aOR), 1.46; 95% confidence interval (CI), 1.31-1.62) and completion (aOR, 1.56; 95% CI, 1.27-1.92) than those in the control practices (a 9.5-absolute percentage point increase in HPV vaccine series initiation and a 4.4-absolute percentage point increase in HPV vaccine series completion in intervention practices). The intervention had a greater effect in paediatric practices compared with family medicine practices and in private practices compared with public ones (reasons for which the researchers explore in the article). Improvements in HPV vaccination among intervention practices occurred primarily at well-child care visits; given that adolescents see medical professionals for sick visits more commonly than for preventive visits, the research team suggests that finding mechanisms to improve vaccination at sick visits is a clear research priority.

Each intervention component was used by 26.0% to 90.0% of HCPs over the 12-month study period. Of these, the communication techniques and fact sheets were reported as the most frequently used, with 72.2% to 90.0% and 51.5% to 84.4% of medical professionals reporting using them over the study period, respectively. Surveys done at the end of the intervention period demonstrated that 98.0% of HCPs were likely to continue to use the fact sheets and that 91.0% of HCPs were likely to continue to use the communication techniques.

"Future research will need to examine if similar effects on vaccination rates can be achieved through more generalizable dissemination methods, such as via the internet or through the public health department network."