Pediatrician-Parent Conversations About Human Papillomavirus Vaccination: An Analysis of Audio Recordings

"...findings highlight the need to develop and evaluate physician-focused trainings on using presumptive language for same-day HPV vaccination."

In the view of the researchers who conducted this study, in contrast to self-report and retrospective report of clinical encounters, objective observation of conversations between paediatricians, caregivers, and adolescents may clarify communication strategies that encourage or discourage vaccination uptake. For example, in an observational study that focused on early childhood immunisation, the results indicated that using presumptive language (i.e., words conveying assumption of vaccine delivery) led to higher rates of vaccine acceptance compared with a participatory approach. The present study had the following objectives: to describe the frequencies of pediatrician human papillomavirus (HPV) vaccine communication behaviours; to evaluate the associations between paediatrician HPV vaccine communication behaviours and parental agreement to same-day HPV vaccination; and to describe common themes observed across paediatricians' discussions about HPV vaccination.

To meet these objectives, the researchers used quantitative and qualitative analyses of audio recordings/transcripts of full clinical encounters that took place in the United States (US) between January and June 2013 among paediatricians, 11- to 12-year-old patients, and their caregivers. Seventy-five transcripts from 19 paediatricians were coded to capture whether the paediatrician (1) used presumptive versus nonpresumptive language; (2) offered a strong, moderate, weak, or no recommendation for HPV vaccine; (3) offered/recommended delay of vaccination; (4) used a risk-based approach to the need for HPV vaccination; (5) provided information, including misinformation, about HPV infection or vaccination; (6) responded to parent hesitancy with, for example, immediate acquiescence, provision of additional information, or elicitation of specific parent concerns with the goal of vaccine acceptance; (7) specifically mentioned sexual transmission of HPV; (8) shared personal vaccination practices (i.e., paediatrician vaccinating own or future offspring); and (9) engaged in lengthy scientific monologues about HPV vaccination.

Participating paediatricians were experienced, all from private practices in urban settings, located predominantly in the Midwest and South. The majority of well-child visits were with white patients; 34 were with girls (45%) and 41 boys (55%) aged 11 or 12 years. Less than one-third of the visits (29%) resulted in same-day vaccine acceptance, which was not associated with patient sex (p = .45).

Using logistic regression, the researchers evaluated the association between paediatrician communication approaches and agreement to same-day HPV vaccination. Generalised estimating equations accounted for clustering of patients within paediatricians.

In short, they found that paediatricians in the sample often provided parents with inconsistent, mixed messages and sometimes offered information about HPV or HPV vaccination that was inaccurate (and they inconsistently educated about the vaccine preventing one or more cancers). Back-and-forth dialogue about HPV vaccine in which parental questions or concerns were elicited was not the norm. Instead, paediatricians sometimes provided a monologue of scientific facts. Selective findings with regard to predictors of same-day HPV vaccine acceptance:

• Paediatricians used presumptive language in only 11 of 75 encounters; when used, presumptive language was associated with 9 times greater odds of same-day vaccination (73% vs. 22%; odds ratio (OR) = 8.96; 95% confidence interval (CI) = 2.32-34.70).
• Paediatricians offered or recommended delay in most encounters (65%); when they encountered caregiver hesitancy or concern about possible side effects of HPV vaccine, they typically acquiesced at once. HPV vaccine acceptance occurred far more often when paediatricians did not mention delaying vaccination (82% vs. 6%; OR = 80.84; 95% CI = 15.72-415.67).
• Same-day vaccination was not associated with strength of recommendation or paediatrician reference to vaccinating their own children.
• No patient sex differences were found in paediatrician offer of delay (p = .88), presumptive recommendation (p = .62), or strength of recommendation (p = .45).

So: "A geographically diverse sample of pediatricians seeing children aged 11 and 12 years, typically conveyed a mixed message about HPV vaccine by treating it differently from other vaccines, offering to delay or acquiescing to parental desire for delay, and failing to make clear, strong recommendations." The researchers cite research documenting physician anticipation of parental hesitancy regarding HPV vaccination, suggesting that "when pediatricians expect parental hesitancy, they may actually fuel parental hesitancy and reduce the likelihood of vaccine acceptance - a self-fulfilling prophecy."

One potential limitation of the study is that awareness of audio-recording a visit may have altered physician behaviour, resulting in what the physician might consider his/her "best case" communication behaviour.

The researchers conclude that the findings from this study are consistent with the emerging literature on physician-family communication about HPV vaccination. "This study identifies urgency and presumptive communication as critical for motivating same-day HPV vaccination."