User-Centered Design for Developing Interventions to Improve Clinician Recommendation of Human Papillomavirus Vaccination

"User-centered design is a promising method to address low uptake of the HPV vaccine because the largest hurdle to improving uptake seems to be ineffective or insufficient communication among clinicians, parents, and teenagers about the vaccine."

Human papillomavirus (HPV) is the most common sexually transmitted infection (STI) in the United States (US) and is associated with multiple types of cancer. Although effective HPV vaccines have been available since 2006, coverage rates in the US remain much lower than with other adolescent vaccinations. Prior research has shown that a strong recommendation from a clinician is a critical determinant in HPV vaccine uptake and coverage. In the interest of helping clinicians communicate more effectively with their patients about the HPV vaccine, this study employed user-centred (also known as "human-centred") design, an approach that focuses on the needs and preferences of the people who will ultimately be affected by clinical or policy changes.

The researchers cite prior research suggesting that clinicians may communicate differently about HPV vaccine compared with the other adolescent vaccines. For example, clinicians may frame the HPV vaccine as less important than the other vaccines or may even suggest deferring the vaccine to a later visit. Because clinicians are uniquely positioned to educate patients and parents, providing needed supports for clinician behaviour change and empowering clinicians to recommend the vaccine could greatly increase HPV vaccine coverage. However, traditional intervention methods, such as clinician education and public awareness campaigns, are not having a large impact on HPV vaccination rates. Perhaps, as this study will explore, health care interventions designed according to user-centred design principles will suit the needs of time-constrained clinicians and staff and will operate within the complex structure and workflows of health care delivery organisations.

The user-centred design cycle includes 6 steps: 1) understanding the environment, 2) framing opportunities, 3) imagining possibilities, 4) prototyping, 5) piloting, and 6) spreading innovation. For the current study, the goal was to complete the first 3 steps to generate one or more innovative intervention ideas that might be developed and tested in future work.

Interview participants (N = 14) included 6 primary care clinicians, 5 subject matter experts, or SMEs (e.g., a social marketing and health communications consultant), and 3 representatives from analogous industries outside health care that had the potential to inform effective clinician endorsement of the HPV vaccine (a middle school guidance counselor, a marijuana legalisation activist, and a retail curriculum expert). Interview guides included questions about: knowledge, attitudes, and beliefs about HPV vaccination; typical workflow; potential barriers to recommending vaccination; and tools or processes that facilitate communication about or recommendation of the HPV vaccine.

The problems for which the researchers were trying to design solutions were as follows: 1) clinicians must communicate with both parents and teens, who may have different priorities and values; 2) clinicians must communicate about issues that may raise a taboo subject (i.e., adolescent sexuality); and 3) clinicians need effective tools, training, or professional orientation to help them communicate more effectively with their patients.

Four primary themes emerged from the interviews regarding how clinicians approach discussing the HPV vaccine with parents: 1) the importance of enhancing parents' trust in the clinician, developing rapport between the clinician and the parent, and effective communication skills on the part of the clinician; 2) clinician knowledge about common parental concerns about vaccination; 3) the ability to develop talking points and messaging to effectively address these common concerns; and 4) increasing clinicians' comfort with discussing difficult topics with their patients or parents.

The paper describes the carrying out of data analysis meetings and a data synthesis workshop with multiple stakeholders. Several of these stakeholders were also parents of preteens or teens, some of whom had recently discussed HPV vaccination with their child's primary care clinician. Workshop participants generated 5 potential intervention concepts; each attendee voted for up to 3 of them.

• The most popular intervention concept, a "shared values approach", emphasises determining the parent's values as they relate to vaccines and constructing messaging salient to these values. This intervention strategy also emphasises capitalising on trust in the clinician and the health care organisation - for example, empowering the clinician as a resource to help filter through discordant information readily available through the internet or social media.
• The second most popular intervention idea, Ready, Set, Grow!, would involve a set of workbooks (in print or preferably online format) for teens and parents to celebrate milestone birthdays (transitions to middle school and high school). The stakeholders emphasised the importance of designing the workbooks to appeal to youth, using, for example, an interactive "graphic novel" format. The workbooks would cover a broad range of preventive health issues, including HPV and the HPV vaccine. However, the emphasis would be on helping youth learn how to critically evaluate health information available from multiple sources and communicate effectively with their clinician. The stakeholders envisioned tear-out (or printout) worksheets that youth could take to upcoming visits with clinicians, with one worksheet specifically devoted to HPV and other adolescent vaccines.

The next steps are to develop a prototype for an intervention with the input of key stakeholders, including teenagers, parents, and clinicians, and then conduct a pilot study in a clinical setting to assess effectiveness and feasibility.