Announcements Versus Conversations to Improve HPV Vaccination Coverage: A Randomized Trial

"[A]nnouncements normalize HPV vaccination for both providers and parents, making providers more likely to raise the topic and parents more likely to consent to vaccination."

In the United States (US), national guidelines recommend routine human papillomavirus (HPV) vaccination for all 11- or 12-year-olds; however, vaccine coverage is persistently low. Provider recommendation for HPV vaccination has been shown to be critical for motivating uptake, yet many providers make these recommendations hesitantly, late, or not at all; concerns include the time it takes to recommend the vaccine, anticipation of an uncomfortable conversation related to sex, and a false perception that parents do not value HPV vaccination. The present study was carried out to determine the effectiveness of training providers to improve their recommendations using either presumptive "announcements" (brief statements that assume parents are ready to vaccinate) or participatory "conversations" that engage parents in open-ended discussions.

The researchers conducted a randomised clinical trial including 29 paediatric and family medicine practices in central North Carolina, US. They randomly assigned clinics to receive announcement training, conversation training, or no training. From May to August 2015, a physician educator traveled to participating clinics to lead 1-hour training sessions, using a standardised script and PowerPoint slide set to lead the 4-part training. The first section, "Review Evidence", was a didactic review of the latest research on HPV vaccination. In the second section, "Build Skills", the educator taught participants how to deliver effective HPV vaccine recommendations using either announcements or conversations, depending on the training.

• The announcement training instructed providers to first announce that the child is due for 3 vaccines to be given today, placing HPV vaccine in the middle of list. Only if parents raised a concern would providers then identify and ease parents' main concern about HPV vaccine, using a structured approach and strongly recommending same-day HPV vaccination.
• The conversation training built on the principles of shared decision making. It instructed providers to first start the conversation about 3 adolescent vaccines. Key elements of this first step included providers introducing the 3 vaccines recommended for children this age, placing HPV vaccine in the middle of the list to deemphasise it and make it routine, discussing the health benefits of these vaccines, and inviting parents' questions while saving the recommendation for later in the conversation.

Both trainings provided general advice on addressing common problems posed by HPV vaccine communication. For instance, if parents associated the vaccine with sex, it was suggested that providers redirect the conversation to be about cancer prevention.

In the third section, "Practice", the educator gave participants a note card that outlined relevant steps and asked them to complete a brief exercise to adapt the suggested material to their own personal style and language. This section included role-play with a colleague and discussion about the benefits and challenges of using announcements or conversations. In the fourth section, "Application to Your Practice", the educator engaged participants in a discussion of how they would apply the training to their clinical practice, allowing them to align their communication as a group.

The North Carolina Immunization Registry provided data on the primary trial outcome: 6-month coverage change in HPV vaccine initiation (≥1 dose) for adolescents aged 11 or 12 years. The registry attributed 17 173 adolescents aged 11 or 12 to the 29 clinics still open at 6-months posttraining. Six-month increases in HPV vaccination coverage were larger for patients in clinics that received announcement training versus those in control clinics (5.4% difference, 95% confidence interval (CI): 1.1%-9.7%). Stratified analyses showed increases for both girls (4.6% difference) and boys (6.2% difference). Patients in clinics receiving conversation training did not differ from those in control clinics with respect to changes in HPV vaccination coverage. Neither training was effective for changing coverage for other vaccination outcomes or for adolescents aged 13 through 17 (n = 37,796).

In short, what was found to be effective here was not a participatory communication approach but, rather, a brief recommendation approach that avoids discussing sex and gives parents an opportunity to ask questions should they wish to, issues that the trainings addressed. "Additional research is need to better understand how trainings improve coverage and the extent to which providers use announcements in routine clinical practice."