Effective HPV Vaccination Strategies: What Does the Evidence Say? An Integrated Literature Review

"Providers and nurses need to shift conversations to strong recommendations for the HPV vaccination and include additional reminder systems, including protocols to meet Healthy People 2020 goals for HPV vaccination."

The low rates of human papillomavirus (HPV) vaccination in the United States (US) motivated this researcher to examine, through a literature review, the current state of available evidence to identify effective strategies for improving outcomes of HPV vaccination completion in the US.

The search was limited to studies published in peer-reviewed journals in the last 10 years. This search strategy identified 201 studies that met inclusion criteria, with 46 studies meriting further review. The review focused on US population groups, although 2 international studies (Sweden and Canada) were included under provider recommendation interventions.

To provide some context for the interventions later discussed, the review examines not only risk factors for HPV infection but also barriers to vaccination. On the latter, common barriers to HPV vaccination identified in the literature include lack of knowledge for the need to vaccinate, parental concerns, costs of the vaccinations, and missed opportunities. More specifically, related to communication, safety concerns with HPV vaccine have been noted to be a cause for vaccine hesitancy. As research has found, despite minimal side effects, there is a plethora of misinformation that parents are exposed to through unreliable internet sources. Also contributing to vaccine hesitancy or refusal is a fear that the adolescent would become sexually active once the HPV vaccination was completed. There have been numerous studies conducted that refute that concern.

The integrative review focused on interventions implemented to increase vaccination uptake, including provider recommendation, text message reminders, and multi-method intervention strategies (see Table 1, Table 2, Table 3 in the paper). In sum:

• Provider-specific strategies: Effective strategies to overcome some of the barriers discussed above include education of the parents (e.g., providing reliable health information resources), education of the providers on the Advisory Committee on Immunization Practices (ACIP) guidelines and HPV vaccine efficacy, and options to decrease the costs involved for both the parents and the providers. For example, correcting misinformation indicating sexual disinhibition once the adolescent is fully vaccinated with educational interventions and redirection to reliable health information sources could have a direct influence on parental decision making. Providing anticipatory guidance earlier in the process may help decrease the misinformation exposure to the parent. Research shows that providers need to continue to offer recommendations at every contact with the adolescent population, as many who delay will eventually accept vaccination at a later visit. Using the so-called announcement communication technique has been found to be the most effective communication method to increase HPV vaccination uptake. (This entails provider communication to the parents presented as a confident statement, assuming the parent will accept the recommendation to vaccinate. In contrast, the open-ended conversational or informational communication technique invitates the parent for discussion on the topic; this technique can be effective in building rapport with the patient or family but has not been found to be as effective in increasing vaccination uptake.) While the announcement technique has been found to increase initial HPV vaccination uptake, it has not been found to be consistently effective in increasing completion rates of the HPV series.
• Text message reminders: In the US, a majority of parents have unlimited text message plans and prefer that method for communication of vaccine reminders. This method has been found to be most effective if used for both scheduling the vaccination appointment and reminders to attend that appointment. In short, if used with other interventions, text message reminders have shown great promise as an effective strategy to increase HPV vaccination uptake.
• Multi-method interventions: The available evidence demonstrates that forming a team approach, utilising technology to implement reminder systems, and practicing the announcement technique for high-quality recommendations at all visits is a cost-effective approach to this preventative care vaccine. Other interventions showing promise are bundling the vaccine with other adolescent vaccinations and decreasing missed opportunities.

Research has found that education on HPV infection and vaccination provided to health care professionals varies across the US. Thus, there is a need to incorporate a focus on effective methods to increase vaccination acceptance, including high-quality recommendation communication strategies, at all levels of health profession education.

According to the researcher, further study is called for to understand which multi-method interventions are most effective in sustaining increased rates for HPV vaccination. In addition, there is a need to compare interventions utilised in the US with other countries. Furthermore, in the US, one barrier to HPV vaccination is the lack of preventive care visits in the adolescent age groups. Research exploring strategies to increase rates of wellness visits in this population group may have an indirect impact on increasing the HPV vaccination uptake. Finally, there are limited studies in non-Hispanic, non-Black, higher-educated, and higher-income population groups. Further research could help identify effective strategies to increase vaccination in those groups.

In conclusion: "Providers need to recognize their potential to create change through effective recommendations using announcement technique. Using a multi-method approach to the problem will also increase vaccination uptake in HPV vaccination series. Collaborating with parents and the healthcare team, providers can provide patient-centered health promotion care that will decrease risks of cancer in the future."