The Role of Healthcare Providers in HPV Vaccination Programs - A Meeting Report

"Insufficient communication, engagement and education of HCPs related to vaccination can jeopardize vaccine uptake and attempts at improving public confidence."

The HPV Prevention and Control Board organises technical and country meetings, where international and local experts exchange experiences and insights to strengthen countries' efforts to secure human papillomavirus (HPV) prevention and control. This report captures discussions from the fifth meeting in the series, which was held in Bucharest, Romania, May 15-16 2018, to explore the role of healthcare providers (HCPs) in prevention programmes, with a focus on confidence (an attitude that vaccines are good or bad) and hesitancy is (a motivation, or lack of it, related to getting vaccinated or giving the vaccine).

Thoughts on the role of HCPs in vaccination programmes in general:

• Lessons learned from influenza vaccination acceptance among HCPs include several general principles related to increasing vaccination among HCPs:
  • Increase education of HCPs related to vaccination and vaccines;
  • Emphasise the norms of vaccination (e.g., to protect patients, colleagues, and family) among HCPs; and
  • Make it easier for HCPs to get vaccinated (e.g., by making vaccines free of charge and improving access to vaccination by supplying them at the work space).

  "When HCPs truly are hesitant, education will not always solve these issues, in which case engagement is needed, as well as providing a space to listen to and address their concerns."

• A qualitative study of HCPs from 4 different European countries (Croatia, France, Greece, and Romania) showed that, while in general the benefits of vaccination were appreciated, perceived risks played an important role in their attitudes towards vaccination. In general, HCPs felt that vaccine confidence could be improved by providing more information to HCPs and their patients (e.g., on side effects), offering provider training (e.g., on communication skills), and passing stricter legislation (e.g., action against vaccine-hesitant HCPs).
• The 2009-2011 measles outbreak in Bulgaria, 90% of cases of which occurred in the Roma population, helped develop and strengthen national and local vaccination activities through enhanced collaboration between HCPs and Roma organisations. Bulgaria tested the Guide to Tailoring Immunization Programs (TIP) and participated in the European Centre for Disease Prevention and Control (ECDC) and World Health Communication Associates (WHCA) project "Let's Talk about Protection: An ECDC Action Guide to Enhance Childhood Vaccination Uptake". The guide, adapted to the context in Bulgaria, was published and distributed for use by HCPs and Roma health mediators (HMs).
• Currently, limited activities are undertaken to try to understand and measure HCPs' concerns about vaccines and immunisation across countries. Attendees at the meeting indicated that measurement of vaccine confidence among HCPs should be introduced into vaccination surveillance systems; other measurements include provider behaviour (recommendation), patient behaviour (how often patients who want to delay or refuse vaccination are encountered), and HCPs' reactions to parent hesitancy. "Education of HCPs related to vaccination and communication is essential to permit them to provide appropriate, accurate information to parents."

The role of HCPs in implementing and expanding coverage of HPV vaccination - country examples:

• Bulgaria: The role of health mediators in reaching the Roma population - In the Roma communities, HMs generally do not encounter anti-vaccine sentiments, but challenges occur due to a lack of information, poor communication, and access to general practitioners (GPs).
• Scotland: School immunisation teams and the HPV programme - Vaccine uptake rates have remained high, despite some growth in anti-vaccine sentiment and attempts at coordinated anti-HPV campaigns.
• France: The role of HCPs in vaccination - A study has shown that people who trust the healthcare system and health professionals were more likely to have been vaccinated. Furthermore, those who were advised by HCPs to be vaccinated showed the intention to do so. An HCP recommendation, together with subjective norms, had the strongest association with self-reported vaccination.
• Flanders (Belgium): Training of medical students and vaccinators, and the Flemish Vaccination Board - The latter: advises about the implementation of the vaccination programme and about communication and vaccination campaigns; prepares common communications about vaccinations; and, in case of a potential crisis, provides proactive communication (in one voice) to vaccinators and the Minister of Health.
• Colombia: The role of the HCP/specialist after a mass psychogenic event - At the time of HPV vaccine introduction, confusion about the vaccine was high among both GPs and parents. The intense communication campaign for the introduction was not supported by providing information and education to those responsible for administration of the vaccine, leaving them unprepared for questions from the public. Hence, following the launch of the HPV vaccination programme in 2012, Colombia was not prepared for the crisis that happened in Carmen de Bolivar in 2014. This crisis, and the follow-up actions, led to a sharp decline in HPV vaccine coverage from 88% in 2012 to 14% in 2016. Among the actions taken since to increase HPV vaccine advocacy: A roundtable has been established (including the Liga Colombiana contra el Cancer, the Ministry of Health, and clinical societies) and an e-course on HPV vaccine efficacy and safety has been developed.

Meeting attendees discussed the strengths and weaknesses of different school and GP-based HPV vaccination programmes as implemented worldwide. For instance, because students are among friends, vaccination may turn into a shared experience, potentially leading to higher uptake. (This speaks to the importance of increasing HCP norms of getting vaccinated.) As a weakness, this group setting may turn against the programme, because vaccination of groups may be more prone to mass psychogenic illness, e.g. fainting, especially if the actual vaccination process is seen by the peers. The major strength of the GP-based programme is the personal relationship between the GP and the vaccinees and their parents; a major weakness is vaccine-hesitant GPs, which may affect vaccination of all patients in the practice.

Strategies to enhance the impact of HCPs in improving HPV vaccination coverage:

• Making effective HPV vaccine recommendations - "Patient-provider communication is key to ensuring a successful HPV vaccination program and optimal coverage rates." Research has shown that an announcement approach can improve HPV vaccine uptake. For all families, the provider states that 3 vaccines will be provided at the end of the consultation, mentioning HPV vaccine in the middle. If the parent is hesitant, the provider asks for the main concern, addresses it, and ends with a strong recommendation. The announcement approach was further refined and is now: Announce + Connect, Clarify, Counsel.
• Working with media: Helping HCPs address HPV queries - It is important to build relationships with the media. HCPs should be prepared by knowing: how HPV is being covered in the news and social media; the main themes and arguments presented on various sides of the issue; and the gaps in stories, facts, or perspectives that could help improve support for HPV vaccination. Furthermore, HCPs are advised to develop effective communication skills to avoid common pitfalls. "One must strive for evidence-based communication, get your facts right, while keeping in mind that cultural adaptation of materials may be necessary. It is important to help HPV vaccine advocates tell their stories and then amplify messages through social media. Another...strategy is to be opportunistic by linking in HPV vaccination information to important events, taking advantage of breaking news, and providing key information when the target population may be receptive."
• Providing appropriate training of HCPs, who feel more confident in giving advice when they receive appropriate training (e.g., through an e-learning programme) - "HCPs need more support to manage the changes in society (more assertive patients, actively seek information, which is not always scientifically correct) as well as the quickly evolving vaccine environment, through training, incorporation of vaccinology into the medical curriculum, providing access to tools and resources."

On the latter point, this report discusses and provides links to various information and training materials: from the United States (US) Centers for Disease Control and Prevention (CDC); ECDC; World Health Organization, Regional Office for Europe (WHO/Europe); the Catalan Institute of Oncology online oncology community; and others. While many resources are available, further needs were raised during the meeting, especially related to the need for answers to specific, frequently asked questions (FAQs). "This material should be in plain language and easy to comprehend, but with high-quality and evidence-based information, to circumvent concerns from escalating and ultimately to increase vaccine uptake. The information should be country-specific, which goes beyond simple translation, as the message should ideally be locally and culturally adapted." It was suggested that there be an effort to centralise and coordinate education and information material - e.g., in a "one-stop shop" for both HCPs and the general public.

The report concludes with a recap of lessons learned. Considering that HCPs, especially those with specialisations not traditionally involved in vaccinations (e.g., obstetricians), can have the same questions, doubts, and fears about vaccines as their patients, "it is essential to take the time to actively listen to HCPs' concerns about vaccination." Furthermore, it is suggested that those involved in vaccine programme design and implementation rebuild trust among HCPs "by including them at the earliest possible stage: in decision making for vaccine recommendations and policies, as well as the design of communication materials. Finally, as vaccinated HCPs are more likely to recommend vaccination to their patients, there is a need to restore and maintain vaccination as a norm among the health community: the HCP as role model."