The HPV Vaccine Announcement for Children and Adolescents: HPV Cancer Prevention Starts with You

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Welcome to CME on ReachMD. This activity, entitled “The HPV Vaccine Announcement for Children and Adolescents: HPV Cancer Prevention Starts with You” is provided by Prova Education.

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Dr. Kenneth Alexander:
As an immunizer, do you know how to use the HPV vaccination Announcement Approach and how to respond when parents don't say yes to vaccination? Let's review the science behind the Announcement Approach, what the communication process looks like, and where you can go for more information to help you counsel and inform.

This is CME on ReachMD, and I'm Dr. Kenneth Alexander.

Dr. Noel Brewer:
And I'm Dr. Noel Brewer.

Ken, can you refresh us on the ACIP recommendations for children and why we should start HPV vaccinations at age 9?

Dr. Kenneth Alexander:
Thanks, Noel. The Advisory Committee on Immunization Practices, or ACIP, has given clear guidance around HPV vaccination. The ACIP recommends that routine HPV vaccination be initiated for all children aged 11 to 12 years. Vaccination can be started as early as 9 years. HPV vaccination is also recommended for all people ages 13 to 26, who have not yet been vaccinated or completed the HPV vaccine series.

Now, there are 3 things here that merit special attention. First, young people who start the vaccine series before their 15th birthday need only 2 doses to be fully protected. People who start the vaccine series on or after their 15th birthday need 3 doses. So immunizing early means fewer doses need to be given. That's good vaccine stewardship.

Second, starting HPV vaccination at age 9 is a priority for many national organizations, including the American Academy of Pediatrics. By starting HPV vaccination at age 9, we ensure a robust immune response and increase the chances that young people will complete the 2-dose series. Immunizing at age 9 also avoids the busy adolescent platform that includes Tdap and meningococcal vaccines that we normally give around ages 11 to 12.

And finally, it's worth noting that the ACIP, as they talk about HPV vaccination, uses the word “recommended.” Now it turns out that recommended is a loaded word here. If the ACIP were saying to us, HPV vaccination is a good idea, do it if you want to, they would have said that HPV vaccination is encouraged. Instead, they use the word recommended, which puts the recommendation for HPV vaccination on the same tier as the recommendations for measles, polio, tetanus, and all the other vaccines that you and I view as essential.

So, Noel, herein lies the challenge that we as immunizers have faced. Many of us are uncomfortable bringing up HPV vaccination with parents. The idea of talking about a sexually transmitted infection makes many of us uneasy, and we tend to assume wrongly that parents frequently don't want the HPV vaccine for their children. As a consequence of our discomfort and uncertainty, we’re often either giving poor quality recommendations or we avoid bringing up HPV vaccination altogether.

I do have some good news here. Research shows us 2 important things. First, our assumption that parents don't value HPV vaccination for their children is wrong. Most parents do think that HPV vaccination is important. Parents are waiting for our recommendation to move ahead and protect their children.

Secondly, we've learned that parents are less concerned about HPV disease transmission and more concerned about preventing the ravages of HPV disease itself. Parents don't want us to talk about HPV transmission. Therefore, to give parents the information they need, and to help ourselves stay focused on what's important, the main thing that we have to tell parents is that HPV vaccination is cancer prevention, that with this vaccine, we can prevent 6 cancers.

Can you give us an overview of what communication science is telling us as immunizers about what we're missing, why we're missing the mark, and how we as providers might become more effective vaccine communicators?

Dr. Noel Brewer:
Remember, HPV vaccine is older than your iPhone, so there's nothing new here. This is just part of routine care, and it's important that you communicate in a way that says this is routine. There is a specific technique called the Announcement Approach that my group developed, and that builds on using presumptive language that assumes the parents are ready to vaccinate. “I see your child's 12. Based on this, they're due for these vaccines, and we're going to give the vaccine today.” So that's a nice way to save time, set everyone at ease, and help your clinic flow keep moving. What's especially important, though, is that parents prefer this style of communication. It makes them more satisfied with a visit. It also allows them to have time for other important concerns that they have. It's also true that some providers misunderstand how important their voice is with parents. They may walk away thinking, “Wow, I've had a couple of really awkward conversations that are really different than I remember having. And it just seems like vaccines are barely worth talking about now.” And that's wrong. Think actually about most conversations, which go pretty well and are pretty efficient and pretty on track. So when there's one conversation that doesn't go exactly as you hope, just take that as being the exception to this.

A provider's recommendation is the single most important influence on vaccine uptake. And it has a bigger influence than the patient's own beliefs, their race or ethnicity, or their education.

Dr. Kenneth Alexander:
I think you've hit on a couple of important things as we think about how we run the business of vaccinating. One, that we are uncomfortable, and we're looking for ways to be more comfortable with our recommendations. And as you point out, this announcement process seems to be a much more efficient way to move forward.

Dr. Noel Brewer:
Our group conducted a randomized clinical trial showing that using the Announcement Approach increases vaccine uptake by 5%. However, when we compare that to using a usual conversational approach, where you try to pull out every concern and you pass the talking stick the whole time, that didn't have any impact on vaccine uptake. So using efficient announcements paired with addressing a parent's key concern is highly effective.

Dr. Kenneth Alexander:
For those just tuning in, you're listening to CME on ReachMD. I'm Dr. Kenneth Alexander, and here with me today is Dr. Noel Brewer. We're discussing how providers may use the Announcement Approach for promoting HPV vaccination.

Take me, again, in detail in how this announcement process is constructed.

Dr. Noel Brewer:
So a clear and effective HPV vaccine recommendation is going to follow 3 steps. Step one is to announce, which we just talked about a little bit. Step 2 is to connect and counsel. And step 3 is, if you need to, try again. I'm going to go through each one of those right now.

The best way to begin a recommendation is to announce that they're due for HPV vaccination, using language that assumes the family will be vaccinating. The idea is to use the same brief and warm language that you use for many other vaccines and preventive services for children this age. Many parents agree to vaccination after hearing an announcement. Specifically, you'll note the child's age, say children this age are due for vaccines that prevent 6 cancers and that you'll give the vaccine today.

And here's another example of that. For children ages 9 or 10 years, the announcement might sound like this. “Alex is now 9, so today they'll get a vaccine that prevents 6 HPV cancers.” So as you just heard, announcements are brief, taking maybe 15 seconds. They help parents who are ready to vaccinate and don't need or want a long discussion. The time saved can be spent on managing chronic health problems, screening, or anticipatory guidance. The announce step makes use of several communication principles to maximize its impact. You use presumptive language, which parents will recognize from many other clinical interactions, and set the norm to make HPV vaccine like the many other vaccines that children receive routinely. You also focus on diseases, but not vaccines, because parents are interested in the benefit to the child, especially for cancer prevention.

And finally, announcements show urgency so that the parent clearly hears that the provider would like to vaccinate today, because some parents may incorrectly think that the discussion is about preparing for HPV vaccination at a later appointment instead of vaccinating today.

Now let's talk about the second step, connect and counsel. You'll use this step with parents hesitant about vaccination. While announcements are brief and use similar language across patients, the pace of the visit is going to slow down during this step, and the communication content is tailored to each patient and family. The specifics of the connect-and-counsel step are to identify the single biggest concern by asking for the main concern, regardless of what the parent may have already voiced. Next, show you're listening by restating the concern in your own words, because many parents are more open to hearing your advice once they know you've listened to them. Now that you've established a connection with a parent, you can use a research-tested message that you tailor to their concern. We host those at HPVIQ.org. There's 7 different ones that address the different main concerns that parents have. Finally, show urgency by making a clear recommendation for vaccination today. Some parents will still think this is a discussion about an eventual decision rather than about getting vaccinated today. So clearly recommending same-day vaccination is key.

Here's an example of what the connect-and-counsel step might sound like. “You mentioned you didn't know enough about the vaccine. What would you say is your main concern?” And then you listen carefully to the parent. And then you might ask or say, “You said that you were surprised that Alex will get a vaccine at this age. I get that. It may help to know that the American Academy of Pediatrics recommends that kids get the HPV vaccine starting at age 9 to prevent 6 cancers. It's a really important opportunity to protect kids well before they're ever exposed. That's why I recommend Alex get it today, because the vaccine works better when given at younger ages.”

Our research has found that parents can be more confident in HPV vaccine and motivated to vaccinate when they receive research-tested messages about HPV vaccination. We have developed messages to address the 7 most common parent concerns. Many studies have shown that messages about cancer prevention are especially effective. A surprising finding is that parents want messages that are longer and do not reflect urgency. It's also important to leave the sense of urgency for the final part of the connect-and-counsel step where you remind them that you advise vaccinating today.

Now let's talk about the third step. Try again at a later visit. You'll use this if a family declines HPV vaccine. Some families may need to think about what they have heard about HPV vaccination or consult with another parent. The visit now picks up speed again as you wrap up this conversation, move on to another topic. Try again takes perhaps 15 seconds. The specifics of the try-again step are to set the stage by saying you'll talk about the vaccine at the next visit. It’s that simple. Here's an example of what it might sound like. “We'll talk more about HPV vaccine and Alex's next checkup. It's important for them to have every opportunity for cancer prevention, so I've added a note to their chart. Let's be sure to revisit this discussion.”

So be sure to rely on your clinical record system by making a note in the chart to prompt a follow-up when you see them again. A good practice is to focus notes on the need to revisit and recommend HPV vaccination, rather than simply noting that the parent has declined. That way other providers will be assured that the family expects another recommendation, rather than assuming that the conversation is closed and should be avoided. Research indicates that agreeing to HPV vaccination after an initial dec-declination is common. Of parents who decline HPV vaccination, almost 70% get it at the next visit or plan to within the next year.

Dr. Kenneth Alexander:
Noel, this sounds very elegant, and I want to make sure I understand this entirely. What you're saying, then, is the announcement method has been shown through research to be, one, an approach that parents want, two, one that works well for providers, three, is time efficient, and fourth, actually gets kids vaccinated. Is that right?

Dr. Noel Brewer:
That's exactly right. It does all of those things. And I'll add a fifth thing: It's so simple that you can actually hand this approach off to nurses and medical assistants to at least do the announcements before you even see a patient. And that can improve clinic flow.

Dr. Kenneth Alexander:
What about dealing with an 11- to 12-year-old where we're not only giving HPV but we're maybe talking about giving meningococcal and Tdap vaccines as well. How does that process differ?

Dr. Noel Brewer:
The main difference is now you'll recommend 3 vaccines: meningitis, HPV, and Tdap. So you're going to bundle them into 1 statement. And remember to focus on the diseases you're preventing instead of the vaccine names. The announcement for ages 11 to 12 might sound like this: “Now that Jasmine is 11, she's due for 3 vaccines. Today, she'll get vaccines against meningitis, HPV cancers, and whooping cough.”

Dr. Kenneth Alexander:
So as we close out, I guess there's a couple of take-home messages. My take home is that as vaccinators communication matters, and it matters because HPV vaccination prevents cancers and saves lives.

Noel, what's your take-home here?

Dr. Noel Brewer:
You can use the Announcement Approach to make your life easier in the clinic. Announce to start, move on to connect and counsel if they're hesitant, and then if they declined, try again at the next visit.

Dr. Kenneth Alexander:
So I want to thank our audience for listening and especially thank you, Noel, for joining me and for sharing your valuable insights and expertise. It was a pleasure as always speaking with you.

Dr. Noel Brewer:
Thanks for having me.

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