Parents Who Decline HPV Vaccination: Who Later Accepts and Why?

"An initial high-quality provider recommendation and subsequent follow-up counseling after declination are promising strategies to promote secondary acceptance."

The phenomenon of parents declining human papillomavirus (HPV) for their adolescent children is a key contributor to low uptake, reflected in coverage in the United States (US) that is far below the Healthy People 2020 goal of 80%. In fact, a national survey found that more than one-third of parents (36%) reported ever having refused or intentionally delayed HPV vaccination for their adolescent children. The Centers for Disease Control and Prevention (CDC) and other public health organisations encourage providers to give high-quality recommendations to prevent declination and to discuss the vaccine again at future visits if parents decline. In the interest of helping providers increase their success in counseling parents, this study sought to assess the prevalence and correlates of accepting HPV vaccination after declination as well as parents' self-reported reasons for doing so.

The researchers conducted a cross-sectional online survey of 1,253 parents of children ages 11 to 17 in September 2016. Respondents were members of KnowledgePanel, a nationally representative panel of US adults maintained by the survey research company GfK. For those who reported having ever declined HPV vaccination for their children during the initial discussion with their child's healthcare provider (n = 494), the survey assessed whether they accepted the vaccine at a subsequent visit. The researchers used multivariable logistic regression to assess correlates of secondary acceptance.

Half of parents in the sample reported on a son, and the average child age was 14 years (standard deviation (SD), 2.0 years). The average child age at the first discussion about HPV vaccine with a health care provider was 12 years (SD, 1.6 years), and on average, the first discussion had occurred 2.1 years (SD, 1.6) before the survey. More than three-quarters (78%; n = 383) of parents reported having received a recommendation for HPV vaccination from their child's provider the first time it was discussed. Among these 383 parents, 288 (or 75%) received a high-quality initial recommendation, and 95 (or 25%) received a low-quality initial recommendation.

Almost half (45%) of parents reported secondary acceptance of HPV vaccination, and an additional 24% intended to vaccinate in the next 12 months. In multivariable analyses, secondary acceptance was:

• ...associated with receiving follow-up counseling about HPV vaccination from a health care provider (odds ratio (OR), 2.16; 95% confidence interval (CI), 1.42-3.28). However, only 53% of parents overall reported receiving such counseling.
• ...more commonly reported by parents who: received a higher-quality HPV vaccine recommendation from a provider during the initial discussion (adjusted odds ratio (aOR), 1.78; 95% CI, 1.04-3.04), received follow-up counseling (vs. none; aOR, 2.16; 95% CI, 1.42-3.28), had high vaccination confidence (vs. low confidence; aOR, 1.99; 95% CI, 1.03-3.83), or reported high or medium satisfaction with provider communication during the first discussion (vs. low satisfaction; aOR, 3.72; 95% CI, 1.90-7.25; aOR, 2.11; 95% CI, 1.22-3.65).

Furthermore:

• Increasing time since the initial discussion was associated with secondary acceptance (aOR, 1.59; 95% CI, 1.34-1.88).
• Parents of 13- to 15-year-old children had approximately 2 times higher odds of secondary acceptance compared with parents of 11- to 12-year-old children (aOR, 2.07; 95% CI, 1.16-3.68).
• Among the reasons for secondary acceptance, parents most commonly reported the child getting older (45%), learning more about HPV vaccine (34%), and receiving a provider recommendation (33%).

According to the researchers, "These results are encouraging because they suggest that, across demographic groups, many of the estimated 36% of US parents who decline HPV vaccination for their children eventually reconsider....In this way, our findings raise the possibility that parents' decision-making about HPV vaccination might be more fluid and amenable to intervention than some providers perceive it to be."

The importance of follow-up counseling, which is provided by only half of providers, highlights missed opportunities for providers to deliver additional HPV vaccine recommendations and education. (The findings also speak to the need for improving provider communication about HPV vaccination, because approximately one-third of parents in the sample reported lower levels of satisfaction with their provider's communication, and approximately one-fifth did not recall receiving a recommendation.) The parents in this study who received follow-up counseling were more likely to report as their reason for secondary acceptance that they learned more about the vaccine, and that they received a provider recommendation, than parents who did not receive such counseling. Follow-up counseling might also be important for meeting parents' communication preferences; previous research published by these researchers suggests that many parents who refuse or delay HPV vaccination prefer to decide about the vaccine at a later visit rather than the same day. "Although providers should continue to prioritize the goal of preventing declination, follow-up counseling is likely to play an important role in parental acceptance of HPV vaccination when declination does occur."

The researchers discuss implications of the study, including:

1. Considering that time since the initial provider discussion as well as parents' vaccination confidence were associated with secondary acceptance, providers need efficient communication strategies for improving parents' vaccination confidence and perception of the importance of on-time vaccination. Helping parents achieve a better understanding of the higher immune response produced by the vaccine in younger adolescents could potentially increase vaccination confidence and reduce declination.
2. Future research is needed on strategies to encourage follow-up counseling after declination, including the effect of parental declination forms and reminder/recall systems.