Healthcare professionals’ awareness of and barriers to shared-clinical-decision-making for HPV vaccination among adults 27–45 years

ABSTRACT

The Advisory Committee on Immunization Practices recommends human papillomavirus (HPV) vaccination for inadequately vaccinated adults aged 27–45 based on shared clinical decision-making (SCDM). However, little is known about awareness and barriers to SCDM among US healthcare providers (HCPs), especially in Texas, where HPV vaccination rates are below the national average. Between January and April 2021, we conducted a population-based cross-sectional survey (12% response rate) of HCPs licensed in Texas to assess the prevalence and factors associated with awareness of the SCDM recommendation. HCPs were asked if they were aware and if they foresaw any barriers in implementing SCDM for HPV vaccine recommendation. Among the 1,279 respondents, 54.26% were aware of this recommendation. HCPs practicing as gynecologists/obstetricians (adjusted odds ratio [aOR]: 6.12; 95%CI: 2.60–14.40, p < .001), those working in Federally Qualified Health Centers (aOR: 2.13, 95%CI: 1.24–3.65, p = .006) or group practices (aOR: 1.68, 95%CI: 1.22–2.30, p = .001), those seeing ≤ 100 patients/week (aOR: 1.70, 95%CI: 1.15–2.51, p = .008), those who had received formal training on HPV vaccination promotion and counseling within the past two years (aOR: 3.42, 95%CI: 2.29–5.10, p = < 0.001), between two and five years ago (aOR: 2.35, 95%CI: 1.67–3.30, p = < 0.001), and more than five years ago (aOR: 1.70, 95%CI: 1.16–2.50, p = .006) had significantly higher odds of awareness of SCDM recommendation. HCPs practicing as nurse practitioners/advanced nurse practitioners (aOR: 0.56; 95%CI: 0.38–0.82, p = .003), physician assistants (aOR: 0.62; 95%CI: 0.41–0.94, p = .023), aged 55 years or older (aOR: 0.57; 95%CI: 0.32–0.99, p = .046), Asian (aOR: 0.59, 95%CI: 0.43–0.81, p = .001) and non-Hispanic Black (aOR: 0.62, 95%CI: 0.40–0.97, p = .037) had significantly lower odds of awareness of SCDM recommendation. Overall, 44.96% of HCPs anticipated no barriers and planned to engage in SCDM, while 18.32% cited time commitment as an anticipated barrier. Internists cited time commitment (39.13%) as an anticipated barrier more frequently than other specialties, while physician assistants were more frequently unclear about how to implement SCDM (12.36%). We found limited awareness of the SCDM recommendation guideline for HPV vaccination among Texas HCPs. Therefore, training HCPs to use decision aids to actively engage patients in the SCDM process could improve HPV vaccination rates among unvaccinated adults aged 27–45.

Introduction

In the United States, the most common sexually transmitted infection spreading through intimate skin-to-skin contact is caused by the human papillomavirus (HPV).¹ Although most of the HPV infections are asymptomatic and become undetectable, the persistent infection with high-risk types of HPV develops cancers of the cervix, vagina, vulva, penis, anus, and oropharynx later in life.^1,2 HPV-associated cancers contribute approximately 47,984 new cases every year in the US.³

In the past decade, the US Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) has been recommending the HPV vaccine to be administered routinely at ages 11 to 12 years,⁴ along with catch-up of HPV vaccination for individuals through age 26 years if inadequately vaccinated.⁴ In June 2019, the ACIP recommended for the first time an extension of HPV vaccination to adults aged 27–45 years based on shared clinical decision-making (SCDM).^4,5 This recommendation provides benefits to people in this age group, particularly to unvaccinated or inadequately vaccinated individuals who lack immunity from natural infection or may be at risk of future HPV infections.^4,5 Since the HCPs, patients, and caregivers are partners in the provision of preventive or curative services, the process of SCDM offers them opportunities to contribute meaningfully to the discussion about the importance of HPV vaccination in individuals aged 27 to 45 years.⁵ Specifically, SCDM enables HCPs to assess individual risks and preferences, facilitating personalized vaccine recommendations.⁵ For patients and caregivers, SCDM offers an opportunity to ask questions, and express their values, preferences, and concerns, ensuring that medical decisions align with their patients’ goals and experiences.⁵ Although most adults have already been exposed to certain strains of HPV through sexual activity, new infections can still occur with new sex partners.⁶ Furthermore, even if an individual has already been exposed to some strains of the HPV virus before the age of 27, vaccination can still offer protection against other strains, including high-risk types not previously encountered that could lead to cancer.⁷ Therefore, SCDM is particularly crucial in the context of HPV vaccination for adults aged 27–45 who may not have received the HPV vaccine earlier, or who may have lower levels of prior exposure to the virus. Administering HPV vaccination to adults 27–45 years in the US has the potential to prevent them from getting HPV-associated cancers later in life, with associated costs ranging from $141,000 to $1,471,000 per quality-adjusted life-year gained.⁸

The US Preventive Services Task Force acknowledges the critical role of patients in the shared decision-making process with their clinicians, focusing on the importance of patient collaboration in making informed decisions, especially about preventive services.⁹ In 1993, Quill and Suchman defined shared decision-making as a process where the clinician provides information on the illness and treatment options, and the patient contributes his/her expertise on their own goals, risk attitudes, and preferred outcomes, negotiating for a uniquely tailored solution.^9,10 A Cochrane systematic review of randomized controlled trials studying decision aids that facilitate shared decision-making showed positive outcomes for patients, such as having enhanced knowledge, more realistic expectations of benefits and harms of treatment, decreased decisional conflict, increased proportion of individuals actively participating in decision-making, decreased indecision, and increased agreement between decisions and personal values.¹¹ Furthermore, a cross-sectional survey concluded that patient-centered interventions are required for shared decision-making to engage adults aged 27 to 45 years for HPV vaccination.¹²

In 2019, 13.1% of the US adults reported that they initiated HPV vaccination after the age of 26 years.¹³ Only a few studies have assessed the awareness and knowledge of primary care physicians (PCPs) regarding SCDM for HPV vaccine recommendation in ages 27–45. A survey of PCPs conducted in Fall 2019 reported that 42% of respondents were unaware of the ACIP’s SCDM recommendation for HPV vaccination.¹⁴ Another survey conducted in June 2021 among PCPs found lower awareness of the SCDM recommendation for their patients aged 27–45 years compared to the awareness of the catch-up recommendation for HPV vaccination in the US.¹⁵ Additionally, a recent survey found that 47% of providers serving mid-adults (27–45 years) in the US often or always engaged in SCDM for HPV vaccination.¹⁶ Notably, these studies have focused on internal medicine, family medicine, and obstetrics/gynecology specialties.^14–16 However, little is known about the awareness and anticipated barriers to SCDM recommendations among the other types of health care providers (HCPs), including pediatricians, physician assistants, and nurse practitioners/advanced nurse practitioners. Since the American College of Obstetrics and Gynecology (ACOG) offers several programs to increase the maternal immunization rates with essential vaccines such as the HPV vaccines,¹⁷ we hypothesized that gynecologists/obstetricians had higher odds of being aware of the SCDM for HPV vaccination recommendation to adults aged 27–45 years compared to the other types of the HCPs. In this study, we aimed to determine the prevalence, demographic, practice-related factors, and barriers to recommending the HPV vaccination based on SCDM by the HCPs in Texas. The study findings provide a foundation for developing targeted training programs, such as the ‘HPV Decide’ online tool,¹⁸ and informing public health strategies to increase vaccination rates among adults aged 27–45, ultimately reducing HPV-associated morbidity and mortality.

Methods

Study design, data source, and population

This population-based cross-sectional study used the data from a statewide survey conducted between January and April 2021 by The University of Texas MD Anderson Cancer Center in Texas. We sent a total of three reminder e-mails to HCPs who did not respond to the initial invitation to participate in this survey. The first follow-up e-mail was sent on day eight (±2 days) after the initial reminder, the second follow-up e-mail was sent approximately eight days (±2 days) from the first follow-up, and the third follow-up e-mail was five days (±2 days) from the second follow-up. The purpose of the survey was to evaluate the HCPs’ knowledge, perceptions, and practices regarding HPV vaccine recommendation, whose e-mail addresses were obtained from the LexisNexis Master Provider Referential Database.¹⁹ The survey was conducted online through REDCap, a secure web-based application tailored for research data capture. This study included data from 1,283 HCPs based in Texas who were primary care physicians (family medicine practitioners, pediatricians, gynecologists/obstetricians, internists), physician assistants, and nurse practitioners. The study was approved by the MD Anderson Ethical Review Board (IRB Number: 2019–1257). The study followed the ‘Strengthening the Reporting of Observational Studies in Epidemiology’ guidelines.²⁰ The overall response rate of the survey was 12%.

Measures

Outcome measure

HCPs’ awareness of the recommendation for HPV vaccination based on shared clinical decision-making among adults aged 27–45 years

We assessed the awareness of the recommendation for the HPV vaccination based on SCDM for adults aged 27–45 years by asking the HCPs, “In August 2019, the CDC moved to recommend extension of HPV vaccination to include adults ages 27–45 years who are not adequately vaccinated and might be at risk for new HPV infection. Before now, were you aware of this new recommendation?” The possible responses were 1= “Yes” or 0= “No.”

HCPs’ anticipated barriers to recommending HPV vaccination based on shared clinical decision-making among adults 27–45 years

We further assessed the barriers to recommending HPV vaccination based on SCDM among adults aged 27–45 years by asking the HCPs: “According to the above CDC guidelines, providers are encouraged to employ shared decision making when recommending HPV vaccination to adults aged 27–45 years. What, if any, barrier do you foresee in implementing this recommendation?” The possible responses to this question were “No barriers, I plan to engage patients in shared decision making,” “Time Commitment,” “I am not fully aware of the concept of shared decision making,” “I am aware of shared decision making but unclear how to implement it for HPV vaccination,” and “Other barriers.” To reduce the response burden, barriers to SCDM recommendation for HPV vaccination in ages 27–45 were assessed through multiple-choice questions rather than a dichotomous or Likert-scale format.

Predictors

Type of HCPs

The HCPs were classified as Family Physicians, Pediatricians, Gynecologists/Obstetricians, Internal Medicine, Physician Assistants (PAs), Nurse Practitioners/Advanced Nurse Practitioners (NP/ANPs), and others.

Sociodemographic variables and practice-related factors of the study population

We included the HCP-related characteristics: age ( < 35 years, 35–54 years, and ≥55 years), sex (male and female), race/ethnicity (non-Hispanic White, non-Hispanic Black, Hispanic, Asian, and non-Hispanic Other), and practice location (rural and urban). The 2013 Rural-Urban Continuum Codes (RUCC) determined the HCPs’ location of practice using the reported zip codes.²¹ RUCC codes 1–3 were classified as urban, whereas 4–9 were classified as rural. Other factors assessed were the number of years in practice (less than or equal to 10 years, 11 to 20 years, and more than 20 years), the number of patients seen per week (less than or equal to 100 and more than 100), facility type (solo practice, group practice, university or teaching hospital, federally qualified health center (FQHC), public facility (city/county/public healthcare facility) and recency of formal training on HPV promotion or counseling (less than or equal to two years ago, two to five years ago, and more than five years ago).

Data analysis

We described the demographics and practice-related factors of HCPs according to their awareness of SCDM for HPV vaccine recommendation among adults aged 27–45 years using the frequencies, percentages, and the corresponding 95% confidence intervals. Comparisons between the two groups (aware versus not aware of SCDM) were conducted using Pearson’s chi-square test. Bivariable and multivariable logistic regression analyses were used to estimate the odds of HCPs’ awareness of the SCDM recommendation for the HPV vaccination. The covariates included in the model were HCPs’ age, sex, race/ethnicity, location of practice, years in practice, number of patients seen per week, formal training, and facility type based on the prior literature^22–25 and potential relevance to HCPs’ awareness, knowledge and engagement with recommendations of SCDM. Furthermore, we described the barriers anticipated by the HCPs to implement the SCDM recommendation according to the HCP’s sociodemographic and practice-related factors using percentages and 95% confidence intervals. The analyses were conducted with SAS version 9.4 (SAS Institute Inc., Cary, NC), and statistical significance was set as a two-sided p-value < .05.

Results

HCP’s awareness of the recommendation for HPV vaccination based on shared clinical decision-making among adults aged 27–45 years

A total of 1283 HCPs were included in this statewide survey. There were four missing responses regarding awareness of SCDM. Among 1279 participants included in this study, 54.26% (95%CI: 51.53–57.00) were aware, while 45.74% (95%CI: 43.00–48.47) were not aware of the SCDM recommendation for HPV vaccination among adults aged 27 to 45 years (Table 1). Participant HCPs were predominantly NP/ANPs (32.37%), aged 35 to 54 years (62.31%), females (76.53%), non-Hispanic Whites (52.62%), working in urban areas (95.77%), seeing less than or equal to 100 patients per week (87.59%), and received no formal training about HPV vaccination (57.64%) (Table 1). In addition, about one-third of respondents were participating in group practice (31.74%) and had less than or equal to 10 years of work experience (38.38%). HCPs who were aware of the SCDM recommendation for the HPV vaccination were more frequently gynecologists/obstetricians (90.14%), aged less than 35 years (57.05%), females (54.92%), Hispanic (60.37%), practicing in rural areas (62.96%), working in FQHCs (69.77%), had more than 20 years of practice (60.17%), seeing less than or equal to 100 patients per week (55.73%), trained less than or equal to two years ago (73.78%) (Table 1).

Table 1.

Descriptive statistics of the type of the medical specialty practice, demographics, and practice-related factors of the healthcare providers (HCPs) by the strata of the awareness of HPV vaccine recommendation based on shared clinical decision-making (SCDM) among adults 27–45 years in Texas (n = 1279).

	Total		Aware		Not Aware		ap-value
Characteristics	n = 1279		n = 694 (54.26%)		n = 585 (45.74%)
	N (%)	95% CIb	N (%)	95% CIb	N (%)	95% CIb
Type of the HCP							<.0001
Family Physician	193(15.09)	(13.13–17.05)	116(60.1)	(53.19–67.02)	77(39.9)	(32.98–46.81)
Gynecologist/Obstestrician	71(5.55)	(4.29–6.81)	64(90.14)	(83.2–97.08)	7(9.86)	(2.92–16.8)
Pediatrician	241(18.84)	(16.7–20.99)	147(61)	(54.83–67.16)	94(39)	(32.84–45.17)
Internal Medicine	23(1.8)	(1.07–2.53)	16(69.57)	(50.74–88.4)	7(30.43)	(11.6–49.26)
Physician Assistant	274(21.42)	(19.17–23.67)	135(49.27)	(43.34–55.2)	139(50.73)	(44.8–56.66)
Nurse Practitioner/Advanced Nurse Practitioner	414(32.37)	(29.8–34.94)	198(47.83)	(43.01–52.64)	216(52.17)	(47.36–56.99)
Other	63(4.93)	(3.74–6.11)	18(28.57)	(17.4–39.74)	45(71.43)	(60.26–82.6)
HCP’s age, years							.773
Less than 35	156 (12.76)	(10.88–14.63)	89 (57.05)	(49.27–64.83)	67 (42.95)	(35.17–50.73)
35 to 54	762 (62.31)	(59.59–65.03)	411 (53.94)	(50.39–57.48)	351 (46.06)	(42.52–49.61)
More than and equal to 55	305 (24.94)	(22.51–27.37)	167 (54.75)	(49.16–60.35)	138 (45.25)	(39.65–50.84)
HCP’s sex							.503
Female	965 (76.53)	(74.18–78.87)	530 (54.92)	(51.78–58.07)	435 (45.08)	(41.93–48.22)
Male	296 (23.47)	(21.13–25.82)	156 (52.70)	(47.01–58.40)	140 (47.30)	(41.60–52.99)
HCP’s race/ethnicity							.001
Non-Hispanic White	673 (52.62)	(49.88–55.36)	391 (58.1)	(54.37–61.83)	282 (41.9)	(38.17–45.63)
Non-Hispanic Black	117 (9.15)	(7.57–10.73)	55 (47.01)	(37.95–56.06)	62 (52.99)	(43.94–62.05)
Hispanic	164 (12.82)	(10.99–14.66)	99 (60.37)	(52.87–67.86)	65 (39.63)	(32.14–47.13)
Asian	263 (20.56)	(18.35–22.78)	120 (45.63)	(39.60–51.66)	143 (54.37)	(48.34–60.40)
Others	62 (4.85)	(3.67–6.03)	29 (46.77)	(34.34–59.21)	33 (53.23)	(40.79–65.66)
Location of practice							.192
Rural	54 (4.23)	(3.12–5.33)	34 (62.96)	(50.07–75.86)	20 (37.04)	(24.14–49.93)
Urban	1224 (95.77)	(94.67–96.88)	660 (53.92)	(51.13–56.72)	564 (46.08)	(43.28–48.87)
Type of Facility							<.0001
University or teaching hospital or affiliated clinic	397 (31.04)	(28.50–33.58)	193 (48.61)	(43.69–53.54)	204 (51.39)	(46.46–56.31)
Solo practice	144 (11.26)	(9.52–12.99)	70 (48.61)	(40.44–56.79)	74 (51.39)	(43.21–59.56)
Group practice (single or multi-specialty)	406 (31.74)	(29.19–34.30)	252 (62.07)	(57.34–66.8)	154 (37.93)	(33.21–42.66)
Federally Qualified Health Center (FQHC)	86 (6.72)	(5.35–8.10)	60 (69.77)	(60.05–79.49)	26 (30.23)	(20.51–39.95)
City/County/Public Health Care facility	45 (3.52)	(2.51–4.53)	22 (48.89)	(34.26–63.51)	23 (51.11)	(36.49–65.74)
Faith based hospital/clinic	27 (2.11)	(1.32–2.90)	12 (44.44)	(25.68–63.21)	15 (55.56)	(36.79–74.32)
Employed Physician Practices	74 (5.79)	(4.50–7.07)	35 (47.3)	(35.91–58.69)	39 (52.7)	(41.31–64.09)
Other	100 (7.82)	(6.35–9.29)	50 (50.00)	(40.19–59.81)	50 (50.00)	(40.19–59.81)
Years in practice							.051
Less than or equal to 10	484 (38.38)	(35.69–41.07)	259 (53.51)	(49.06–57.96)	225 (46.49)	(42.04–50.94)
11 to 20	433 (34.34)	(31.71–36.96)	224 (51.73)	(47.02–56.45)	209 (48.27)	(43.55–52.98)
More than 20	344 (27.28)	(24.82–29.74)	207 (60.17)	(54.99–65.35)	137 (39.83)	(34.65–45.01)
No of patients seen per week							.139
More than 100	152 (12.41)	(10.56–14.26)	75 (49.34)	(41.38–57.3)	77 (50.66)	(42.7–58.62)
Less than or equal to 100	1073 (87.59)	(85.74–89.44)	598 (55.73)	(52.76–58.71)	475 (44.27)	(41.29–47.24)
Recency of formal training session attended on HPV							<.0001
Received no training	736 (57.64)	(54.92–60.35)	328 (44.57)	(40.97–48.16)	408 (55.43)	(51.84–59.03)
Training received more than 5 years ago	167 (13.08)	(11.23–14.93)	106 (63.47)	(56.16–70.79)	61 (36.53)	(29.21–43.84)
Training received 2 to 5 years ago	210 (16.44)	(14.41–18.48)	138 (65.71)	(59.29–72.14)	72 (34.29)	(27.86–40.71)
Training received less than or equal to 2 years ago	164 (12.84)	(11.01–14.68)	121 (73.78)	(67.04–80.52)	43 (26.22)	(19.48–32.96)

^aPearson chi-square test with p-value significant at < 0.05.

^bCI- Confidence Interval.

Categories included in ‘Other’ race/ethnicity were American Indian and Others.

Categories included in ‘Other’ type of HCP were allergist/immunologist, anesthesiologist, cardiologist, dietitian, geneticist, dentist, dermatologist, emergency medicine physician, ENT physician, ophthalmologist, surgeon, pathologist, pharmacist, physical therapist, preventive medicine physician, psychiatrist, radiologist, respiratory therapist, urologist, neurologist, resident (specialty not specified) and administrative staff.

Missing observations: 56 missing for provider’s age, 18 missing for provider’s sex, 1 missing for location, 18 missing for years in practice, 54 missing for number of patients, 2 missing for training recency.

In the multivariable logistic regression analysis (Table 2), compared to family physicians, gynecologists/obstetricians had significantly higher odds (adjusted odds ratio [aOR]: 6.12, 95% CI: 2.60–14.4, p < .001), NP/ANP had 44% lower odds (aOR: 0.56, 95%CI: 0.38–0.82, p = .003), and physician assistants had 38% lower odds (aOR: 0.62, 95% CI: 0.41–0.94, p = .023) of being aware of the SCDM for HPV vaccination. Also, compared to HCPs who were less than 35 years of age, the odds of being aware of the SCDM for HPV vaccination among those who were more than or equal to 55 years were 43% lower (aOR: 0.57, 95%CI: 0.32–0.99, p = .046). Compared to non-Hispanic White HCPs, the odds of being aware of the SCDM for HPV vaccination were 41% lower (aOR: 0.59, 95% CI: 0.43–0.81, p = .001) among Asians, and 38% lower (aOR: 0.62, 95%CI: 0.40–0.97, p = .037) among non-Hispanic Blacks. Furthermore, compared to HCPs working in university/teaching hospitals, HCPs working in FQHCs (aOR: 2.13, 95% CI: 1.24–3.65, p = .006), and in group practices (aOR: 1.68, 95% CI: 1.22–2.30, p = .001) had higher odds of being aware of the SCDM for HPV vaccination. Compared to HCPs attending more than 100 patients per week, HCPs consulting less than or equal to 100 patients per week had 70% higher odds (aOR: 1.70, 95%CI: 1.15–2.51, p = .008) of being aware of the SCDM recommendation. Compared to HCPs who received no formal training in HPV vaccination promotion or counseling, those who received less than or equal to two years of training (aOR: 3.42, 95%CI: 2.29–5.10, p < .001), those who were trained between two and five years ago (aOR: 2.35, 95%CI: 1.67–3.30, p < .001), and those who were trained more than five years (aOR: 1.70, 95%CI: 1.16–2.50, p = .006) had higher odds of being aware of the SCDM recommendation. Age, sex, location of practice, and number of years of practice were not associated with awareness of SCDM for HPV vaccination (Table 2).

Table 2.

Bivariable and multivariable logistic regression analyses of the association between HCPs’ type of medical practice and awareness of HPV vaccine recommendation based on shared clinical decision making (SCDM) among adults 27–45 years of age (n = 1279).

Characteristics	Crude OR (95%CI)	p-value	Adjusted OR (95%CI)	p-value
Type of the HCP
Family Physician	Reference	Reference	Reference	Reference
Gynecologist/Obstestrician	6.07(2.64–13.94)	< .0001	6.12(2.60–14.40)	< .0001
Pediatrician	1.04(0.71–1.53)	.850	0.91(0.60–1.39)	.662
Internal Medicine	1.52(0.60–3.86)	.382	1.70(0.64–4.51)	.286
Physician Assistant	0.65(0.44–0.94)	.021	0.62(0.41–0.94)	.023
Nurse/Advanced Nurse Practitioner	0.61(0.43–0.86)	.005	0.56(0.38–0.82)	.003
Other	0.27(0.14–0.49)	< .0001	0.35(0.18–0.69)	.002
HCP’s age, years
Less than 35	Reference	Reference	Reference	Reference
35 to 54	0.88 (0.62–1.25)	.477	0.83 (0.55–1.27)	.392
More than and equal to 55	0.91 (0.62–1.34)	.639	0.57 (0.32–0.99)	.046
HCP’s sex
Female	Reference	Reference	Reference	Reference
Male	0.92 (0.70–1.19)	.503	0.82 (0.61–1.12)	.213
HCP’s race/ethnicity
Non-Hispanic White	Reference	Reference	Reference	Reference
Non-Hispanic Black	0.64 (0.43–0.95)	.026	0.62 (0.40–0.97)	.037
Hispanic	1.10 (0.78–1.56)	.597	1.24 (0.85–1.82)	.260
Asian	0.61 (0.45–0.81)	< .001	0.59 (0.43–0.81)	.001
Others	0.63 (0.38–1.07)	.087	0.64 (0.35–1.16)	.137
Location of practice
Rural	Reference	Reference	Reference	Reference
Urban	0.69 (0.39–1.21)	.194	0.69 (0.38–1.26)	.230
Type of Facility
University or teaching hospital	Reference	Reference	Reference	Reference
City/County/Public Health Care facility	1.01 (0.55–1.87)	.972	0.99(0.51–1.94)	.982
Employed Physician Practices	0.95 (0.58–1.56)	.835	0.92(0.54–1.59)	.772
Faith based hospital/clinic	0.85 (0.39–1.85)	.675	0.75(0.32–1.74)	.500
Federally Qualified Health Center (FQHC)	2.44 (1.48–4.02)	< .001	2.13(1.24–3.65)	.006
Group practice (single or multi-specialty)	1.73 (1.31–2.29)	< .001	1.68(1.22–2.30)	.001
Solo Practice	1.00 (0.68–1.46)	.999	1.01(0.66–1.54)	.964
Other	1.06 (0.68–1.64)	.804	1.15(0.71–1.87)	.566
Years in practice
Less than or equal to 10 years	Reference	Reference	Reference	Reference
11 to 20 years	0.93 (0.72–1.21)	.590	0.83 (0.60–1.14)	.242
More than 20 years	1.31 (0.99–1.74)	.057	1.28 (0.84–1.95)	.246
No of patients seen per week
More than 100	Reference	Reference	Reference	Reference
Less than or equal to 100	1.29 (0.92–1.82)	.139	1.70(1.15–2.51)	.008
Recency of formal training session attended on HPV
Received no training	Reference	Reference	Reference	Reference
Training received more than 5 years ago	2.16 (1.53–3.06)	< .0001	1.70(1.16–2.50)	.006
Training received 2 to 5 years ago	2.38 (1.73–3.28)	< .0001	2.35(1.67–3.30)	< .0001
Training received less than or equal to 2 years ago	3.50 (2.40–5.10)	< .0001	3.42(2.29–5.10)	< .0001

OR: Odds Ratio; CI: Confidence Interval.

In the regression analysis, the “missing data” categories for the predictor variables who had missing data were included in the model.

Missing observations: 56 missing for provider’s age, 18 missing for provider’s sex, 1 missing for location, 18 missing for years in practice, 54 missing for number of patients, 2 missing for training recency.

HCPs’ anticipated barriers to recommending HPV vaccination based on shared clinical decision-making among adults 27–45 years

Among the 1261 HCPs who responded to the survey question on the anticipated barriers to implementing the SCDM recommendation for the HPV vaccination, 45.0% (567) anticipated no barriers and planned to engage in SCDM, 18.3% (231) anticipated time commitment, 9.9% (125) were aware of SCDM but unclear about how to implement it, 7.9% (99) were not fully aware of the concept of SCDM, and 19.0% (239) reported other barriers (Figure 1, Supplementary Table 1).

Figure 1.

Barriers to recommendation of HPV vaccination based on shared clinical decision making among adults 27–45 years, overall (n = 1261). Responses are based on the question: according to the CDC guidelines, providers are encouraged to employ shared decision making when recommending HPV vaccination to adults aged 27–45 years. What, if any, barrier do you foresee in implementing this recommendation?.

According to the specialty, gynecologists/obstetricians (43, 61.4%) were the HCPs that most frequently anticipated no barriers and planned to engage in SCDM for HPV vaccination with patients, followed by family physicians (98, 50.8%), pediatricians (113, 48.1%), internists (10, 43.5%), PAs (103, 38.6%), and NP/ANPs (183, 44.6%) (Figure 2). The time commitment was more frequently anticipated by internists (9, 39.1%), followed by family physicians (50, 25.9%), PAs (59, 22.1%), gynecologists/obstetricians (13, 18.6%), NP/ANP (59, 14.4%), and pediatricians (28, 11.9%), respectively (Figure 2). Similarly, HCPs aware about SCDM but unclear about how to implement it for HPV vaccination were predominantly seen in PAs (33, 12.4%), followed by NP/ANPs (50, 12.2%), internists (2, 8.7%), family physicians (13, 6.7%), gynecologists/obstetricians (4, 5.7%), and pediatricians (13, 5.5%). Additionally, HCPs who were not fully aware of SCDM were most frequently NP/ANP (45, 11.0%), followed by physician assistants (25, 9.4%), internists (2, 8.7%), pediatricians (13, 5.5%), family physicians (5, 2.6%), and gynecologists/obstetricians (1, 1.4%) (Figure 2, Supplementary Table 1).

Figure 2.

Barriers to recommendation of HPV vaccination based on shared clinical decision making among adults 27–45 years by the type of the healthcare provider (n = 1261). Responses are based on the question: according to the CDC guidelines, providers are encouraged to employ shared decision making when recommending HPV vaccination to adults aged 27–45 years. What, if any, barrier do you foresee in implementing this recommendation?.

According to sex, among HCPs who reported time commitment as an anticipated barrier to implementing SCDM for HPV vaccination, 22.3% (65) were males and 16.9% (161) were females. In those who were aware of the SCDM for HPV vaccination but unclear on how to implement it, 10.3% (30) were males and 10.0% (95) were females. Among those who were not fully aware of the SCDM for HPV vaccination, 7.2% (21) were males, and 8.0% (76) were females (Figure 3, Supplementary Table 1).

Figure 3.

Barriers to recommendation of HPV vaccination based on shared clinical decision making among adults 27–45 years by the sex of the healthcare provider (n = 1244). Responses are based on the question: according to the CDC guidelines, providers are encouraged to employ shared decision making when recommending HPV vaccination to adults aged 27–45 years. What, if any, barrier do you foresee in implementing this recommendation?.

When stratifying by race/ethnicity, less than half of HCPs who identified as Hispanics (78, 48.2%), non-Hispanic Blacks (55, 47.4%), non-Hispanic Whites (299, 45.2%), and Asians (107, 41.0%) anticipated no barriers to SCDM recommendation (Figure 4). Time commitment was the most frequently anticipated barrier for Asians (52, 19.9%), followed by non-Hispanic Whites (123, 18.6%), Hispanics (26, 16.1%), and non-Hispanic Black HCPs (16, 13.8%), respectively. Among the HCPs who stated being not fully aware of the SCDM concept, 11.1% (29) were Asians, 10.3% (12) non-Hispanic Blacks, 9.3% (15) Hispanics, and 5.7% (38) non-Hispanic Whites. (Figure 4, Supplementary Table 1).

Figure 4.

Barriers to recommendation of HPV vaccination based on shared clinical decision making among adults 27–45 years by the race/ethnicity of the healthcare provider. (n = 1261). Responses are based on the question: according to the CDC guidelines, providers are encouraged to employ shared decision making when recommending HPV vaccination to adults aged 27–45 years. What, if any, barrier do you foresee in implementing this recommendation?.

The most commonly reported foreseen barrier from open-ended responses was the perception or being unsure that insurance does not cover the cost of the vaccine (n = 42, 29.8%).

Discussion

Our study revealed that nearly half of the surveyed HCPs practicing in Texas were unaware of the recommendation for HPV vaccination for eligible adults aged 27–45, using SCDM. This finding corresponds with a national survey conducted among family medicine and internal medicine physicians a few months after this recommendation was released by the CDC’s ACIP (in the Fall of 2019), which reported that 58% of the PCPs were aware of the SCDM recommendation.¹⁴ According to the awareness-to-adherence model, physicians would need first to become aware of the guidelines and agree intellectually with them before they adopt and adhere to the clinical guidelines.²⁶ Although educational resources on HPV and HPV vaccines have been developed by leading organizations such as the CDC and WHO,^27,28 these educational resources have not often focused on SCDM for HPV vaccination among adults aged 27 to 45 years. Therefore, there is a need to tailor training programs for HCPs to increase awareness of the most recent recommendations about the HPV vaccination among middle-aged adults.

Consistent with our hypothesis, gynecologists/obstetricians were found to be more likely to be aware of the SCDM recommendation for the HPV vaccination than other HCPs. This finding reconciles previous studies showing higher awareness of SCDM recommendation among obstetricians/gynecologists compared to family medicine physicians and internists.¹⁵ This higher awareness of SCDM recommendation among gynecologists/obstetricians could be explained by the fact that the ACOG offers several programs to increase maternal immunization rates with essential vaccines such as the HPV vaccine.¹⁷ Furthermore, we found that family physicians were more likely to be aware of SCDM than PAs and NP/ANPs. This could be explained by the ongoing collaboration between the American Academy of Family Physicians (AAFP) and the ACIP in developing and updating recommendations for the use of vaccines in children, adolescents, and adults.²⁹ Additionally, we found that both PAs and NP/ANPs were equally unclear about how to implement SCDM recommendations. Since PAs and NPs serve as primary care providers mostly for underserved and rural patients,³⁰ there is a need to boost HPV training among PAs and NP/ANPs to increase the awareness of the SCDM recommendation in such patient groups.

In our study, Asian and non-Hispanic Black HCPs were less likely to be aware of the SCDM recommendation. This could be explained by many factors, including racial/ethnic disparities in access to professional development opportunities, gaps in institutional communication, or underrepresentation of racial/ethnic minorities in professional networks where guideline updates are frequently disseminated. In an analysis of the role of race/ethnicity in the professional development of the US healthcare workforce, Asians and Blacks were less likely to receive academic promotions and to access leadership positions, compared with Whites.³¹ Improving the representation of racial/ethnic minorities in professional networks and leadership positions has many advantages, including the ability to reduce bias in care, allowing for a diversity of thought and perspectives in institutional-level decisions, and increasing knowledge, awareness and engagement of HCPs from racial/ethnic minorities in the dissemination of important public health policies such as HPV vaccination.³²

According to the National Association of Community Health Centers, FQHCs serve 90% of patients with low-income, 18% uninsured, 59% publicly insured, and 64% identifying as racial and/or ethnic minorities.³³ The healthcare needs of these low-income populations are compounded by issues like limited access to regular healthcare providers, challenges in obtaining transportation, lower health literacy, and greater access to pharmacies than physician offices for preventive services.³⁴ Furthermore, there is a disparity in access to updated vaccine guidelines, decision aids, and educational resources among vaccinators across different healthcare settings.³⁴ For example, a national survey in 2022 among general internal medicine physicians and family physicians found that only 38% of respondents’ electronic health records (EHR) systems displayed SCDM vaccine recommendations as “recommended,” while 23% indicated that their EHR system did not display such recommendations at all.³⁵ This inconsistency in the EHR system adds another layer of complexity to the awareness and implementation of SCDM, particularly in underserved healthcare settings where providers may lack access to the latest updates and training materials. In our study, HCPs working in FQHCs were more likely to be aware of the SCDM recommendation than those working at the university/teaching hospitals. This could be explained by the priority given to the primary and preventive services at the FQHCs.³⁶ Additionally, we found higher likelihood of awareness of SCDM recommendations among HCPs who worked in group practice. This could be due to the collaborative learning environment or the ease of monitoring clinical performance by peers.³⁷ These findings highlight the need for targeted interventions to increase the awareness of the SCDM recommendation in university/teaching hospitals.

Our study found that HCPs who had been trained on HPV vaccination promotion and counseling were more likely to be aware of the SCDM recommendation for HPV vaccination. This could be explained by the extensive professional experience and frequent participation in several continuing medical educational activities throughout their careers that keep them updated on the latest guidelines. Studies have shown improvement in the performance of HCPs who follow the recommended practices through focused educational meetings.^38,39 In the same vein, HCPs who attend less than 100 patients per week were more likely to be aware of the SCDM recommendation than those who consult more patients. These findings suggest that when HCPs see fewer patients, they may devote more time to seeking and reading health information and updates from federal agencies and scholarly organizations that develop, approve, and disseminate public health guidelines such as the U.S. Food and Drug Administration, the CDC, the American Medical Association, and the American Nurses Association. When they have more time for non-clinical activities, HCPs may also be open to educational activities that will foster their professional development and keep them up-to-date with scientific advances in their field of interest. These findings underscore the importance of continuing medical or nursing education about HPV vaccination in raising awareness of the SCDM recommendation among the HCPs.

About half of the HCPs surveyed anticipated no barriers in implementing SCDM for HPV vaccine recommendation. Of note was that gynecologists/obstetricians most frequently anticipated no barriers to SCDM recommendation, compared to other HCP types. This is likely due to the immunization programs released by the ACOG that guide clinicians and their patients to increase acceptance of the vaccines.¹⁷ Additionally, we found that among the anticipated barriers, time commitment was reported as the most frequent barrier to implementing the SCDM recommendation by internists. This finding could be explained by the fact that both physicians and patients see time constraints as a barrier to SCDM in clinical practice.^40–44 The physicians have just a few minutes for shared-decision making for HPV vaccination in a primary care setting.⁴⁵ Due to the lack of standardized guidelines for SCDM conversations, patient-provider discussions about SCDM could be time-consuming.³⁴ A survey of family physicians and internists found that 90% of respondents agreed that SCDM requires more time with patients than routine recommendations.³⁵ As providers need to balance multiple topics during the appointment, time spent discussing vaccinations may be limited or may come at the expense of other important health concerns.³⁴ Therefore, decision aids such as the ‘HPV Decide’ online tool could help in performing SCDM for mid-adult HPV vaccination within the timeframe allotted for the patient-physician interaction.¹⁸ As our survey did not capture detailed insights into the specific reasons behind the time-related barrier, further studies are needed to explore whether this barrier is due to a lack of sufficient staff, competing priorities, or time constraints due to administrative duties, patient load, or the complexity of the vaccination process in busy clinical settings.

We found that HCPs who are more than 55 years old were less likely to be aware of the SCDM recommendation. This could be explained by a reduced exposure to information about recent guidelines among these HCPs, resulting from their lower participation in continuing educational activities, workshops, certified training seminars, and their perception that the knowledge and experience they have acquired over time are sufficient for their clinical practice. We included the age and sex of the HCPs in our study due to their association with key factors such as the recency of formal training, level of professional experience, communication style, and cultural competence influencing SCDM implementation. Prior research suggests that the provider’s age and sex can influence the degree and quality of SCDM in patients.^46–49 For example, older providers, particularly males, may be less engaged in SCDM,⁵⁰ while female providers are more likely to actively engage patients in the SCDM process.^46,48 Additionally, some studies indicate that patients may feel more comfortable discussing preferences with female providers, especially within specific cultural contexts.⁴⁹

Our study has some limitations. Due to the cross-sectional nature of the study, we were not able to assess the temporality between exposure and outcome. Therefore, we could only determine the association and not a causal relationship between the awareness of SCDM for HPV vaccine recommendation by HCPs and practice-related factors (e.g., years of practice, formal training). Future research should focus on prospective longitudinal studies, which would allow for a more comprehensive understanding of the influence of the provider and practice-level factors on SCDM recommendation awareness among the HCPs. The small sample size for internists and gynecologists/obstetricians, compared to other HCPs, limits the generalizability of comparisons between these groups. The overall response rate of the survey was 12%, consistent with a previous national physician survey reporting a response rate of 8.5%.⁵¹ Although such response rates are common given the demanding schedules of HCPs and survey fatigue, a low response rate could lead to potential nonresponse bias and limit the generalizability of our findings to all HCPs in Texas. Furthermore, since our study was based on self-reported data, recall and social desirability biases were possible. We attempted to minimize this bias by assuring the confidentiality of the HCP’s responses to the survey. Additionally, most of the healthcare professionals were practicing in urban areas, suggesting that our findings may not reflect the attitudes toward SCDM for HPV vaccination of HCPs practicing in rural areas. The barriers to implementing SCDM for HPV vaccination among individuals aged 27–45 in rural settings may be more pronounced due to factors such as limited healthcare resources and a shortage of healthcare workforce.⁵² These challenges often result in shorter patient consultations and heavier workloads, making it harder to engage in SCDM discussions. To address these issues, interventions might need to be tailored to rural healthcare settings by providing more flexible training formats for HCPs, expanding telehealth services to reduce patient burden, and ensuring that essential healthcare resources are accessible to patients.

Conclusion

Our study provided valuable insights into the level of awareness of the SCDM recommendation among HCPs in Texas, the associated factors, and the foreseen barriers to its implementation for HPV vaccination. We found that factors such as being trained as a gynecologist, being Asian or non-Hispanic Black, working in FQHCs or group practices, older age, consulting a smaller number of patients, and having received training on HPV vaccine promotion were associated with higher odds of being aware of the SCDM recommendation for HPV vaccination in Texas. Additionally, HCPs identified time commitment as the common barrier to the implementation of SCDM for HPV vaccination. These findings underscore the need for targeted interventions and training programs to address HCPs’ awareness gap about SCDM for HPV vaccination. A comprehensive training program on HPV vaccination for HCPs could include updated vaccine guidelines, decision aids, and culturally relevant communication techniques according to the demographic distribution of the population. Additionally, implementing measures to assess the training outcomes, such as pre- and post-assessment surveys or tools for tracking changes in vaccination rates, are essential to evaluate the success of these initiatives.

Biography

Dr. Sanjay Shete is a Professor of Biostatistics and Epidemiology and holder of the Betty B. Marcus endowed chair in Cancer Prevention at the University of Texas MD Anderson Cancer Center, Houston, TX. He serves as Director of the Network of Primary Care Physicians in Texas; Executive Director, Population Health Assessment; Deputy Division Head, Research and Training, Cancer Prevention and Population Sciences; and Chief, Behavioral and Social Statistics.

Funding Statement

The study was funded by the National Cancer Institute [P30CA016672] to S. Shete, the Betty B. Marcus Chair in Cancer Prevention (to S. Shete), and the Duncan Family Institute for Cancer Prevention and Risk Assessment (to S. Shete).

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data related to this manuscript are available from the corresponding author upon request and are subject to additional ethical approval since the data is not deposited in a public repository.

Role of the funder

The funders were not involved in the study design, analysis, interpretation of data, or manuscript writing.

Supplementary Information

Supplemental data for this article can be accessed online at https://doi.org/10.1080/21645515.2025.2560061