HPV vaccination training experience among family medicine residents and faculty

Abstract

Background and Objectives

Residency training is a pivotal time to establish skills for career-long practices, particularly for challenging skills such as HPV vaccine recommendation. Training experience and preferences related to delivering HPV vaccine recommendations were examined for family medicine (FM) residents and faculty.

Methods

Residents (n=28) and faculty (n=19) were identified through a national FM residency directory and recruited from training programs in Florida. Participants completed a phone interview assessing key aspects of HPV vaccine recommendation training. Interviews were audio recorded, transcribed verbatim, and analyzed using content analysis. A brief follow-up survey assessing training, practices, and demographics was emailed after the interview.

Results

Residents’ training experience with HPV vaccine recommendation varied from none to extensive, and was often self-directed. Variation in training was seen between and within programs. Faculty often noted HPV vaccination training was not standardized and residents lacked instruction about effective communication. Most programs relied on preceptors for training residents but training from preceptors varied widely and was often not standardized within the program.

Conclusions

This study identified a lack of consistent and standardized training for delivering HPV vaccine recommendations. A training curriculum that uses multiple modalities and reflects resident and faculty preferences is needed.

Introduction

The United States (U.S.) Advisory Committee on Immunization Practices has recommended Human Papillomavirus (HPV) vaccination for females ages 11–26 years since 2006,¹ and males ages 11–21 since 2011.² Despite recommendations, in 2015, only 62.8% of adolescent girls and 49.8% of adolescent boys ages 13–17 years received at least one HPV vaccine dose³ and an even smaller proportion of adolescents completed all three doses (41.9% and 28.1%, respectively).³ Without continued efforts to increase vaccine initiation and completion, the Healthy People 2020 objective to have 80% of adolescents complete the HPV vaccine series by ages 13–15 years⁴ will not be achieved.

Healthcare providers’ recommendations are central to increasing HPV vaccine coverage. Previous studies demonstrated parents of adolescents who received an HPV vaccine recommendation from their child’s healthcare provider were 5–23 times more likely to agree to vaccination.^5–12 Work from our group, conducted nationally and in Florida, showed a lower proportion of family medicine (FM) physicians than pediatricians consistently recommended HPV vaccine across all adolescent female and male patient age groups.^13–16 This suggests an unmet need to support FM physicians’ HPV vaccine recommendations.

A study of recent FM residency graduates found most did not recommend HPV vaccine for males, and those who practiced in the Southeastern U.S. (including Florida) were less likely to offer HPV vaccine to females than FM graduates practicing in other states.¹⁷ Another study demonstrated recent FM graduates desired vaccine communication training opportunities.¹⁸ Residency training is a critical time to establish knowledge and skills to support career-long communication practices. Yet, little is known about residents’ training related to delivering HPV vaccine recommendations. To address this gap, the current study examined FM residency training for delivering HPV vaccine recommendations.

Methods

An interpretive description (ID) approach was utilized in this study to provide an understanding about residents’ experiences providing HPV vaccine recommendation to adolescents and their parents. ID is an approach to conducting applied qualitative research about clinical phenomena by uncovering structures, patterns, and themes.^19–21 With foundations in grounded theory, interpretative description is a non-categorical methodology, that is aimed at moving qualitative data beyond description, yet does not approach the level of theorizing achieved in grounded theory.¹⁹ Residents and faculty of FM training programs were asked to describe and provide feedback regarding education on HPV vaccination and delivering recommendations. This study was conducted in two phases: resident interviews followed by faculty interviews. Responses and preliminary analysis of the resident interviews informed the development of the interview guide for faculty. This study was approved by the University of South Florida Institutional Review Board.

Recruitment

A purposive sampling technique was used to recruit participants from residency training programs in Florida.²⁰ Using the American Academy of Family Physicians residency training program directory, 16 training programs in Florida were identified. Multiple sources were used to identify resident and training program contact information including: (1) training program websites; (2) the American Medical Association Masterfile list; and (3) referrals from study participants. We sought to obtain at least one resident and one faculty member from each training program in order to acquire maximum variation on possible emergent themes and ensure relevant influential factors were examined.^19,20,22,23 For the faculty interviews we included PhD faculty along with MD faculty because the PhD faculty involved in resident training programs are often involved in the behavioral and communication aspects of resident training, a crucial component necessary for the development of future communication training interventions.

Letters were mailed in three waves from September to October, 2014 to a random sample of 84 prospective medical residents; 99 letters were sent (waves 1–3, 15 of the participants who did not respond to the first letter were sent a second letter in wave 2), 8 were undeliverable, and 15 residents agreed to participate in an interview. To recruit additional residents, referral requests were e-mailed to program directors to forward to their residents, and participants were asked to provide contact information for peers who may be interested in participating. These approaches yielded an additional 13 interviews.

Faculty recruitment was conducted in three waves from May to July, 2015. Letters were initially sent to all faculty members (n = 148). Subsequently, targeted emails were sent to faculty members from training programs where there was already representation from at least one resident, and faculty for whom there was an e-mail address available (n = 11). The second wave of mailings were sent to those who had not responded to the initial request and who were faculty in a program from which representation was lacking (n = 29). The second e-mail was sent to FM residency program directors for whom there was an e-mail address available (n = 4). Due to the difficulty recruiting, a third e-mail also was sent to all faculty members for whom there was an e-mail address from any residency program (n = 20). Finally, mailings were sent to 105 faculty members.

Data Collection

Instruments

The resident and faculty interview guides were developed by an expert team including a physician faculty member from a FM residency training program, and researchers with expertise in HPV infection and vaccination, educational interventions, and qualitative methods. Development included an initial team meeting to identify overarching interview questions. Following the meeting, a draft interview guide was circulated to team members for feedback and revisions. The final resident interview guide included 14 open-ended questions with additional probes/follow-up questions focused on residents’ experience covering categories about HPV vaccine training. Resident demographic characteristics were assessed at the conclusion of the interview. The faculty interview guide was revised to address themes and questions raised during the resident interviews. The final faculty interview guide included 11 open-ended questions with additional probes/follow-up questions focused on HPV vaccine recommendation training currently provided to residents. Residents and faculty were asked to complete a brief online survey (7 and 16-items, respectively) within three days of the interview. Both surveys assessed training opportunities and preferences, HPV vaccination practices, and perceived confidence in communicating with patients and parents. The faculty survey also included demographic questions.

Procedures

After obtaining informed consent, one of three study team members trained in qualitative interviewing (C.L.S., G.Q., and T.L.M.) conducted semi-structured individual telephone interviews, assisted by a note taker. Interviews lasted between 25–60 minutes for residents and faculty. Following survey completion, residents and faculty were mailed $50 and $100 retail gift cards, respectively. Interviews were audio recorded, transcribed, and reviewed for accuracy.

Analysis

Analysis was conducted by three study team members (K.N.A., P.L., and C.L.S.) using the methods described in ID.^19,20 Overarching questions guiding the first phase of analysis were: “how do residents experience training to deliver HPV vaccine recommendations,” and “what are residents’ experiences like when delivering HPV vaccine recommendations?” Initially, team members independently reviewed all resident transcripts (n=28) and took notes on major topics described in the interview related to the two overarching questions.²⁴ The team members then created a draft codebook by discussing, comparing, and revising the overarching topics identified.²⁴ Following the draft of the codebook, team members independently coded the transcripts using MAXQDA v. 11. Meetings were held after individually coding 3–4 transcripts to discuss any ambiguities, overlap, and provide category clarification.²⁴ Previously coded transcripts were recoded as emergent themes and codebook restructuring occurred.

Results

Residents

A total of 28 residents from 9 of 16 (56%) Florida training programs participated in the study. The majority were female (n = 18; 64.3%), non-Hispanic White (n = 15; 53.6%), and in their second or third year of training (n = 24; 85.7%) For all demographic characteristics, see Table 1. Qualitative themes and quotes are listed in Table 2.

Table 1.

Resident Demographics (N = 28)

Characteristics		n (%)
Gender	Female	18 (64.3)
	Male	10 (35.7)
Race	White Hispanic	1 (3.6)
	White Non-Hispanic	15 (53.6)
	Black	8 (28.6)
	Asian	4 (14.3)
Residency Year	PGY-I	4 (14.3)
	PGY-II	14 (50.0)
	PGY-III	10 (35.7)
Residency Program	Community-based medical school administered	5 (17.9)
	Community-based medical school affiliated	18 (64.3)
	Community-based non-affiliated	4 (14.3)
	Military program	1 (3.6)

Table 2.

Resident training experience themes and exemplar quotes

Theme	Description	Quotes
Variation in formal training	Residents described differing amounts of training within and between programs.	“We haven’t had a whole lot of not really any formal training [about HPV vaccine], not even in medical school” (Res 15).
		“We had morning reports which were 30 minute talks on the vaccine and who’s eligible for it and then also a dedicated noon conference which are like an hour long on the barriers to giving the vaccine and how our experience has been” (Res 24).
	Residents with different patient populations reported different HPV vaccination educational needs.	“We don’t see all that many children, so it’s really only teenagers…I really haven’t seen a 12–17 year old in our clinic, we just for whatever reason haven’t had um patients in that age range.” (Res 11)
		“We have a pretty peds [pediatric] heavy practice and I think for our family medicine residency, we see about 30–35% of our patients in clinic are peds” (Res 16).
	HPV vaccination was often a sub-topic in broader lectures.	“We had a general lecture on childhood vaccination, and that was kind of like a snippet, maybe like 5 minutes of the HPV vaccine being available for males and females ages 11 to 26 and that was pretty much it” (Res 13).
Self-directed learning	Residents described seeking out additional information on their own.	“…as far as informal training… just going to different websites and… in the years past they used to have the Gardasil commercials on TV.” (Res 26).
	Additional training opportunities through other resident’s quality improvement projects.	“…we have actually had a fairly good amount of training regarding that vaccine because we’ve had two different residents do line in-house research projects…one presented a noon conference on the importance of offering the vaccine… and then we had another resident do a follow up study… about the importance of offering the vaccine to patients and gage the indications” (Res 16).
Informal observation of preceptor	Training to provide recommendation for HPV vaccine was most often provided during precepting in clinic, and in some cases was the only training residents reported receiving.	“I guess a big addition to my experience, just to see that model and see the way that the physician in particular, um discussed the HPV vaccine with the patient” (Res 19).
Barriers to vaccination	Parental hesitation due to misinformation can be overcome with provider discussion.	“I think that patients [parents], one thing that really makes them hesitant is just not knowing about the vaccine, so once they’ve received the appropriate education and reassurance and then I think they will be more willing to… but I think just forcing it upon them, making them make a decision too quickly I think is a negative thing” (Res 7).
	Parental hesitation resulted in the provider giving information and suggesting delaying the vaccine.	“If they still weren’t sure… I would give them some literature to go home and look at, direct them to good websites, you know the CDC, kind of help guide them to more reputable sources where they can kind of do some homework and come back and you know talk about it at their next visit” (Res 19).
	Residents hesitate to encourage HPV vaccine with the fear that it will damage the patient-provider relationship.	“I guess the challenge, the general you know, group of people who are against immunizations all together. Sometimes that’s the challenge you can’t overcome because it’s just, they just are…for whatever reason, no matter what you tell them – they are just against immunizations all together” (Res 6).
		“You have broken rapport if you push the vaccine on them. Don’t destroy the relationship on that one issue, there is potential to suggest it again later” (Res 21).
Facilitators to vaccination	Positive patient-provider relationship	“I’ve seen some of these kids for a couple of years… So if they know me and trust me and they feel like I’ve done things in their child’s best interest for 2 years then hopefully they’re going to be more likely to say ‘yeah we think you wouldn’t offer us something that was going to be to our detriment’ you know” (Res 16).
	Patient-provider discussions of the vaccine	“Yeah, so um usually what I start off by is asking… you know, what their thoughts are about that, just to kind of get an idea of where they’re coming from, and then uh usually with both, you know, the patient and the parent and the parents there in the room, I’ll just have a discussion with them” (Res 19).

Training was varied and self-directed

Residents were asked about the training they received to deliver HPV vaccine recommendations to adolescents and their parents. The type and extent of formal training residents received varied drastically across the training programs represented, and approximately one-third reported receiving no training. Although some residents ascribed their lack of training to the fact that they were early in their residency, more advanced residents in the same program described a similar lack of training. Residents described formal lectures where HPV vaccine was included as short and focused on clinical aspects of the vaccine such as indications, coverage, and side effects. Few residents reported receiving training about communication strategies to discuss HPV vaccination, or strategies for overcoming parental barriers. Informal training through precepting was sometimes the only training residents received and such training varied in content and detail. Only a couple of residents discussed quality improvement projects where a fellow resident provided a lecture dedicated to HPV and described HPV vaccine communication strategies.

HPV Vaccine Recommendation Barriers

Barriers to delivering HPV vaccine recommendations reported by residents included: parental hesitancy, cost, concerns about recommending a vaccine for a sexually transmitted virus, and general vaccine hesitation. When residents encountered vaccine hesitancy among parents, they encouraged parents to defer the decision about vaccination to a later date especially because it was not mandated for school. Residents also discussed the potential impact of HPV vaccine recommendation on the patient-provider relationship. In some cases, residents were concerned pressing parents to accept HPV vaccine may negatively impact their relationship by upsetting the parent and reducing trust in them as a provider. Residents believed establishing a positive relationship with adolescents and their parents facilitated trust in the provider, resulting in a more effective conversation about HPV vaccination. They described having a conversation with the parents about HPV vaccine instead of providing a simple recommendation as one way to maintain their relationship with parents and patients.

Faculty

Faculty represented 7 of the 16 Florida programs (44%). Of the 20 faculty interviewed, 19 provided demographic information. The majority were female (n=14; 73.7%), non-Hispanic White (n=14; 73.7%), and held an MD/DO degree (n=16; 84.2%) (Table 3). On average, participants were part of the residency program for 9.26 years (SD = 7.04). Table 4 lists themes and quotes from faculty.

Table 3.

Faculty Demographics (N = 19)

Characteristics		n (%)
Gender	Female	14 (73.7)
	Male	5 (26.3)
Race	White Hispanic	2 (10.5)
	White Non-Hispanic	14 (73.7)
	Black	3 (15.8)
Residency Program	Community-based medical school administered	1 (5.3)
	Community-based medical school affiliated	14 (73.7)
	Community-based non-affiliated	4 (21.1)
Academic Training	MD/DO	16 (84.2)
	Ph.D.	3 (15.8)
Role in Residency Program	Core Faculty	8 (42.1)
	Director	9 (47.4)
	Other	2 (10.5)
Years in Faculty Position	Mean (SD)	9.26 (7.04)

Table 4.

Faculty training experience themes and exemplar quotes

Theme	Description	Quotes
Lack of standardized training	Training was often informal but formal training occurred through didactics such as noon lectures often as a sub-topic in a broader lecture.	“The didactic training is… at least once every two years, and it’s not specifically… an HPV only discussion. It’s lumped in with all the, all the childhood vaccinations and discussed as part of that” (Fac 19).
		“We do the whole lecture series on an 18 month rolling series because our conference attendance requirement is 50%, so you know if they have 100% conference attendance they’re going to get it within the first 18 months of their residency. But if they don’t, they may not pick it up until later.” (Fac. 20)
Dependence on preceptors for training	Precepting as an alternative to didactic training	“Ideally, every intern would learn every topic and every lecture when they first arrive and obviously that’s totally impractical…so what happens is some interns hear it their first year, and some don’t hear that lecture until their second years…now the stopgap for that is they’re exposed to it and coached through it down in clinic” (Fac 2).
	Variation in training residents received from preceptors	“They [residents] have a handout they can give them [parents] about HPV and vaccination. I mean, basically, just make it a routine part of the conversation, but make sure you cover it.” (Fac 4).
		“…if they [resident] don’t know a lot then usually that’s when I kind of give them my script for it and how to discuss and go through it and let them give it a try and see what comes out of it. I think probably after a few of those encounters with faculty they’ve gotten 2 or 3 opinions about how to counsel patients about it and they just assimilate it into whatever kind of overarching style they’re developing for talking to patients” (Fac 1).
	Faculty unsure if preceptor was providing training	“…they work with community pediatricians, so they would have some exposure [to HPV vaccine recommendations] in that context, but I wouldn’t be able to tell you, how, what that interaction is like” (Fac 3).
		“Another educational element is to make sure that the faculty is well-equipped with those kinds of arguments [when faced with resistant parents], in fact, I could see that as a barrier to training if faculty have not been versed or pre-armed with those counter uh detailing points. They need to be because they have to serve as the role model for the residents.” (Fac 2).
Structural facilitators of training	Pediatric clinic population results in opportunities to vaccinate for HPV	“…we’re a major vaccine site because we got a pretty good size pediatric population, so all of our residents actually get a fair amount of exposure to routine vaccination schedules, which does include the HPV usually staring at age 11” (Fac 2).
	Presence of organizational champion for HPV vaccine	“I think the residents in our program are receiving adequate training to provide HPV vaccination recommendations to patients for a couple of reasons. One, our faculty is pretty committed to making sure they get the information [about HPV vaccine] and we also have peds and OB [obstetrics] in-house who are full-time faculty in our residency. So they’ve got those resources always available who also reinforce it and stress it. So I think they do” (Fac 4).
Suggestions to improve training	Faculty believed residents needed training on how to communicate with hesitant or resistant parents	“We are good at giving them a lot of information, but I don’t know if we’re as good at training them what their answers should be to parents questions and how to response to some parents’ concerns, or sometime, parents will say, “well, my daughter’s not sexually active. I don’t need to worry about it yet” How are you going to answer that question? I think that part of the training could probably be better, so they feel better equipped to answer those kinds of questions.” (Fac 5).
	Methods for training	“…if you could do perhaps like frequently asked questions in more of a lecture format. And then beyond that actually have some role-play between the residents and assign residents to be parents and residents to be providers and have them go back and forth and counsel that…and then afterwards do like a fishbowl and kind of review, alright so what went well there? What could have gone better? …it would be most interesting probably to residents to not just be HPV but to be in the context overall about sexual counseling in adolescents and with the parents and without the parents so” (Fac 1).
		“…upgrade the EMR so it’s in your face, like you’re getting ready to close out you know close out the visit before you leave the room, and it says ‘you forgot to talk about HPV.’ Like nothing more than that. You want them to remember that” (Fac 10).
		“A lot of times, if you give handouts, they get tossed. I mean, if there was something electronic or an easy app - I don't even know if one exists, but if there was something that was easy for them to put on their phone you know or something electronically easy for them to access, we might consider doing that” (Fac 5).
	Suggestions for timing of training	“I would probably advocate early – as early as possible in the residency, in the intern year ideally. but it also couldn’t hurt to repeat it later on because we all have the best intentions, but we can't remember everything, and it's a good reminder to reinforce habits that, you know, may have slipped a little bit with time” (Fac 3).

Barriers and Facilitators to Training

Similar to residents, some faculty said their program provided no formal training about HPV vaccine, and those who did provide formal training described it as a brief sub-topic included in larger lectures. Faculty also noted didactic content mostly focused on clinical aspects of HPV vaccine including safety, efficacy, and indications. They mentioned it was possible for residents to miss didactic training due to their clinical rotation schedule, competing demands on their time, and the fact that attendance was not required in any residency program.

Given the possibility to miss lectures about HPV vaccine, faculty viewed precepting as an alternative to didactic training. However, there was variation in, and uncertainty about, the training residents received in clinic from their preceptors. Given the reliance on preceptors to provide training in clinic, particularly to residents who missed didactic training, faculty noted it may be necessary to provide preceptor training to ensure standardization programs. Comparable to resident comments, faculty stated that clinics with a large volume of pediatric patients were regarded as providing more opportunities for residents to discuss vaccines with adolescents and their parents, compared to clinics with few pediatric patients. Furthermore, certain faculty members took ownership for training residents about adolescent vaccinations, including HPV vaccine (i.e., a faculty champion).

Training improvement suggestions

Although faculty believed resident training was satisfactory regarding biological and clinical aspects of HPV, training regarding communication around delivering the recommendation was identified as an area for improvement. Adding interactive educational opportunities focused on developing residents’ communication skills with resistant patients to existing training was viewed as an ideal scenario. In addition to the brief traditional didactic session, several faculty recommended role-play and a chance for reflection as mechanisms to strengthen residents’ skills for recommending the vaccine. Faculty had differing opinions on the utility of providing residents with additional HPV-related materials. Digital formats, such as a smartphone application, were suggested as alternatives to paper handouts, which most believed would just be discarded. Faculty believed any feedback including statistics indicating their current training program is inadequate would motivate them to invest additional time to improving HPV-related resident training.

Discussion

Provider recommendation is important for HPV vaccine uptake, yet recommendations are often low-quality, if providers recommend at all.^25,26 This study is among the first to examine both faculty and resident experiences with HPV vaccination education. The findings show HPV vaccination training varied between and within FM residency programs, and did not facilitate delivery of high-quality recommendations. This is consistent with previous research indicating significant variation in pediatric residency programs, particularly for topics concerning adolescent patients.²⁷ Residency is an optimal time to instill requisite knowledge and desirable behaviors for delivering high-quality HPV vaccine recommendations. This is particularly important given that an inability to overcome inertia of previous practice has been cited as a barrier to following clinical practice guidelines.²⁸

Participants in this study revealed HPV vaccination training is inconsistent and primarily focuses on clinical aspects of the vaccine such as indications, safety, and efficacy. These results are consistent with findings from previous studies of resident training programs that found communication training was lacking for HPV²⁹ and vaccines in general.¹⁸ However, our study is novel in that we explored residents’ concerns about damaging the patient-provider relationship, a concept that has not been explored previously. Additionally, we examined faculty preferences for teaching, an important step because any training for the residents would also have to be acceptable to faculty.

Research suggests faculty pedagogical preferences are shifting toward electronic teaching tools compared to print materials.³⁰ Faculty in this study were no exception. They suggested using the electronic medical record (EMR), applications for smartphones, and material from the internet as possible channels for information delivery. However, they also recognized the importance of face-to-face training and providing residents an opportunity to practice and model delivering HPV vaccine recommendations.

In this study, residents and faculty alike commented on the value of seeing preceptors modeling effective HPV communication; however, this type of training was not systematic and experiences varied from preceptor-to-preceptor. While research demonstrates that residents report effective preceptors are knowledgeable and are actively engaged in teaching,^31,32 and preceptors themselves report they should be effective role models for residents,³³ there is little research on the standardization of preceptor training. It is also possible preceptors are not trained to deliver HPV vaccine recommendations themselves, thus creating a potential barrier to training residents.

When residents described conversations with parents, their stated approaches diverged from what have been described as best practices for HPV vaccine recommendations, indicating a critical area for interventions.²⁶ In this study, when residents encountered vaccine hesitancy they encouraged parents to defer the decision to a later date. By departing from best practices, residents may be missing an opportunity to vaccinate at an age at which the immune response is optimal. They also risk a missed-opportunity if the adolescent does not return in a timely manner. Residents should be aware that best practices also include the practice of strongly recommending the HPV vaccine, using presumptive language or an “announcement” technique, is pivotal to vaccine acceptance.^5–12,34

HPV vaccine should be recommended in a manner similar to other adolescent platform vaccines. Often, residents are taught the importance of communication on the patient-provider relationship³⁵ and some expressed concern that promoting vaccination to parents would damage the relationship. As such, there may be two different areas to address when developing a more uniform training program for residents: (1) developing skills to adequately communicate with hesitant parents, and (2) maintaining rapport with patients and families. It would be important for an intervention to contain both a skills-based component (what to say) and a psychosocial component (how to say it) to address these concerns. Motivational Interviewing (MI) is well-suited for brief communication-based interventions by primary care providers^36–39 and holds promise to address parental HPV vaccine hesitancy.⁴⁰

This study does have some limitations that suggest the results should be interpreted with caution. The qualitative nature of the study with a relatively low response rate to the request for an interview limits the generalizability of the findings. Furthermore, because the findings were self-report, they are subject to recall bias. There is also selection bias and those who agreed to participate might have had inherently more positive attitudes about HPV vaccination training opportunities than those who declined. Because these were interviews, participants may have responded in a way they believed was socially acceptable. However, prior research has shown social desirability bias is less probable with telephone compared to face-to-face interviews.⁴¹ Despite these limitations, this study is novel in that we examined responses from both residents and faculty in order to examine current practices and assess ideas for an intervention that would be feasible and acceptable to both parties in order to increase HPV vaccine uptake among adolescents. Such an intervention is critical, given the substantial gaps we identified regarding training about delivering HPV vaccine recommendations. Teaching residents how to deliver effective, high-quality HPV vaccine recommendations can improve vaccine coverage^5–12 and, in turn, reduce the burden of HPV-associated disease.