Clinicians, particularly primary care clinicians, often ask how to approach vaccine hesitancy or outright vaccine refusal, especially with the human papillomavirus (HPV) vaccine. The Advisory Committee on Immunization Practices recommends HPV vaccination for males and females at 11 to 12 years of age, giving clinicians permission to vaccinate as early as 9 or 10 years of age and recommendations for catch-up through age 21 years for males and 26 years for females.
Population acceptance of the HPV vaccine remains poor relative to our success with other vaccines due at age 11 to 12 years—the tetanus-diphtheria-acellular pertussis (Tdap) and the quadrivalent conjugated meningococcal (MenACWY) vaccines. The National Immunization Survey NIS-TEEN measured the uptake of these vaccines among 13- to 17-year-old adolescents in 2017. For those living in Minnesota, 87.5 percent had received a Tdap and MenACWY vaccine but only 46.9 percent had completed the HPV vaccine series. Parents of adolescents in this age group have reported a number of reasons why they don’t plan to vaccinate their teens against HPV, including their providernot recommending the vaccine, the belief that their child is too young and concerns about vaccine safety.
Published studies show that clinicians should make strong recommendations for HPV vaccination —and should persist when they meet resistance. How can a clinician preserve the relationship to the parent and patient, address the basis for the hesitation and confirm the strong recommendation?
In previous articles in this journal, we have written about the use of the CASE approach first developed by Alison Tepper Singer to address vaccine hesitancy. With the CASE approach, the clinician framesa response to the vaccine hesitant parent that Corroborates awareness of the parent’s hesitancy while identifying a shared underlying value. Next, the clinician makes an About me statement, summarizing how the clinician, through professional development, obtained their understanding of the vaccine in terms of this underlying shared belief, summarizing the Science that supports the clinician’s recommendation and leading the clinician to Explain the clinician’s Advice.
We have identified eight common concerns parents express regarding the HPV vaccine and created scripts for how you might address parents’ questions and vaccine hesitancy using the CASE approach.
1. “The HPV vaccine’s too new. We don’t know yet if it really works or if it is really safe.”
CORROBORATE
“I agree with you that many treatments are too new and unstudied to prescribe.”
ABOUT ME
“And, as one of your health care team’s clinicians, I wouldn’t want to recommend a vaccine until we have well-established effectiveness and safety data.”
SCIENCE
“In the United States, vaccines are tested for safety long before they are licensed or recommended, and these tests are performed in very large clinical trials involving tens of thousands of patients the same age as your child.”
EXPLAIN ADVICE
“That’s why I’m recommending your child get the HPV vaccine, in part because of my confidence in its well-established, long-standing effectiveness and safety record.”
2. “I am concerned about the HPV vaccine causing long-lasting health problems.”
CORROBORATE
“I share your concern that we must avoid preventive measures like vaccines if they can cause long-lasting health problems in even a small percentage of patients.”
ABOUT ME
“And, I have learned in my studies as a clinician that vaccines must meet a much higher standard for safety and avoidance of side effects than medicines used to treat disease once the disease is present. This is because they are given to so many more people simply to prevent illness.”
SCIENCE
“Both the very large trials before licensure and the even larger studies conducted since licensure in 2006 show that HPV vaccines don’t cause chronic disease or long-lasting injury.”
EXPLAIN ADVICE
“That’s why I am confident to recommend this vaccine to all of my patients who are your child’s age.”
3. “HPV vaccine’s not one of the required vaccines.”
CORROBORATE
“It’s true that the schools do not require the HPV vaccine series—or the yearly flu vaccines, for that matter.”
ABOUT ME
“And, as a member of your child’s health care team, I need you to know that we don’t make our decision to recommend a vaccine or not based on school requirements. Important vaccines like HPV and influenza weren’t included in the school requirements because the number of doses and the timing of those doses would overwhelm school nurses in monitoring vaccination.”
SCIENCE
“Rather than recommend a vaccine because it is required, we recommend a vaccine because the studies show the vaccine is effective in preventing disease, safe to receive at the age to be given, and needed, given the risk of the disease otherwise. Not all vaccines meet these standards; we only recommend the ones that do.”
EXPLAIN ADVICE
“That’s why I am recommending the HPV vaccine for your child today; the vaccine is proven effective, safe and necessary.”
4. “My child’s too young to get the HPV vaccine.”
CORROBORATE
“I agree with you that we wouldn’t wantto give this vaccine—or any vaccine—to a person if the preventive effects would wear off before the person needed it.”
ABOUT ME
“And, as a healthcare professional, I’m committed to prescribing only things that would be of lasting benefit to your child.”
SCIENCE
“This particular vaccine’s protection does not weaken or go away in time. Children ages 9 through 14 have a much better response to this vaccine than older teens. Vaccinating now means having to receive only two doses. Waiting for even a few more years would mean needing three doses because a teen’s immune systemis no longer as responsive as that of a younger child.”
EXPLAIN ADVICE
“That’s why I’m recommending this vaccine today when your child is young and will have a strong immune response with a vaccine whose protection does not fade away.”
5. “Because of our family values, my child will never be at risk for the disease and does not need the vaccine.”
CORROBORATE
“I think you will find that you and I have a lot of family values in common …”
ABOUT ME
“… and, as a clinician, I believe that completing this vaccine series does not compromise your values but rather provides future protection that all people deserve. While we don’t like to think about it, not all sex is consensual and by vaccinating today you are protecting your child for a lifetime of risks and situations we cannot foresee today.”
SCIENCE
“Studies show that completing the HPV vaccine series does not influence sexual behaviors or choices for teenagers. We know now that the infection is so common that HPV will infect nearly 80 percent of U.S. adults by the time they are 50. The infection is invisible, undiagnosed and without symptoms in most people. The vaccine prevents the infection that causes cancer.”
EXPLAIN ADVICE
“That’s why I’m recommending this vaccine to every one of my patients—because all of my patients are at risk for this infection.”
6. “It’s too expensive. We can’t afford it.”
CORROBORATE
“I agree that we have to avoid expensive treatments and reduce the burden of healthcare costs.”
ABOUT ME
“And, I’m glad you raised the question of affordability. Many of my patients’ parents don’t realize that these recommended vaccines are covered 100 percent by insurance, with no copay or deductible. I’ve learned in my role as a health care professional …”
SCIENCE
“…that with current insurance-coverage laws, my patients’ parents have no out-of-pocket expenses with vaccines, including the HPV vaccine.”
EXPLAIN ADVICE
“While things may change in the future, for now, this vaccine, while expensive, is covered completely. That’s one of the reasons why I am recommending the vaccination now with the first dose today.”
7. “My child’s not sexually active. My child doesn’t need the HPV vaccine yet.”
CORROBORATE
“I understand what you are saying. Your child is not going to be exposed to this infection for years and years to come.”
ABOUT ME
“And, as your child’s health care provider, I don’t want to do anything that is could be done at a later time and work just as well.”
SCIENCE
“I know from my readings and the conferences that I attend that we just don’t see teens and young adults in our offices regularly and we can’t depend on waiting until a checkup several years from now that most of the time will not happen. We want to complete the series before a person is exposed and when completing the series isn’t such a big disruption. Vaccinating now means having to receive only two doses. Waiting for even a few more years would mean needing three doses because a teen’s immune system is no longer as responsive. Studies show that the vaccine works best after you complete the series, but it does not wane or lose its protection. Studies also show that people who wait to start the vaccine series often fail to finish it because life, school, sports and other activities get in the way.”
EXPLAIN ADVICE
“That’s why I’m recommending we start the series today and finish it in six months while your child’s young enough to need only two doses and have the best response to the vaccine.”
8. “We are just here for the acne/ankle sprain/ ADHD and nothing else. We can deal with the vaccines due another time.”
CORROBORATE
“I share your concern that we definitely need to focus on why you and your daughter are here today.”
ABOUT ME
“And, I know from my experience as a health care professional, how hard it is to get in and get your concerns taken care of, especially with an adolescent with so many demands on her time with school, work, athletics, music, friends and family life.”
SCIENCE
“It turns out that in Minnesota, no matter what the insurance and despite full insurance coverage for preventive care, most teens do not stick to the schedule of regular preventive care visits.”
EXPLAIN ADVICE
“That’s why my colleagues and I have agreed to use every opportunity to bring our teens up to speed with their preventive care at any of the visits they make with anyone of us, rather than wait, and that’s why I’m recommending your teen get the HPV vaccine due today.”
When the nurse lets you know a parent has indicated he or she plans to decline the HPV vaccine.
The examples we’ve used address the most common expressions of parental vaccine hesitancy primary care clinicians face when we recommend the HPV vaccine. But you can respond to any concern using the CASE approach.
You might start the conversation saying, “The nurse noted that you indicated you were declining the HPV vaccine. I would like to learn from you why you wish to defer so that I can better understand your plans.” Then proceed with CASE approach.
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The CASE approach to responding to patient concerns.
CORROBORATE
Express the shared value that underlies the concern.
ABOUT ME
Make an about me statement with an “and” rather than a “but” that emphasizes your professional standing and expertise relevant to the shared value.
SCIENCE
Summarize the science, referring to science that supports your take on the concern, with regard to the shared value.
EXPLAIN ADVICE
Explain why you’re giving this advice and restate your strong recommendation to vaccinate today in terms of the shared belief and the science.
Acknowledgments
This work was supported in whole by the National Cancer Institute of the National Institutes of Health under award number R01CA217889. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
Contributor Information
ROBERT M. JACOBSON, department of Pediatric and Adolescent Medicine at Mayo Clinic.
LILA J. FINNEY RUTTEN, department of Health Sciences Research at Mayo Clinic..
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