JUST ANOTHER SHOT: REFRAMING THE HPV VACCINE From the MINNESOTA Department of Health JUST ANOTHER SHOT: REFRAMING THE HPV VACCINE HTTPS://WWW.YOUTUBE.COM/WATCH?V=VFHJK5L0T-Y

Communication Strategies to Increase HPV Immunization Coverage Sharon Humiston, MD, MPH, FAAP Professor of Pediatrics Children’s Mercy Kansas City, MO Office Staff Parent & Child Provider EHR, IIS This work was funded by a grant from the CDC to Hager Sharp Inc.

Learning Objectives Identify and implement the “same way, same day” approach to HPV vaccination for all 11- & 12-year-olds (as well as older unvaccinated patients) in the pediatric health care setting. Recruit your whole office team to take a role in HPV vaccination communication Model other evidence-based strategies to increase HPV vaccination coverage in your office. Introduce >2 new practice tools into to help support HPV vaccination in the pediatric health care setting.

Objective #1 “SAME DAY, SAME WAY”

Sometimes we send messages we did not intend to send.

Doctor: “What do you want to do about shots today?” Parent: “Hmmm…What do you think we should do?” Doctor: “Tdap is required for school and some colleges require the meningitis vaccine. There’s also an optional vaccine, HPV, we could give at this age.” Parent: “That one isn’t required for school? Well, if it’s not really necessary, maybe we should hold off.” Doctor: “Well…if you don’t want it…Okay. Emma is such a good kid…I’m sure it can wait ‘til next time.”

Recommend HPV vaccine the same day & the same way as other adolescent immunizations Same day: Recommend HPV vaccine today, i.e., the same day you recommend Tdap & meningococcal vaccines. Unpublished CDC data, 2013.

Recommend HPV vaccine the same day & the same way as other adolescent immunizations Same day: Recommend HPV vaccine today, i.e., the same day you recommend Tdap & meningococcal vaccines. More convenient for the parent More reliable Unpublished CDC data, 2013.

Recommend HPV vaccine the same day & the same way as other adolescent immunizations Same day: Recommend HPV vaccine today, i.e., the same day you recommend Tdap & meningococcal vaccines. Same way: Bundle all the adolescent vaccines and recommend them all in the same way with the assumption that the parent will want protection for their child. Unpublished CDC data, 2013.

Today, Michelle should have 3 shots that will protect her from the cancers caused by HPV, and infections causing meningitis, whooping cough, tetanus, & diphtheria.  What questions do you have for me about these vaccines?

Notice that I’m recommending a presumptive style. There’s some preliminary evidence that a “participatory” style is associated with lower vaccination uptake. Avoid starting with a bland inquiry like, “Let’s discuss how you feel about the vaccinations for adolescents.”

Use a practical communication strategy when a parent has a question Vaccinate Ask/ Respond Recommend ACKNOWLEDGE Plan for next step ADVISE

Use a practical communication strategy when a parent has a question Vaccinate Ask/ Respond Recommend When a parent has a question, don’t panic. My 2 knee jerk rxns – feel like we’re heading into time-sucking conflict & feel like my authority’s being challenged Interpret a question as a request for reassurance from YOU, a clinician they trust ACKNOWLEDGE Plan for next step ADVISE

Be prepared to address specific concerns

Be prepared to address specific concerns http://www.cdc.gov/vaccines/who/teens/for-hcp-tipsheet-hpv.html

Use a practical communication strategy when a parent has a question Vaccinate Ask/ Respond Recommend ACKNOWLEDGE Plan for next step ADVISE

Use a practical communication strategy when a parent has a question Vaccinate Ask/ Respond Recommend DECLINE FOR NOW ACKNOWLEDGE Plan for next step ADVISE

If a parent declines… Declination is not final. The conversation can be revisited. Declining = Delaying End the conversation with at least 1 action you both agree on. Because waiting to vaccinate is the risky choice, many pediatricians ask the parent to sign a Declination Form

https://www2.aap.org/immunization/pediatricians/pdf/refusaltovaccinate.pdf

Putting it all together https://www.dropbox.com/s/1g0srzgro9s0t8c/Clip1_AdolescentGirl.wmv?dl=0

Great job! He seized the moment He did not “profile” (he recommended the vaccine even though this girl does not look like she’s interested in having sex soon) He bundled the recommendation He asked for mom’s question He answered mom’s question accurately and calmly (if a bit long winded) When mom asked the 2nd question: “some people…”, he stayed positive He cared (“I’d feel better”)

“I don’t want to talk about sex.”

“I don’t want to talk about sex.” Did you explain fecal-oral spread before you gave the polio vaccine? https://en.wikipedia.org/wiki/Fecal-oral_route

Who Makes the HPV Decision? Cross-sectional sample of women in SE Texas With >1 child age 9-17 yrs in 2011-2013 31% 24% Effect of the Decision-making Process in the Family on HPV Vaccination Rates among Adolescents 9-17 years of age. Human Vaccine Immunotherapy

Every part of your practice influences parents’ perceptions

Objective #2 Recruit your whole office team to take a role in HPV vaccination communication

Passion is energy

Be sure everyone in the office understands the mission Human stories often influence people more than statistics To understand the human stories behind HPV, listen to survivors Shot By Shot Unprotected People on www.immunize.org

http://shotbyshot.org/cervical-cancer-and-hpv/heathers-story/

http://www.hpvepidemic.com/

The Opener Announce the child needs 3 vaccines (4 if flu vaccine is available) Encourage convenient same-day vaccination “Today, Pat should have 3 vaccines. They’re designed to protect him from the cancers caused by HPV and from meningitis, tetanus, diphtheria, & pertussis. What questions do you have for me?” If a parents hesitates, the MA/nurse should say “Our team is so dedicated to cancer prevention -- I’m sure the doctor will want to respond to your concerns.”

In your office, who has this role in i m m u n i z a t i o n c o m m u n i c a t i o n ? Give the VIS Explain the VISs Answer questions if they arise Vaccinate Arrange for the next dose

other evidence-based strategies to increase HPV vaccination coverage Objective #3 other evidence-based strategies to increase HPV vaccination coverage

How to improve: 2 Approaches Increase the # of target patients who: Come in Leave the office vaccinated

Using reminder or recall messages 1. # who come in Using reminder or recall messages Timing Reminder – to patients who will be due soon Recall – to patients who are past due Medium Letter Phone call – personal or auto-dialer Text Email

By making access easier 1. # who come in By making access easier Office hours – e.g., one evening/week, Saturday mornings Nurse only visits

2. # who leave vaccinated

Actual and Potentially Achievable Vaccination Coverage if Vaccines Were Given Simultaneously NIS-Teen, 2012

By vaccinating at every visit type 2. # who leave vaccinated By vaccinating at every visit type Well care Chronic care Acute care

2. # who leave vaccinated Standing Orders Empower non-physician personnel to vaccinate patients (after assessing for specific contra- indications) without direct physician involvement Preapproved orders to vaccinate on file Templates available for all routine vaccines at www.immunize.org/standing-orders/ To save physicians’ time, staff have to be aware of the S.O. and trained to use it

2. # who leave vaccinated Provider Prompts Prompt the person who is supposed to order the vaccine How? Nursing personnel EHR Both Attention to prompts tends to wear off

Provider Prompts: QI

Objective 4 PRACTICE TOOLS

Email questions or comments to CDC Vaccines for Preteens and Teens: For more information, including free resources for yourself and your patients/clients, visit: cdc.gov/vaccines/YouAreTheKey Email questions or comments to CDC Vaccines for Preteens and Teens: PreteenVaccines@cdc.gov

http://www.cdc.gov/vaccines/who/teens/for-hcp/hpv-resources.html

For More Information Shot by Shot AAP http://shotbyshot.org/story-gallery AAP Info for parents (healthychildren.org) Info for clinicians (http://www2.aap.org/ immunization/illnesses/hpv/hpv.html) Immunization Action Coalition http://www.immunize.org/ CHOP Vaccine Education Center http://vec.chop.edu/ EZ IZ http://eziz.org/ American Cancer Society

FREE!

Review Use the “same way, same day” approach to HPV vaccination for all 11- & 12-year-olds and older unvaccinated patients. Recruit your whole office team – heart and mind – to take a role in HPV vaccination communication Model other evidence-based strategies to increase HPV vaccination coverage in your office. Introduce >2 new practice tools into to help support HPV vaccination in the pediatric health care setting.

The End Thank you for watching!