Quality of Physician Communication about HPV Vaccine—Letter

The United States was first to introduce human papillomavirus (HPV) vaccination but a decade later, despite demonstrated effectiveness and safety, uptake remains lower than in other countries and in comparison with other adolescent vaccines. Numerous factors explain these disparities. The prevailing thinking is that vaccine uptake could be improved by having physicians recommend HPV vaccination according to guidelines. Although physicians are influential in patient decision-making, we suggest that it is overly simplistic to think that their recommendations alone will ensure targeted goals. Given the putative influence of physicians' recommendations in the context of suboptimal HPV vaccine uptake, one might assume that either physicians do not recommend HPV vaccination, or how they communicate recommendations is not acceptable to patients.

In this journal, Gilkey and colleagues (1) recently concluded that instrumental aspects (timeliness, consistency, urgency, strength) of overall vaccination recommendation quality comprise an index reflective of the quality of physician recommendation communications, and implying the use of more prescriptive communications improves HPV vaccination rates. In an accompanying commentary, Zimet lauds this index of overall vaccination quality as a potentially valuable tool for use in interventions to promote HPV vaccination (2). The intention of this study is commendable, but we believe it conflates instrumental communication practices with overall recommendation quality.

We agree that physicians' communication of recommendations must be examined, but not from a physician-centered perspective and instead from the perspective of patient–provider shared decision-making that recognizes the principle of informed choice (3). We would argue that any discussion of a recommendation, in addition to the possible inclusion of some of the more instrumental aspects of recommendations, needs to be embedded within this patient-centered discussion. Our ongoing work confirms that many physicians are unable or unwilling to engage in a patient-centered discussion needed to overcome vaccine hesitancy (4). Furthermore, physicians who discuss HPV vaccination with girls ages 11 to 12 and their mothers are more likely to start and sustain vaccine administration. Interestingly, Zimet previously presented work in support of our position that effective communication emphasizes the process of respectful elicitation and responses (5).

The prevailing zeitgeist in health care reform stresses the need for informed decision-making and patient-centeredness. A directive mode of communicating vaccine recommendations may work with infants and toddlers, but not with adolescents. Physicians' HPV vaccination recommendations should be examined in terms of their instrumental quality and also from the perspective of a communication that considers the acceptability of the recommendation for the patient.

See the Response, p. 868