Our December Pieces of the Continent interviewee is Gregory Zimet – a Social Scientist who has investigated vaccines and prevention of sexually transmitted infections, including HPV. He told us about his work and what he believes can be done to improve vaccination rates.
Please introduce yourself and tell us a bit about your background
Hi. My name is Gregory Zimet. I am professor of pediatrics and clinical psychology at Indiana University School of Medicine. My training was in Clinical Psychology and, up until about 12 years ago, I did psychotherapy with adolescents and their families. I received my PhD from Duke University in 1985. Subsequently, I did post-doctoral training and worked at Case Western Reserve University School of Medicine in Cleveland, Ohio for about eight years, then moved to Indiana University in 1993. Going back to my college years I have had a great interest in health psychology research. During that time, I worked as a research assistant at a biofeedback lab and at National Jewish Hospital in Denver, CO. Shortly after I arrived in Indianapolis I started developing a research program focused on understanding psychosocial determinants of vaccine acceptance. I conducted my first study of attitudes about HPV vaccination in the late 1990s, years before Gardasil was first licensed in the U.S. I published a paper on that study in Journal of Women’s Health & Gender-Based Medicine in 2000. I haven’t stopped studying HPV vaccination since that time.
What sort of research into HPV have you recently conducted?
One aspect of research that I enjoy the most is collaborations with other researchers across multiple disciplines. One recently published study involved a collaboration with a pediatric health services researcher, an informatics researcher, and a biostatistician. We investigated whether electronic health record prompts delivered to pediatric clinicians would improve delivery of HPV vaccination. A simple prompt did not differ from the no-prompt condition, but an elaborated prompt that included suggested recommendation language resulted in substantially higher HPV vaccine initiation rates compared to the no-prompt condition. In a study that another group of colleagues and I have just launched, we are testing the effect of brief video messages on parental intentions to vaccinate their children. The intervention focuses on parents who express reluctance to vaccinate. This research team includes researchers from pediatrics, health communication, nursing, and epidemiology. I am also a co-investigator on a project led by a nursing faculty member at Boston College. This project is designed to reach young men who have sex with men through a social networking app and encourage them to get vaccinated against HPV at a community health clinic.
What have you found to be the main facilitators to high HPV vaccination rates?
At the state level, it is clear that strong state-based public health policies around HPV vaccination can improve vaccination rates. Rhode Island, which instituted a school-entry requirement for HPV vaccination in 2015 is a leader in HPV vaccination rates, with a very high percentage of boys and girls getting vaccinated. Rhode Island and the District of Columbia may be the only two jurisdictions in the U.S. to reach the Health People 2020 goal of 80% series completion for HPV vaccination by 2020.
At the practice level it is also very clear that a strong, clear provider recommendation is important to facilitate high HPV vaccination rates. The consensus among HPV vaccine researchers is that health care providers should start with a presumptive, bundled, same-day recommendation of vaccines for all children 11-12 years of age. Those vaccines include meningococcal ACWY (MenACWY), HPV, tetanus, diphtheria, pertussis booster (Tdap), and influenza vaccine (in season). Ideally, HPV should be placed in the middle of the recommendation in order to minimize hesitation. Parents who agree to vaccinate identify the provider’s recommendation as a primary motivation.
What have you found to be the obstacles to high HPV vaccination rates?
One major obstacle has been the failure of some health care providers to make strong, clear, on-time recommendations for HPV vaccine among the other recommended vaccines. Too often health care providers encourage delay of HPV vaccination or discuss it in a way that communicates that it is different from the other routinely recommended vaccines, and less important for the child’s future health. Many parents who do not vaccinate indicate that their child’s provider did not make a strong recommendation.
Another huge obstacle is the broad dissemination of false information about HPV vaccination on social media, blogs, and other websites. HPV vaccine is extraordinarily safe and effective and prevents multiple cancers. However, some websites claim it is dangerous, ineffective, and does not prevent cancer. Unfortunately, these websites can scare parents and it can be difficult for them to sort out lies from truth. There are good, accurate websites available, including https://hpvroundtable.org/ and the Centers for Disease Control & Prevention (https://www.cdc.gov/hpv/parents/index.html) among others.
What possible interventions would help increase vaccination rates?
There are interventions being developed and tested to help health care providers improve their approaches to communication about HPV vaccination. These interventions are very promising in terms of increasing HPV vaccination rates. I also believe that messaging interventions directed to parents that can be delivered in a clinic setting may also prove to be effective. We have found that a number of messaging strategies that address safety and effectiveness can increase parental intention to vaccinate. The challenge is to find ways to implement these approaches in clinics.
Any final thoughts? Anything we haven’t covered that you would like to mention?
There are some really positive trends that are important to remember amidst all of the challenges. For instance, vaccination of males has increased at a rapid rate and is now quite close to the rates of female vaccination. The latest National Immunization Survey-Teen (NIS-Teen) data for 2017 indicate that over 65% of adolescents ages 13-17 have received 1 or more doses of HPV vaccine. This means that HPV vaccination is statistically normative in the U.S. We should leverage this fact – that getting vaccinated is normative – as part of our communication strategies. Also, it can change the discussion from asking about the side-effects of HPV vaccination (i.e., mostly pain and swelling at the injection site, and, rarely, fainting) to asking about the side-effects of non-vaccination (i.e., cervical cancer and pre-cancer, anal cancer and pre-cancer, vulvar cancer, and vaginal cancer).
It is likely that vaccination will prevent HPV-related oropharyngeal cancers (OPC). Particularly in Western, industrialized countries, OPC has increased sharply in men over the past 15 years. In fact, there are now more HPV-related OPCs diagnosed each year in the U.S. than cervical cancers.