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Nudging Parents Plus Auditing Providers Increased HPV Vaccine Uptake in Tweens

Reminding parents of tweens who were due for a human papillomavirus (HPV) vaccine increased uptake, especially when combined with auditing healthcare professionals after appointments, a cluster randomized trial showed.

Among more than 9,000 kids ages 11 and 12, the odds of HPV vaccination were higher when parents received reminders compared with usual care (OR 1.56, 95% CI 1.23-1.97), reported Lila Finney Rutten, PhD, of the Mayo Clinic in Rochester, Minnesota, and colleagues.

Those odds were even better when parents got reminders and healthcare professionals were audited (OR 2.03, 95% CI 1.44-2.85), they noted in JAMA Pediatrics.

However, auditing healthcare professionals alone did not significantly increase HPV vaccination uptake (OR 1.19, 95% CI 0.94-1.51).

Finney Rutten told MedPage Today that her team “selected these strategies to target both patients/parents and providers.”

With usual care, 21.9% of patients received an HPV vaccine dose. With an added parent reminder, the rate jumped to 34.6%, and with the healthcare professional audit, the rate was 30.4%. But with both interventions, 39.7% of patients were vaccinated.

“We more than doubled HPV vaccine rates during a pandemic that triggered very polarized perspectives on vaccination in the U.S.,” Finney Rutten said.

Despite being a critical tool in preventing HPV, and thus HPV-attributable cancers, HPV vaccine uptake lags behind comparators.

Ultimately, the authors concluded that the interventions were “an effective and scalable approach to improving HPV vaccination and reducing HPV-associated cancer burden.”

“An effective treatment or practice is only as good as people’s willingness to adopt the intervention,” Finney Rutten noted.

In an accompanying editorial, Alexander Fiks, MD, MSCE, of Children’s Hospital of Philadelphia, and colleagues, pointed to several other interventions that hospital systems could use to increase HPV vaccine uptake.

In an age where electronic health records are nearly universal, hospital systems have plenty of data on patients, Fiks and team said. They recommended continuing education credits as provider incentive and virtual trainings, in addition to the interventions Finney Rutten and colleagues utilized. Another tool they recommended is training providers on communicating effectively to vaccine-hesitant parents and patients.

Implementing data-supported strategies such as these should be a priority, they stressed.

“These approaches will not just improve childhood HPV vaccination rates but ultimately protect the adult U.S. population from thousands of HPV-associated cancers, related morbidities, and deaths each year,” Fiks and colleagues wrote, noting that the findings add to studies that “highlight the potential for health system-level interventions to increase HPV vaccination.”

This cluster randomized trial was conducted at six primary care sites affiliated with the Mayo Clinic in southeastern Minnesota. The authors used a stepped-wedge design to test each intervention at each location, which also meant that each practice was its own control. Age- and dose-eligible patients were identified using guidelines from the CDC’s Advisory Committee on Immunization Practices.

In total, there were 9,242 participants, of whom 55.9% were 11 years old and 44.1% were 12 years old; 52.5% were boys, 72.5% were white, and 9% were Black. Of these kids, 70.9% started the vaccination series, and 29.1% completed vaccination.

In the intervention group, parents were mailed information following their child’s birthday and/or healthcare professionals received confidential audit/feedback on their personal in-office success with HPV vaccine uptake via intra-campus mail. Groups were block randomized into four 12-month sequences. Step one was usual care, followed by two more steps (none, one, or both interventions). Finally, all practices implemented both interventions. The primary outcome was patients getting any valid dose of HPV vaccine.

The authors noted that because they only followed patients from time of entry until the end of their step, the crude rate of uptake might be underestimated. Additionally, the COVID-19 pandemic delayed step 3 of the trial for 6 months.

Finney Rutten told MedPage Today that future studies should also look into HPV vaccination uptake in rural and low-income areas.

  • Rachael Robertson is a writer on the MedPage Today enterprise and investigative team, also covering OB/GYN news. Her print, data, and audio stories have appeared in Everyday Health, Gizmodo, the Bronx Times, and multiple podcasts. Follow


This research was supported by the National Cancer Institute.

Finney Rutten reported receiving grants from the National Cancer Institute. Other co-authors reported receiving grants from the NIH, the National Institutes of Aging for Interdisciplinary Infrastructure for Aging Research, and the National Cancer Institute; one co-author received personal fees from Merck.

Fiks reported no conflicts of interest. A co-author reported receiving a grant from the National Cancer Institute.

Primary Source

JAMA Pediatrics

Source Reference: Finney Rutten LJ, et al “Multilevel implementation strategies for adolescent human papillomavirus vaccine uptake: a cluster randomized clinical trial” JAMA Pediatr 2023; DOI: 10.1001/jamapediatrics.2023.4932.

Secondary Source

JAMA Pediatrics

Source Reference: Kelly MK, et al “What health systems can do now to improve human papillomavirus vaccination” JAMA Pediatr 2023; DOI: 10.1001/jamapediatrics.2023.5070.

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