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Original Investigation
May 24, 2021

Effect of Training Pediatric Clinicians in Human Papillomavirus Communication Strategies on Human Papillomavirus Vaccination Rates: A Cluster Randomized Clinical Trial

Author Affiliations
  • 1Department of Pediatrics, University of California, Los Angeles, UCLA Mattel Children’s Hospital, Los Angeles
  • 2Department of Pediatrics, Children’s Mercy, Kansas City, Missouri
  • 3Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 4Center for Pediatric Clinical Effectiveness, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
  • 5Primary Care Research, American Academy of Pediatrics, Itasca, Illinois
  • 6Pediatric Research in Office Settings, American Academy of Pediatrics, Itasca, Illinois
  • 7Department of Biomedical and Health Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
  • 8Department of Pediatrics, University of Rochester, Rochester, New York
  • 9UCLA Center for Health Policy Research, University of California Los Angeles, Los Angeles
JAMA Pediatr. 2021;175(9):901-910. doi:10.1001/jamapediatrics.2021.0766
Key Points

Question  Can training pediatric clinicians in human papillomavirus (HPV) communication strategies using online modules reduce missed opportunities for HPV vaccination and increase rates of HPV vaccination?

Findings  In this cluster randomized clinical trial involving 48 pediatric practices across 19 states, online communication training reduced missed opportunities for HPV vaccination, particularly by improving receipt of the first HPV vaccine dose.

Meaning  Online training of pediatric clinicians focused on effective communication may increase rates of HPV vaccination.


Importance  Missed opportunities for human papillomavirus (HPV) vaccination during pediatric health care visits are common.

Objectives  To evaluate the effect of online communication training for clinicians on missed opportunities for HPV vaccination rates overall and at well-child care (WCC) visits and visits for acute or chronic illness (hereafter referred to as acute or chronic visits) and on adolescent HPV vaccination rates.

Design, Setting, and Participants  From December 26, 2018, to July 30, 2019, a longitudinal cluster randomized clinical trial allocated practices to communication training vs standard of care in staggered 6-month periods. A total of 48 primary care pediatric practices in 19 states were recruited from the American Academy of Pediatrics Pediatric Research in Office Settings network. Participants were clinicians in intervention practices. Outcomes were evaluated for all 11- to 17-year-old adolescents attending 24 intervention practices (188 clinicians) and 24 control practices (177 clinicians). Analyses were as randomized and performed on an intent-to-treat basis, accounting for clustering by practice.

Interventions  Three sequential online educational modules were developed to help participating clinicians communicate with parents about the HPV vaccine. Weekly text messages were sent to participating clinicians to reinforce learning. Statisticians were blinded to group assignment.

Main Outcomes and Measures  Main outcomes were missed opportunities for HPV vaccination overall and for HPV vaccine initiation and subsequent doses at WCC and acute or chronic visits (visit-level outcome). Secondary outcomes were HPV vaccination rates (person-level outcome). Outcomes were compared during the intervention vs baseline.

Results  Altogether, 122 of 188 clinicians in intervention practices participated; of these, 120, 119, and 116 clinicians completed training modules 1, 2, and 3, respectively. During the intervention period, 29 206 adolescents (14 664 girls [50.2%]; mean [SD] age, 14.2 [2.0] years) made 15 888 WCC and 28 123 acute or chronic visits to intervention practices; 33 914 adolescents (17 069 girls [50.3%]; mean [SD] age, 14.2 [2.0] years) made 17 910 WCC and 35 281 acute or chronic visits to control practices. Intervention practices reduced missed opportunities overall by 2.4 percentage points (−2.4%; 95% CI, −3.5% to −1.2%) more than controls. Intervention practices reduced missed opportunities for vaccine initiation during WCC visits by 6.8 percentage points (−6.8%; 95% CI, −9.7% to −3.9%) more than controls. The intervention had no effect on missed opportunities for subsequent doses of the HPV vaccine or at acute or chronic visits. Adolescents in intervention practices had a 3.4-percentage point (95% CI, 0.6%-6.2%) greater improvement in HPV vaccine initiation compared with adolescents in control practices.

Conclusions and Relevance  This scalable, online communication training increased HPV vaccination, particularly HPV vaccine initiation at WCC visits. Results support dissemination of this intervention.

Trial Registration  ClinicalTrials.gov Identifier: NCT03599557

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