Wide Open Spaces: Supporting HPV Vaccination with Rural Communities

Retooling Provider HPV Vaccine Communication Styles to Increase Rural HPV Vaccine Coverage

By Lisa Spees, PhD and Olufeyisayo “Feyi” Odebunmi, MPH, BPharm

It is well-known that rural areas have lower rates of HPV vaccination and higher rates of HPV-related infections and cancers than non-rural areas. Some reasons for these rural disparities include low access to primary care clinics, limited health literacy and HPV awareness, and high HPV vaccine hesitancy. A provider-led HPV vaccine recommendation, like a presumptive recommendation, has achieved greater HPV vaccine uptake. A presumptive recommendation style involves a provider communicating their assumption that a parent or caregiver will get the HPV vaccine for their kids. For example, a statement like “Andrew is 11. He is due for three vaccines. Today, he will get vaccines against meningitis, HPV cancers, and whooping cough” can be very powerful.

Photo of medical clinic in North Carolina

Blowing Rock Medical Park (A division of Caldwell Memorial Hospital) in Blowing Rock, NC

Widespread use of, and comfortability with, a presumptive recommendation approach among rural and non-rural primary care professionals (PCPs), including pediatricians, family medicine physicians, nurses, and medical assistants, is needed to increase HPV vaccine coverage, especially in rural areas. 

Since little is known about how often PCPs use this presumptive communication style and their experiences with it, our team used a mixed methods approach (national survey, n=2500+, and semi-structured interviews, n=36) to answer these questions. Overall, our study revealed that rural and non-rural PCPs viewed a presumptive recommendation style favorably, with more than half (58%) of survey respondents using it routinely. In interviews, some rural PCPs reported more issues when addressing parents’ concerns about HPV vaccine safety and noted that the presumptive approach might not work well in certain situations, like with parents from rural areas who have had negative experiences with the healthcare system. 

photo of Lisa Spees

Increasing HPV vaccination in rural areas should be a key public health priority, as it would significantly reduce cancer disparities experienced by this population.

- Dr. Lisa Spees

Olufeyisayo “Feyi” Odebunmi, MPH, BPharm

HPV vaccination is highly preventive against HPV-related cancers, and our efforts to increase HPV vaccine coverage, especially in rural areas, should move beyond the patient to provider- and health system-level strategies.

- Olufeyisayo “Feyi” Odebunmi, MPH, BPharm

Our takeaway was that although a presumptive style can positively impact HPV vaccination rates, perceived challenges with its use, especially with rural populations, can affect HPV vaccine uptake in the long term. As a result, further exploration is needed of strategies that can enhance presumptive recommendations about HPV vaccination with parents in geographically diverse clinic contexts. The Announcement Approach (AA) is a highly effective three-step HPV communication style recommended by the National Cancer Institute. The AA builds on the presumptive communication style and provides additional steps (“connect-and-counsel” and “follow-up”) that PCPs can utilize when they encounter challenges in giving a presumptive recommendation. Our team is conducting randomized controlled trials that test different strategies that can enhance the AA (e.g. standing orders, provider incentives, clinic champions) to improve rural and non-rural HPV vaccination rates. We are also assessing implementation costs in diverse settings.

HPV vaccination is essential to eliminating HPV-related infections and cancers. Provider recommendations are the most effective approach to increasing HPV vaccination. Proven provider communication techniques such as AA should be utilized widely, especially in rural areas with the most need, but widespread adoption in rural and non-rural areas may be aided by strategies that engage the entire primary care team and address patients’ concerns directly.

About the authors

Lisa Spees, PhD
Assistant Professor
University of North Carolina at Chapel Hill

Dr. Spees is currently an Assistant Professor in the Department of Health Policy and Management at UNC’s Gillings School of Public Health. She is a health services researcher and decision scientist focused on improving care quality, equity, and values for cancer populations. Her past research has focused on identifying multi-level barriers across the cancer care continuum using both qualitative and quantitative methods. Currently, her research focuses specifically on improving rural cancer care through community-engaged research methods and cost-effectiveness analyses.

Olufeyisayo “Feyi” Odebunmi, MPH, BPharm
PhD Candidate, Department of Health Policy and Management, Gillings School of Global Public Health, Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill

Feyi has a background as a trained pharmacist in Nigeria, her pharmacy work made her passionate about increasing access to care and tackling health disparities. She is pursuing a doctoral program in the Department of Health Policy and Management at UNC Chapel Hill. Feyi’s research interests are centered around cancer prevention and control and cancer care equity. She has been involved in cancer research for the past few years, leveraging her experience in mixed methods analyses, implementation science, and healthcare quality and access. She enjoys binge-watching TV shows, catching up with friends, and hiking during her leisure time.