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The Role of Physician Recommendations and Public Policy in Human Papillomavirus Vaccinations

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Abstract

Background

Immunization rates for human papillomavirus (HPV) infections remain low among teenagers despite strong evidence of the effectiveness of vaccines. Physician recommendations of the vaccine are far from universal. Several states have enacted policies that mandate HPV vaccination or distribute educational materials.

Objectives

To provide policy makers, physicians, and researchers information on the relative importance of physician recommendations and early state-level policies to promote HPV vaccinations among targeted age groups.

Methods

We first use probit models to determine the strongest correlates of immunization in a nationally representative US sample of teenagers. We then use instrumental variable probit models to determine the direct role that physician recommendations play in vaccination using plausibly exogenous physician encounters that are likely not the result of more health-conscious parents seeking out information on the vaccine.

Results

We show that children in the targeted age range who are more likely to encounter physicians for reasons other than seeking out the vaccine, such as through mandatory wellness exams or previous asthma diagnoses, are significantly more likely to get the vaccine. There is no consistent evidence that the state policies we analyze have been effective.

Conclusion

Encouraging recommendations by physicians may be the most effective path toward increasing HPV vaccination. State-level mandates and policies are yet to exhibit effectiveness.

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Notes

  1. ACIP provided guidance that Gardasil may be given to males aged 9 through 26 years in October 2006 but did not recommend the HPV vaccine for routine use among males. ACIP recommended routine use of Gardasil in males aged 11 and 12 years on 25 October 2011.

  2. See https://www.arhp.org/Publications-and-Resources/Patient-Resources/Fact-Sheets/Understanding-HPV-Vaccine.

  3. See http://www.cdc.gov/nchs/nis/about_nis.htm for more information.

  4. See http://www.ncsl.org/research/health/hpv-vaccine-state-legislation-and-statutes.aspx for a review of the statutes.

  5. Federal programs include Vaccine for Children (VFC) program, and Section 317 of the Public Health Services Act. At the state level, Universal Purchase programs (dubbed as “universal states”) supplement federal funds to provide ACIP-recommended vaccines for privately insured children, as well as Vaccine for Children (VFC) eligible ones (Alaska, New Hampshire, New Mexico, Rhode Island, Vermont, Washington, and Wyoming). Alaska changed its status in January 2009, Washington in July 2009, and Wyoming in July 2011 to “universal select” states, meaning that they cover all but selected vaccines (not including the HPV vaccine).

  6. This includes Arkansas, California, Colorado, Connecticut, Delaware, DC, Florida, Georgia, Hawaii, Illinois, Kansas, Louisiana, Maryland, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania, Rhode Island, Texas, Virginia, West Virginia, and Wisconsin. In addition to those states, a new insurances and plans under the ACA are required to provide preventive services as of 23 September 2010, including ACIP-recommended vaccines without imposing out of pocket costs on the policy holder such as co-payment or co-insurances.

  7. We initially include all the universal states and the states with a public awareness campaigns. We drop those states that have changed their status to “universal select” during the sample period (Alaska and Washington) for robustness check. These results are qualitatively the same and will be available upon request.

  8. Results are robust to linear probability models, which do not have the complications arising from incidental parameters, but do not fit the data as well as a probit.

  9. Failure to obtain provider data is attributable to two main reasons. First, the family did not give consent to contact the teen’s vaccination provider. Second, communication with the provider was not possible because either contact information for the provider was not adequate or the provider did not respond. We estimated regressions that treat the unavailable vaccination records from the provider as missing, or use household data and include a dummy variable that represents when data from provider is missing, and Heckman probit model for selection. In all the cases, the results are qualitatively the same.

  10. There are 35 states that have Tdap requirements for school entry. This includes Alabama, Alaska, Arizona, Arkansas, Colorado, Florida, Illinois, Indiana, Kansas, Kentucky, Louisiana, Massachusetts, Michigan, Minnesota, Montana, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Carolina, North Dakota, Ohio, Oregon, Pennsylvania, Rhode Island, South Carolina, Tennessee, Texas, Utah, Vermont, Virginia, Washington, Wisconsin, and Wyoming.

  11. We conducted a series of robustness checks that we report and describe in the supplementary electronic file to ensure that the null effect of these state policies are accurate. Specifically, we address issue related to collinearity of the policies and comparability of comparison states to those with education and mandate policies. The null effects of both policies endure.

  12. In addition to two-stage least squares, we also estimated two-stage residual inclusion models using both history of asthma and checkup, and alternatively only history of asthma. In either case, the effect of physician recommendation remains a significant and strong predictor of all vaccine outcomes and the point estimates are even larger. These estimates are available upon request.

  13. See http://journalofethics.ama-assn.org/2012/01/ccas1-1201.html for a more detailed discussion.

References

  1. Center for Disease Control and Prevention. Human papillomavirus (HPV). 2014. http://www.cdc.gov/std/hpv/. Accessed 1 Dec 2015.

  2. Center for Disease Control and Prevention. Vaccine safety, human papillomavirus (HPV) vaccine. 2014. http://www.cdc.gov/vaccinesafety/vaccines/HPV/index.html. Accessed 1 Dec 2015.

  3. Daley MF, Crane LA, Markowitz LE, Black SR, Beaty BL, Barrow J, Babbel C, Kempe A. Human papillomavirus vaccination practices: a survey of US physicians 18 months after licensure. Pediatrics. 2010;126(3):425–33.

    Article  PubMed  Google Scholar 

  4. Jain N, Euler GL, Shefer A, Lu P, Yankey D, Markowitz L. Human papillomavirus (HPV) awareness and vaccination initiation among women in the United States, National Immunization Survey-Adult 2007. Prev Med. 2009;48(5):426–31.

    Article  PubMed  Google Scholar 

  5. Black LL, Zimet GD, Short MB, Sturm L, Rosenthal SL. Literature review of human papillomavirus vaccine acceptability among women over 26 years. Vaccine. 2009;27(11):1668–73.

    Article  PubMed  Google Scholar 

  6. Brewer NT, Fazekas KI. Predictors of HPV vaccine acceptability: a theory-informed, systematic review. Prev Med. 2007;45:107–14.

    Article  PubMed  Google Scholar 

  7. Holman DM, Benard V, Roland KB, Watson M, Liddon N, Stokley S. Barriers to human papillomavirus vaccination among US adolescents: a systematic review of the literature. JAMA Pediatr. 2014;168(1):76–82.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Colgrove J, Abiola S, Mello MM. HPV vaccination mandates-lawmaking amid political and scientific controversy. N Engl J Med. 2010;363(8):785–91.

    Article  CAS  PubMed  Google Scholar 

  9. Bugenske E, Stokley S, Kennedy A, Dorell C. Middle school vaccination requirements and adolescent vaccination coverage. Pediatrics. 2012;129(6):1056–63.

    Article  PubMed  Google Scholar 

  10. Kenkel DS, Terza JV. The effect of physician advice on alcohol consumption: count regression with an endogenous treatment effect. J Appl Econom. 2001;16(2):165–84.

    Article  Google Scholar 

  11. Kreuter MW, Chheda SG, Bull FC. How does physician advice influence patient behavior? evidence for priming effect. Arch Fam Med. 2000;9(5):426–33.

    Article  CAS  PubMed  Google Scholar 

  12. Maurer J, Harris KM, Uscher-Pines L. Can routine offering of influenza vaccination in office-based settings reduce racial and ethnic disparities in adult influenza vaccination? J Gen Intern Med. 2014;29(12):1624–30.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Maurer J, Harris KM. Issuance of patient reminders for influenza vaccination by US-based primary care physicians during the first year of universal influenza vaccination recommendations. Am J Public Health. 2014;104(6):e60–2.

    Article  PubMed  Google Scholar 

  14. Nowak GJ, Sheedy K, Bursey K, Smith TM, Basket M. Promoting influenza vaccination: insights from a qualitative meta-analysis of 14 years of influenza-related communications research by US Centers for Disease Control and Prevention (CDC). Vaccine. 2015;33(24):2741–56.

    Article  PubMed  Google Scholar 

  15. Szilagyi PG, Rand CM, McLaurin J, Tan L, Britto M, Francis A, Rickert D. Delivering adolescent vaccinations in the medical home: a new era? Pediatrics. 2008;121(Supplement 1):S15–24.

    Article  PubMed  Google Scholar 

  16. Ylitalo KR, Lee H, Mehta NK. Health care provider recommendation, human papillomavirus vaccination, and race/ethnicity in the US National Immunization Survey. Am J Public Health. 2013;103(1):164–9.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Rosenthal SL, Weiss TW, Zimet GD, Ma L, Good MB, Vichnin MD. Predictors of HPV vaccine uptake among women aged 19–26: importance of a physician’s recommendation. Vaccine. 2011;29(5):890–5.

    Article  CAS  PubMed  Google Scholar 

  18. Do YK, Wong KY. Awareness and acceptability of human papillomavirus vaccine: an application of the instrumental variables bivariate probit model. BMC Public Health. 2012;12(1):31.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Laz TH, Rahman M, Berenson AB. An update on human papillomavirus vaccine uptake among 11–17 Year old girls in the United States: National Health Interview Survey, 2010. Vaccine. 2012;30(24):3534–40.

    Article  PubMed  PubMed Central  Google Scholar 

  20. National Conference of State Legislatures. Immunization policy issues overview. 2011. http://www.ncsl.org/research/health/immunizations-policy-issues-overview.aspx. Accessed 1 Dec 2015.

  21. Rosenbaum S, Stewart A, Cox M, Mitchell M. The epidemiology of US. Immunization law: mandated coverage of immunization under State Health Insurance Laws. Report from Center for Health Service and Research Policy. 2003.

  22. Currie J, Gruber J. Health insurance eligibility, utilization of medical care, and child health. Q J Econ. 1996;111(2):431–66.

    Article  Google Scholar 

  23. Decker SL. In 2011 nearly one-third of physicians said they would not accept new medicaid patients, but rising fees may help. Health Affairs (Project Hope). 2012;31(8):1673–9.

    Article  Google Scholar 

  24. Tomljenovic L, Shaw CA. Too fast or not too fast: the FDA’s approval of Merck’s HPV vaccine Gardasil. J Law Med Ethics J Am Soc Law Med Ethics. 2012;40(3):673–81.

    Google Scholar 

  25. Akinbami LJ, Moorman JE, Liu X, National Center for Health Statistics (US). Asthma prevalence, health care use, and mortality: United States, 2005–2009. Hyattsville, MD: US Dept. of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics; 2011.

  26. Bloom B, Jones LI, Freeman G. Summary health statistics for US children: National Health Interview Survey, 2012. National Center for Health Statistics. Vital Health Stat. 2013;10(258):4–8.

    Google Scholar 

  27. Bednarczyk A, Birkhead GS, Morse DL, Doleyres H. Human papillomavirus vaccine uptake and barrier, actual risk and race/ethnicity among female student at a New York State University, 2010. Vaccine. 2011;29:3138–43.

    Article  PubMed  Google Scholar 

  28. Barrett S. Economic considerations for the eradication endgame. Philos Trans R Soc B Biol Sci. 2013;368(1623):20120149.

    Article  Google Scholar 

  29. Anikeeva O, Braunack-Mayer A, Rogers W. Requiring influenza vaccination for health care workers. Am J Public Health. 2009;99(1):24.

    Article  PubMed  PubMed Central  Google Scholar 

  30. May T. Public communication, risk perception, and the viability of preventive vaccination against communicable diseases. Bioethics. 2005;19(4):407–21.

    Article  PubMed  Google Scholar 

  31. Maurer J. Who has a clue to preventing the flu? Unravelling supply and demand effects on the take-up of influenza vaccinations. J Health Econ. 2009;28(3):704–17.

    Article  PubMed  Google Scholar 

  32. Hamlish T, Clarke L, Alexander KA. Barriers to HPV immunization for African American adolescent females. Vaccine. 2012;30(45):6472–6.

    Article  PubMed  Google Scholar 

  33. Gamble HL, Klosky JL, Parra GR, Randolph ME. Factors influencing familial decision-making regarding human papillomavirus vaccination. J Pediatr Psychol. 2010;35(7):704–15.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Neubrand TP, Breitkopf CR, Rupp R, Breitkopf D, Rosenthal SL. Factors associated with completion of the human papillomavirus vaccine series. Clin Pediatr. 2009;48(9):966–9.

    Article  Google Scholar 

  35. Hebert PL, Frick KD, Kane RL, McBean AM. The causes of racial and ethnic differences in influenza vaccination rates among elderly medicare beneficiaries. Blackwell Science Inc. 2005. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361154. Accessed 1 Dec 2015.

  36. Gelman A, Miller E, Schwarz EB, Akers AY, Jeong K, Borrero S. Racial disparities in human papillomavirus vaccination: does access matter?”. J Adolesc Health Off Publ Soc Adolesc Med. 2013;53(6):756–62.

    Article  Google Scholar 

  37. Niccolai LM, Mehta NR, Hadler JL. Racial/Ethnic and poverty disparities in human papillomavirus vaccination completion. Am J Prev Med. 2011;41(4):428–33.

    Article  PubMed  Google Scholar 

  38. Reiter PL, Noel T, Brewer SL, Gottlieb AM, Smith JS. Parents’ health beliefs and HPV vaccination of their adolescent daughters. Soc Sci Med. 2009;69(3):475–80.

    Article  PubMed  Google Scholar 

  39. Saslow D, Castle PE, Cox JT, Davey DD, Einstein MH, Ferris DG, Goldie SJ, Gynecologic Cancer Advisory Group. American Cancer Society Guideline for human papillomavirus (HPV) vaccine use to prevent cervical cancer and its precursors. CA Cancer J Clin. 2007;57(1):7–28.

    Article  PubMed  Google Scholar 

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Author information

Authors and Affiliations

  1. School of Medicine and Health Science, George Washington University, Washington, DC, USA

    Ali Moghtaderi

  2. Department of Economics, University of Wisconsin-Milwaukee, Bolton Hall 802, 3210 N. Maryland Ave., Milwaukee, WI, 53201, USA

    Scott Adams

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  1. Ali Moghtaderi
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Correspondence to Scott Adams.

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No funding was received for this study. Neither Ali Moghtaderi nor Scott Adams have any conflicts of interest.

Author contributions

Ali Moghtaderi completed all statistical analyses and prepared all tabular results. Each author contributed equally to the methodological design and writing of the manuscript.

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Moghtaderi, A., Adams, S. The Role of Physician Recommendations and Public Policy in Human Papillomavirus Vaccinations. Appl Health Econ Health Policy 14, 349–359 (2016). https://doi.org/10.1007/s40258-016-0225-6

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