Overall, many plans cited general vaccine refusal and vaccine safety concerns among plan members as an important barrier to HPV vaccination. Plans reported challenges in countering media coverage regarding HPV vaccine safety (e.g., reports of adverse reactions to the vaccine), and overcoming the stigma of the vaccine’s connection to sexually transmitted disease. Some plans suggested that providers may not mention the vaccine until adolescents are older because of parents’ discomfort with the implication that their child would soon become sexually active. One plan stated that mentioning sexually transmitted disease when offering the vaccine makes parents “…instantly cautious, and they will choose what they think is the most prudent path at that point, which is to stall and wait and think about it some more.” A few plans also suggested that the risk for HPV is not immediately apparent (i.e., cervical cancer develops many years later), so the reward for providers or patients is not immediately apparent, which may contribute to delay. Multiple plans suggested improving general messaging about the HPV vaccine to the public, to better communicate the vaccine’s safety, efficacy and role in cancer prevention.

Many plans reported difficulty in getting adolescents to come in for all three doses of the vaccine. Plans noted it is typically challenging to get adolescents to the clinic even for a single wellness visit, and more difficult to get adolescents to return on two additional occasions before their thirteenth birthday.

To improve HPV vaccination rates, multiple plans emphasized “normalizing” HPV immunization as part of an adolescent well-visit. This involves helping patients and parents understand that the HPV vaccine is a normal part of adolescent immunization (rather than an optional vaccine administered separately from other recommended adolescent vaccines). This strategy was consistently mentioned by every plan interviewed and was often identified as critical for improving HPV vaccination rates and for addressing parental concerns about the vaccine.

Plans acknowledged that efforts were not always consistent and that some providers presented the HPV vaccine as optional. One plan found that a critical approach to improving the HPV vaccination rate was simply to “…routinely give all three teen vaccinations at one time; if they offer the Tdap, give the HPV and the Menactra [meningococcal conjugate vaccine] at the same time.” Another plan suggested that the language used to present the vaccine is critical; for example, asking a patient, “Would you like an HPV vaccine?” produced potentially less effective results than, “You’re due for your HPV vaccine today—do you want it in your right arm or your left arm?” In both cases, clinicians would recommend the HPV vaccine in the same way and on the same day that other adolescent vaccines are recommended.

Plans suggested emphasizing that the HPV vaccine is “recommended for good health” and important for cancer prevention in educational materials and in conversations with patients. Presenting the vaccine as part of standard recommended practices for preventive health may help reduce the stigma of its connection to sexual activity. One plan stated that using terms that place people in a “state of cognitive ease… ‘prevention,’ ‘prevention of cancer’…is a highly persuasive technique” and that it strives to “label this as an anticancer vaccine…and get away from the perception that it’s a sex vaccine.”

Plans regarded patient and provider education as integral to supporting HPV vaccination, citing a variety of resources used to disseminate information to patients, including Web sites, written materials, newsletters or other regular communication. Plans emphasized the importance of referencing community organizations when creating educational materials for patients. For example, one plan mentioned that educational materials were more meaningful to patients when they cited recognized sources outside the plan (e.g., the CDC), and suggested that patients may mistrust recommendations from the plan because of fears that the plan may have financial or other motives perceived to be less trustworthy.

As one plan put it, collaborating with other organizations allows the message to become more persuasive, and “…not just the health plan telling people ‘this is what you should do.’” Reducing perceived bias may improve uptake of educational materials and facilitate HPV vaccine uptake. One plan conducted “…research looking at uptake of education information and [found] that it was…stronger when the health plan partnered with a non-profit entity that was recognizable, like the American Cancer Society.”

Plans also mentioned provider outreach as critical. Some plans specifically conducted outreach to engage providers and convey the importance of presenting the HPV vaccine as routine and to facilitate consistent messaging about the HPV vaccine. Plans pointed out that, without provider buy-in and advocacy, there is a risk that adolescents may not be immunized or may not be immunized early enough for the vaccine to be effective. One plan described reviewing notations in patient charts—“…‘Discussed HPV. Parent deferred’ or ‘Will discuss again at next visit’”—and concluded, “…if the providers aren’t into it, it doesn’t really matter what the plan does.”

Plans also described the importance of provider-to-provider outreach, including use of provider immunization groups and “physician champions”. One plan described physician champions as an important “knowledge base” and “peer group” to help drive improvement. Some plans took advantage of grant funding or developed partnerships with community organizations to facilitate provider education in clinics. One plan used grant funding to assess current physician attitudes and improve provider education.

Plans reported that patient and provider reminders helped support vaccination. For example, plans used automated phone calls to remind patients of subsequent doses of vaccine after the initial dose, or sent postcards and letters stating the next vaccination due date. Some plans used automated reminders for providers, or sent providers reports of patients who had not yet completed or received the vaccine. Plans also mentioned the importance of varying their approach. At one plan, staff were encouraged to make manual reminder phone calls to patients who had not responded to automated reminders. Other plans sent birthday cards or messages with reminders about the vaccine, in addition to regular reminders to patients.

Plans discussed the importance of increasing care opportunities to provide HPV vaccinations, particularly the need to minimize missed opportunities and to streamline processes. One plan took a “total health” approach: when patients come in for a visit, “they can look at any of their care gaps,” including seeing “what vaccines they need, and [if] HPV is one of them…so [the plan] can vaccinate them.” Another plan mentioned speaking to female obstetric/gynecologic patients who come in for a visit, and who “will eventually have a daughter or son reaching the age where he or she is due for their HPV vaccine.” This plan mentioned using the visit as an opportunity to “speak about the significance of HPV… to talk up the vaccine and inquire whether they have daughters [who have] gotten the vaccine. Or if they have young children who are going to be aging into needing the vaccine.”

Other plans discussed streamlining processes to encourage HPV vaccination. One plan mentioned making the process as “user-friendly” as possible, including “walk-in shot clinics [where]…you don’t need an appointment” and a “doctor visit isn’t required for the member to get a vaccine,” as well as ensuring “there’s no co-pay.” Plans emphasized the value of standing orders for HPV vaccination, allowing members of the care team (besides the physician) to administer the vaccine. As one plan put it, “I think most providers would agree there are certain things that should be taken out of their hands, and immunizations are one of them.” Additionally, some health plans reported that their integrated electronic health record system facilitates collaboration across specialties and ensures that standardized messaging about the vaccine is communicated to patients and providers.

Many plans emphasized the importance of sharing performance data with providers. Plans suggested that giving reports to providers about their population’s immunization rates and allowing them to view their performance relative to other providers in the plan inspires healthy competition that increases vaccination rates overall. “Everyone is tuned in to this data…there is basically an internal competition that just happens. People don’t ever want to come in last, and especially doctors.”

Plans used different approaches to provide feedback: some provided written reports, others granted access to interactive Web sites to view and compare performance. Plans could also use data to reach out to divisions, practices or providers that were not performing as well. One plan found that an area with a lower HPV vaccination rate was a “big hotspot of refusers,” and encouraged use of persuasive techniques (e.g., normalizing the vaccine, linking the vaccine to health) to counter the refusals. Regardless of the approach, many plans felt that data transparency was critical to enhanced performance. One plan said, “The…underlying concept that happens is…if someone is doing well on a metric, any quality metric…that basically tells you that it can be done.”

Multiple plans stated that access to a state immunization information system (IIS), also called an immunization registry, is useful for tracking vaccinated patients. IIS are confidential, population-based, computerized databases that record all immunization doses administered by participating providers to persons residing within a given geopolitical area.¹⁵ Plans reported varying levels of access to IIS data: some health plans could submit data to an IIS, but could not request data; some plans could both request data from and submit data to their IIS. Some plans operated in states that did not require vaccine doses to be reported to IIS. To the extent it was available, this supplemental source of data was regarded as an important contributor to reported vaccination rates, although it is not clear how much of the measured HEDIS vaccination rate was accounted for by IIS data (i.e., from capturing data on vaccines provided outside the plan’s network). One plan identified access to IIS data as the largest contributor to success: “…Not only are we able to capture the information that comes from our currently assigned primary care sites, but if a member goes anywhere within the county to get that test or that immunization, we’re able to capture it.”