Reducing physician hesitancy in recommending the HPV vaccine to adolescent girls

This project used a behavioural lens to examine low uptake of the Human Papillomavirus (HPV) vaccine in India. Physician hesitancy in recommending the HPV vaccine to female patients aged 9-14 years is a key behavioural barrier to vaccination. CSBC conducted a behavioural diagnostic study to identify the drivers of physician hesitancy to recommend the HPV vaccine and designed and tested interventions that address these barriers.

Introduction

In India, cervical cancer is the second-highest cause of cancer deaths among women, accounting for over 96,922 new cases and an estimated 60,078 deaths reported annually (Arbyn et al., 2018).

The HPV vaccine, which is recommended to be administered to adolescent girls, is a simple solution and part of a comprehensive strategy to eliminate cervical cancer. However, this vaccine sees very low uptake in India. Among other reasons, physician hesitancy in initiating conversations on the vaccine, providing counsel, and encouraging its administration contribute to the poor demand for the vaccine across the country.

There is high reverence for and reliance on doctors for all types of medical information in India. Thus, physicians' hesitancy in recommending the HPV vaccine can have serious adverse consequences. CSBC, in collaboration with the Cancer Foundation of India (CFI) and with support from the American Cancer Society (ACS), conducted research with key stakeholders to understand this hesitancy, design behavioural interventions, and test their impact on intentions to recommend the vaccine.

Key results

Our diagnosis revealed that physicians are subject to certain behavioural biases which make them hesitant to recommend the vaccine:

• Physicians underestimate the incidence and risk of HPV and, therefore, the importance and necessity of the vaccine.
• Physicians expressed reduced trust in the safety and efficacy of the vaccine, which reduces their confidence in the vaccine as a safe and effective solution for HPV.
• Physicians felt they might upset socio-cultural norms by discussing sexually transmitted infections or cancer with young girls and their parents.

Results from our experimental study on different behaviourally-informed solutions suggest that reminding medical professionals about the dangers of cervical cancer and the ease of its prevention and getting an endorsement of the vaccine by a trusted medical champion significantly boost physicians' intentions to recommend the HPV vaccine. In the short term, when exposed to either of these treatments, physicians display about a 100% increase in the likelihood of expressing an intention to recommend the HPV vaccine.

Description and methodology

We conducted the diagnostic study in West Bengal with the support of RTI International. The team completed 97 interviews (89 in-depth interviews and eight focus group discussions). The sample consisted of physicians, adolescent girls and their parents or guardians, government officials, school teachers of adolescent girls, and front-line health workers.

Subsequently, we held an ideation workshop with representatives from key organisations like the World Health Organization (WHO), the Indian Medical Association (IMA), the Indian Academy of Pediatrics (IAP), the Federation of Obstetric and Gynaecological Societies of India (FOGSI), the American Cancer Society (ACS), the Cancer Foundation of India (CFI), and the Indian Council of Medical Research (ICMR).

We shortlisted the following interventions after the ideation workshop:

• Endorsement by a trusted medical champion
• Creating icebreakers for sensitive conversations
• Bundling with other recommendations
• Introducing environmental cues to initiate conversation
• Refreshing the dangers of cervical cancer and the ease of its prevention

We evaluated the shortlisted interventions using a randomised experiment. The sample comprised 600 respondents, including paediatricians, gynaecologists and general physicians. We assessed the effectiveness of the shortlisted interventions by examining their causal effect on the following outcomes:

• Primary outcome variable: Intention to recommend the HPV vaccine and Sustained intention to recommend the vaccine after 1 week.
• Secondary outcome variables: Trust in the HPV vaccine and Self-efficacy in having conversations around the vaccine.
• Also measured other variables such as perception of positive norms around HPV vaccine recommendations, knowledge, intention to recommend the Td/Tdap vaccine and practice of recommendation.

Results and highlights

Two of these interventions increased the likelihood that physicians would prescribe the vaccine: the intervention designed to refresh the dangers of cervical cancer and the ease of prevention and endorsement by a trusted medical champion.

Compared with the control group, the intervention directed at refreshing dangers of cervical cancer and ease of prevention were 2.16 times more likely to report that they would recommend the vaccine to adolescent girls. This effect was statistically significant at a 5% level. The physicians we showed the endorsement of the HPV vaccine by a trusted medical champion were 2.07 times more likely to report that they would recommend the vaccine to adolescent girls. This effect was statistically significant at a 10% level.

Discussion

The possible reasons that the interventions on refreshing the dangers of cervical cancer and the ease of prevention and endorsement by a trusted medical champion are effective are:

• These interventions emphasised the burden of cervical cancer in India and thus targeted any biased risk assessment of HPV and cervical cancer.
• Both interventions stressed the safety and efficacy of the HPV vaccine and presented it as an important and easy solution for cervical cancer.
• These interventions highlighted the importance and responsibility of doctors' recommendations for the HPV vaccine in cervical cancer.

The following solutions may be important components of HPV vaccine promotion initiatives targeted at medical professionals.

• Refresh physicians on the dangers and risks associated with HPV, the burden of cervical cancer, and the ease of prevention through vaccines.
• Build trust in the HPV vaccine by having trusted, well-known medical professionals endorse it publicly.
• Emphasise the responsibility of doctors to protect their patients from the risks of cervical cancer.

From a policy perspective, our research highlights how service providers can also be subject to behavioural biases that might impede their decision-making and result in poor health outcomes. Health service providers are usually overburdened and cannot always be expected to work optimally. Simple solutions or nudges like the ones discovered for the HPV vaccine can make a significant difference in prompting physicians to overcome biases and hesitancy and provide the best medical care for their patients.