User-Centered Design for Developing Interventions to Improve Clinician Recommendation of Human Papillomavirus Vaccination

User-Centered Design for Developing Interventions to Improve Clinician Recommendation of Human Papillomavirus Vaccination

 

Michelle L Henninger, PhD; Carmit K McMullen, PhD; Alison J Firemark, MA;
Allison L Naleway, PhD; Nora B Henrikson, PhD, MPH; Joseph A Turcotte

Perm J 2017;21:16-191 [Full Citation]

https://doi.org/10.7812/TPP/16-191
E-pub: 09/08/2017

ABSTRACT

Introduction: Human papillomavirus (HPV) is the most common sexually transmitted infection in the US and is associated with multiple types of cancer. Although effective HPV vaccines have been available since 2006, coverage rates in the US remain much lower than with other adolescent vaccinations. Prior research has shown that a strong recommendation from a clinician is a critical determinant in HPV vaccine uptake and coverage. However, few published studies to date have specifically addressed the issue of helping clinicians communicate more effectively with their patients about the HPV vaccine.
Objective: To develop one or more novel interventions for helping clinicians make strong and effective recommendations for HPV vaccination.
Methods: Using principles of user-centered design, we conducted qualitative interviews, interviews with persons from analogous industries, and a data synthesis workshop with multiple stakeholders.
Results: Five potential intervention strategies targeted at health care clinicians, youth, and their parents were developed. The two most popular choices to pursue were a values-based communication strategy and a puberty education workbook.
Conclusion: User-centered design is a useful strategy for developing potential interventions to improve the rate and success of clinicians recommending the HPV vaccine. Further research is needed to test the effectiveness and acceptability of these interventions in clinical settings.

INTRODUCTION

Human papillomavirus (HPV) is the most common sexually transmitted infection in the US.1 This infection is associated with cervical, anal, and oropharyngeal cancers, as well as genital warts. The Advisory Committee on Immunization Practices recommends vaccination to prevent infection from the most common cancer-causing types of HPV.2,3 The first HPV vaccine became available in 2006; however, the national coverage estimates for 2014 show that only 60% of US female teenagers aged 13 to 17 years begin the vaccine series (≥ 1 dose) and 40% complete the series (≥ 3 doses). For male adolescents, initiation and completion rates in 2014 were only 42% and 22%, respectively.4 Although the HPV vaccination coverage rate for both female and male adolescents has improved during the past several years, it remains lower than with other adolescent vaccinations such as tetanus-diphtheria-acellular pertussis and quadrivalent meningococcal conjugate vaccines, which had national coverage rates at 88% and 79% in 2014, respectively.4

A clinician’s recommendation for vaccination has been consistently demonstrated as one of the best predictors of vaccine acceptance.5-11 However, a 2014 national survey of parents of adolescents found that 48% of parents reported no clinician recommendation for HPV vaccination and 16% reported receiving low-quality recommendations.12 Only 36% reported receiving high-quality recommendations. In addition, the odds of vaccine initiation were 9 times higher when parents received high-quality recommendations vs no recommendation. Gilkey et al12 defined high-quality recommendations as having 3 components: strength of endorsement (clinician described the HPV vaccine as “very” or “extremely” important), prevention message (clinician said the HPV vaccine prevents cancer), and urgency (clinician recommended same-day vaccination). Some research suggests that clinicians may procrastinate in recommending the vaccine to younger adolescents and do not consider their patients “off schedule” until they reach age 26 years, the upper limit of the recommended age range for vaccination.13 Another study suggested that a clinician’s recommendation might be even more critical in improving vaccination rates in male patients. When asked for a reason for not vaccinating, parents of sons were most likely to report that the clinician did not recommend the vaccine and that the parent did not know the vaccine was available for boys.14

Educational interventions can improve clinicians’ knowledge and beliefs about the HPV vaccine.15,16 Because clinicians are uniquely positioned to educate patients and parents, providing needed supports for clinician behavior change and empowering clinicians to recommend the vaccine could greatly increase HPV vaccine coverage. However, traditional intervention methods, such as clinician education and public awareness campaigns, are not having a large impact on HPV vaccination rates, which have plateaued at a level well below those of other adolescent vaccines that are required for school attendance.17,18

In this study, we employed user-centered design to develop interventions to help clinicians communicate more effectively about HPV vaccination. Although user-centered design is increasingly being used to drive innovation in health care and other industries,19,20 it has not been used to design tools for improving vaccine uptake. User-centered design is a promising method to address low uptake of the HPV vaccine because the largest hurdle to improving uptake seems to be ineffective or insufficient communication among clinicians, parents, and teenagers about the vaccine.

METHODS

This project was conducted at the Kaiser Permanente Center for Health Research in Portland, OR, between September 2014 and August 2015. The Kaiser Permanente Northwest (KPNW) institutional review board determined this project to be exempt from institutional review board review.

User-Centered Design

User-centered (also known as “human-centered”) design is increasingly being used to drive innovation in health care and other industries.19 User-centered design employs “design thinking,” system science, and ethnographic methods to obtain creative, implementation-ready solutions to complex problems. This approach focuses on the needs and preferences of the people who will ultimately be affected by clinical or policy changes. As a result, health care interventions designed according to these principles will suit the needs of time-constrained clinicians and staff and will operate within the complex structure and workflows of health care delivery organizations.21,22

The user-centered design cycle includes six steps: 1) understanding the environment, 2) framing opportunities, 3) imagining possibilities, 4) prototyping, 5) piloting, and 6) spreading innovation. We adopted the Kaiser Permanente user-centered design methods23 and referred to design resources such as the Stanford Design Program’s workshop modules24 and previous experience holding workshops to engage stakeholders in priority setting to plan our approach for identifying intervention opportunities to improve postoperative recovery. For the current study, our goal was to complete the first three steps to generate one or more innovative intervention ideas that might be developed and tested in future work.

Interviews

Interview participants (N = 14) included 6 primary care clinicians, 5 subject matter experts (SMEs), and 3 representatives from analogous industries (described below). The primary care clinicians were current or former KPNW pediatric or family medicine physicians who volunteered to be interviewed for this project. The SMEs included 2 KPNW clinician performance consultants, a program coordinator from KPNW Clinical Quality Support Services, a social marketing and health communications consultant (JT), and a PhD-level researcher from a partner institution who specializes in vaccine compliance research (NH). Analogous industry representatives included a middle school guidance counselor, a marijuana legalization activist, and a retail curriculum expert from a large athletic retail company.

Two project team members (CM and AF) conducted semistructured interviews25 in person or by telephone. Interview guides were developed by the project team and included questions about knowledge, attitudes, and beliefs about HPV vaccination; typical workflow; potential barriers to recommending vaccination; and tools or processes that facilitate communication about or recommendation of the HPV vaccine. The interviews were audiorecorded and professionally transcribed to facilitate qualitative analysis.

Once the clinician and SME interviews were completed and findings synthesized by the project team, we consulted with the Kaiser Permanente Innovation Consultancy26 to identify three analogous industries outside health care that had the potential to inform effective clinician endorsement of the HPV vaccine. We articulated the problems for which we were trying to design solutions before proceeding with analogous industry interviews. The problems we identified were as follows: 1) clinicians must communicate with both parents and teens, who may have different priorities and values; 2) clinicians must communicate about issues that may raise a taboo subject (ie, adolescent sexuality); and 3) clinicians need effective tools, training, or professional orientation to help them communicate more effectively with their patients. With these problems in mind, we selected a middle school guidance counselor because of that person’s relevent experience advising parents and teens who may have different or even competing priorities. The marijuana legalization activist had the potential to offer unique insight into normalizing taboo or potentially stygmatizing topics, such as the link between HPV and sexually transmitted infections. Finally, the retail curriculum expert offered insight into training retail personnel to engage with customers and endorse products effectively.

Rapid Assessment Technique

We used rapid assessment techniques27,28 to analyze qualitative interview data. Specifically, the interviewers (CM and AF) verbally debriefed the research team after each interview to summarize observations and key ideas. At least two team members reviewed each interview transcript; recurring themes and selected interviewee quotes were summarized in a spreadsheet (Microsoft Excel, Microsoft Corp, Redmond, WA) that was subsequently used in data analysis meetings.

Data Analysis Meetings

The research team held 3 internal data analysis sessions to synthesize findings from qualitative interviews by using methods from the Hasso Plattner Institute of Design at Stanford University, Stanford, CA.29 The first 2 meetings focused on synthesizing data from the clinician, SME, and analogous industry interviews. The final meeting focused on developing and refining brainstorming prompts for use at the workshop. Each data analysis meeting lasted approximately 1.5 to 2 hours.

Workshop

We held a 4-hour data synthesis workshop at the Kaiser Permanente Center for Health Research, which was led by an investigator (CM) with assistance from the other members of our research team. Workshop participants (N = 17) included a KPNW pediatric physician, 2 KPNW clinician performance consultants, a KPNW Health Education program manager, 6 Kaiser Permanente Center for Health Research staff with experience in vaccine research or qualitive research methods, as well as all 6 authors of this article. Several of the stakeholders were also parents of preteens or teens, some of whom had recently discussed HPV vaccination with their child’s primary care clinician. Therefore, we were able to incorporate parent perspectives in the workshop as well.

The workshop agenda included a summary of the qualitative data analysis, presentation of brainstorming prompts in the form of “How might we?” statements (see Sidebar: “How Might We … ?” Questions Developed for a Data Synthesis Workshop), and an overview of the brainstorming process. Attendees then met in small groups to discuss the brainstorming prompts and develop at least one idea for a potential intervention. Each small group presented its favorite idea to the larger group, and all attendees voted on the best concepts. Each attendee voted for up to three intervention concepts. Approximately two weeks after the workshop, we conducted a one-hour follow-up Webinar to debrief and summarize the results of the workshop with the participants.

User-Centered Design for Developing Interventions to Improve Clinician Recommendation of Human Papillomavirus Vaccination

RESULTS

Four primary themes emerged regarding how clinicians approach discussing the HPV vaccine with parents: 1) the importance of enhancing parents’ trust in the clinician, developing rapport between the clinician and the parent, and effective communication skills on the part of the clinician; 2) clinician knowledge about common parental concerns about vaccination; 3) the ability to develop talking points and messaging to effectively address these common concerns; and 4) increasing clinicians’ comfort with discussing difficult topics with their patients or parents (Table 1).

Many themes that emerged from the analogous industry interviews (Table 2) were consistent with findings from the clinician and SME interviews: the importance of developing rapport, constructing effective messages that are salient to the receiver, and the willingness to keep trying when first attempts are unsuccessful. However, we also revealed some additional strategies, such as approaching the conversation as a “wellness advocate” (rather than as an expert), speaking in terms of “benefit language” (rather than technical language), and using compelling storytelling.

Stakeholders who participated in the data synthesis workshop generated 5 potential intervention concepts (Table 3), with 2 intervention concepts receiving greater than 50% of the attendees’ votes. The most popular intervention concept, a “shared values approach,” emphasizes determining the parent’s values as they relate to vaccines and constructing messaging salient to these values. The second most popular intervention idea, Ready, Set, Grow! involved developing a puberty education workbook that would include information about adolescent vaccines and a tear-out worksheet to help prepare adolescent patients for discussing HPV vaccination at their next clinician visit.

User-Centered Design for Developing Interventions to Improve Clinician Recommendation of Human Papillomavirus Vaccination

User-Centered Design for Developing Interventions to Improve Clinician Recommendation of Human Papillomavirus Vaccination

User-Centered Design for Developing Interventions to Improve Clinician Recommendation of Human Papillomavirus Vaccination

DISCUSSION

Although coverage rates of other adolescent vaccines such as tetanus-diphtheria-acellular pertussis or quadrivalent meningococcal conjugate meet or exceed Healthy People 2020 targets,30 the HPV vaccination coverage rate remains lower. Four leading medical associations, in collaboration with the Immunization Action Coalition and the Centers for Disease Control and Prevention, recently issued a call to action stressing the importance of clinicians educating their patients or parents about HPV and to strongly recommend vaccination against HPV.31 The American Academy of Family Physicians describes a strong recommendation as one that emphasizes the safety, effectiveness, and importance of vaccination.32 As well, the Centers for Disease Control and Prevention’s “You Are the Key to HPV Cancer Prevention” campaign aims to improve the knowledge of clinicians about HPV-related cancers and vaccination, and it offers effective tools for discussing HPV vaccination with their patients or parents.33

Prior research has suggested that clinicians may communicate differently about HPV vaccine compared with the other adolescent vaccines.12 For example, clinicians may frame the HPV vaccine as less important than the other vaccines or may even suggest deferring the vaccine to a later visit. A 2016 systematic review by Gilkey and McRee34 found only 2 published studies of interventions designed to improve clinician recommendation of the HPV vaccination. The first study evaluated a social marketing campaign to increase initiation of HPV vaccination in preteen girls in rural North Carolina.35 The 3-month campaign included posters, brochures, a Web site, news releases, and physician recommendations. A follow-up survey indicated that 82% of respondent mothers had heard or seen campaign messages and 94% of respondent clinicians had used campaign materials with their patients or parents. Compared with nonintervention counties, vaccination rates in intervention counties increased by 2% within 6 months of the intervention launch.

The second study evaluated a multicomponent decision support intervention targeting both clinicians and families.17 The clinician components of the intervention included immunization alerts in the electronic medical record, education, and feedback. Additionally, families received telephone reminders when vaccinations were due and a referral to an educational Web site. The study found that although parents from intervention clinics were more likely to discuss HPV vaccination with their child’s clinician, they were no more likely to receive a strong vaccine recommendation from the clinician.

Using a user-centered design approach, this project generated five potential interventions to help clinicians communicate more effectively with parents and youth about HPV vaccination. Two interventions, the “shared values approach” and Ready, Set, Grow!, received the most support from multiple stakeholders involved in this project. To our knowledge, neither of these approaches has been tested empirically to date.17

The “shared values approach” emphasizes the importance of the clinician’s ability to assess and to respond to the parent’s value system, as well as the social context in which parents are making health care decisions, as it relates to HPV vaccination. Researchers from the Canadian Immunization Research Network have suggested that there are actually several different types of vaccine-hesitant parents and that effective clinician response may differ according to hesitancy type.36 For example, a parent who is misinformed about the safety of the vaccine should be provided with correct information and reassurance, whereas a parent who wants to delay vaccination until the child is older should be provided with reasons why vaccinating on schedule would be preferable. By accurately assessing the parent’s values regarding vaccination, the clinician can more adequately respond with “benefit language” specific to those values. This intervention strategy also emphasizes capitalizing on trust in the clinician and the health care organization, for example, empowering the clinician as a resource to help filter through discordant information readily available through the Internet or social media. Specific to the Kaiser Permanente setting, stakeholders emphasized that the vaccination campaign could piggyback on the popular and effective Kaiser Permanente Thrive campaign.37

The second intervention concept, Ready, Set, Grow!, would involve a set of workbooks for teens and parents to celebrate milestone birthdays (transitions to middle school and high school). The stakeholders envisioned developing preteen (aged 10-12 years) and teen versions (aged 13-14 years) in print or preferably online formats. The stakeholders emphasized the importance of designing the workbooks to appeal to youth and suggested that a “graphic novel” format that was interactive in nature might be most effective. The workbooks would optimally cover a broad range of preventive health issues, including HPV and the HPV vaccine. However, the emphasis would be on helping youth learn how to critically evaluate health information available from multiple sources and communicate effectively with their clinician. The stakeholders envisioned tear-out (or printout) worksheets that youth could take to upcoming visits with clinicians, with one worksheet specifically devoted to HPV and other adolescent vaccines.

Although user-centered design is a novel and useful approach to addressing emergent health care issues, it also poses special challenges in research settings. Flexibility in incorporating health care clinicians in qualitative interviews and focus groups or workshops is essential because of scheduling constraints and, in some cases, union policies about “volunteering” work time for research efforts. Although we conducted interviews with several clinicians, we were able to arrange for only one clinician to attend the data synthesis workshop. Likewise, we had originally planned a full-day data synthesis workshop but later streamlined our agenda to a half-day workshop to better accommodate our clinician stakeholder.

Another challenge with this type of qualitative research includes ensuring that all the relevant stakeholders are involved and that they have adequate input into the development of the “How Might We?” questions (see Sidebar: “How Might We … ?” Questions Developed for a Data Synthesis Workshop) to be resolved at the data synthesis workshop. Other limitations of this project were that parents and youth were not included as interviewees (although several of the workshop participants were parents of preteens and teens), and the brainstorming questions for the workshop were developed by the project team without stakeholder input.

The scope of this project was purposefully limited to the first three steps of user-centered design: understanding the environment, framing opportunities, and imagining possibilities. The next three steps are prototyping ideas, piloting solutions, and operationalizing to spread innovation.23 Prototyping involves quickly and inexpensively trying out ideas and rapid iteration until a final solution is determined. Importantly, end users are actively engaged in the prototype design process. Next, we would pilot the intervention in one or two of our pediatric clinics and assess changes in vaccination rates, as well as feasibility and acceptability to patients, parents, and clinicians. Assuming the intervention was successful, the final step would be to offer the intervention to pediatric clinics throughout the KPNW Region and nationally as appropriate.

CONCLUSION

User-centered design is an effective tool for developing interventions to improve HPV vaccination rates. We identified several potential interventions that could help clinicians communicate more effectively with parents and teens about the HPV vaccine. The next steps are to develop a prototype for an intervention with the input of key stakeholders, including teenagers, parents, and clinicians, and then conduct a pilot study in a clinical setting to assess effectiveness and feasibility.

Disclosure Statement

Drs Henninger and Naleway received funding from Pfizer Independent Grants for Learning & Change, New York, NY, for an unrelated project. Dr Naleway has received research funding from Merck & Co, Kenilworth, NJ; MedImmune, Gaithersburg, MD; and Pfizer for unrelated studies. The remaining author(s) have no conflicts of interest to disclose.

Acknowledgements

This study was supported by a grant from the National Cancer Institute, Cancer Research Network, Developmental and Pilot Projects Program (Prime Grant 5 U24 CA171524-02), Rockville, MD. The study sponsor had no role in study design; data collection, analysis, and interpretation; writing of the report; or the decision to submit for publication.

The authors wish to thank the Communication & Dissemination Workgroup of the Cancer Research Network for their input during the duration of the project. We also thank the Kaiser Permanente Garfield Innovation Center for guidance in development of focus group and interview materials as well as identification of appropriate analogous industries for this project.

Finally, we are grateful to all of the stakeholders who participated in focus groups, interviews, and data synthesis workshop. In particular, we would like to thank Claire Kaufmann, MBA, Northwest Regional Director BDS Analytics, for serving as one of our analogous industry representatives.

Kathleen Louden, ELS, of Louden Health Communications provided editorial assistance.

How to Cite this Article

Henninger ML, McMullen CK, Firemark AJ, Naleway AL, Henrikson NB, Turcotte JA. User-centered design for developing interventions to improve clinician recommendation of human papillomavirus vaccination. Perm J 2017;21:16-191. DOI: https://doi.org/10.7812/TPP/16-191.

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