Disparities in collaborative

patient-provider communication

about HPV vaccination

Jennifer L. Moss, PhD1,2, Melissa B. Gilkey, PhD3,

Barbara K. Rimer, DrPH1, Noel T. Brewer, PhD1

1University of North Carolina

2National Cancer Institute

3Harvard Medical School

May 20, 2016

2

Disclosures

JLM, MBG, and BKR have no potential conflicts to report.

NTB has served on paid advisory boards or received research grants

from Merck, GSK, CDC, and FDA, and now serves as chair of the

CDC-funded National HPV Vaccination Roundtable.

This research was supported by a grant from National Cancer Institute (F31 CA189411;

PI: Moss) and data support from the National Center for Health Statistics.

Opinions do not necessarily reflect the official positions of the NCI or the NCHS.

3

Introduction: HPV

Infection can lead to

Genital warts (>300k cases/yr in US)

Cancer (26k cases/yr in US)

High-priority populations

Racial/ethnic minorities

Un/underinsured

Vaccine

Lack of health disparities in uptake

Suboptimal uptake overall

U.S. HPV vaccine initiation, 2014

Girls 60%

Boys 42%

4

Introduction: Patient-provider interactions

Provider recommendation

Communication style?

Paternalistic v. collaborative

Association with HPV vaccination: Mixed findings

Differences in communication style by patient characteristics

5

Methods

National Immunization Survey-Teen, 2010

n=4,124 parents of girls

Measures

Collaborative communication (Charles et al., 1997, 1999, 2006)

HPV vaccine initiation (verified by healthcare providers)

Formal test of mediation (Iacobucci, 2012; Sobel, 1982)

Demographics

Collaborative

communication

HPV vaccine

initiation

6

Results: Participant characteristics (n=4,124)

Non-Hispanic white 61%

Privately insured 62%

Mother with >HS degree 64%

At/above poverty 78%

Urban 85%

7

Results: Communication and vaccination

Overall HPV vaccine initiation: 49%

0%

20%

40%

60%

80%

100%

Non-collaborativecommunication

Collaborativecommunication

***p<.001

% initia

ting H

PV

vaccin

e

***OR=4.70

(95% CI=4.12-5.36)

8

Results: Collaborative communication

Overall prevalence = 53%

0%

20%

40%

60%

80%

100%N

H W

hite

v H

isp

an

ic

Priva

tev p

ublic

in

su

r

Mo

m >

HS

v m

om

≤ H

S

At o

r a

bove

v b

elo

w p

ov

Urb

/su

bu

rbv r

ura

l

**********

% r

eport

ing c

olla

bora

tive

com

munic

ation

*p<.05

**p<.01

***p<.001

9

Results: Mediation (I) – Ethnicity

Hispanic v

non-Hispanic white

Collaborative v

non-collaborative

Vaccination v

no vaccination

-0.69* 1.07

(0.38)0.56*

Mediation z = -2.94*

Controlling for provider recommendation for vaccination.

*p<.05

10

Results: Mediation (II) – Health insurance

Public v

private insurance

Collaborative v

non-collaborative

Vaccination v

no vaccination

-0.35* 1.05*

(0.28*)0.36*

Mediation z = -2.28*

Controlling for provider recommendation for vaccination.

*p<.05

11

Below federal poverty level 1.83

Spanish speaking -1.40

Lower maternal education -1.14

- †

- †

Summary

Underserved

groups

Collaborative

communication

HPV vaccine

initiation

a = -

(c = +)c’ = ++

b = +

†p<.10

*p<.05Underserved group z -score for

mediation

Hispanic ethnicity -2.94*

Public insurance -2.28*

.

12

Strengths and limitations

Strengths

Nationally-representative sample

Provider-verified vaccination status

Limitations

Cross-sectional analysis

Parental self-report of communication

13

Conclusions

HPV vaccination

Higher when parents reported collaborative communication

Equal or higher in high-priority groups

Evident disparities in collaborative patient-provider communication

Lower in high-priority groups

Disparities in communication suppressed differences in vaccination

Equalizing communication styles across groups

could result in more favorable vaccination outcomes

overall and for high-priority groups.

14

Moss, J. L., Gilkey, M. B., Rimer, B. K., & Brewer, N. T. (in press).

Disparities in collaborative patient-provider communication

about human papillomavirus (HPV) vaccination.

Human Vaccines & Immunotherapeutics.

Jennifer L. Moss, PhD

Cancer Prevention Fellow

National Cancer Institute

jennifer.moss@nih.gov

@Jennifer_L_Moss

cpfp.cancer.gov www.cancer.gov

16

Mediation results (III): Poverty

Below vabove poverty level

Collaborative v non-collaborative

Vaccination v no vaccination

-0.42* 1.55*

(0.31)0.53*

Mediation z = -2.59*

*p<.01

Rural vs urban

Collaborative v non-collaborative

Vaccination v no vaccination

0.36* 1.55*

(0.18)0.08

Mediation z = 2.87*

*p<.01

Mediation results (IV): Rurality

Results (V.a.): Moderation

0

10

20

30

40

50

60

70

80

Rural Urban/suburban

Perc

ent

initia

ting H

PV

vaccin

ation

No

Yes

Moderation p=.02

Non-collaborative communication

Collaborative communication

+46% +33%

0

10

20

30

40

50

60

70

80

Non-Hispanicwhite

Non-Hispanicblack

Hispanic Other

Perc

en

t in

itia

ting

HP

V v

accin

ation

No

Yes

Results (V.b.): Moderation

Moderation p=.01

Non-collab.communication

Collaborative communication

+44% +16% +40% +18%

20

Step 1: Demographics & vaccinationDem.

Comm.

Vacc.

0.0

0.5

1.0

1.5

2.0

2.5

Race/ethnicity Insurance Poverty

Od

ds

rati

o o

f H

PV

vac

cin

atio

n

Well-served

Underserved

Hispanic(v. non-Hispanic

white ref.)

OR=1.30

Public ins.(v. private

insurance ref.)

OR=1.11

Below pov. level(v. at/above poverty

ref.)

OR=1.36

21

Step 2: Demographics & communication

0.0

0.5

1.0

1.5

2.0

2.5

Race/ethnicity Insurance Poverty

Od

ds

rati

o o

f re

po

rtin

g co

llab

. co

mm

.

Well-served

Underserved

Hispanic(v. non-Hispanic

white ref.)

OR=0.54*

Public ins.(v. private

insurance ref.)

OR=0.63**

Below pov. level(v. at/above poverty

ref.)

OR=0.66*

Dem.

Comm.

Vacc.

*p<.01**p<.001

22

HPV vaccination: 49%

(OR is controlling for provider recommendation for vaccination)

Step 3: Communication & vaccinationDem.

Comm.

Vacc.

HPV vax OR (95% CI)

DID NOT report collaborative communication 31% ref.

DID report collaborative communication 66% 4.70 (4.12-5.36)

23

Step 4: Demographics, communication, and vaccination

Demographics(underserved

groups)

Collaborative communication

HPV vaccination

a = -

(c = +)c’ = ++

b = +

Differences in vaccination odds

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Od

ds

rati

o o

f H

PV

vac

cin

atio

n

Hispanics (v. non-Hispanic

white ref.)z = -3.04*

Public ins. (v. private

insurance ref.) z = -3.67*

Below pov. (v. at/above poverty ref.)

z = -2.59*

*p<.01

c c' c c' c c'