Educating Future Providers About Human Papillomavirus

AUTHORS:

Blaire A. Cote, MD¹; Sarvika Bommakanti, BS²; Janelle Torres, DO³; Monica Tromer, DO⁴

¹University of Florida Pediatric Residency Program, Shands Children’s Hospital, Gainesville, FL
²Florida Atlantic University Charles E Schmidt College of Medicine, Boca Raton, FL
³Nicklaus Children’s Hospital Pediatric Residency Program, Miami, FL
⁴Johns Hopkins All Children’s Hospital Pediatric Residency Program, St. Petersburg, FL

Student QI Article | PUBLISHED summer 2024 | Volume 44, Issue 3

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Abstract

Objectives/Background

This project aims to address the lack of knowledge regarding human papillomavirus (HPV) and the HPV vaccine in Florida by creating an educational webinar and educational materials to distribute to current and future healthcare providers. The goal is that these efforts will increase current and future providers’ knowledge of HPV, which can one day be translated into greater public knowledge and improved Florida HPV vaccination rates.

Methods

An educational webinar and pamphlet on HPV and HPV vaccines were created and distributed to Florida’s medical and dental schools and the Florida Chapter of the American Academy of Pediatrics. Twenty participants completed a webinar survey that asked them to answer content questions about HPV after watching the webinar and self-report their HPV knowledge before and after the webinar.

Results

11 of the 12 HPV knowledge questions were answered correctly by all 20 participants after viewing the webinar. There was a statistically significant increase in self-reported knowledge after viewing the webinar regarding HPV and HPV vaccine hesitancy using the Wilcoxon Signed Rank test with an alpha level of 0.05.

Conclusions

This project’s goals were realized, as results indicated a statistically significant difference between self-reported knowledge before and after viewing the webinar.This suggests that short webinars improve current and future providers’ knowledge base. Future goals include expanding HPV education efforts into school curriculums to increase provider HPV knowledge and vaccination counseling efficacy.

Introduction

Background

Human papillomavirus (HPV) and its manifestations impact multidisciplinary health fields, including pediatrics, family medicine, gynecology, and dentistry. Many patients with HPV have no clinical consequences. However, HPV infections with high-risk strains may develop serious clinical sequelae, including genital warts, oropharyngeal cancer, and genitourinary cancer. Over 30,000 Americans will be diagnosed with oropharyngeal cancer this year.¹

Statement of Problem / Rationale

Florida has the 9th highest incidence of oral cancers in the United States but ranks near the bottom for HPV vaccination rates among both males and females.One study suggests a lack of public knowledge regarding HPV’s manifestations, with about 70% of US adults not knowing that HPV causes oral, anal, and penile cancers.² Another study indicates that educating healthcare providers on the importance of HPV vaccination and effective communication with patients about HPV may increase the number of quality recommendations for HPV vaccination.³

Project Aims

This project aims to address the lack of knowledge regarding human papillomavirus (HPV) and the HPV vaccine in Florida by creating an educational webinar and educational materials to distribute to current and future medical and dental providers. The goal is that these efforts will increase current and future providers’ knowledge base of HPV, which can one day be translated into greater public knowledge and improved Florida HPV vaccination rates.

Methods

The HPV Team of the Medical Student Committee (MSC) of Florida’s Chapter of the American Academy of Pediatrics (FCAAP) collected data for this project from spring 2021 – spring 2022.

The first step was creating an educational webinar about various topics related to HPV using a collaborative approach with medical and dental students on the HPV Team. The webinar featured medical student speakers from medical schools across Florida. The webinar length was 37 minutes. Final approval of the webinar, including the script and slide set, was provided by the FCAAP Immunizations Committee. The objectives of the webinar are enumerated in Table 1. The HPV Team also created an educational pamphlet to be used in the clinical setting to teach patients about HPV, HPV-related cancers, HPV prevention, and HPV vaccine access, as seen in Figure 1.

A crucial component of this project, displayed within the webinar and on the educational pamphlet, was a map of Florida with HPV vaccine access locations. To obtain this data, each county health department in Florida was contacted by phone and/or email up to three times in spring 2021 to acquire information regarding department availability, eligibility, and cost of HPV vaccines. This task aimed to show areas of free or low-cost HPV access across Florida that future and current healthcare providers could recommend to patients as necessary.At the time of data collection, 77.6% of Florida county health departments offered HPV vaccines at no/low cost for patients up to age 18. 10.4% offered no/low-cost HPV vaccines for patients up to age 26. 4.5% did not currently offer HPV vaccines for various reasons, including the impact of COVID-19 and Hepatitis A outbreaks, funding, and vaccine availability. 7.5% of health departments were unable to be successfully contacted.

The educational webinar and pamphlet were distributed to Pediatric Interest Groups in Florida medical schools, student organizations at Florida dental schools, and the FCAAP Medical Student Committee members. Participants volunteered to view the webinar and complete the survey within those distribution groups. The 20 participants included 17 medical students from four medical schools, two dental students, and one physician (Figure 2).

After watching the webinar and reviewing the educational pamphlet, each participant was asked to complete a survey created by the HPV Team. The survey included background questions about the participant, a content quiz utilizing multiple-choice questions, and questions regarding self-reported knowledge about HPV before and after viewing the webinar using a sliding scale from 0 (least knowledgeable) to 5 (most knowledgeable). The survey utilized in this project can be seen in Table 2.

Several months after the webinar was distributed, the FCAAP offered a Live question-and-answer session online conference for those who viewed the webinar and wanted to participate in a discussion or ask questions about the topics presented.

Analysis/Measurement Used

Survey data was collected from each participant who completed the post-webinar survey. Analysis of these data was specifically focused on participants’ self-reported knowledge about HPV, HPV vaccine hesitancy, and confidence to address patient’s concerns regarding the HPV vaccine in the future (Question #13 vs. Question #14 and Question #15 vs. Question #16 on the survey. Table 2). The content quiz was also graded for each participant. Note that the entirety of the survey was completed after viewing the webinar and that before vs. after webinar knowledge questions were self-reported by each participant.

Results

All 20 participants completed the post-webinar multiple-choice content questions. All participants answered 11 of the 12 questions correctly. Question #11 (Table 2) was correctly answered by 18 of the 20 participants (90%).

Because the data about self-reported knowledge before and after viewing the webinar was ordinal matched data that was not normally distributed, the Wilcoxon Signed Rank Test was used instead of Paired T-Tests. The Wilcoxon Signed Rank Test is a statistical test comparing two sets of scores from the same participants. The conditions for the use of the Wilcoxon Signed Rank Test include dependent observation (before and after measurements accounting for individual differences from baseline), assumed independence (even distribution of webinar to schools and Florida Chapter of AAP), continuous variable (survey questions sliding scale with maximum score of 5), and ordinal measurement (values compared on same scale or ranking system) were met.

There was a statistically significant difference in the mean self-reported score before and after viewing the HPV educational webinar using the Wilcoxon Signed Rank Test with an alpha level of 0.05 for both knowledge of HPV and HPV vaccination and confidence in addressing concerns about HPV vaccination. These data can be seen in Figure 3. The statistical analysis explanation for these data can be found in Table 3.

Discussion

Summary

The goal of this project, which was to increase current and future providers’ knowledge base of HPV, was to use an educational webinar, which was successful. Survey data indicated a statistically significant difference between self-reported knowledge before and after viewing the webinar.

Interpretation

The results of this project show that increasing provider education with methods such as short webinars is effective. The purpose of increased provider knowledge regarding HPV and the HPV vaccine was to encourage and enable more effective communication with patients, which may ultimately increase Florida’s vaccination rates and public knowledge of HPV.

Project Strengths

A strength of this project was the multidisciplinary and state-wide collaboration within the HPV Team, which created the project. This allowed greater collaboration and experience as many hands were involved in making the material easy to understand and the webinar successful.When asked about the strengths of the webinar, participants commented on concise information addressing many HPV-related topics, the speakers, the helpful visuals, and the scienced-backed data to address common reasons for vaccine hesitancy.

Project Limitations

A limitation was the low number of webinar viewers. With the target audience of busy healthcare students and healthcare providers, few possible participants viewed the webinar and completed the survey. This could be changed if the webinar is incorporated into the curricula of medical and dental schools in Florida or if it became part of a continuing medical education or other similar conference.Another limitation is that the survey quality improvement questions relied on self-reported before and after approximations of how comfortable the participants were with HPV and related topics. It would be more accurate to use multiple surveys of HPV content-based questions completed over various time points, a lengthier quiz, and a scored patient interaction scenario in which the participant would discuss HPV vaccine hesitancy with a patient and their family. These methods were not possible in this project due to various constraints. Finally, when asked about the weaknesses of the webinar, four participants commented that it was too long, with an ideal length of the webinar being less than 30 minutes. The remaining participants commented that the length of the webinar was appropriate.

Conclusions/ Implications

Webinars are an effective way of providing education regarding HPV to future and current healthcare providers.

Recommendations/ Future Directions

Future projects focusing on HPV provider education may consider in-person sessions as part of a school or residency curriculum or sessions at conferences to increase webinar viewership. This project model could be applied to other topics in pediatrics and other specialties. Tracking changes in Florida’s HPV vaccination rates after large-scale HPV educational projects among healthcare students and providers would be an interesting addition to future projects.

Acknowledgments

The authors acknowledge and offer special thanks to past and present members of the FCAAP Medical Student Committee HPV Team who worked on this project, including dental students who joined in the research. Special recognition for their contributions to this project, specifically to creating the educational webinar, goes to Hannah Zwiebel, Jennifer Ferrante, Amber Bulna, Nichole Anderez, and Emilee Flament. Special recognition for those who helped with the distribution of the webinar goes to Ally Fraser, Arielle Sanghvi, Ashley McGrath, Samantha Hicks, Amelia Hartje, Rebecca Ratusnik, Arielle Ashkenazi, and Alyssa Haag.

Thank you to the FCAAP for supporting this project, helping distribute and advertise the webinar, and assisting with technical concerns along the way. Special recognition for their contributions in making this project possible goes to Alicia Adams, Melanie Range, Dana Mykytyn, Dr. Audrey Ofir, and the FCAAP Immunizations Committee. Further thanks to the Department of Health in Florida and to each county health department representative who assisted in providing information and resources regarding HPV vaccination.

In-Text Citations

1. Weinberg MA, Estefan DJ. Assessing oral malignancies.Am Fam Physician. 2002;65(7):1379-1384.
2. Suk R, Montealegre JR, Nemutlu GS, et al. Public knowledge of human papillomavirus and receipt of vaccination recommendations.JAMA Pediatr. 2019;173(11):1099-1102
3. Gilkey MB, Malo TL, Shah PD, Hall ME, Brewer NT. Quality of physician communication about human papillomavirus vaccine: findings from a national survey.Cancer Epidemiol Biomarkers Prev. 2015;24(11):1673-1679.

Additional References Used in the Creation of the Webinar

1. Edwards KM, Hackell JM; Committee on Infectious Diseases, The Committee on Practice and Ambulatory Medicine. Countering vaccine hesitancy. Pediatrics. 2016;138(3):e20162146.
2. FUTURE II Study Group. Quadrivalent vaccine against human papillomavirus to prevent high-grade cervical lesionsN Engl J Med. 2007;356(19):1915–1927.
3. Garland SM, Hernandez-Avila M, Wheeler CM, et al.; Females United to Unilaterally Reduce Endo/Ectocervical Disease (FUTURE) I investigators. Quadrivalent vaccine against human papillomavirus to prevent anogenital diseases.N Engl J Med. 2007;356(19):1928–1943.
4. Gilkey MB, Malo TL, Shah PD, et al. Quality of physician communication about human papillomavirus vaccine: findings from a national survey. Cancer Epidemiol Biomarkers Prev. 2015;24(11):1673-9.
5. Hakeem A, Catalanotto FA. The role of dental professionals in managing HPV infection and oral cancer.J Cancer PrevCurrRes. 2019;10(4):82-88.
6. Mohanty S, Carroll-Scott A, Wheeler M, et al. Vaccine Hesitancy In Pediatric Primary Care Practices.Qual Health Res. 2018;28(13):2071-2080.
7. Shen SC, Dubey V. Addressing vaccine hesitancy: Clinical guidance for primary care physicians working with parents.Can Fam Physician. 2019;65(3):175-181.
8. Suk R, Montealegre JR, Nemutlu GS, et al. Public knowledge of human papillomavirus and receipt of vaccination recommendations. JAMA Pediatr. 2019;173(11):1099-1102.