Evaluation of Pediatric Human Papillomavirus Vaccination Provider Counseling Written Materials: A Health Literacy Perspective

"Promoting the use of materials that incorporate health literacy best practices, particularly for at-risk, low-literacy populations, is a modifiable aspect of the health care system that can lead to improved child health outcomes, with the potential to reduce health disparities."

Despite recommendations supporting human papillomavirus (HPV) vaccination, paediatric vaccination rates remain suboptimal in the United States (US). Most parents report not having enough information about HPV vaccination and difficulty understanding the importance of the vaccine; this could be due to the fact that approximately 1 in 3 US parents has limited health literacy. Appropriately designed print materials could support a standardised approach to vaccination counseling and help ensure that barriers are addressed. This study evaluated HPV-related counseling materials and assessed parent perceptions of materials, using a health literacy perspective.

A systematic search was conducted for written materials developed for HPV vaccination counseling by examining state Department of Health Web sites and associated links to local and national organizations. Materials were assessed for the following: 1) readability (Flesch Reading Ease, Flesch-Kincaid, Gunning Fog, Simple Measure of Gobbledygook, Fry), 2) suitability (understandability and actionability) (Suitability Assessment of Materials; Patient Education Materials Assessment Tool for Printable Materials), and 3) coverage of 8 key content areas (recommended by the Centers for Disease Control and Prevention, or CDC). Semistructured interviews were conducted with English-speaking parents or caregivers of children 9 to 17 years of age from 3 paediatric clinics (New York, Ohio, Illinois) serving predominantly low-income families to assess perceptions and usefulness of 4 handouts selected for review.

Thirty-eight documents were assessed. Mean ± standard deviation (SD) reading grade level was 9.4 ± 2; 10.5% (n = 4) had a reading level of 6th grade or below; 68.4% (n = 26) were considered not suitable. Mean understandability was 41.7%, and mean actionability was 20.7%. Nearly all documents addressed disease information and positioned the vaccine as cancer prevention. The average number of areas addressed was nearly 7 of 8 areas, yet only 2 documents (5.3%) addressed all key content areas.

Twenty-five parents of preteens and teens were recruited from each of 3 sites (total n = 75) in order to take part in interviews in which they evaluated 4 documents:

1. HPV Vaccine Gardasil: What You Need to Know (Source: CDC) - Of the 4 documents, this was the one that the most parents reported would convince them to vaccinate their child (76.7%). It was considered comprehensive in terms of information about the safety and need for the vaccine, types of cancers it prevents and how well it works, at which ages to give the vaccine, and the importance of getting the vaccine for both boys and girls.
2. Why Your Doctor Says You Should Get All 3 HPV Vaccine Shots [PDF] (Source: Academic Pediatric Association) - Over half of parents (56.8%) indicated that this brochure would convince them to get the vaccine for their child. Parents commented about how colourful, simple, and clear the document was.
3. HPV Is a Serious Disease...Make Sure Your Child Is Protected [PDF] (Source: Immunization Action Coalition) - Over half of parents (52.7%) reported that this brochure would convince them to make a positive decision regarding getting the HPV vaccine for their child.
4. How Important Is HPV Vaccine for Preteens and Teens? Ask Kristen's Dad [PDF] (Source: California Department of Public Health) - 92.0% reported that reading a personal story by a parent, as in this brochure, was an effective strategy. Parents noted that imagining your own child going through something similar made the connection between cervical cancer and HPV vaccine seem more real and served as a prompt to act.

Overall, this study found few available educational handouts on HPV vaccination that are optimal from a health literacy best practices perspective, with few containing all recommended content. On average, assessed documents were written at the 9th grade level - too high for the average US adult to understand. Only 4 documents were written at the recommended 6th grade level or lower. In addition, nearly half of existing materials were categorised as not suitable, indicating that there were major flaws in the design of these documents. Many materials did not use an active, conversational style, which is recognised to be helpful in engaging patients and families. Although images, including photographs and illustrations, can help convey information in a more effective manner, few documents optimised the use of visual aids to help reinforce key concepts. In addition to presentation of content, areas in need of improvement include focus of content on behaviours and actions over statement of facts, and inclusion of summary or key takeaway points to highlight main messages.

Notably, there were some domains in which documents scored well. Handouts were generally divided into short sections, allowing for easier information processing. In some documents, visual cues like bold type, large font size, bullets, and boxes helped draw attention to key points, although these strategies were often not fully used. A strategy that was especially helpful in some handouts was provision of the exact wording of a script that could be used by providers in talking about HPV vaccination.

In conclusion, comprehensiveness of content, as well as inclusion of a personal story, were identified by parents as 2 aspects of written materials that are especially helpful. A potential next step would be to approach the groups that designed documents that scored well in readability and suitability to see if additional key content identified by this evaluation could be added. Organisations that developed the most comprehensive documents could also be advised about how to better integrate readability and suitability considerations into their existing documents. It is hoped that a targeted approach to the design and content of these documents could help increase vaccination rates.