Reducing Physician Hesitancy around HPV Vaccine Recommendation

The study was grounded in diagnostic research conducted in West Bengal with the support of RTI International. Ninety-seven interviews were completed (89 in-depth interviews and 8 focus group discussions) with physicians, adolescent girls and their parents or guardians as decision-makers, and government officials, schoolteachers, and frontline health workers. The study found:

• Availability and optimism bias: Physicians underestimate the incidence and risk of HPV ("availability bias": the tendency to make judgements about the likelihood of an event occurring based on how readily an example comes to mind). They also reported believing the incidence of cervical cancer to be higher among women who belong to lower socio-economic categories, live in rural areas (with low hygiene maintenance), and/or follow "sexually unsafe" practices - in essence, an "othering". This stance leads them to be more optimistic about their "regular" patients, believing they would not be at high risk of HPV ("optimism bias").
• Skewed perception of trust: Physicians display a lack of confidence of the vaccine being a safe and effective solution for HPV.
• Concern about breaking social norms: Physicians are uncomfortable talking about HPV (a sexually transmitted infection - STI) or even bringing up fearsome words like 'cancer' with parents of young girls.

Diagnosing the specific behavioural biases among physicians that result in hesitancy around recommending the HPV vaccine made it possible to apply insights from behavioural sciences to design nudges and interventions that directly target the biases and minimise the level of hesitancy among physicians - hopefully resulting in a stronger recommendation of the vaccine and potentially increased uptake. The shortlisted video-based solutions included:

1. Endorsement by a trusted medical champion: A video of Dr Soumya Swaminathan, Chief Scientist, World Health Organization (WHO), highlighting the risks of cervical cancer and the safety and efficacy of the HPV vaccine. Rationale: Trust can be transitive in nature - i.e. it can spill over from one known trusted party to another who is less known and trusted. Leveraging this transitive nature of trust, the video endorsement by a trusted, well-known medical professional may result in the rollover of trust from the individual to the vaccine they recommend.
2. Refreshing the dangers of cervical cancer and the ease of prevention: A video that showed the danger of HPV and cervical cancer incidence in India and the deaths from it. The information was paired with details on the safety and effectiveness numbers for the vaccine to reinforce the point that there exists a convenient preventive solution. Rationale: Mental accessibility promotes mental efficiency - i.e., an idea that is more salient might be easier to reach in a given situation than one that is drowned out. By making prominent the nature and extent of the problem (cervical cancer) and the role of physicians in solving it (by promoting HPV vaccine), it is possible to change current beliefs around the problem not being a major one or being a problem of certain groups.
3. Interventions targeting ways to make the HPV recommendation easy: Rationale: People tend to avoid socially awkward conversations due to fear that it might threaten their acceptance from others. Physicians display this tendency when they avoid talking about STIs with their patients, as they fear it would be breaking cultural norms. Such awkwardness can also arise when they fear rejection of their recommendation by the patient. Three interventions were designed to make the conversation easier for doctors:
   • Icebreakers for sensitive conversations: A video that explained simple social cues and examples for initiating conversations on the HPV vaccine and that demonstrated these different conversation techniques being used by a doctor to talk about the HPV vaccine with the parents of an adolescent girl, and them being receptive to it.
   • Introducing environmental cues to initiate conversation: A video that showed a poster urging doctors to talk about the HPV vaccine with their patients to protect their lives being used as an environmental cue to initiate the conversation on the vaccine. (Insertion of such an environmental cue can pin the initiation of the conversation to a third agent, outside of the two principal agents of the doctor and the patient - making it less awkward by reducing the dissonance when the conversation is initiated.)
   • Bundling the HPV recommendation with other recommendations: A video that showed how, through the use of a prescription format that included appointment dates for both the HPV vaccine and the Td/Tdap vaccine, the doctor could bundle the conversation on both with their patient, leading to a coupling effect that neutralises the conversation and makes it easier for the parent to accept both.

Organisers used a survey-based experiment to evaluate the impact of these interventions. The overall sample consisted of 616 doctors from West Bengal. High attrition between the main survey and follow-up (in part due to COVID-19) resulted in only 29% of the total sample completing the follow-up survey. However, it was clear that the interventions #1 and #2 above had significant effects in improving intentionality to recommend the HPV vaccine. When compared with the control group, the intervention of endorsement by a trusted medical champion had a positive effect of 2.07 odds ratio at a 10% significance level, indicating a 100% increase in the likelihood of expressing an intention to prescribe HPV vaccine. Similarly, the intervention directed at refreshing dangers of cervical cancer and ease of prevention saw a positive effect of 2.16 odds ratio at 5% significance level.

Immunisation and Vaccines, Youth

In a country like India - where there is high reverence and reliance on doctors for all types of medical information - hesitancy on the part of physicians to recommend the HPV vaccine can have serious adverse consequences for the general public - in knowing about the vaccine, actively seeking it, and therefore in increasing the incidence and risks of cervical cancer.

Recommendations going forward, based on the project described above, include:

• Refresh physicians on the dangers and risks associated with HPV and the burden of cervical cancer and the ease of prevention through vaccines: Regular emphasis on it, along with presenting the vaccine as a simple solution, can go a long way in pushing them to initiate the conversation on this with their patients.
• Build trust in the HPV vaccine by having trusted well-known medical professionals endorse it publicly: Such endorsements can help physicians move past uncertainty and more confidently encourage their patients to take the vaccine.
• Emphasise the responsibility of doctors to protect their patients from the risks of cervical cancer: This emphasis can help doctors realise how their limited encouragement or counselling on the HPV vaccine could put the patient at risk and could nudge them to be a more active champion for their patient.
• Understand, from a larger policy perspective, how service providers can also be subject to behavioural biases that might impede their decision-making and result in poor health outcomes: Policymakers should know that health service providers are usually over-burdened by the health system, and so simple solutions or nudges like the ones unearthed in this project can prompt physicians to shift away from their biases and hesitancy.