“The HPV vaccine is one of the best cancer research discoveries we've had in the last hundred years. We need to better communicate the benefits of the vaccine so that we create a community demand for this great opportunity to prevent cancer.”

--Dr. Jasmin Tiro

As an Associate Professor in the Department of Population and Data Sciences at University of Texas Southwestern Medical Center, Dr. Jasmin Tiro researches behavioral interventions to help providers, patients, and healthcare systems prevent cancer, focusing specifically on underserved communities.  Dr. Tiro is Associate Director for Community Outreach, Engagement, and Equity at the Simmons Comprehensive Cancer Center and is committed to addressing cancer health disparities in Texas.She received her PhD in Behavioral Sciences from the University of Texas School of Public Health (UTSPH) and completed post-doctoral training with the National Cancer Institute’s Cancer Prevention Fellowship Program.

We spoke to Dr. Tiro about her work on HPV vaccine promotion.

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Texas Health Journal: Could you describe your work with the HPV vaccine?

Jasmin Tiro: Over the past 11 years, I've been studying issues related to HPV vaccine promotion here in North Texas. That has involved a range of different things, including understanding how parents and providers communicate about HPV vaccination and testing interventions.  

I've also worked to understand how factors operating at different levels—at the provider level, at the clinic level, at the patient level—are influencing effective delivery of the HPV vaccine to boys and girls.  Unlike other countries that systematically offer vaccines in schools, we have an opportunistic system. So we have to take advantage of every opportunity patients and parents come into the doctor's office and make sure that everything in the doctor's office goes smoothly.

Finally, I've also designed and tested interventions to improve delivery.  When we discover that parents are hesitant about the HPV vaccine—that they lack knowledge about the issues, need more information before they make a decision, and feel unprepared when they show up to a doctor's visit—we've tested sending educational information prior to the visit by mail and through mobile Health apps. Our goal is to get our HPV vaccine rates up to 80% in the United States.  

What's been most interesting about your findings?

The American Academy of Pediatrics and the CDC launched a campaign a couple years ago that told providers that what you say about vaccines matters and how you say it matters even more, but they didn't really have data that backed that up. Through our studies published in Patient Education & Counseling and Pediatrics, we’ve shown how parents use a range of strategies in how they express their hesitancy. Some ask questions, some make very assertive statements, and some express concerns like "I'm worried," or "What about side effects?" When providers persist in probing what the parent’s concern is, addressing the issue, and providing a rationale for their recommendation, they can be quite effective in persuading parents to get the vaccine on the same day.

Also, I’ve found that a lot of doctors approach conversations with vaccine hesitant parents with anxiety because they are concerned that they don’t have the time to engage in a lengthy discussion.  However, we found that, on average, these conversations take two to four minutes, and persistence works, so that's really encouraging. The other finding that’s really consistent with reports that I hear from my provider colleagues is that the tone that you use with parents is really important. Approaching the conversation like you're an adversary with the parent who is concerned about a vaccine can come across as condescending. Doctors often feel tension between acknowledging a parent’s right to make choices for their child and not surrendering their medical expertise by softening their recommendation for the HPV vaccine. Also, it's not just medical providers who matter; it’s important that everyone on the clinic team, from the front desk staff to the nurse to the medical assistant to the physician, understands why the HPV vaccine is being recommended. It's vital that everyone's on the same page.

The other aspect to remember is that a lot of parents are not as immersed in the health issue as we (clinical and public health experts) are. So basic education can make a difference, but that can be time consuming. We have tested an app that can prepare parents better for an upcoming pediatrician’s visit so that they know what adolescent vaccines will be recommended and why they are important to protect their child’s health.

Sometimes parents turn to me and say, “Well, can you say there's no chance that 20 or 30 years down the road we won't discover something negative about this vaccine?”  I'm a scientist, so I can’t say there is no chance. But what I can tell you is that in over 15 years’ worth of data we've accumulated on millions and millions of doses that have been given to adolescents, and we've never seen anything that suggests various negative outcomes.

It's really important to understand that parents have the best of intentions. They just want to protect and maintain their child's health. Given all the misinformation out there, it's not surprising that parents are concerned. Providers really have to work with parents and help them understand that you're coming from the same perspective as they are. We're all trying to protect kids and trying to keep them healthy.

What’s at stake for our community?

Almost one in 11 children in the United States live in Texas, and in the DFW Metroplex, every year 215,000 11-to-12 year-olds are due for the HPV vaccine. We have the power to vaccinate 215,000 kids every year in North Texas, and that's a lot to of power to prevent cancer. In Dallas County alone, we diagnose just under 100 cervical cancers a year, and there's no reason for a woman to have invasive cervical cancer in this day and age. We've got effective screening with Pap and HPV tests, we've got effective treatments to remove pre-cancers, and we've got this cancer prevention vaccine to prevent HPV infection. It's really heartbreaking when we diagnose cervical cancer because it affects fertility and it has a difficult treatment. In addition, we don’t have any effective screening tests for the HPV-related cancers affecting males. So the best way to prevent those cancers is to make sure adolescent boys receive the HPV vaccine.

Many people just talk about how we just need to raise awareness among parents and the community. And I would say that awareness is important. But just because you know something doesn't mean you do it, right? So, instead, I think we need to create community demand for vaccinations. The HPV vaccine is one of the best cancer research discoveries we've had in the last hundred years. It's one of the few times where we can actually prevent a cancer from even happening. In the next few years, we have the potential to eliminate a cancer from occurring in the same way that we eliminated other contagious diseases. So, it's hard for me to hear all these people not wanting to get this vaccine.

I’ve been doing this work for 10 years. My daughter was born when the HPV vaccine was first FDA approved, and she's 12 now.  I've been waiting for 11 years to give the HPV vaccine to her, and we just finished her vaccine series. It's been exciting for me to finally make sure she's protected, and I want other children to be protected too. We need to better communicate the benefits of the vaccine so that we create a community demand for this great opportunity to prevent cancer.