Abstract
Purpose: Human papillomavirus (HPV) is the most prevalent sexually transmitted infection in the United States and oral healthcare providers (OHPs) have become increasingly focused on preventing oral health outcomes related to HPV through screening for oral cancer and recommending HPV vaccination. The purpose of this study was to explore the comfort of having HPV-related discussions with OHPs among a college-age population.
Methods: Students enrolled in an introductory-level, personal health class at a large, public, mid-Atlantic institution were invited to participate in an anonymous survey. Ten items related to participant’s perceptions of HPV discussions with an OHP were part of a larger 100 item online survey designed to measure various aspects of college student health. Comfort with an OHPs’ discussion of various health issues (including oral cancer, the relationship between oral cancer and HPV, and HPV vaccination) was measured on a 5-point scale with follow up, open-ended questions. Descriptive statistics were used to analyze the data; thematic coding was used to analyze the open-ended items.
Results: A total of 3,236 students were invited to participate during the two data collection waves; 2,198 surveys were fully completed, representing a 67.9% response rate. Participants reported having the greatest level of comfort discussing oral health prevention behaviors such as tooth brushing and flossing and the least comfort discussing HPV-related topics with OHPs. Among those expressing low levels of comfort, qualitative responses highlighted participants limited knowledge related to HPV and the HPV vaccination along with the belief that these discussions were better suited for physicians.
Conclusions: Results from this study demonstrated that college-age students may be uncomfortable with HPV-related discussions in a dental care setting. However, given the relationship between HPV infection and poor oral health outcomes, it is important that this population be informed about the oral-systemic HPV relationship and of the HPV vaccination as means for primary prevention. These findings highlight the need to address the public’s perceptions regarding the role that OHPs play in educating the public about oral-systemic health.
- oral-systemic health
- dental hygienists
- oral health care providers
- human papillomavirus
- HPV vaccinations
- public health
Introduction
Human papillomavirus (HPV) is the most prevalent sexually transmitted infection (STI) in the United States (US), accounting for 63% of all existing and 50% of all new STI cases among 15 to 59-year-olds in the United States.1 Nearly all sexually active people will have become infected with HPV in their lifetime;2 most will spontaneously eliminate or clear the viral infection within two years.3 However, a small proportion of those infected with HPV retain the virus;4 these ‘persistent’ infections may lead to the development of a squamous cell carcinoma or genital warts.5
Whereas many people are aware of anogenital HPV-related cancers, there is less knowledge of HPV as a causative agent for oropharyngeal cancer, primarily transmitted to the oral cavity via oral sex.6,7 Approximately 11.5% of adults in the United States are estimated to have an oral HPV infection.5 Though direct causation cannot be assumed, the incidence of HPV16 and HPV18 associated oropharyngeal cancers has increased to account for over 70% of all oropharyngeal cancers and is the most diagnosed HPV-related cancer.8,9 Oropharyngeal cancer is associated with approximately 10, 700 deaths annually.10 Risk factors for persistent oral HPV infection include male sex, older age, history of smoking, and the number of lifetime oral sex partners.5,7,11,12 Though it is unknown why some HPV infections clear and others do not, persistent oral HPV infection is a risk factor for HPV-associated oropharyngeal cancer.12
Oral health care providers (OHPs) and professional organizations have become increasingly more focused on utilizing secondary prevention measures, such as oral cancer screening, to prevent negative HPV-related oral health outcomes. Early detection of oropharyngeal cancer however, can be challenging due to the location and lack of a presenting lesion to serve as a visual cue.13 Additionally, there is no standard routine screening test for oral cavity, pharyngeal, and laryngeal cancer13 and as a result, oral cancer screening by OHPs is not consistently practiced.14, 15
Due to the challenges with secondary prevention through a standardized oral cancer screening approach, primary prevention (i.e., vaccination) is a more promising preventative strategy for HPV-related oral cancer. Vaccination has the potential of preventing HPV infection, whereas oral cancer screening at best may only detect oral cancer in its early stages. In 2011, the Centers for Disease Control and Prevention (CDC) recommended routine HPV vaccination for girls and boys between the ages of 9 and 26 for the prevention of cervical and anogenital HPV cancers16 and this recommendation was expanded to age 45 (based on shared decision-making with health care providers) in 2019.17 The current vaccine protects against 90% of cancer-causing HPV variants.18 Vaccinated individuals have also shown a decreased risk for oral HPV infection.19-21
Though HPV vaccination rates are increasing, they remain relatively low with about 68% of adolescents having received at least one dose, and with males less likely to be vaccinated.22 Health care provider recommendation is one of the most important factors in predicting vaccination behavior.23-25 However, the impact of provider recommendation on vaccination behavior has only been studied with medical providers, not OHPs. Discussing the relationship between HPV and poor oral health outcomes and recommending HPV vaccination in a clinical oral health setting offers unique opportunities. Unlike medical doctors whom patients typically seek out for specific or acute medical care, patients regularly attend bi-annual dental screenings, with 64.9% of adults and 85.9% of children visiting a dentist in the previous year.26 In addition, both oral health professional organizations and oral health care providers see a role for themselves in discussing HPV-related oral cancer and encouraging HPV vaccination with their patients, though some OHPs have reported discomfort in providing direct vaccination if permissible to do so.27-30 Lack of provider knowledge about HPV and vaccination, lack of time and privacy in dental settings, and fear of offending patients have been reported as barriers to these discussions.29-31
There is robust literature related to the knowledge, perceptions, and attitudes of OHPs in discussing HPV-related oral health outcomes and HPV vaccination;27-31 however there have been few studies exploring the patient’s perspectives.32-34 These studies have looked almost exclusively at parent perceptions of the role of oral health providers’ in discussing HPV and providing HPV vaccination for their minor children in dental settings. Based on current research, parents are more comfortable with dentists recommending HPV vaccination for their children than providing direct HPV vaccination.32-34 College-age students are generally receptive to discussing HPV as a risk factor for oral cancer but are slightly less receptive to talking about the HPV vaccine or receiving a recommendation for HPV vaccination from OHPs.35
Oral health professional organizations have increasingly championed HPV vaccine advocacy by encouraging oral health providers to become knowledgeable about and participate in conversations with patients regarding the relationship between HPV and oral health outcomes.36-38 In addition, professional organizations also encourage OHPs to recommend HPV vaccination among those who are eligible, however there have been few published studies examining patient perspectives on these discussions.32-35 The purpose of this study was to explore comfort of HPV-related discussions with OHPs among a college-age population at a large public mid-Atlantic institution. Though oropharyngeal cancer frequently presents in older men with a higher number of lifetime sexual partners, primary prevention aims to intervene before individuals are likely to have been exposed to the HPV virus. Thus, sampling from a college-age population may provide insight into the barriers and facilitators of HPV-related discussions within a dental setting among those who may be newly responsible for their healthcare decisions, who are within the recommended catch-up vaccination age range, and whom may be without or only had limited sexual experience.
Methods
This mixed-methods study is part of a larger study on college student health at a large Mid-Atlantic Public University. Data were collected via an online, anonymous survey (Qualtrics; Provo, UT, USA).39 The original 100-item survey was developed by primary investigators, all with doctoral degrees in health-related fields, and covered several health topics. The survey was administered to students enrolled in an introductory-level personal health course, which is one of two options to fulfill the wellness requirement for graduation. Given most students elect to take the personal health course to fulfill the graduation requirement, this represented a reasonable strategy to sample from most of the student population at the institution. After receiving IRB approval (IRB #21-2204), the surveys were pilot tested during the 2018-2019 academic year and revised for the two data collection waves presented in this paper (2019-2020 and 2020-2021). Students were given the option to take the survey for extra credit or opt to complete an alternative assignment for the same credit. Course instructors had no access to student data; student identity for the purposes of receiving credit was separate from their survey answers, thus reducing the impact of coercion on participant answers.
Instrument
Whereas the survey measured various aspects of college student health, this paper uses data from four demographic questions and ten items measuring participants’ comfort with the OHP’s discussion of various health issues. Demographic variables included sex assigned at birth (male or female) and other, age, race/ethnicity, dental insurance status, and the last time the participant visited the dentist or dental hygienist.
Quantitative measures
Comfort with OHPs’ discussion of various health issues were adapted from Daley et al.35 Items included “I would feel comfortable if an oral health care provider talked to me about oral health prevention behaviors, such as tooth brushing and flossing” and “I would feel comfortable if an oral health care provider talked to me about the HPV vaccine.” Response options ranged on a 5-point Likert scale from strongly agree to strongly disagree.
Qualitative measures
For the item, “I would feel comfortable if an oral health care provider recommended the HPV vaccine to me”, participants who indicated “strongly disagree,” “disagree”, or “neither agree or disagree” were asked to provide an open-ended response to the question, “What are some reasons for not being comfortable with an oral health care provider recommending the HPV vaccine for you?”
Desire to discuss HPV and HPV vaccination with an OHP was measured with the item, “I would like an oral health care provider to talk to me about HPV and the HPV vaccine at my next visit.” Those who answered, “strongly agree” or “agree” were asked to provide an open-ended response to the question, “What are your reasons for wanting to discuss HPV and the HPV vaccine with your oral health care provider?” Participants who answered, “strongly disagree,” “disagree”, or “neither agree nor disagree” were asked to provide an open-ended response to the question, “What are your reasons for not wanting to discuss HPV and the HPV vaccine with your oral health care provider?”
Data Analysis
Descriptive statistics were conducted to describe the sample. Means and standard deviations were calculated for each of the comfort items. Item differences were compared using dependent samples t-test with a matched pairs design matching participant responses to discussing oral health and oral cancer.
For the qualitative analysis, using the pilot-tested data (2018-2019), the primary investigators used open-coding, coding the data to identify major themes, to develop content codes for the responses to the open-ended questions.40 Investigators then discussed the codes, grouping them into larger thematic codes. Two undergraduate research assistants were trained using the pilot-tested data until they were able to code consistently before independently coding all the open-ended items. After independently coding all open-ended items, the research assistants met with primary investigators to discuss any discrepancies until agreement was reached with all items
Results
Demographics
A total of 3,236 students were offered the online version of the survey containing items used in this analysis during the two data collection waves (2019-2020 and 2020-2021); 2,198 surveys were fully completed, representing a 67.9% response rate. The sample (n = 2198) identified mostly as female (71.0%; n = 1556), white (73.1%; n = 1831), between the ages of 18-19 (76.4%; n = 1676), and most had dental insurance (84.9%; n = 1865). Of the participants who had dental insurance, most received their dental insurance through their parents (97.4%; n = 1814). Participants who had never seen an OHP (n=9) were eliminated from the analysis. Sample demographics are shown in Table I.
Demographics
Comfort Discussing Health Topics with OHPs
Differences in comfort with OHPs discussing various health topics are shown in Table II. Participants had the greatest comfort discussing oral health prevention behaviors such as tooth brushing and flossing (M=3.71, SD=.717). Participants were least comfortable discussing HPV-related topics including HPV as a risk factor for oral cancer (M=3.31, SD=.852), the HPV vaccine (M=3.16, SD=.966), recommending the HPV vaccine (M=3.00, SD=1.05), and discussing HPV and the HPV vaccine at their next visit (M=2.21, SD=.982). Table III displays differences in attitudes towards comfort discussing oral health and oral cancer. All differences were statistically significant except the difference between “I would feel comfortable if an oral health care provider talked to me about oral cancer screening” and “I would feel comfortable if an oral health care provider talked to me about smoking and alcohol as risk factors for oral cancer.”
Comfort with Oral Health Care Providers Discussing Various Health Topics
Mean Differences in Attitudes Towards Comfort with Oral Health Providers Discussing Oral Health Behaviors and Oral Cancer*
Comfort Discussing HPV and Recommending the HPV Vaccine with OHPs
Open-Ended Responses
Given that participants were more comfortable discussing general oral health prevention behaviors compared to any discussions related to HPV and oral cancer, it is important to explore why participants may hold these beliefs. Qualitative responses provide richer explanation than quantitative alone.
Table IV displays the frequency of the codes and example statements for the open-ended questions related to wanting and comfort of OHPs discussing HPV and recommending the HPV vaccine. According to frequency data, most responses to the question about wanting an OHP to discuss HPV/the vaccine were coded (74.1%) as the following: wanting to seek information and increasing one’s own knowledge to improve their own health, to prevent a serious poor health outcome, and to be safe. The remaining responses were not as common. Participants stated that they would want to talk to an OHP because they had no prior knowledge of HPV or of its connection to oral health (6.3%). Some participants also felt OHPs were an appropriate provider to have this discussion with given their training, experience, and knowledge of the subject (3.9%). Of these respondents, 3.6% discussed increasing awareness of HPV and vaccination and the relationship to oral health was in the interest of the general public, rather than connecting this awareness to their own personal health.
Qualitative Codes, Frequencies, and Response Examples
When participants were asked why they would not want an OHP to discuss HPV and or the HPV vaccine, the most common coded response implied that a discussion on this topic was not relevant to them (30.5%). Some of the reasons that participants indicated that this type of discussion was irrelevant included already being vaccinated for HPV, perceived low risk for HPV transmission, and the need to discuss such an issue with a parent rather than an OHP. The second most common coded response was not having a concrete reason or not knowing why they would not participate in such as discussion (27.8%). Some participants also indicated OHPs were not the appropriate health provider to have this discussion (14.7%), not seeing them as a legitimate medical health care provider, as having the appropriate knowledge/training for such discussions, not seeing such a discussion as relating to other oral health topics, or preferring the discussion happen with their primary care physician or gynecologist. Some responses were coded as being an emotional response to this type of discussion (12.1%) either because participants had a fear of needles and vaccines, found the topic too personal to discuss, or thought the conversation would be ‘awkward.’ Approximately 7.2% of participants gave an ambivalent or neutral response to the question, stating they wouldn’t be opposed to such a discussion if needed. Approximately 5% indicated anti-vaccine sentiments or misinformation about the efficacy and safety of vaccines in general or the HPV vaccine specifically.
Similar to the reasons for not wanting OHPs to discuss HPV and/or the HPV vaccine, the most common coded response to the question about why participants would not be comfortable with an OHP recommending the vaccine, was the belief that OHPs were not the appropriate health care provider to have this discussion (40.0%), stating it was a conversation more suited for a physician, that OHPs are not doctors, or HPV was about genital health not oral health. These responses were similar to the reasons that were given for why participants would not want to discuss HPV or the HPV vaccine with an OHP. Participants also responded with emotional responses (14.8%) related to feeling the topic was embarrassing or taboo. Participants also indicated that discussing HPV and or the HPV vaccine was irrelevant to them (11.1%) either because they already vaccinated, or they didn’t feel that they needed it. Participants also indicated they were uncomfortable due to the lack of knowledge they had regarding the vaccine (6.9%) including anti-vaccine sentiments and not knowing about HPV in general. Some participants didn’t provide an explanation (8.6%) stating that they had none or there was no reason for their discomfort; a few indicated that they would be comfortable (2.1%). Some responses could not be captured in the developed codes (16.1%) as the responses ranged widely from thinking the OHP might somehow benefit by administering the vaccines or that it was the individual’s personal choice to initiate the discussion.
Discussion
The purpose of this study was to explore young adults’ comfort with oral health care providers’ discussion of HPV and the HPV vaccine. Quantitative results showed that participants were less comfortable discussing HPV-related oral health topics with OHPs than other oral health topics like tooth brushing and flossing. As the topics moved from oral health to oral cancer and its risk factors, there was markedly less comfort with the discussion. The lowest comfort was reported for the HPV vaccine and whether participants wanted their OHP to recommend the HPV vaccine at their next visit. Participants were less comfortable with their OHPs discussing HPV and the HPV vaccine compared with oral cancer screening in general and oral cancer risk related to smoking and alcohol use. Discussions of HPV were seen as being related to genital health rather than oral health, perhaps underscoring why OHPs may not be viewed as the appropriate health care provider for these discussions and why such discussions may be awkward.
The open-ended responses provided insights into the reasons for the lack of comfort discussing HPV and the HPV vaccine seen in the quantitative results. Participants in the current study had limited knowledge related to HPV and HPV vaccination based on their qualitative responses. Participants were unaware that HPV could also cause oral cancer, felt they were at low risk for HPV and were unaware of the safety and efficacy of the HPV vaccine. Previous research on HPV vaccination knowledge found while most adults are aware of HPV, the HPV vaccine, and HPV as a cause of cervical cancer, they were unaware of the relationship between HPV and oropharyngeal cancer.41 Participants also acknowledged that they were unaware of the connection between HPV and oral cancer prior to being surveyed and expressed that this was a reason they would want to talk to an OHP about HPV and the vaccine. Unlike those who were uncomfortable, participants who acknowledged they were unaware of the connection between HPV and oral cancer also felt OHPs were an appropriate provider to have this conversation with, given their training, experience, and knowledge of the subject.
While some OHPs recognize their role in preventing HPV and oropharyngeal cancers, OHPs have also expressed relatively low knowledge regarding HPV-related oropharyngeal cancers and the HPV vaccine.27, 30, 42-45 Dental health opinion leaders can influence professional practice by serving as change agents for the dissemination of new health practices such as discussing and recommending the HPV vaccine.46 Therefore, strategies to enhance knowledge among key OHP opinion leaders is necessary. Future research should attempt to identify opinion leaders within oral health organizations and explore ways to disseminate HPV information amongst OHPs.
Lack of HPV and HPV vaccination knowledge may be the reason participants gave emotional responses related to feeling embarrassed to have an HPV discussion with an OHP. Adolescents have expressed discomfort discussing sexual health with adults and while they may be comfortable discussing sexual health with their friends, this comfort does not translate to health care providers.47,48 Concerns regarding confidentiality and feeling judged by health care providers for sexual behavior have been expressed and people may feel offended or caught off guard when an unfamiliar health care provider asks questions about sexual health.47 This may be why some participants may have felt the topic was private and would rather initiate the conversation themselves.
However, patients may not recognize that they are at risk for a particular health outcome, necessitating providers to initiate these important conversations. This can be problematic because some OHPs have low self-efficacy in discussing HPV prevention and lack the necessary communication skills for these discussions. In addition, OHPs have reported a preference of having patients initiate these sensitive conversations.49 Sexual health communication among college students is influenced by their subjective norms, specifically norms about their caregivers, parents, and peers.50 - 53 This suggests young adults may be more comfortable discussing sexual health related topics with their parents or friends rather than an OHP.
Many participants self-reported limited HPV and HPV vaccination knowledge and indicated that they were comfortable with having OHPs to discuss oral cancer, HPV, and the HPV vaccine at dental visits. Open-ended responses indicated a willingness to have increased knowledge from any source to improve their own health and prevent a serious negative health outcome. Although health care providers’ strong and consistent recommendations are considered the best predictor of vaccine uptake,24,54 OHPs have reported that they have relatively low knowledge of various HPV-related topics.27,30,42-45 Limited provider knowledge will make it difficult for OHPs to deliver education and vaccine recommendations to patients. Recognizing this barrier to HPV vaccination information, the American Dental Association’s Council on Scientific Affairs issued a statement in 2012 encouraging dentists to “educate themselves and their patients about the relationship between HPV and oropharyngeal cancer, especially the growing prevalence of these cancers in young non-smokers and non-drinkers.”55 Patients receive preventive dental care more frequently than medical care. Given one of the strongest predictors of vaccination is a health care provider’s recommendation,56-58 dental visits offer a unique opportunity to increase HPV vaccination. Such discussions would require that OHPs have sufficient knowledge of HPV, HPV vaccination, and the connection to oral health as well as the skills and self-efficacy to communicate about sensitive topics.49
Participants also indicated their lack of comfort towards discussing HPV and/or the HPV vaccine was related to already having received the HPV vaccine. Although the United States HPV vaccination program has resulted in increased immunity to the virus,59-62 additional efforts are needed to continue to increase HPV vaccination uptake. Expanding OHPs roles to include educating patients about HPV and the importance of the HPV vaccination offers an innovative approach to increasing HPV vaccination rates and ultimately reducing HPV-related cancers. This approach will require translating HPV prevention evidence into current practices among dentists, dental hygienists, and key leaders in dental organizations.49 If all OHPs are going to adequately address HPV and HPV vaccination education, dental and dental hygiene schools must offer training opportunities for students to become more comfortable discussing these topics.
Participants also felt HPV and the HPV vaccine were more suited discussion topics for physicians either because they did not perceive an OHP, including dentists, to be on an equal level as a medical doctor or because they felt OHPs should only be concerned about oral health. One participant expressed their feelings with the following colorful exemplary comment: “Here for my teeth, not my cooter.” Other studies have identified similar patterns. Raja et al. found patients were comfortable discussing standard oral health questions in dental settings, but were less comfortable discussing questions relating to behavioral health and social conditions.63 Greenberg et al. found patients generally accepted some physical health screenings, such as blood pressure and weight, in an oral health care setting, although patients in private practice settings were less likely to accept these health screenings as compared to those delivered in public health clinical settings.64 Findings from this study point to several misperceptions regarding the professional role of OHPs and health topics not perceived as relating to the mouth or teeth as well as the role of HPV in oral health outcomes.
Traditionally, OHPs have not participated in recommending vaccinations, however dental professionals, policy makers, and dental educators have begun to broaden the scope OHPs play in overall health.65 If these efforts are to be successful in bridging the gap between OHPs and physicians, dental and dental hygiene schools must offer more training opportunities for students to increase their HPV knowledge and comfort. Participants in this study and in previous studies examining OHPs roles, perceived discussions related to HPV to be uncomfortable due to their intimate nature.27 However, these discussions need not focus on sexual health behaviors, but rather the safety and efficacy of the HPV vaccine in preventing cancer. Online HPV vaccine professional development programs may also be an avenue to increasing HPV knowledge and communication skills.66 These online interventions can increase knowledge, perceptions, attitudes, and practice behaviors if created using strategic health communication design principles.67-71 Future research should continue to evaluate the effectiveness of online HPV vaccine education interventions and extend this opportunity to OHPs.
Despite the survey’s use of the phrase OHPs, based on the open-ended responses, it is likely that this was interpreted by participants to mean dentists rather than dental hygienists. There was only one reference to a dental hygienist in the open-ended responses. This may be due to participants not having a clear understanding of the dental hygienists’ scope of practice. Dental hygienists have previously reported in the literature that the general public does not recognize their expertise in oral health care, only being seen as a “cleaning lady.”44 However, dental hygienists have been shown to be more likely to discuss oral cancer screenings, prevention, and HPV, with patients as they are more often tasked with providing oral health education as compared to dentists.72-74 Efforts to promote HPV vaccination should include dental hygienists and all other OHPs.44 Furthermore, some participants in this study did not see OHPs as knowledgeable on subjects related to HPV. Seeing certain health topics as purely in the domain of physicians may due to the legacy of the dental-medical divide.75 Given that patients are more likely to attend bi-annual dental checkups than seek routine medical care,26 improving patient perception of OHPs expertise in oral-systemic health issues is an important strategy.
Limitations
The study was conducted at a single institution with participants whose demographics (primarily white, self-identified females, with health and dental insurance) matched that of the institution but may not be generalizable to other populations. Future studies are warranted which explore similar research questions in more diverse populations that may be more impacted by social and economic barriers. While college students are adults and can make their own health decisions, the HPV vaccine is recommended for a younger age group where parents may be the primary decision maker. Reliability and validity information for the scale used in this study was not available as it has not been utilized in any published studies. However, given the exploratory nature of this study, the reliability established within this sample was deemed sufficient to understand the perceptions of the participants. While the open-ended responses helped to understand the scaled items, the responses provided by participants were limited to short text-based responses. Future qualitative studies could be conducted to understand the comfort level more deeply with the goal of having OHPs discuss HPV and the HPV vaccine.
Conclusion
Quantitative results showed that participants were less comfortable discussing HPV-related oral health outcomes and HPV vaccines than other oral health topics. The qualitative findings provided some context to these results. While some participants saw OHPs as an appropriate provider to have HPV-related discussions, others viewed OHPs as lacking the knowledge or authority to do so. Some participants also did not view HPV as part of oral-systemic health, and therefore such discussions were perceived as inappropriate to dental settings. Future research should also explore these issues in more diverse settings. As OHPs include discussions related to HPV and vaccinations as part of standard of care, it is important to understand patients’ perceptions and their receptiveness to these topics. Changing the public’s perception of the oral-systemic health link and of the role that OHPs play in health care is of critical importance.
Footnotes
This manuscript supports the NDHRA priority area, Client level: Oral health care (health promotion: treatments, behaviors, products).
- Received September 13, 2021.
- Accepted February 17, 2022.
- Copyright © 2022 The American Dental Hygienists’ Association
