Understanding Unconscious Biases About HPV Vaccination

Summary and Comment |
September 15, 2016

Understanding Unconscious Biases About HPV Vaccination

  1. Louis M. Bell, MD

Unconscious biases may cause pediatricians to underestimate the risks and impact of human papillomavirus–caused diseases, leading to poor uptake of HPV vaccine in our patients.

  1. Louis M. Bell, MD

A thoughtful and succinct Perspectives piece in Pediatrics explores clinicians' unconscious cognitive bias as an explanation for the poor uptake of the human papillomavirus (HPV) vaccine. In 2014, only 40% of girls and 22% of boys aged 13 to 17 years had received all three recommended doses of HPV vaccine. Coverage with other vaccines recommended in this age group ranges from 80% to 90%. Previous research has shown that an unequivocal recommendation by a trusted provider is the key element to reassurance about vaccination.

The authors describe two types of cognitive bias. The first is the “bias of retrievability,” which may lead pediatricians to underestimate the risks of HPV-related disease because it is less familiar. We likely will remember a child we cared for who had poor outcome from meningococcal sepsis or pertussis, but most of us have not experienced HPV disease in our patients, making it seem less urgent. Yet meningococcal disease and pertussis account for fewer than 200 deaths per year, whereas HPV-related cancers account for 6000 deaths annually in men and women.

The second is the “bias of imaginability,” in which being able to imagine a scenario leads us to overestimate its risk. For example, we can easily imagine the acute onset of a severe disease like meningococcemia, the parent's concern about their child, and our response. In contrast, most of us don't have a similar image of patients dying from HPV-associated cancer, and so we are less likely to urge vaccination against this disease.


The first step toward improving rates of HPV vaccination is to be aware of our own cognitive biases. We are fortunate to have this safe and effective vaccine to prevent HPV disease, and we should be strongly recommending it.

Editor Disclosures at Time of Publication

  • Disclosures for Louis M. Bell, MD at time of publication Grant / Research support NIH Institutional Clinical and Translational Science Award; Agency for Healthcare Research and Quality National Center for Pediatric Practice Based Research Learning; Patient-Centered Outcomes Research Institute Editorial boards Current Problems in Pediatric Adolescent Healthcare (Associate Editor)


Reader Comments (3)

Kurt Elward, MD Physician, Family Medicine/General Practice

I think the two "biases" mentioned are far off the mark. In family medicine, where we DO see the repercussions of non vaccination, the majority of times we "fail" to provide HPV vaccination is the decision to wait until later than 12 to immunize - this is harshly criticized, but it may take time to discuss and alleviate concerns. The very high pressure practices of the pharmaceutical industry including the ridiculously accusatory commercials about "how could my mother allow me to get cancer?" have turned off thousands of parents who see this as just another marketing tool.

Several points should be considered, though the advocates for vaccination will likely have just as closed ears as the Luddites who would never vaccinate at any point:

1. This vaccine can be helpful but it not a God send. I see many breakthroughs despite adequate vaccination.
2. Some of this failure may due to "amount of exposure" but it shouldn't be. Whenever I try to discuss this with ID or vaccine reps, the issue is pooh-pooh'd.
3. The vaccine visits are promoted as being "quick and you don't even need to see them." This is horrible advice. What we try to do in our practice is to use these visits to create dialogue with parents and the patients about WHY we need this vaccine, the need to delay sexual activity, and the fact that it is 70% effective - which means it is not 100% effective. Almost every Merck rep I have talked to and most ID people smile condescendingly at the preventive practices discussion we try to have, saying that "they will be doing it anyway."

While unfortunately true in some cases, it a) assumes the kids are animals without any level of self control, b) the parents can't be supported and empowered. This sounds like all they want to do is sell the vaccine. Given that OCPs do nothing to prevent HPV and may allow increases in exposure, and that condoms provide inadequate protection against HPV, there should be far better resources to accompany the vaccine, and use these 2-3 opportunities to educate and empower teens and their parents to avoid early sexual activity and make far better choices. Otherwise the cynicism that is in the provider and parental community will continue.

Sheldon Ball, PhD, MD Physician, Geriatrics, Humana

Why is it that the bias of financial incentive seems to be ignored? Why not put issues in full perspective? Is not financial incentive ALWAYS a consideration in anything produced by the pharmaceutical industry? Or ... is the purpose only to sell pharmaceuticals?


As a Med-Peds provider who has seen more than my share of HPV-related disease, I have often considered meeting with Peds only practices to talk about my patients who would have directly benefited from the HPV vaccine. Perhaps that is one way to address these unintentional biases.

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