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Tablet-Based Patient Education Regarding Human Papillomavirus Vaccination in Colposcopy Clinic

Gockley, Allison A. MD1,2; Pena, Nancy BA, ONP-CG1,3; Vitonis, Allison ScM2,4,5; Welch, Kelly BS6; Duffey-Lind, Eileen C. RN MSN CRNP6,7; Feldman, Sarah MD, MPH1,2

Journal of Lower Genital Tract Disease: July 2019 - Volume 23 - Issue 3 - p 188–192
doi: 10.1097/LGT.0000000000000474
Original Research Articles: Cervix and HPV

Objective The aim of this study was to use an electronic tablet–based education module to increase patient knowledge about human papillomavirus (HPV).

Methods Patients presenting to an academic colposcopy clinic were first queried as to whether they had been infected with HPV. A quality improvement project was then conducted using a 4-question pretest assessing baseline knowledge about HPV and cancer, followed by a tablet-based education module and a 5-question posttest.

Results Between June 2017 and January 2018, 119 patients participated in the tablet education. At their initial visit, only 50 (42.0%) of patients were aware that they had an HPV infection; however, medical records revealed that 74 women (62.2%) were presenting with a documented HPV infection. After the tablet education, 95% of women identified cervical cancer as a problem that can be caused by HPV, as compared with 88.2% in the pretest (p = .046). Knowledge of head and neck cancer as a disease that can be caused by HPV increased from 10.9% to 80.7% (p < .001). More patients answered that they “definitely” or “probably” would consider the vaccine for a child in their family: 108 (95.6%) pretest vs. 112 (99.1%) posttest (p = .046). The activities were ranked as “extremely” or “very” helpful by 93.3% of patients.

Conclusions Patients presenting to colposcopy clinic are not well educated regarding the connection between an abnormal Pap test, HPV infection, and certain cancers. Tablet-based education improves patient knowledge of HPV-associated cancers in an outpatient clinic setting.

1Division of Gynecologic Oncology, Department of Obstetrics, Gynecology and Reproductive Biology, Brigham and Women's Hospital, Boston, MA;

2Harvard Medical School, Boston, MA;

3Dana-Farber Cancer Institute, Boston, MA;

4Obstetrics and Gynecology Epidemiology Center, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, MA;

5Department of Epidemiology, Harvard School of Public Health, Boston, MA;

6Team Maureen, Boston, MA; and

7Dana-Farber Cancer Institute, Pediatric Oncology, Boston, MA

Reprint requests to: Allison A. Gockley, MD, Division of Gynecologic Oncology, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115. E-mail:

The authors have declared they have no conflicts of interest.

Presented at the Annual Meeting of the American Society of Colposcopy and Cervical Pathology, April 18–21, 2018, Las Vegas, NV.

This study was supported by state-specific funds from the American Cancer Society. This project was approved by the Partner's Institutional Review Board.

Online date: April 10, 2019

Human papillomavirus (HPV) vaccine provides protection against high-risk strains of HPV and is effective in reducing high-grade cervical dysplasia.1 Furthermore, HPV infection is associated with other diseases, such as genital warts, and many cancers including anal, vulvar, vaginal, penile, and oropharyngeal carcinomas. It is estimated that 5% of the world's cancer burden is related to HPV infection.2 The vaccination series includes a schedule of 2 doses for ages 9 to 14 years and 3 doses for ages 15 to 45 years.3 Although the vaccine has been recommended to both boys and girls starting at 11 to 12 years old,4 uptake of vaccination in the United States continues to be low. A recent study using national immunization data suggested that only 46% of girls underwent early vaccination, before the age of 13 years.5 Although the percentage of girls being vaccinated continues to rise, vaccination rates are barely exceeding 50% by the age of 18 years.6 Rates of vaccination among boys are even lower, with only 30.3% of males being vaccinated by the age of 18 years.6

There are many diverse strategies to increase immunization7 and efforts have focused on various modalities including the Internet,8 parental education,9 videos,10 and handouts.11 Recent work has investigated using tablet-based education to enhance patient and parental acceptance of vaccination and cervical cancer screening12,13; however, there is, to our knowledge, no published literature evaluating the efficacy of tablet-based education tools to increase patient knowledge regarding the connection between HPV and several cancers. In other areas of medicine such as neurosurgery and otology, tablet-based educational interventions have increased patient knowledge and satisfaction in a clinic setting.14,15 The colposcopy clinic is a specialized clinic serving patients with abnormal Pap tests and preinvasive lower genital tract dysplasias. At the first visit, we ask patients why they were referred and if they ever had an HPV infection. Almost every patient is referred for an HPV-related diagnosis. We postulated that this clinic population provides a unique opportunity to educate patients because patients in the clinic are often personally affected by HPV and therefore may be interested in HPV education and potentially encouraging vaccination of others in their family. The aim of the study is to use an electronic tablet–based education module to increase knowledge about HPV infection and assess if the module is associated with a reported increase in likelihood of vaccination of patients or children in their family.

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With internal review board approval, a quality improvement project was undertaken from June 1, 2017, to January 21, 2018. The study was conducted of all new patients presenting to our academic colposcopy clinic. This clinic is a high-volume specialty outpatient clinic that serves patients with Pap and HPV test abnormalities as well as cervical, vulvar, vaginal, or anal dysplasia. Patients are referred to the clinic through their primary care physician, obstetrician/gynecologist, or other specialist. Data from all patients seen in the clinic are entered into a registry. Patients are asked specifically, “Why are you seeing a doctor today?” as well as “Have you ever had an HPV infection?”

Our clinic uses a patient navigator to support patients throughout their appointment and follow-up. We have previously studied the effect of patient navigation on improving follow-up and reducing the no-show rate.16 In addition to providing support, our patient navigator assists with education. As a quality initiative, each new patient was approached by our patient navigator and, if willing to participate, took a 4-question pretest and then completed an education module on the electronic tablet followed by a 5-question posttest. The pretest and posttest questions can be seen in Figure 1. The module included a short video from the Centers for Disease Control, which can be viewed through the following link This short video highlights HPV infection statistics and the link between infection and cancers in both men and women. The video emphasizes that these cancers are preventable with vaccination, ending with a statement encouraging vaccination of all children aged 11 to 12 years. The flashcard questions focus on the pathogenesis of cervical abnormalities and the connection between HPV and cervical cancer, head and neck cancer, and genital warts. The education module was designed with 8 “flashcards,” which presented a question, and when manually selected by the patient, the card flipped over to reveal the answers (see Figures 2A, B). Patients were also provided with pamphlets containing a summary of these education materials. The educational materials were developed by Team Maureen, a nonprofit organization whose goal is to fight and prevent cervical cancers and enhance the lives of those who live with the disease. In 2014, Team Maureen developed robust and user-friendly educational materials, which included online materials and a brochure entitled “Understanding HPV & Cancer” with input from doctors, nurses, educators, and other experts. The pretest and posttest questions were validated for effectiveness through a previous educational initiative at the Dana-Farber Cancer Institute. The materials were approved by the Massachusetts Department of Public Health as part of a statewide initiative to increase HPV education. These materials were adapted for the patients at an academic colposcopy clinic. All materials were available in both English and Spanish.





Patient characteristics, including demographics, preferred language, previous abnormal results, vaccination history, and general medical history, were collected from a self-reported information sheet completed by each new patient as part of their initial visit to the clinic. Patient characteristics and test responses were examined using descriptive statistics. We used 2-sided McNemar's tests to compare how responses changed after the tablet education. Data were analyzed with SAS statistical software (Version 9.4; SAS Institute Inc, Cary, NC). Significance was set at a p value of less than or equal to 0.05.

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Role of Funding Source

This work was supported by state-specific funds from the American Cancer Society. The corresponding author had final responsibility for the decision to submit this work for publication.

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Between June 2017 and January 2018, 128 new patients were approached and 125 new patients voluntarily participated in the tablet education. Three patients declined to participate, two of these patients accepted printed educational materials and one patient declined all educational materials. Six patients were excluded for incomplete responses, leaving 119 patients for analysis. The self-reported characteristics of these patients can be found in Table 1. Most patients were white, English-speaking, and had private insurance. However, 49.4% patients were of a nonwhite ethnicity (26.2% Hispanic and 17.5% African American). A total of 16.5% of patients spoke Spanish. The clinic is a referral center for high-risk patients, and as such, 56.9% of patients had other medical illness and 3.4% were currently pregnant. The median (range) age was 30 (19–79) years.



Among all new patients, 50 (42.0%) stated that they were being seen for an HPV infection and 57 (47.9%) stated that they had ever had an HPV infection. However, medical records revealed that 74 (62.2%) women were presenting with a documented HPV infection. Most women (93.3%) were referred for a cervical abnormality, whereas vulvar and other abnormalities were uncommon accounting for 4.2% and 2.5% of referrals, respectively.

Only 3 patients (2.5%) had received the HPV vaccine previously. Contraception was used by most women; oral contraceptive pills were the most common type of contraception, used by 30% of women. Condoms (25%) and intrauterine devices (20%) were also common. Although 70% of women had no smoking history, 18.8% were former smokers and 11.1% were current smokers (see Table 1).

After the tablet education, there was a significant improvement in knowledge of the connection between HPV and cervical cancer, head and neck cancer, abnormal Pap tests, and genital warts (see Table 2). The most significant improvement in knowledge was with regard to the connection between HPV and head and neck cancer. Only 13 women (10.9%) correctly identified that head and neck cancer could be caused by HPV in the pretest as compared with 96 women (80.7%) in the posttest (p < .001). Several women incorrectly identified HPV as being connected to breast cancer. Interestingly, there was a trend toward more women selecting this incorrect connection in the posttest than the pretest (3.4% vs. 9.2%, p = .05).



In response to the question, “How important do you think the HPV vaccine is for the health of children?” most patients answered “extremely” or “very.” There was no significant change in response between the pretest and the posttest (see Table 3). However, there was a trend toward more patients answering “definitely” or “probably would” in response to the question “How likely would you be to get the HPV vaccine for a child in your family?” (p = .05) (see Table 4). In the pretest, 108 patients (95.5%) answered that they “definitely” or “probably” would consider the vaccine. In the posttest, 112 (99.1%) answered that either “definitely” or “probably” would consider the vaccine.





The final question in the posttest asked patients, “How helpful were these activities?” Most patients found the activities helpful with 93.3% of patients indicating that the activities were “extremely” or “very” helpful. Eight patients (6.7%) indicated that the activities were “somewhat” helpful. No patients indicated that the activities were “not very helpful.”

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This study of 119 patients in a specialized colposcopy clinic for 6 months suggests that fewer than 50% of patients recognized that they had ever had an HPV infection or understood that the infection was the primary reason for being seen in clinic. An electronic tablet–based model of HPV vaccine education increased patient knowledge of the HPV and the connection between HPV infection and associated cancers. Our findings suggest that this combination of tablet-based flashcards and videos may increase patient willingness to vaccinate children in their family.

After the electronic tablet–based module, a significant improvement in knowledge was observed for all diseases that were queried, except for breast cancer. Interestingly, more patients incorrectly answered that HPV was related to breast cancer in the posttest than the pretest (p = .05). This may be attributable to it being the only disease queried that was not related to HPV or confusion about HPV pathogenesis or an incorrect association of breast tissue as a “gynecologic” organ. Regardless of the reason for this confusion, for women who answered that breast cancer was related to HPV, additional verbal education was provided by the provider team in the clinic.

Although improvement was observed in responses regarding the connections between HPV and cervical cancer, abnormal Pap tests and genital warts, the improvement was greatest with regard to head and neck cancer. During the pretest, only 10.9% of patients responded that HPV was related to head and neck cancer, compared with 80.7% in the posttest. This vast improvement suggests that general knowledge regarding the connection between HPV and head and neck cancer is lacking and that the electronic tablet–based module is an effective intervention to increase knowledge. A recent study of more than 300 pediatricians found that most providers had “fair” or “no” education regarding oropharyngeal squamous cell carcinoma and HPV. The authors found that this translated into more than 50% of providers “never” discussing oropharyngeal squamous cell carcinoma while counseling about HPV vaccination.17 Education regarding the link between HPV and head and neck cancers is needed at both the provider and the patient level and further educational initiatives should include an emphasis on this critical link as the incidence of HPV-related head and neck cancers continue to rise.18

Interestingly, the intervention did not change how important patients thought that the HPV vaccine was for the health of children; however, most patients rated the vaccine as “extremely” or “very” important in the pretest so there was little opportunity for improvement. Despite not observing a significant change in patient's perception of importance, more patients responded in the posttest that they “definitely” or “probably” would get the HPV vaccine for a child in their family. This suggests that the tablet-based module is a feasible tool to educate patients about the HPV vaccine and may translate into changed attitudes surrounding vaccination and potentially more vaccinated children. Baldwin et al.13 recently published a study using tablet-based self-persuasion tools to assess parental indecision in HPV vaccination. In this study, 45 parents completed a tablet module and cognitive interview. These responses were used to generate a group of prompts that were identified by parents as helpful. Overall, 81.8% of parents decided to vaccinate their children after this intervention. The authors concluded that this approach may increase vaccine uptake among adolescents. Although this study involved intensive cognitive interviewing and was conducted in a pediatric clinic, the findings suggest similar conclusions to our study in that guided education with a tablet module is feasible, acceptable to patients, and has the potential to increase HPV vaccination.

This study has several limitations. The relatively small sample size and high levels of baseline knowledge may have affected the ability to detect significant differences in pretest and posttest responses. However, we were able to demonstrate a significant improvement in knowledge related to HPV-related cancers. Not all patients responded to every question on the demographic patient information sheet, which limited how many patients with certain characteristics who could be analyzed by each variable. In addition, although this study involved materials in Spanish and English, we were not able to provide these educational materials or pretest/posttest questions for women speaking other languages. Of note, women who spoke languages other than English and Spanish were seen in our clinic in association with an interpreter and were provided verbal education regarding HPV through the patient navigator. In addition, the patient navigator was present for the tablet intervention and we cannot assess how much of the success of this approach may be attributable to having a one-on-one educational intervention. However, the primary information was provided via the electronic tablet with the navigator's assistance, and although not all clinics have access to a patient navigator, the tablet-based education can be provided without a navigator. In this study, it may be difficult to assess the impact of the tablet-based education as compared with the effect of the patient navigator's involvement. Further studies should investigate patient usage of tablet-based education in the absence of a patient navigator. Lastly, this intervention required the development and implementation of the tablet modules as well as the tablet itself. These interventions can have significant expense as shown by a study by Karanth et al.19; however, although further research is needed, they may provide superior education to traditional modalities and may streamline patient education.

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Tablet-based education improves patient knowledge of HPV-associated cancers, is feasible in an outpatient clinic setting, and increases patient willingness to consider HPV vaccination. Patients considered this education intervention helpful and further efforts to improve HPV vaccine education could include tablet-based modules.

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human papillomavirus; HPV vaccine; tablet education; HPV-related cancers; colposcopy

Copyright © 2019 by the American Society for Colposcopy and Cervical Pathology