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By Natoshia Askelson, PhD, MPH and Jennifer Sukalski, PhD MS, RDH

In 2021, the Iowa Cancer Registry brought to light a concerning finding: Iowa had the second highest incidence of oropharyngeal cancer in the nation. This was particularly troubling given that in 2020, the FDA approved HPV vaccination as a method of preventing oropharyngeal cancer. Our team at the University of Iowa Cancer Prevention and Control Research Network Collaborating Center (CPCRN) had been working with colleagues at the University of Iowa College of Dentistry to leverage dental offices as settings in which we could promote the HPV vaccine. Together, we developed Educate, Recommend, Refer, an intervention aimed at training and aiding dental professionals to promote HPV vaccination to the parents of their patients. 

Our work started in 2019, when we interviewed and surveyed dentists and dental hygienists to better understand how we could support them in recommending the vaccine to parents. Dental providers regularly screen their patients for oropharyngeal cancer, however, they do not typically educate their patients on HPV or HPV vaccination. Formative research indicated that dental professionals lacked the knowledge and self-efficacy to educate parents about HPV, to make a strong recommendation, and to refer parents to a vaccine provider. In response, we created a training which focused on these three topics and addressed other barriers uncovered during the formative research. The interactive training also includes role playing and demonstrates how support materials can be used in interactions with parents. The goal of this intervention was to encourage dental professionals to educate parents about HPV, oropharyngeal cancer, and HPV vaccination, recommend that patients receive it, and refer them to a vaccine provider. 

“The goal of the intervention is to train dentists and dental hygienists so that they can make a strong recommendation for the HPV vaccine to the parents of the [adolescent] patients that they see. The more times a parent hears about the vaccine- the more it is normalized and hopefully that results in more vaccinations.”
– Natoshia Askelson, PhD, MPH, Associate Professor, Community & Behavioral Health

In 2024, we implemented Educate, Recommend, Refer in two private practice dental offices. Dentists, dental hygienists, and dental assistants completed the training session, which was provided by a member of our team who is a PhD-trained dental hygienist. Participants learned about HPV vaccination and methods of educating parents on this topic. We also practiced methods of recommending the vaccine and provided materials to help facilitate these discussions, including educational brochures for parents. The dental offices also received detailed information on local vaccine providers, how appointments could be made, cost, and hours of operation.

“It is important for us as dental providers to stay informed about emerging health concerns and actively contribute to solutions, like reducing HPV infections to help prevent oral cancer. As dental providers committed to delivering the best care, we routinely perform oral cancer screenings, and with our long-lasting patient relationships, we are well-positioned to promote cancer prevention through HPV discussions.”
– Jennifer Sukalski, PhD MS, RDH, Assistant Professor of Preventive and Community Dentistry

Since implementation, the two offices have referred all age-eligible not-yet-vaccinated adolescents to receive the vaccine. Parents are receptive and no negative comments have been received. As this program ends over the next few months, we will conduct both post-intervention surveys and interviews. This information will be vital in scaling up this intervention to a greater number of dental offices, particularly those in rural settings. 

About the Authors

Natoshia Askelson is an associate professor of Community and Behavioral Health in the University of Iowa College of Public Health, Department of Community & Behavioral Health. She serves as the PI for Iowa’s Cancer Prevention and Control Research Network Collaborating Center. Dr. Askelson is the interim Associate Director for Community Outreach and Engagement at the Holden Comprehensive Cancer Center. She is also a director at the Institute of Public Health Practice, Research, and Policy. She is trained as a behavioral scientist and much of her work focuses on increasing HPV vaccine uptake to reduce the incidence of HPV-associated cancers. 

Jennifer Sukalski is an Assistant Professor at the University of Iowa College of Dentistry, a Dental Public Health professional, and a registered dental hygienist providing oral health services to underserved populations. Dr. Sukalski is a recipient of the Bernstein Research Fellowship. Her research focuses on the effects of healthcare reform on overall health, oral health, access to care, as well as dental workforce trends in Iowa.